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Examination of the Cardiovascular system Tutors: Students saw a demo of a cardio respiratory examination and covered the principles of systematic examination in the introductory session. They have also already done BP, pulses and respiratory rate Time 5 min 15 min Activity Setting the stage Introductions Motivation (Clinical relevance) –essential skill, CVD is common Explain objectives for session Stimulate prior recall – Introduction – systematic examination and Vital Signs Exercise 1 – Surface anatomy Exercise 2 – Apex beat and listening to normal heart sounds (working in threes using the other cubicle.) 30 min Core learning activity – 4 stage teach as per handout You will need to use one of the men in the group as a model but make sure he gets to practice on one of the others. Stage 1 – Perform examination without talking Stage 2 – run through the examination explaining what you are doing and describe any findings (positive or negative). Stage 3 – ask the students to guide you through the examination. Stage 4 – get the students to do the examination – they can do one bit each to break it up. 35 min Practice with feedback Break into two groups using both cubicles for practice. 5 min Encourage ongoing practice and transfer Encourage on-going practice, Self directed learning JVP and murmurs in preparation for T-year Remind re SDL room/Harvey/discs 1 Examination of the Cardiovascular system Learning outcomes By the end of this session you should be able to: Apply the principles of systematic examination to the cardiovascular system Carry out a competent examination of the cardiovascular system on a colleague Recognise and describe normal heart sounds Dress Code Policy Clinical relevance The cardiovascular (CVS) examination is an essential part of a patient’s assessment. A large number of people suffer from cardiovascular conditions such as heart failure, ischaemic heart disease or arrhythmias. Cardiovascular problems are one of the top causes of death in the UK. Although there are various investigations which allow you to assess the state of the patient’s heart, the CVS exam still provides useful information which helps in diagnosis and both the monitoring of the condition and the effects of therapeutic interventions. Links with other learning In this session we are mainly concentrating on the examination of the heart and general signs of cardiovascular disease. You have already learned how to palpate the radial and carotid pulses, measure the pulse rate and take blood pressure – essential components of the CVS examination. The peripheral vascular examination is also considered part of a full cardiovascular examination. This will be covered in a separate session. Related Basic Science Please prepare for this session by understanding the relevant physiology and learning the relevant anatomy below. Physiology Jugular venous pressure (JVP) As a pump, the heart normally has an inflow pressure and there is an equal “back pressure” of blood in the great veins as they enter the right atrium. The jugular vein therefore acts like a manometer and indicates the filling pressure of the right side of the heart. If the heart fails and is unable to pump effectively, the height of the JVP increases. Conversely the pressure will drop if there is insufficient circulating blood in a patient who is bleeding. In an intensive care situation the pressure can be formally measured by putting a line into the superior vena cava via the internal jugular or subclavian vein, and attaching a manometer. This records the central venous pressure (CVP). 2 Examination of the Cardiovascular system Laminar v turbulent flow, heart sounds. Sounds heard from the vascular system indicate turbulent flow – normal smooth laminar flow is not audible. The normal heart sounds reflect the turbulence created as valve cusps abruptly close. The first sound (S1) comprises closure of the mitral and tricuspid valves. The second sound (S2) comprises closure of the aortic and pulmonary valves. Each of these two normal heart sounds actually consist of two sounds very close together because the two valves do not close simultaneously- the left sided mitral and aortic valves close slightly ahead of their corresponding right sided valves. It is extremely difficult to hear the physiological splitting of the first heart sound. Physiological splitting of the second sound is easier to hear especially during deep inspiration. This is because during inspiration a decrease in thoracic pressure increases venous return to the right side of the heart. The results in the right side taking longer to fill and contract which delays the closure of the pulmonary valve resulting in a wide gap. Because of the nature of the sounds we use the diaphragm of the stethoscope to listen with apart from at the apex when we use the bell. In a normal subject you should be able to hear the first and second heart sounds in all areas. In at least the pulmonary area you should be able to hear that the second sound is “split” and that this splitting varies with inspiration. In many normal young subjects you can hear a soft sound after the second heart sound. This is a physiological third heart sound reflecting rapid ventricular filling during diastole. Sounds from the apical region can be accentuated by rolling the patient partially onto their left side and listening round towards the axilla with the bell of the stethoscope. Aortic sounds can be accentuated by sitting the subject up, leaning them forwards and listening whilst holding the breath in expiration. To avoid being confused by breath sounds you can ask the patient to hold their breath whilst listening in all areas – but remember to hold yours as the same time so that you can tell them to start breathing again in time to stop them getting uncomfortable. Additional and abnormal sounds arise when flow is rapid or when it is constricted. Examples: Rapid flow of blood, through a stenosed valve, for example, will give rise to a murmur and the timing of this will depend on when blood is flowing through it in the cardiac cycle. A fourth heart sound can occur in late diastole just before the first heart sound. It is produced during atrial contraction when a sudden bolus of blood hit a stiff, non-compliant ventricle. It is pathological. 