Download 诊断学——循环系统检体

Cardiovascular
Examination
Deling Zou
1
Anatomy
2
3
Inspection
1 Precardial projection
and excavation
2 Apical impulse
3 Abnormal pulsations
of precardium
4
Inspection
1 Precardial projection and
excavation
1) Precardial projection
• congenital heart disease: tetralogy of
Fallot
• Valvular heart disease-MS,PS
• pericardial effusion (large , childhood)
5
• The second right intercostal
space(2nd ICS-RS)
• aneurysm of aortic arch
• dilatation of ascending aorta
2) flat chest
3) pigeon chest/funnel chest
6
Inspection
2 Apical impulse
*Normal:
• position—the fifth left intercostal
space 0.5-1.0cm medial to the
midclavicular line
range—2.0-2.5cm in diameter
7
*Abnormal
1) Location
#diaphragm:
• “transverse position” upper,outward
•
obesity ,child, pregnacy;
•
ascites; tumor of abdominal cavity
•
• “vertical position” (thin, high,
emphysema) inferior,inner
8
9
#mediastinum:
• one side pleural effusion or
pneumothorax—to the healthy
side
• one side atelectesis or pleural
adhesion—to the affected
10
#enlargement of the heart
• right ventricular dilatation –left or
slightly upper
• left ventricular dilatation—left
inferior
• LV &RV dilatation –left inferior
(both side dilatation)
11
12
#Posture:
• recumbent position—upper
• left lateral position—to the left 23cm
• right lateral position—to the right
1.0-2.5cm
•
Dextrocardia: 5-ICS—RS
13
Inspectionapical impulse - abnormal
2)Intensity and extent changes
Decrease
Increase
Physiological Chest wall pachynsis
Thin chest wall
Narrow intercostol space Broaden intercostol space
exercise,euphoric mood
Pathological . myopathy(AMI,DCM) .LV hypertrophy
. pericardial effusion
.hyperthyroidism
. emphysema
. fever
.constrictive pericarditis
.anemia
. left side massive pleural
effusion or
pneumothroax
14
Inspection
-apical impulse - abnormal
3)Inward impulse:
• apex excavation in the systole
•
seen: adhensive pericarditis
prominent RV hypertrophy
15
Inspection
3 Abnomal pulsations of
percardium
1)left third-forth intercostal space
lateral to the sternum(3,4ICS-LS)
• seen: RV hypertrophy
16
2)hypoxiphoid process
seen:
difference
deep inspiration
RV hypertrophy
↑
abdominal aorta (aneurysm) ↓
17
3)basal part of the heart
• 2 ICS-LS: dilatation of the
pulmonary artery or pulmonary
hypertensin, occasionally healthy
young man
• 2 ICS-RS: aneurysm of aortic arch
or dilatation of ascending aorta
18
Palpation
1 Apical impulse and
pulsation of precardium
2 Thrill
3 Pericardial friction rub
19
Palpation
1 Apical impulse and
pulsation of precardium
• Exact position of apex
• The beginning of systole of
ventricle
first sound
• Heaving apex impulse: reliable
of LV hypertrophy
20
2 Thrill
• One of characteristic signs of organic heart disease
• Mechanism : the flow of blood→narrowed
orifice→vortices→
vibration→chest wall
• thrill-high frequency
murmurs-low frequency
• Method:position,phase of cardiac cycle,clinical
significance
• seen: CHD or valvular stenosis ,
occasionally insurficiency
21
Clinical significance of thrill
Location
phase
Disease
2 ICS-RS
Systole
AS (RHD,CHD,senile)
2 ICS-LS
Systole
PS (CHD)
3,4 ICS-LS Systole
VSD (CHD)
Apex
Systole
MI (severe)
Apex
Diastole MS (RHD)
2 ICS-LS
Continous PDA
CHD:congenital heart disease
22
3
Pericardil friction rub
1)Precardium-4th ICS-LS
2) both phases of the cardiac cycle
3) systolic period, sitting erect and leaning
forward, the end of expiration
4)mechanism: rub of the visceral and
parietal layers of pleura
5)seen:acute pericarditis
23
Percussion
• Aim:to determine the size and
shape of the heart .
