Download Anatomy Review

Heart/Neck Vessels &
Peripheral Vascular/Lymphatics
Anatomy Review

4 chambers
– Right/left
atrium
– Right/left
ventricle

4 valves
–
–
–
–
Tricuspid
Mitral
Pulmonic
Aortic
Anatomy and Physiology

Cardiac output
(L/min) determined by:
– Heart rate
(beats/min)
– Stroke volume
(L/beat)
• CO = SV x HR
Measure
Typical value
Normal
range
end-diastolic
120 ml[1]
volume (EDV)
65 - 240 ml[1]
end-systolic
50 ml[1]
volume (ESV)
16 - 143 ml[1]
stroke volume
70 ml
(SV)
55 - 100 ml
ejection
fraction (Ef)
58%
55 to 70%[2]
heart rate
(HR)
70 bpm
60 to 100
bpm[3]
cardiac
output (CO)
4.9 L/minute
4.0 - 8.0
L/min
Health History

Chest pain
– Do you have any chest pain or discomfort?
• OLDCART
– Do you do you use any recreational drugs?
– Do you have any increased life stress/anxiety?

Dyspnea
– Do you have any labored or difficulty breathing
(dyspnea)?
• OLDCART
• Related to exercise (exertional dyspnea)?
– Quantify: Have far can you walk before getting short of breath?
• Related to position/lying supine (orthopnea)?
– How many pillows do you sleep on at night?
Health History

Palpitations
– Ever have palpitations/or unpleasant awareness of
heartbeat? (“fluttering/ pounding”)

Dizziness or Syncope
– Have you felt dizzy or ever lost
consciousness/passed out (syncope)?

Fatigue
– Do you seem to tire easily?

Cyanosis or pallor
– Ever noted your facial skin turn blue or ashen
gray?
Health History

Cough
– Any pink or blood tinged frothy sputum?

Edema
– Do you have any swelling in your feet or legs?

Nocturia
– Do you awaken at night with an urgent need to
urinate?
Health History

Past Cardiac History
– CHF, angina, MI, murmurs, rheumatic fever,
congenital heart disease

Assess for risk factors of coronary artery
disease
– Hypertension, hyperlipidemia, diabetes, physical
inactivity, obesity, smoking, stress, increasing age.
family history of CAD (especially in 1st degree
relatives F<65, M<55)
– Additional for women: Menopause or use of oral
contraceptives
What the History Can Tell You

Angina (pain resulting from ischemia)
– Onset: Abrupt, often precipitated by event such as
emotion, exertion, cold or eating.
– Location: Substernal or retrosternal pain.
– Duration: Usually lasts a few minutes and then
subsides.
– Characteristic: Described as squeezing or heavy
pressure
– Radiation: May radiate to the neck, jaw, or arms
– Relieving Factors/Treatments Tried: Often relieved with
sublingual nitroglycerin
What the History Can Tell You

Myocardial Infarction
–
–
–
–
Onset: Abrupt, often unrelated to precipitating event.
Location: Substernal or over precordium.
Duration: Prolonged
Characteristic: Severe, described as viselike or
crushing
– Associated Symptoms: dyspnea, dizziness, nausea,
diaphoresis, palpitations, anxiety (sense of doom)
– Radiation: May radiate to neck, jaw, arms or hands.
– Treatments Tried: Sublingual nitroglycerin without
relief
What the History Can Tell You

Congestive Heart Failure
– Right-sided
• Dependent Edema
• Nocturia
– Left-sided
•
•
•
•
•
•
•
Coughing/Hemoptysis (pink frothy)
Orthopnea
Dyspnea with exertion
Cyanosis or ashen color
Cold, moist extremities
Oliguria
Restlessness/anxiety
Carotid Artery

Inspect for pulsation
– Absent pulse wave with arterial occlusion
or stenosis

Palpate lightly & one at a time for:
– Contour
• Smooth with rapid upstroke
– Amplitude
•
•
•
•
•
•