3 Examination of the Cardiovascular system Anatomy It is essential to know the following surface anatomy: Exercise 1 Work through the following landmarks with your tutor using a volunteer. The common carotid artery and pulse This artery runs upwards and backwards through the neck from the sternoclavicular joint to the upper border of the thyroid cartilage where it divides into the external and internal carotid arteries. The pulse can be palpated by pressing in a posterior direction just lateral to the upper border of the thyroid cartilage (“adam’s apple”) medial to the SCM. The internal jugular vein This descends in the neck in the carotid sheath postero-medially to the sternocleidomastoid muscle (SCM). Just above the clavicle it lies between the two heads of the SCM, and unites with the subclavian vein behind the medial end of the clavicle to form the brachiocephalic vein. The sternocleidomastoid muscle This muscle has two heads. Their joint action pulls the mastoid process of the same side down towards the sternum. Turning the head away from the side of the muscle will clearly show the head attaching to the sternum. This is sufficient a manoeuvre in order to look at the JVP. For educational reasons identify the other head by asking your volunteer to tilt the head slightly upwards against resistance (place hand over mandible) and you will see the head which attaches to the clavicle. If done correctly the ear on the same side as the muscle being tested should feel as though it is being pulled down towards the sternum. Manubrio-sternal angle. This is formed by the articulation of the manubrium with the body of the sternum and can be recognised by the presence of a transverse ridge on the anterior aspect of the sternum. The transverse ridge lies at the level of the second costal cartilage, the point from which costal cartilages, ribs and intercostal spaces are counted. Mid clavicular line This runs vertically downwards from the midpoint of the clavicle (in males the line usually falls just medial to the nipple) Anterior axillary line This runs vertically downward from the anterior axillary fold (find the edge of the pectoralis major muscle) Posterior axillary line This runs vertically down from the posterior axillary line (find the edge of the latissimus dorsi muscle) Mid axillary line This runs vertically downwards from a point midway between the anterior and posterior folds. Lung bases The lungs only fill about half the space under the ribcage and extend down to the 89th rib posteriorly. A useful landmark is the tip of the scapula which approximates to level T6 4 Examination of the Cardiovascular system Exercise 2 Palpate the apex beat, listen to and recognise normal heart sounds in a colleague. Gross anatomy of the heart The sternocostal surface of the heart is formed mainly by the right atrium and right ventricle. The right border is formed mainly by the right atrium The left border is formed by the left ventricle and part of the left auricle. The apex of the heart, formed by the left ventricle, is directed downward, forward, and to the left. As the heart beats it rotates slightly and in doing so the apex of the left ventricle can be felt through the chest wall. The point furthest inferiorly and laterally where this beat can be felt is the position of the apex beat. In a normal person the apex beat is usually felt in the left 5th ICS, mid-clavicular line. Auscultation areas It is important to remember that when auscultating the heart we do not listen over the anatomical position of the valves but in the following areas (which lie “downstream” in the direction of flow through the valve concerned): Mitral area – apex Tricuspid area – lower left sternal edge Pulmonary area – 2nd left intercostal space Aortic area – 2nd right intercostal space Work in threes using both cubicles Identify the following and listen in all the areas. Use the diaphragm of the stethoscope apart from at the apex when we use the bell and keep one finger on the carotid pulse for orientation. Apex beat – Feel initially with the flat of the hand and then localise to the point furthest down and laterally at which the beat can be felt with one finger. Describe the position carefully in relation to the intercostal spaces and anatomical lines. Tutors - Stress that they must find the apex beat by palpation and then work out where it is (rather than finding the 5th LICS and looking there for the apex beat) Mitral area Listen where you have identified the apex beat Tricuspid area Listen at the lower left sternal edge Pulmonary area Listen in the 2nd left ICS, ask your colleague to take deep breaths and see if you can hear the physiological splitting vary with breathing (wider gap in inspiration). Aortic area Listen in the 2nd right ICS Then roll your colleague onto their left side, listen again at the apex with the bell and towards the axilla to accentuate the mitral sounds. You may also be able to hear a physiological third sound in this position. Then sit your colleague up leaning forwards and ask them to breathe out and hold their breath (this position will accentuate aortic sounds) - listen using the diaphragm again in the aortic area. 5 Examination of the Cardiovascular system Examination of the Cardiovascular System General notes The order in which an examination is carried out is designed to minimise discomfort and inconvenience to the patient You should communicate with the patient as you go along Describe what you find as you go along - it will help you to remember You should describe what you see or cannot see rather than what you are “looking for”. In clinical practice an examination is carried out after you have taken the history you may have a possible diagnosis in mind and will be looking for specific signs. During your clinical attachments you will learn which signs go with which diseases Concentrate now on becoming really familiar with the normal CVS exam. Introduction and Preparation Introduce yourself to the patient and check the patient’s name Explain the procedure. Use words that patients will understand and explain that you need to examine their hands, face and neck as well as their heart. They will need to expose their chest but this can be kept covered until the chest is