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PHYSICAL EXAMINATION CARDIOVASCULAR SYSTEM The Wiggers Diagram Mervyn Gotsman M.D. Department of Cardiology, Hadassah University Hospital, Hebrew University Hadassah Medical School, Jerusalem, Israel PHYSICAL EXAMINATION CARDIOVASCULAR SYSTEM • General examination • Arterial pulse – brachial, carotids, peripheral • Jugular Venous Pressure • The heart • • • • Inspection Palpation Percussion Auscultation x CARDIOVASCULAR SYSTEM General examination • • • • • • • • • Walking and gait Sitting or lying Orthopnoea Cyanosis (central or peripheral), anaemia, jaundice Fever and embolic signs Right heart failure (JVP, dependent oedema, hepatomegaly, ascites, pleural effusions) Left heart failure (dyspnoea, tachypnoea, orthopnoea, cough, basal crepitations Pulmonary disease Sytemic disease: thyrotoxicosis, thyrotoxicosis, scleroderma, scleroderma, lupus erythematosis, erythematosis, etc Left Heart Failure Right Heart Failure •Elevated LVEDP • LAP • PVP •Pulmonary congestion •Dyspnoea •Orthopnoea •Cough •Tiredness and lethargy JVP Hepar Ascites Ankle Edema Weight 1 y Arterial pulse PHYSICAL EXAMINATION CARDIOVASCULAR SYSTEM Radial artery • Arterial pulse • Jugular Venous Pressure • Cardiac Examination: • • • • Inspection Palpation Percussion Auscultation Arterial pulse 120 Arterial pulse Radial artery 80 Carotid artery • Heart rate: ( 6060-100 ). • Rhythm: Regular Irregular: Irregular: Sinus arrhythmia Occasional - Premature beats - Dropped beats Totally - irregular Amplitude/Contour: • Hypokinetic ↓ ( weak ) - Hypovolemia 120 80 Amplitude/Contour: • Bisferiens - HOCUM • Collapsing – AR • Parvus et tardus - AS • Alternans - Heart failure • Bigeminal - Premature beats • Paradoxical - Pericardial tamponade - Constrictive pericarditis • Dicrotic – Cardiomyopathy • Filiform - shock 2 Aortic stenosis • Hyperkinetic ↑ increased stroke volume 120 80 Arterial pulse: Carotid artery Heart failure Fever, anemia, hyperthyroidism AR, bradycardia, atherosclerosis Pulsus parvus et tardus The phono-carotid pulse tracing: • Phono – – • Long systolic ejection murmur Paradoxical split of the 2nd heart sound Carotid pulse tracing – Pulsus parvus et tardus PHYSICAL EXAMINATION CARDIOVASCULAR SYSTEM Jugular Venous Pressure 45o angle • Arterial pulse • Jugular Venous Pressure • The heart • • • • Inspection Palpation Percussion Auscultation Jugular Venous Pressure Jugular Venous Pressure Patient at 30 degrees and oblique lighting Differentiation from arterial pressure • Two waves ( if not in A fib) • Changes with position • Obliterated with pressure • Decreases with respiration Jugular Venous Pressure • • Reflects – – – – Right atrial pressure Blood volume Tricuspid valve Diastolic events in the right ventricle Estimate CVP Maximal 3cm from sternal angle + 5cm from atrium (Right atrial pressure) • Increased pressure Right sided heart failure Constrictive pericarditis Tricuspid stenosis Obstructed SVC Increased intrathoracic pressure 3 Jugular Venous Pressure External jugular vein Internal jugular vein Venous Pressure Jugular Venous Pressure Jugular Venous Pressure a v wave x S1 S2 y descent S1 S2 Angle of Lewis Systole Diastole Jugular Venous Pressure Jugular Venous Pressure Diagnosis ? • Amplitude of pulsations a wave, x descent, v wave, y descent Atrial contraction, relaxation, atrial filling, emptying • Absent ‘a’ wave - atrial fibrillation • Giant ‘a’ wave - tricuspid Stenosis, PHT • Cannon ‘a’ waves - AV dissociation • Large ‘v’ wave - tricuspid regurgitation • Slow ‘y’ descent – tricuspid stenosis מראה1 'תמונה מס גל תותח גבוהA גל בולטV גל ' חזקהY' ירידת 4 • • • • Jugular Venous Pressure Diagnosis ? Jugular Venous Pressure : מראה2 'תמונה מס . הצרות של המסתם הותיני.