4+ Bounding
3+ Full
2+ Normal
1+ Weak
0 Absent
Diminished or unequal with atherosclerosis or other arterial disease
Auscultate
– Over angle of jaw, mid-cervical, & base of neck with bell
– For presence of bruit
• Blowing, swishing sound indicating turbulence
http://www.youtube.com/watch?v=yq74c6KhPuo
Carotid arteries 2+ bilaterally without bruits.
Jugular Venous Pressure

Assessment of jugular veins gives
estimation of heart function
– Ie. CHF

Internal Jugular Vein
– Position patient supine at
45 degrees without a pillow
– Use Angle of Louis to read
CVP at highest level of pulsation
• Normal-Pulsation <2.5cm
• Abnormal- Pulsation >2.5cm
– Indicates increased CVP associated with heart
failure
http://www.youtube.com/watch?v=yq74c6KhPuo

If you cannot find internal jugular veins,
use the external and note point where
look collapsed
Jugular Venous Pressure

External jugular
veins are lateral to
sternomastoid
muscle above the
clavicles
 Assess if:
– Visible (distended)
@ 45 °
External jugular veins
flat @ 45 °
Hepatojugular Reflux
Very sensitive in detecting right-sided
heart failure
 Elevate to 30 degrees
 Press firmly in right upper quadrant
 Observe neck for elevation in JVP

– Rise of >1cm is abnormal
http://www.youtube.com/watch?v=X9fKPIe6nDQ
Inspection & Palpation

Inspect & palpate
precordium for:
– Lifts/Heaves
– Thrills
• Use ball of your hand
firmly on the chest
– Apical impulse
–
http://www.youtube.com/watch?v=FkM6m
uqmve0&feature=related
Apical impulse @ 5th intercostal
space midclavicular line. No lifts,
heaves, or thrills noted.

Note location of heart may also
be determined by percussing for
borders of dullness
Apical Impulse

AKA: Point of maximal impulse (PMI)
 Apical impulse specifically for apex beat.
 Localize apical impulse using one finger. Ask to exhale
and hold breath may help find. May need to roll midway
to left.
– Note: location, size (1cm x 2cm), amplitude (short
gentle tap), duration (short, occupies only first half of
systole
– Not palpable in obese, thick chest wall
 Increased size or location with volume overload,
hypertrophy (HTN, CAD, CHF, cardiomyopathy)
 Increased amplitude & duration with high cardiac output
states (anxiety, fever, hyperthyroidism, anemia
Auscultation

Wth the diaphragm auscultate
@ the apex of the heart for:
– Rate
• Normal Adult Rate: 60-100 beats/min
• Bradycardia–heart rate less than 60
• Tachycardia–heart rate greater than 100.
– Rhythm
•
•
•
•
Regular vs. irregular
Sinus arrythmia (rhythm varies with breathing)
Regularly irregular, irregularly irregular
If pulse irregular assess for pulse deficit
– Auscultate the apical beat while simultaneously palpating the
radial pulse. Every beat hear should perfuse to periphery
Apical pulse 80bpm and regular. No pulse deficit
noted.
Auscultation

Proceed over
precordium with bell
– Best for low pitch

Auscultate over:
–
–
–
–
–
–

Aortic area
Pulmonic area
Erb’s point
Tricuspid area
Mitral area
Epigastric
For:
– Gallops (best with bell)
– Murmurs (depends)
– Rubs
Normal Heart Sounds

S1
– “Lubb”
– Sound of mitral & tricuspid
valve closing simultaneously
• Start of systole
– Heard loudest at apex of heart
• Approx 5th intercostal space, midclavicular line on left

