Cvs

I---- Wash your hands Introduce yourself Consent of the patient Expose the area Position the patient
(45deg)
 
General inspection:(at the foot of the bed)
1)Stand far While checking if patient looks unwell. Check if they are holding chest/pain. Check if
short of breath. (gives an idea of how fast i want to act)

2)look at surrounding. If oxygen/medications. GTN tablets- glycerintrinitrates.(maybe in the form of

spray. Generally taken during history of angina.---- if holding on to chest most prob has progressed
to heart attack.
 
3)Go to right side of the patient. And 9 signs of cardiac.----->

Peripherally.Checking the wrist:

with own 234 digit. Radial art check.

 
1)Rate--- >100 tachy; <60 brachy
 
2)rhythm (regular or irregular), regularly irregular--- extra beats ectopic beat. Some beats are
regular.
irregularly irregular--- totally gone. When atrial fibrulations twitches (common cause)
 
3)character(how the pulse rise and how it falls. eg: collapsing pulse (ask patient if shoulder pain
andsudden rise of upp limb. Will feel sudden collapse of pulse)--- cause patent ductus arteriosis.---
blood from aorta to pulmonary trunk (aortic regurgeregurge)---

check for- slow rising pulse[delayed upstroke] occurs in aortic valve stenosis because the aortic valve
is narrowed when the valve is in open posn and as a result the blood leves the ventricle slower and
the pulse rises slowly---tardus(latin)

aortic stenosis also has a small volume(amplitude) or weak pulse.--- weak means parvus
as such aortic stenosis pulse is called pulsus parvus et tardus
 
4)Volume (best assessed when feeling carotids)-decreased stroke volume--aotirc valve
stenosis/severe blood loss, vomiting severe diahorrea/ or severe tachycardia may cause low volume.
 
5)check for radio-radial delay. Wont know which one is bad not which one.
to check which one? Check the radial and carotid. For synchrony.

6)radio femoral delay(to be done when lower examination in the end.) (because have to do it once.)
coarctation of aorta (important cause of high bp of upper limb. In comparison to lower.

7)move to the brachial artery. Just medial to biceps tendon. Flex and then extend to feel pulse. Feel
and compare. And then take bp. On both sides. If major difference---aortic dissection (mostly caused
due to high bp or connective tissue problems.). Blood pressure when significantly difference in both
arms.

8)check the bp of the patient lying and standing. After resting for about 10-15 minutes. Check it after
your standing for about 2 minutes. Because you dont want the bp when adapting. You want it when
adapted. (especially if someone has dizziness, vomiting diahorea or blood loss)---mostly due to fluid
loss.
need to check for diff of more than 20 systolic.-----postural hypertension

Centrally.
Face
1) eyes.--- eyelids-xanthalasma--- cholesterol pockets/Yellowish plaques. Verify with blood tests.
 
checkedeal arcus senilis--edge of the cornea. Normal in old people. In younger indicative of
hypercholestrol

3)inside of lower eyelid (ask permission) ask patient to look up and then gently pull down lower
eyelid.
check if pale (anemia) check if dry/moist (dehydration)

4)cheeks--- malar flush (mitral valve stenosis).

mouth--- (gum disease(bact infection can go to bad valve and infective endocarditis)--normally
infective endocarditis how? Childhood valve damage say rheumatic fever--- then turbulent blood
flow

1)tongue--- pink/pale/dry
2)central cyanosis: check tongue--- causes different--- might indicate respiratory blockage. (much
more serious than peripheral)---- hypoxic hypoxia

neck---
carotid pulse and internal jug vein pulse---(as empties in r.atria, for high right atrial pressure which
in turn tells us of r.ventricular function---- indicates the RV failure)
normally jvp non palpable.
[height of column of blood in jvp tells us the right atrial pressure. Normally jvp is felt less than 4cm of
sternal angle. Vert height. look between two heads of the SCM, if more than 4cm then high and
near the carotid.]
please check vert height!!!patient at 45 deg.
jvp and carotid palpating distinction
a).---(change posn.) the jvp changes posn while the carotid remains.--- sitting up jvp falls)[45---90]
b)deep breath--- the jvp comes down. Because chest pressure down.
c)if press right below coastal margin (liver). And inc the inferior vena cava pressure. Transitially the
jvp will rise as traffic into the RA will inc.----hepatojugular reflux
 
 
 
Chest

1)inspection--- expose area. Ask person to raise up arms

look for surgical scars.
a)big midline scar- valve replacement or coronary art bypass graft (more common).
b)sides-- valve replacements
look for deformities.---might push heart out of area and loss of func.
look for visible pulsation--- apex beat(contraction and rotation) can see in some people. Thinner
look for any pace makers--- under clavicle bulge. (either side)