א .צניפי- הצרות של המסתם הדו.ב . יתר לחץ דם ריאתי.ג - אי ספיקה של המסתם התלת.ד צניפי PHYSICAL EXAMINATION CARDIOVASCULAR SYSTEM • Arterial pulse • Jugular Venous Pressure • Cardiac Examination • • • • 5 Inspection Palpation Percussion Auscultation • Hepatojugular reflux • Sustained rise of JVP Heart failure. Kussmaul’ Kussmaul’s sign - Increase with inspiration Constrictive pericarditis Heart failure Cardiac Examination: Inspection Cardiac Examination: Inspection Cardiac pulsations PMI Parasternal lift S3, S4 Dyskinesis Aneurysm PHYSICAL EXAMINATION: CARDIOVASCULAR SYSTEM • Arterial pulse • Jugular Venous Pressure • Cardiac Examination • • • • Inspection Palpation Percussion Auscultation Cardiac Examination: Palpation • Apical impulse (PMI) 6 Cardiac Examination: Palpation Areas of palpation • • • • • Apical impulse (PMI) Left sternal border Left and right 2nd interspace Epigastric area Thrills Cardiac Examination: Palpation • Apical impulse (PMI) Cardiac Examination: Palpation Cardiac Examination - Palpation Left parasternal lift • Right ventricular volume load • Right ventricular pressure load – ASD – Pulmonary incompetence – Tricuspid incompetence - seesee-saw motion – Pulmonary hypertension – Pulmonary stenosis • Left atrial lift • Apical impulse (PMI) – Mitral incompetence Cardiac Examination: Palpation Cardiac Examination: Palpation • Left 2nd interspace - Pulmonic: PHT • Right 2nd interspace - Aortic: HTN • Epigastric area - Right ventricle in hyperinflated lungs • Thrills - Murmurs grade 4+ • Left sternal border - Right ventricle Apexcardiogram in aortic stenosis The normal apex-cardiogram The normal apex cardiogram: • • • Normal outward motion fills the first third of systole Small presystolic outward motion Rapid filling wave • • RFW Prominent outward presystolic motion Prolonged sustained outward motion fills all of systole ‘a’ 7 Apexcardiogram in aortic stenosis מראה4 'תמונה מס • • Prominent outward presystolic motion Prolonged sustained outward motion fills all of systole PHYSICAL EXAMINATION CARDIOVASCULAR SYSTEM • Arterial pulse • Jugular Venous Pressure • Cardiac Examination • • • • 8 Inspection Palpation Percussion Auscultation . חוד מוסט שמאלה.א . חוד עם הולם מאורך.ב . דופק מתמוטט.ג . הרמה של חדר ימני.ד Cardiac Examination: Auscultation Areas of auscultation • • • • Apex Left Sternal Border Aortic Pulmonic Cardiac Examination: Auscultation Cardiac Examination: Auscultation Areas of auscultation: Apex Areas of auscultation: Left Sternal Border Cardiac Examination: Auscultation Cardiac Examination: Auscultation Stethoscope • Diaphragm ( high pitched ) - S1, S2, AR, MR, clicks, friction rubs • Bell ( low pitched ) - S3, S4, MS. Position • Areas of auscultation: Aortic, Pulmonic Left decubitus - S3, S4, mitral sounds ( MS ) • Lean forward and exhale - Aortic (AR) Cardiac Examination: Auscultation Cardiac Examination: Auscultation Lean forward and exhale The Wiggers Diagram Left decubitus Cardiac Examination: Auscultation • First heart sound (S1): Closure of Mitral and Tricuspid valves S1 x S2 y MT Systole 9 S1 MT Diastole S2 Cardiac Examination: Auscultation First heart sound (S1) • Intensity • Second – LV dp/dt – P-R