S2
http://www.youtube.com/watch?v=2aO0HKIP3vI
– “Dubb”
– Sound of simultaneous closing of pulmonic and
aortic valves
• End of systole
– Heard loudest at base of heart
• Best over 2nd intercostal space on right
Gallops: S3 & S4
Heart
Sound
Associated
Heart Process
S3
Early diastolic
Heard
@ apex
or LL
sternal
border
with bell
S4
Normal
Characteristics
Heard more often
in children and
Occurs after S2 young adults
Late diastolic
(atrial filling)
Heard
@ apex Occurs before
with bell S1
Pathological
Characteristics
Cadence
Word Clue
Higher pitch
“Ken-tu-cky.”
Louder
““SLOSH-ingin”
Waxes and
Wanes
More constant
sound
May disappear
when pt sits up
Associated with
volume overload
and left
ventricular
systolic
dysfunction
No typical
characteristics
Seen in
uncontrolled
hypertension
“Ten-nes-see”
“a-STIFF-wall”
Murmurs
– Swishing or blowing noises that occurs
with turbulent blood flow in heart or great
vessels.
– Categorized as:
• Innocent
– Always systolic & without evidence of
physiological/structural abnormalities
• Functional
– Associated with physiological alterations such as
high cardiac output states
» i.e. exercise, anemia, hyperthyroidism or
increased blood volume associated with
pregnancy
• Pathologic
– Caused by structural abnormalities in valves or
chambers
» Stenosis, regurgitation, patent ductus arteriosis
Structural Abnormalities in
Valves and Chambers
Murmur Characteristics

Timing
• Systolic: Heard during systole
(between S1 and S2)
– If possible note: early, late or mid systolic)
• Diastolic: Heard during diastole
(between S2 and S1)
– If possible note: early, late or mid diastolic
• Continuous: Heard in both systole and
diastole
http://www.youtube.com/watch?v=XvtBpnV_lOE
Valvular Disease &
Murmur Locations
Valve
Systolic Murmur
Diastolic Murmur
Aortic
Aortic stenosis
Aortic regurgitation
Pulmonic
Pulmonic stenosis
Pulmonic regurgitation
Mitral
Mitral regurgitation
Mitral stenosis
Tricuspid
Tricuspid regurgitation
Tricuspid stenosis
http://www.merckmanuals.com/professional/resources/multimedia/name/audio.html
Murmur Characteristics

Quality (Shape/Pattern & Sound)
– Shape/Pattern
• Crescendo/Decrescendo
– AKA- Diamond shaped murmur; ejection type
murmur
– Primary causes: Stenotic valves
• Holosystolic
– AKA- Pansystolic
• Decrescendo
– Primary causes: Aortic and pulmonic regurgitation,
Mitral and tricuspid stenosis
http://www.merckmanuals.com/professional/resources/multimedia/name/audio.html
Murmur Characteristics

Quality
– Sound
• Musical, blowing, harsh, or rumbling

Pitch
– High, medium, or low; Loud or soft

Location
– Area of maximal intensity

Radiation
– May be heard in another place on
precordium or neck, back or axilla
Murmur Characteristics
– Intensity (loudness)
• 1 - Very faint, heard only after listener has
“tuned in;” may not be heard in all positions
• 2 - Quiet, but heard immediately after placing
the stethoscope on the chest
• 3 - Moderately loud
• 4 – Loud, with palpable thrill
• 5 - Very loud, with thrill. May be heard when
stethoscope is partly off the chest
• 6 – Very loud, with thrill. May be heard with
stethoscope just removed from and not
touching the skin.
Murmur Characteristic Example

Aortic Stenosis
– Timing: Midsystolic
– Pitch: Loud
– Quality: Harsh
– Location: Loudest @ 2nd right interspace
– Radiation: Widely to side of neck, down left
sternal border, or apex
http://www.merckmanuals.com/professional/resources/multimedia/name/audio.html
Auscultation

Pericardial friction
rub
– Membranous sac
surrounding heart
becomes inflamed
– Differentiate
pericardial from
pleural friction rub
by having patient
hold breath
http://www.merckmanuals.com/professional/resources/multi
media/name/audio.html
Physical Exam Findings for CHF
Right-Sided Failure
 Distended neck veins
 Dependent edema
 Ascites
 Hepatomegaly
 Nocturia
Left-Sided Failure
 Pulmonary Edema
–
–
–
–
–
–
Coughing
Hemoptysis
Orthopnea
Dyspnea/Tachypnea
Crackles in lungs
Cyanotic nail beds, ashen
color
– Cold, moist extremities
– Restlessness/anxiety
http://www.youtube.com/watch?v=QODCQ
HwSfOU&feature=related


S3 gallop rhythm
Tachycardia
Peripheral Vascular
& Lymphatics
http://images.google.com
Peripheral Vascular System