examined. Gain consent. Clean your hands Position the patient on the bed inclined at 45 degrees. Ask the patient if they have any pain, and if so where? Examination General inspection Do they look well? Are they sweating or in pain? Is their colour normal? Are they breathless? Look around the bed. Any equipment eg ECG monitor, medications eg oxygen, GTN spray etc? Hands and nails - remember that the hands may show signs of disease in any body system. Is there a tremor? Is the colour normal or abnormal: unusually pale unusually red (vasodilatation from carbon dioxide retention) blue ( cyanosis). Are there tar stains on the fingers? Are there any Osler’s nodes or Janeway lesions (infective endocarditis) Look at the nails – any clubbing or splinter haemorrhages? Capillary return rate - squeeze the finger nail firmly for a few seconds and then release it, how quickly does it go pink again? Colour normally returns within 2-3 sec. Radial pulses and respiratory rate Take hold of both wrists and feel both pulses. Are they the same? If so keep hold of the right wrist and count the pulse (15 sec if it is regular or 30 sec if it is irregular). You need to determine the rate, rhythm and volume of the pulse. Count the respiratory rate for 30 sec and determine the rate. 6 Examination of the Cardiovascular system Feel for a collapsing pulse – ask the patient if they have any shoulder pain – if not then support and lift the arm above the level of the heart whilst feeling across the radial pulse with your fingers. Blood pressure. Tutors –there is no need to do this today but emphasise that this is when you would normally do it. Face Is there malar flush? Look for small fatty deposits around the eyes (xanthalasma) or a white ring around the iris of the eye (corneal arcus) which may be seen with lipid disorders. Look in the lower fornix of the eye – the easiest place to see anaemia (warn the patient that you are going to do this). Look in the mouth for central cyanosis. The best place to look is underneath the tongue. Ask your patient to touch the roof of their mouth with their tongue to that you can see this. Check dental hygiene using a pen torch. Neck JVP When examining from the RHS, ask the person to turn their head to the left. It helps to get down so that you are “gazing” across the SCM rather than looking down at the neck. Shining a light across the SCM may also help. Do not confuse the internal jugular vein with the external jugular vein. The latter is relatively superficial and tends to lie more laterally. In order to measure the approximate pressure within the jugular vein draw an imaginary horizontal line across the top of the pulsation. Measure the vertical distance from the manubriuo-sternal angle to this line. The JVP is recorded as this height. In a normal person it is usually 2-3cm. o If a person has a low JVP you may need to lie them flatter in order to see the top of the “column” because at 45 degrees the top of the column may be hidden behind the sternum. o Conversely, if a patient has a markedly raised JVP, you may need to increase the angle in order to see the actual height because at 45 degrees the top of the “column” may be difficult to see behind the ear. Describe the wave- form – see self directed learning. Carotid pulses. Palpate one at a time. Determine the volume and character. Precordium Close inspection 7 Examination of the Cardiovascular system Is the chest a normal shape? Are there scars eg sterniotomy, pacemaker? Is there a visible pacemaker under the skin? Can you see the apex beat? Is it normal? Listen for audible mechanical sounds (artificial valve) Palpation Apex beat. Feel initially with the flat of the hand and then localise to the point furthest down and laterally at which the beat can be felt with one finger. Describe the character and position and of the apex beat in relation to the intercostal spaces and the clavicle. It is important to be able to locate this position accurately because it will tell you whether the apex is displaced, for example due to cardiac enlargement in heart failure. (In a normal person the apex beat is normally felt in the left 5th ICS, mid-clavicular line). Heaves and thrills. Feel to the left and then the right of the sternum with the flat of the hand. Abnormally forceful heart action will be felt as a “heave” and loud murmurs will be felt as a “thrill” – a vibration (like a cat purring). You would not expect to feel anything in a normal subject. Percussion In theory you can percuss the heart to determine its size but this is not useful or reliable and is no longer done. Auscultation Listen to the four main valve areas keeping one finger on the carotid pulse for orientation. Use the bell for the mitral area and diaphragm for the other areas. Mitral area – apex Tricuspid area – lower left sternal edge Pulmonary area – 2nd left intercostal space Aortic area – 2nd right intercostal space At each point listen specifically to the first heart sound, then to the second. Are there any added sounds or murmurs? Determine the timing of any murmur in relation to the cardiac cycle. Then roll the patient onto their left to accentuate mitral valve sounds and murmurs. Listen again (bell) at the apex and round towards the axilla Then sit the patient up leaning forwards and ask them to breathe out and hold their breath to accentuate aortic valve sounds and murmurs. Listen again (diaphragm) at the second right intercostal space and to the third or fourth intercostal space at the left sternal edge. (Don’t let the patient hold their breath for too long!) Then listen over the anterior part of the SCM above the medial end of the clavicle for aortic bruits / radiation of murmurs. Listen on both sides. Back of chest and legs (the patient should now be sitting up following auscultation) Inspect for scars Auscultate for fluid in the base of the lungs. Mild pulmonary oedema will give rise to fine crackles/crepitations. Palpate for Oedema. Press firmly with a finger or thumb for a few seconds over the sacrum and ankle. There should be no residual indentation when you remove your finger. Full peripheral vascular exam This is an essential part of any cardiovascular examination. Tutors –there is no need to do this today but emphasise that this is when you would normally do it. Closure 8