2)palpation
a)apex beat---if person has a big heart then apex not where it should be. Inferiolaterally felt more.
normal apex beat- mid clavicular line, 2nd rib to start counting sternal angle. Below is 2nd
intercoastal. And the apex beat is in 5th intercoastal space. To check how big start checking from
down. (tells you outer extent.) use palm
exception--- if not big. Then some mass is pushing the heart over.

b)heaves--- lift of the chest wall. Not a beat. actual lift.--- indication of ventricular hypertrophy. To
check use heel. (to appreciate themovement)
check the apex.-- for left ventricular hypertrophy. For right ventricular hypertrophy then check on
the left side of the parasternum.(right next to)
[common mistake hypertrophy doesnt mean heart is big. The walls hypertrose(?) inwards.)

Lc)thrills---palpable vibrations due to turbulent blood flow.---- indication of significantly bad valve. Or
septal defects.
use flat of hand over 4 valve areas.

3)(percussion) not really done here. But done with other systems.

4)ascultation--- two rounds

A)1st round put sth over 4 valve areas.--- lying in the bed.
a)listening for--- normal heart sounds s1 closure of mitral/ tricuspid, s2closure of aortic and
pulmonary,
 
b)added sounds---
s3 rapid filling(mechanism) of ventricle during diastole (normal in young under 40. abnormal in over
40)main causes of s3 leftventricular failure or mitral regurge.
[whathappens (filling of ventricle when the i)mitral valve opens(passive) and ii)when the atria
contracts for little extra blood into ventricle(active) causing the ventricle to expand)]
in lv failure- since la pressure inc then rapid filling into ventricle.
in mitral regurge--- valve not closing properly. during lv contraction some blood move into the la to
inc pressure so when valve opens again then raid filling.
in young people- the circulation is active. So La has good pressure.

s4---always abnormal (pathological)

mechanism- later in diastole- atrial contraction against a stiff ventricle.(common cause
hypertrophied ventricle)--- the sound of blood hitting the walls during the atrial contraction. if atrial
fibrulations in person then no s4.
cause--- systemic hyper tension, narrowing of aortic valve (av stenosis)
 
c) [ murmurs(sounds created by turbulent flow through the heart--- generally heard over bad valves
or septal defects)]

d)pericardial friction rub

cause--- pericarditis--- inflammation swelling.
mech---visceral and parietal layers are coming in contact with eachother
 
B)2nd round--- place the sth
a)under the left axilla--- listening for radiation of mitral regurge murmur. Because the LA is the most
posterior chamber so can hear near the axilla. (USED AS CONFIRMATION)
b)over the mitral area (after asking the patient to move on the left side)looking for murmur for
mitral stenosis)
c)3rd intercoastal space just left of sternum (sit up and learn forward gravity helps)--- murmur for
aortic regurge better heard
d)over both the carotid arteries--- if heard aortic stenosis murmur then listening for radiation of
aortic stenosis murmur.
if no aortic art stenosis murmur then just carotid art bruits.

BACK

1)bottom of the lungs both sides--- pulmonary edema crackles/ trepitations--- left ventricular failure.
The person need to take deep breaths.
2) press over persons sacrum and check if remains indented after release. Pitting sacral edema.---
sign of right sided heart failure.

 
ABDOMEN--- when doing GI will look again. Roughly.

look for signs of rs heart failure

when RA press up. --- systemic pressure up causing.
liver congested. Swelling. hepatomegaly
ascites- fluid moving into peritoneal scape.
abdominal- aortic aneurysm if more than 3cm diameter.(palpation)
sth:
a) just above the umbilicus--- bruit of abdominal aortic aneurysm (most likely because aorta divides
just above the umbilicus)
b)3cm superior and lateral to umbilicus (listening to both renal art)--- renal artery bruits/stenosis
(will hear swishing sound) [cause of high pressure]

LOWER LIMBS
 
1)Vessels
a)Arterial---
i)femoral art (palpate both) in the inguinal ligament halfway bw asis and pubic symphysis. (below
groin crease) compare both and make sure equal
now do radio femoral delay
sth: over both femoral art for bruits

ii)dorsalis pedus--Big toe. Extend. Long tendon. And just lateral to the tendon is the pulsation.
Compare both feet.
iii)posterior tibial- medial. 1cm behind the medial ankle.
 
b)Venous
i))superficial---
varicose--- valves not working well. And pooling of blood.
Ii)) deep vein thrombosis---
signs--- unilateral swelling, red, warm, tender. (signs may show or not)
 
c)Temperature--- from proximal to distal. both at same time.
venous obstruction one side warmer. Art obs one side colder.

d)Right sided Hear Failure--- bilateral swelling and pitting.