• Absolute dullness: contain no gas
Relative dullness : real size
24
1
murneuver of percussion
• patient in erect position –the
pleximeter is vertical with the
intercostal space
• patient in the recumbent position
–the pleximeter is parallel with the
intercostal space
25
2
order :
• left—right ; upwards ; inward
• left margin : from 2-3 cm lateral to
the apex beat up to the 2nd ICS
• right margin : one intercostal space
higher than the border of liver
dullness up to the 2nd ICS
• size: vertical distance from margin
to the anterior midline
26
27
Percussion
3 Normal heart borders
(area of relative dullness)
Right(cm) ICS
Left(cm)
2~3
2~3
Ⅱ
2~3
III
3.5~4.5
3~4
5~6
Ⅳ
7~9
Ⅴ
(LMCL —ML:8~10cm)
28
Percussion
4 The composition of various parts of
the border of the heart
(1)
Right
ICS
Left
II
PA
RA
III
LA
RA
Ⅳ
LV
Ⅴ
LV
SVC,SA
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(2)The upper border –the lower
border of the anterior end of the
third rib↑
(3)The basal part —the second
intercostal space upward
left: aortic node and PA
(4)Concave part –between the aorta
and the left ventricle
30
Percussion
5 Changes in the area of cardiac
dullness and its significance
Cardiac factors :
1)LV enlargement: “boot shape”
Seen:aortic valvular disease ,
hypertension heart disease
31
2)RV enlargement :
slightly↑--absolute dullness↑
Prominent↑--relative dullness↑
to the left side prominently
Seen:PHD, MS
3)Two ventricle ↑:
“generally enlarged heart”
seen:DCM , Kashan cardiomyopathy
32
4)LA and/or pulmonary artery:
LA:concave part disappear
LA+PA:2,3 ICS-LS outwards
“pear shape”
Seen: MS--- “mitrial type”
33
5)pericardial effusion: enlargement of
both sides of the border
body’s position:
• recumbent position：widening of base of
the heart
• erect position:“triangular shape”
34
6)dilatation of the aorta /ascending
aortic aneurysm:
widening if the dull area of first and second
intercostal space (with systolic pulsation)
35
Extacardial factors :
1)large pleural effusions and
pneumothorax → to the healthy side
2)atelectasis /pleural pachynsis →to the
affected
3)a large amount of ascites or big
abdominal tumor:
diaphragm elevated→transverse
position →left side enlargement
36
Ausclutation
37
1 Ausclutatoty valve areas
1)ausclutatory mitral area: apical area
2)ausclutatory pulmonary area:2 ICSLS
3)ausclutatory aortic area: 2 ICS-RS
4)second ausclutatory aortic area: 3rd
ICS-LS—Erb area
5)tricuspid area :4,5 ICS-LS
38
39
2
Order:
MV---PV---AV1---AV2---TV
3
Contents : 1) rate 2)rhythm
3)heart sound 4)extra heart sound
5)murmurs 6)pericardial friction
sound
40
1)heart rate:
• 60~100bpm F＞M
• child (＜3 years) ＞ 100bpm
• tachycardia: normal adult ＞100bpm
child(＜3 years) ＞150bpm
• bradycardia: HR ＜60 bpm
41
Ausclutation
heart rate:60-100bmp
42
2)cardiac rhythm:
*sinus arrythmia—affected by breath
*premature beat:
classification:atrial~ ventricular ~
•
junctional ~
•
frequently:＞6 bpm
•
occasionally: ＜6 bpm
•
bigeminy trigeminy
43
*atrial fibrillation:
absolute irregular rhythm
S1 intensity inequality
Pulse deficit
seen:MS,CHD,hyperthyroidism,
PHD,DCM
44
Ausclutation
atrial fibrillation
•
45
3) cardiac sound
Cycle
Nature
Isovolumetric
Blunt
contraction phase
Duration
S2
Isovolumetric
relaxation phase
S3
S4
S1
0.1″
Site
Apical
area
Mechanism
Closure of the
MV and TV
Distinct
0.08″
Basal
part
Closure of the
AV and PV
The end of
ventricular rapid
filling phase
Weak
Blunt
0. 04″
after S2
0.12~0.18″
Apex
(innerupper)
Ventricular
vibration
The end of
ventricular
diastolic phase
Weak
0. 1″
forward S1
Apex
Atrium
contraction
46
Ausclutation
content
cardiac sound
 S1：
 S2：
47
48
4)Abnormal cardiac sound
*Intensity:
• position of the atrioventricular
valve
• Ventricular contractility and
output
• Valvular integrity and activity
49
S1: Accentuation:
• MS
• HR↑contractility↑
fever,anemia,hyperthyroidism
• complete AVB →cannon sound
50
51
S1 attenuation :
• MI
• P-R interval enlong
• AI
• myocarditis,myopathy,MI,HF
inequality: af, III°AVB