Arteries
– Supply oxygenated
blood to the body
from the heart

Veins
– Return
unoxygenated blood
to the heart
– Contain one-way
valves that keep the
blood from flowing
backwards
– Muscles help
squeeze the blood in
the veins to the heart
Health History

Common or concerning symptoms
– Pain in the arms or legs
– Intermittent claudication: leg or arm pain that is
exercise induced
– Cold, numbness, pallor in the legs; hair loss
– Color change in fingertips or toes in cold weather
– Swelling in calves, legs or feet
– Swelling with redness or tenderness
– High risk: Tobacco use, diabetes, HTN,
Hyperlipidemia, CV disease
– Severity of peripheral vascular disease closely
parallels the risk for heart attack, stoke, and death
from vascular causes
Inspection


Inspect upper and lower extremities for:
– Color
– Symmetry
– Lesions
– Clubbing
– Edema
– Capillary refill
Pitting Edema- Apply pressure with finger for 5
seconds.
– 1+: Slight pitting, 1cm or less, disappears rapidly
– 2+: Deeper pitting, 1.5cm, disappears 10-15 sec.
– 3+: Deep pitting, 2cm, disappears more than 1 minute
– 4+: Very deep pitting, 2.5cm, disappears 2-5 minutes
No pitting edema noted
Inspection

Inspect lower extremities for
– Hair distribution
– Varicosities
– Muscle atrophy
Palpation

Palpate upper and lower extremities for:
– Temperature
– Texture
– Capillary refill
– Lymph nodes
• Epitrochlear, Inguinal
Lymph Nodes

Epitrochlear
– In antecubital fossa
and drains:
• Hand
• Lower hand

Inguinal
– In groin and drains
most of the lymph
• Lower extremities
• External genitalia
• Anterior abdominal wall
Palpation

Peripheral Pulses
– Brachial, radial, femoral, popliteal, posterior
tibial, dorsalis pedis
• Assess for symmetry in limbs
• Force
–
–
–
–
–

4+ Bounding
3+ Full, increased
2+ Normal
1+ Weak
0 Absent
If pulse is difficult to palpate use a
Doppler (ultrasound stethoscope) to
amplify sound of pulse wave
Peripheral Pulses- Brachial

Located medial to
biceps tendon
 Grade force
bilaterally
Peripheral Pulses-Radial

Note:
– Rate
– Rhythm
– Force
Peripheral Pulses-Ulnar

Modified Allen Test
– Evaluate adequacy of collateral circulation prior to cannulating
radial artery
– Firmly occlude both ulnar and radial arteries
– Release pressure on ulnar artery
– Normal- return of color in 2-5 seconds
Peripheral Pulses-Femoral

Located just
below inguinal
ligament halfway
between the
pubis and
anterior superior
iliac spine.
 Grade force
bilaterally
 If weak
auscultate for
bruit
Peripheral Pulses-Popliteal
Located
just lateral
to medial
tendon
 Grade
force
bilaterally

Peripheral Pulses-Posterior Tibial

Located behind the groove
between the malleolus and
Achilles tendon
 Grade force bilaterally
Peripheral Pulses-Dorsalis Pedis

Located just lateral to &
parallel with the extensor
tendon of the big toe.
 Force should be
symmetrical
Assess for Deep Vein Thrombosis

Assess for:
– Erythema
– Calf Edema
– Increased warmth
No calf erythema, edema,
warmth
No longer widely practiced
– Tenderness with
palpation
– Homan’s sign
No calf erythema, edema,
or warmth.
Venous vs. Arterial Insufficiency
Assessment Criterion
Venous
Arterial
Color
Normal or cyanotic
Pale; worsened by
elevation; dusky red
when extremity is
lowered
Temperature
Normal
Cool (blood flow
blocked to extremity)
Pulse
Normal
Decreased or absent
Edema
Often marked
Absent or mild
Skin Changes
Brown pigment around
ankles
Thin, shiny skin;
decreased hair growth;
thickened nails.
Arterial
Venous
Is that all? 
MIDTERM
40 points all multiple choice