interval Accentuated: Accentuated: • Diminished • Splitting heart sound (S2): Closure of Aortic and Pulmonic valves • Short PR – loud • Long PR - soft • Cardiac Examination: Auscultation – Short PR interval – high cardiac output states – MS S1 A2 P2 S1 Inspiration Expiration – 1st degreeAVB, degreeAVB, – MR. Systole Diastole Normal – RBBB – VPB’ VPB’s. Cardiac Examination: Auscultation Cardiac Examination: Auscultation • Second • Second heart sound (S2): Closure of Aortic and Pulmonic valves S1 A2 P2 S1 A2 P2 Inspiration Expiration Systole heart sound (S2): Closure of Aortic and Pulmonic valves S1 P2 A2 S1 Diastole Inspiration Systole Cardiac Examination: Auscultation • • • • Second heart sound (S2-A2, P2) SingleSingle- common ventricle or truncus, truncus, valve atresia Fixed splitting - ASD Splitting is due to differences in LV and RV systolic duration RVET>LVET Wider splitting • Paradoxical splitting • • – Longer RVET - overloading – Shorter LVET - underloading – Longer LVET -overloading – Shorter RVET -underloading A2 P2 Expiration Diastole Normal but wide 10 A2 P2 Reversed splitting Cardiac Examination: Auscultation Third heart sound ( S3 ) • • • • Sudden expansion of the ventricle by rapid ventricular filling Often palpable Physiological in young people and during exercise Pathological in volume overload and heart failure S1 S2 S3 Systole Diastole S1 S2 S3 Cardiac Examination: Auscultation Fourth heart sound ( S4 ) • Sudden expansion of the ventricle • • (right or left) by atrial contraction Physiological in athletes, older people. Pathological due to decreased compliance (right or left ventricle) S1 S2 Systole S4 S1 S2 Fourth heart sound ( S4 ) • Physiological in athletes, older people • Pathological due to decreased compliance • • Diastole Cardiac Examination: Auscultation Extra systolic sounds: • Ejection sound – Aortic – Pulmonary • Midsystolic click • Mitral Valve Prolapse Extra diastolic sounds: • Opening snap • Mitral Stenosis (thick wall or poor relaxation Pressure overload - HTN, AS Ischemia, Cardiomyopathies Right sided S4: pressure overload ( PS, PHT ) Accentuated by exercise Cardiac Examination: Auscultation Ejection sound : Left or right • Valve stenosis • Increased blood flow through the valve • Arterial hypertension • Dilatation of the artery Cardiac Examination: Auscultation Cardiac Examination: Auscultation • Ejection sound: Aortic Stenosis • Ejection sound: Aortic Stenosis Extra systolic sounds: Ej S1 S2 Systole 11 Cardiac Examination: Auscultation S1 Diastole S2 Extra systolic sounds: Ej S1 Systole S2 S1 Diastole S2 Cardiac Examination: Auscultation Extra systolic sounds: • Ejection sound: Aortic Stenosis Ej S1 S2 Systole S1 Diastole S2 OS Systole Systole S1 S2 Diastole Cardiac Examination: Auscultation Murmurs: • Ejection: Left and right ventricular outflow tract stenosis (subvalvular (subvalvular,, valvular, valvular, ring, supravalvular) supravalvular) S2 Systole 12 • Midsystolic click: S1 Diastole Mitral Valve Prolapse S1 Cl S2 • Opening snap: Mitral or tricuspid stenosis • Severe stenosis – shorter 22-os interval S1 Extra systolic sounds: S2 Cardiac Examination: Auscultation Extra diastolic sounds: S1 Cardiac Examination: Auscultation S2 S1 S2 Diastole Cardiac Examination: Auscultation Murmurs: • • • • • • • • Timing - Systolic - ( mid, pan ) Diastolic - ( early, mid, late ). Shape - crescendo, decrescendo, plateau. Location Radiation - Axilla, Axilla, Back,Suprasternal notch Intensity ( 1 - 6 ). Pitch Quality - blowing, harsh, rumbling, musical Changes with physiological interventions – exercise, standing, squatting, Valsalva Cardiac Examination: Auscultation Murmurs: • Ejection: Left and right ventricular outflow tract stenosis (subvalvular (subvalvular,, valvular, valvular, ring, supravalvular) supravalvular) S1 S2 Systole S1 Diastole S2 Aortic stenosis Aortic stenosis - murmur Apexcardiogram in aortic stenosis The normal apex-cardiogram The normal apex cardiogram: • • • Normal outward motion fills the first third of systole Small presystolic outward motion Rapid filling wave • • RFW Prominent outward presystolic motion Prolonged sustained outward motion fills all of systole ‘a’ Apexcardiogram in aortic stenosis • • 13 Prominent outward presystolic motion Prolonged sustained outward motion fills all of systole Pulmonary stenosis Right ventricular outflow tract stenosis Hypertrophic myopathy Interventricular septum Abnormal mitral valve chordae HOCUM Mitral incompetence Double pulse Large ‘a’ wave Double apex Systolic ejection murmur Response of murmur Cardiac Examination: Auscultation Murmurs: Cardiac Examination: Auscultation Severe MR • Pansystolic: Pansystolic: Mitral, Tricuspid Regurgitation, Ventricular septal defect S1 S2 Systole 14 S1 Diastole S2 S1 A 2 P2 S 3 Systole Diastole S1 S2 Cardiac Examination: Auscultation Murmurs: : מראה5 'תמונה מס • MidMid-diastolic+presystolic הדבר שאנו הבולט באי ספיקה קשה של המסתם :צניפי הם-הדו . איושה פן סיסטולית-א . פיצול רחב של הקול השני-ב . קול שלישי-ג . קול רביעי חזק-ד • Mid – Mitral, tricuspid stenosis diastolic flow murmurs S1 S2 Systole S1 S2 Diastole Cardiac Examination: Auscultation Mitral stenosis 1. Opening snap 2. MidMid-diastolic murmrur 3. Presystolic accentuation 4. Loud first heart sound S2 OS S1 S1 Mitral stenosis Ring Cusps Chordae S2 Papillary muscles Systole Diastole Auscultatory Signs A A22P P22 S S11 S S22 S S11 OS OS MDM MDM A A22P P22 S S11 S S22 A A22P P22 S S11 OS OS S S11 S S22 A A22P P22 S S11 S S11 S S22 S S11 A A22P P22 S S11 15 PSM PSM S S22 Mild Stenosis Severe Stenosis Calcific Valve OS OS MDM MDM S S11 Atrial Fibrillation : מראה6 'תמונה מס Mitral stenosis ? • מה אינו נכון הפסקה בין איוושה אמצע- צניפי- הצרות המסתם הדו.א . מראה שההצרות קלה מאד,דיאסטולית ופרי סיסטולית . העדרות של צליל פתיחת המסתם מראה מסתם מסויד.ב המרחק בין הקול השני וצליל פתיחת המסתם מתערך עם.ג .חומרת ההצרות עוצמת הקול השני )חלק הריאתי( מגדיר את החומרה של.ד יתר לחץ דם ריאתי וכן חומרת הצרות המסתם Cardiac Examination: Auscultation Murmurs: • Early diastolic – Aortic insufficiency – mild, severe – Pulmonary insufficiency S2 S1 Systole S1 Cusps Chordae Papillary muscles Cardiac Examination: Auscultation Murmurs: • Early diastolic – Aortic insufficiency – Pulmonary insufficiency S2 S1 Diastole • Early diastolic – Aortic insufficiency – Pulmonary insufficiency S2 S1 16 Diastole S1 S2 Diastole Cardiac Examination: Auscultation Special physiological maneuvers: • Squatting - venous return ↑ , vascular resistance ↑ - LV volume ↑ Murmurs of MVP ↓, HOCM ↓, AS ↑ S2 • Valsalva, Standing The opposite effect • Inspiration Systole S2 Systole Cardiac Examination: Auscultation Murmurs: S1 Ring – increase in right sided flow and event – decrease in left sided flow and events Cardiac Examination: Auscultation Murmurs: • Continuous – Patent ductus arteriosus – Aortopulmonary window – ArterioArterio-venous fistula – Ruptured sinus of Valsalva S1 S2 Systole 17 S1 Diastole S2