52
53
S2---A2,P2
S2 ↑ ---pressure and flow of
blood ↑
A2 : hypertensin, arterisclerosis
P2 : PHD,CoHD(L--R),LVF
S2 ↓ ---pressure↓ flow ↓
Seen:hypotension,AS/AL,PS/PI
54
55
*Quality
mono rhythm
pendular rhythm---embryocardia
*Splitting of heart sound
S1 splitting:
seen—RBBB, right heart failure
Ebetein malformation ,MS
LA myxoma
56
57
• S2 splitting:
(1)physiological splitting :end of
inspiration
(2)general splitting : most commonly
seen: CRBBB, PS, MS,MI ,VSD
(3)fixed splitting :ASD
(4)paradoxical splitting(reversed
splitting) :pathological
seen: CLBBB ,AS, hypertension
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59
• 5)extra cardiac sound
Diastolic period
1)gallop rhythm:
--protodiastolic gallop: S1+S2+S3 the third
sound gallop (sign of organic heart disease)
seen : HF（AMI, severe myocarditis ,
myopathy etc.）
-- late diastolic gallop: atrial gallop S1+S2+S4
seen : HBP ,HCM ,AS ,CHD
-- summation gallop: quadruple rhythm
seen:HF,cardiomyopathy
60
61
62
• 5) extra cardiac sound
Diastolic period
2)opening snap:MS
3)pericardial knock: constrictive
pericarditis
4)tumor plop: LA myxoma
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Ausclutation
CONTENT
Tumor plop
65
• Systolic period
(1)early systolic ejection sound(click)
pulmonary :pulmonary hypertension;
pulmonary artery dilatation
PS, ASD, VSD
Aortic: hypertension, aneurysm ,
AS, AI ,aorta constriction
(2)mid and late systolic click:
S1----mid＜0.08″ late＞0.08″
seen: mitral prolapse
66
67
68
• iatrogenic
(1)prosthetic valvular sound
(2)pacemaker
69
6)cardiac murmurs
*Mechanism:
acceleration of blood flow
stenosis of valvular orifice
or great vessles
valvular insufficiency
abnormal passage
foreign body
dilatation of vessles(aneurysm)
turbulent flow
vortices
70
71
• *characterization of murmur and
ausclutatory key points
(1)location:L3,4 –VSD L2,3—PDA
(2)transmission:
MI ---left axilla
AS---neck
(3)phase: systolic murmurs
diastolic ~
continuous ~
biphasic ~
• early,mid,late,whole
murmurs
72
(4)quality: blowing—MI
rumbling—MS
sighing--AI
machinery--PDA
(5)intensity :Levine 6 grade classification
shape: crescendo---MS
decrescendo---AI
crescendo-decrescendo---AS
continuous---PDA
regular---MI
murmurs
73
(6) others:
• body position:
MS--left lateral position
AI--sitting erected and forward
MI,TI,PVS--lie on one’ back
Lie → stand: HCM
• breath:expiration--LV murmurs
inspiration --RV murmurs
valsalva--HCM
• exercise: HR↑--murmurs ↑
murmurs
74
• clinical significance murmurs:
functional and organic
7)pericardial friction sound:
• both phases , unaffected by
respiration .
• seen: pericarditis ,
RHD ,AMI ,renal failure, SLE
75
* clinical significance of cardiac
murmurs
systolic murmurs
MV：functional:exercise,fever,anemia,pregnancy,
hyperthyroidism
relative:HBP,CHD,DCM,anemia
organic：MI(RHD),mitral prolapse
76
77
* clinical significance of cardiac
murmurs
systolic murmurs
Aortic area：organic：AS
relative：dilatation of ascending aorta
78
79
* clinical significance of cardiac
murmurs
systolic murmurs
pulmonary ：physiology
relative：MS、ASD
organic：PS
TV：relative ：RV enlarged
organic ：rare
80
* clinical significance of cardiac
murmurs
Diastolic murmurs
MV:organic:RHD(MS)
relative:AI(severe)
Austin Flint murmur
AV:AI
81
82
83
* clinical significance of cardiac
murmurs
Diastolic murmurs
PV:organic murmur is rare
PI(dilatation of pulmonary artery)
MS+P2 ---- Graham Steell murmur
TV:rare
84
* clinical significance of cardiac
murmurs
continuous murmurs
PDA
innocent murmur
85
Vascular examination
The second clinical hospital of CMU
86
pulse
pulse rate
pulse rhythm
tensions and state of arterial
wall
intensity
pulse wave
87
pulse
pulse rate
Atrial fibrillation and frequent premature
beat stroke volume
peripheral artery
no pulse pulse rate less than HR(pulse
deficit)
88
pulse
pulse rhythm
pulse deficit；
bigeminal pulse,trigeminal pulse；
dropped pulse
89
pulse
tensions and state of arterial wall
Artery tension depending on blood
pressure (mainly SBP).
Judge state of artery wall
90
pulse
intensity
Bownding pulse
seen:high fever, hyperthyroidism, AI
Microsphygmia
seen:HF,AS and shock
91
pulse
pulse wave
• normal pulse wave
composed of upstroke（knocking wave）、
peak （tide wave）and downstroke
（dicrotic wave）
92
pulse
pulse wave
• water hammer pulse seen:AI,hyperthyroidism,PDA,
severe anemia
• pulse tardus
seen:AS
• dicrotic pulse
seen:HCM
• pulsus alternans seen:HBP,AMI,AI
• paradoxical pulse
seen:cardiac tamponade,constrictive pericarditis
• Pulseless
seen:serious shock, arteritis
93
blood pressure
• method of measurement
direct measurement method
indirect measurement method
94
blood pressure
• standard
definition of Bp level and classification(older than 18 years old)
classification
SBP(mmHg)
DBP(mmHg)
Ideal BP
120
80
Normal BP
130
85
High limit of BP
130-139
85-89
Grade 1（mild）
140-159
90-99
subgroup：
boundline hypertension
140-149
90-94
Grade 2（moderate）
160-179
100-109
Grade 3（severe）
≥ 180
≥110
Simple systolic hypertension 140
90
subgroup：
boundline systolic hypertension 140-149
90
95
blood pressure
• clinical significance of BP changes
hypertension：higher than 140/90mmHg for 3 times not in
the same day
hypotension：lower than 90/60-50mmHg
Shock,,MI,acute cardiac tamponade
obvious difference between bilateral upper limbs：more than
10mmHg---arteritis,congenital artery malformation
difference between upper and lower limbs：lower limb BP is
20-40mmHg higher than upper one normally
pathological:constrictive aorta ,arteritis(chest-abdominal aorta)
change of pulse BP：
40mmHg，wide pulse BP---hyperthyroidism,AI
96
30mmHg，narrow pulse BP---AS,pericardial effusion
blood pressure
• dynamic BP monitoring
Average BP for 24h 130/80mmHg;
bright day 135/85mmHg;
night: 125/75mmHg
Peak:6am—10am,4pm—6pm
97
Vessel murmur and peripheral
vessel sign
• venous murmur
jungular murmur：is caused by the rapid
flow of jungular vein into SVC
(superior vena cava)
98
Vessel murmur and peripheral
vessel sign
• artery murmur
Continuous murmur in the lateral lobe of
thyroid in the patient with hyperthyroidism
Systolic murmur in the upper abnormal region
or lumber region caused by stenosis of renal
artery.
Arterio-venous fistula
99
Vessel murmur and peripheral
vessel sign
• peripheral vessel sign
pistol shot sound
Seen:AI,hyperthyroidism,severe anemia
Durozier’s murmur
capillary pulsation
100
• The main symptoms and
signs of common
diseases of circulatory
system
101
Mitrial stenosis
• Causes:
•
RHD:rheumatic heart disease
CHD:congenital heart disease
Other reasons: senile retrograde
102
• Symptoms:
•
cough;
• hemoptysis;
• dyspnea: dyspnea on exertion→
paroxysmal nocturnal dyspnea →
pneumonedema
103
• Signs:
• Inspection :
mitrial face
Apex impulse may be displaced to the left
• Palpation :diastolic thrill palpable over the
apical area
• Percussion :
normal heart borders→pear shape heart
104
• Auscultation :
1)the first sound (S1)↑
2)diastolic murmur :apical area; localized; mild
and late diastolic ;crescendo ;rumbling; more
clearly when the patient is lying on his left side.
3) opening snap may be auscultatory
4)accentuation of second pulmonary sound (P2↑),
splitting
5)Graham Steel’s murmur (PV diastolic)
6)Maybe atrial fibrillation(late stage)
105
Mitral Insufficiency
• RHD / non-RHD ; acute/chronic
• Symptoms:
•
fatigue,
• palpitations,
• dyspnea on exertion,
• Left heart failure
106
• Signs :
Inspection : apex beat is
displaced downwards and to the
left
107
• Palpitation :
apical impulse forceful
Heaving apex impulse
Severe systolic thrill
• Percussion :
the area of dullness to left and
downwards
108
• Auscultation :
1)S1 ↓(attenuation)
2)murmurs: harsh;
pansystolic murmur;
blowing;
3/6 grade ↑
wide spread-transmitted to left axilla
left infrascapular angle
109
Aortic Stenosis
• Causes: RHD
Congenital
Senile retrograde
• Symptoms :
palpitation ,dizziness, angina pectoris,
syncope, HF-dyspnea
110
• Signs :
• Inspection : apical impulse increase
Displaced to left and downwards
• Palpation :
apex beat is elevated and forceful
systolic thrill can be palpated over aortic
auscultatory valve area
Pulse tardus
111
• Percussion:
the area of dullness is normal or to left and
downward
• Auscultation :
1)murmur:
aortic auscultatory valve area systolic murmur
harsh ,ejection sound ,
3/6 grade ↑(thrill)
transmitted to neck
2)A2 ↓,reversed splitting
3)S4
112
Aortic Insufficiency
• Causes:
• RHD
Non-RHD：congenital
prolapse
syphilis aortitis
arteriosclerosis
endocarditis
acute/chronic
113
• Symptoms :
palpitation, dizziness, LHF
• Signs
Inspection :
apical impulse to left and downwards
Palpation :
apex impulse to left and downwards
Heaving apex impulse
114
• Percussion :
the area of cardiac dullness is enlarged
downwards and to the left;
the concave part of the heart is not
enlarged (boot shape)
115
• Auscultation :
1)specific murmur:
diastolic ;
sighing ;
aortic area;
heard clearly sitting erect and forward
2)Austin Flint murmur :relative MS
(rumbling mid-diastolic murmur)
116
• Peripheral vascular signs
*head bobbing (Musset’s sign):nodding motion of
the head with each systole;
*signs of capillary pulsation;
*water hammer pulse;
*pistol shot sounds : esp. Femoral arteries;
*Duroziez’s murmur;
*Visible pulsation of carotid arteries
117
Pericardial effusion
• Causes:
infective and non-infective pericarditis
• Symptoms :
pain over the pericardial region
Dyspnea, cough, fever, lassitude
Shock
118
• Signs :
Inspection :
diminution in strength of the apex beat
or absence of the apex beat ;
jugular venous enlargement
119
• Palpation :
*diminution in strength of the apex beat or the
apex beat palpated uneasily
*paradoxical pulse may be present
120
• Percussion :
enlargement of the cardiac dullness
bilaterally, changed with posture
121
• Auscultation :
*pericardial friction sound
*HR↑,diminution of intensity of cardiac
sound (S1/S2↓)
*pericardial knock may be heard
122
*Large
•
•
•
•
effusion:
Jugular varicosity
Liver enlargement
Paradoxical pulse
Pulse pressure ↓
123
* Kussmaul sign:
deep inspiration –jugular vein distension
*Ewart sign: left infrascapular region
vocal fremitus↑
dullness -- percussion
bronchovesicular breath sound-auscultation
124
• Causes :
Heart Failure
myopathy ; ventricular load ↑
promote factors
• Symptoms:
1 LHF: fatigue, cough, frothy sputum
dyspnea(on exertion → orthopnea → paroxysmal
nocturnal ~)
2 RHF: abdominal distension, oliguria, nausea, vomiting
125
• Signs :
1 LHF:
*Inspection : tachypnea , cyanosis,
semireclining/sitting position
Acute pneumoedema:
frothy sputum, hyperhidrosis
*Palpation :pulse alternans
*Percussion :
*Auscultation :diastolic gallop rhythm
P2↑
Fine rales, rhonchi
126
• 2 RHF:
*Inspection :Jugular distension
Pericardial cyanosis
Edema(pitting, pendulous)
*Palpation : liver enlargement, tenderness
Hepatojugular reflux(+)
*Percussion :
pleural effusion (right side)
ascites
*Auscultation : RV diastolic gallop rhythm
TV systolic blowing murmurs
127