SY 2011-2012

Subject:Physical Diagnosis Topic: Skills in CVS1 Lecturer:Dr. Tirona Date of Lecture:September 7, 2011 Transcriptionist: Original Sin Editor:deray lover Pages: 7

Physical Examination • Inspection ○ Anatomical landmarks in cardiovascular examination ○ Body habitus ○ Stature ○ Skin exam ○ Cachectic? ○ Obese? ○ Gait abnormalities • Palpation • Percussion • Arterial pulses • Jugular venous pressure Congenital problems associated with CV disorders MarfanSyndrome • Aortic aneurysm • Aortic regurgitation: classic for Marfan’s • Mitral regurgitation: can coexist with AR • Pt. tends to be male, tall, with significant aortic regurgitation

Part of metabolic syndrome, which also has hypertension, hypercholesterolemia, diabetes. Can lead to strokes and heart attacks. Cardiac cachexia, seen in: ○ CHF, especially those with chronic low output states ○

Respiration • CHF ○ Orthopnea: patient needs to be elevated with pillows while sleeping ○ Cheyne – Stokes respiration with sleep apnea • COPD ○ The “blue bloater” of chronic bronchitis and “pink puffer” with emphysema • Cyanosis ○ Peripheral detected in exposed skin (lips, nose, earlobes, and extremities) ○ Central cyanosis seen in the tongue, uvula, and buccal mucus membrane  Intrapulmonary or intracardiac right to left shunting Edema • Generalized edema ○ Nephrotic syndrome and sepsis ○ Heart problem or vascular disease • Dependent edema ○ Right heart failure • Ascites in the absence of edema of the lower extremities ○ Liver disease, ie, cirrhosis or hepatitis Skin • CHF ○ Slate or bronze pigmentation of the skin (hemochromatosis) ○ Mild jaundice • Hypercholesterolemia ○ Arcus: white rim around iris ○ Xanthelasma • Acute rheumatic fever ○ Erythema marginatum (pink rings on the trunk and inner surfaces of the arms and legs)

Klinefelter Syndrome • Tall stature, long extremities, eunuchoid • Congenital heart diseases ○ Ventricular septal defect ○ Patent ductusarteriosus ○ Tetralogy of Fallot Gait Abnormalities Seen in: • Cardioembolic strokes • Hypertensive CV disease • Shy – Drager syndrome ○ Degenerative disease of the autonomic nervous system ○ Parkinsonian gait Body Habitus • Obesity

○ Rheumatic nodules Bacterial endocarditis ○ Conjunctival hemorrhages, purpuric skin rash, petechial lesions, and splinter hemorrhages ○ Osler nodes (palms, soles of the feet and pads of the fingers and toes, tender and result from microemboli ○ Janeway lesions (non – tender, raised hemorrhagic nodules on the palms of the hands and soles of the feet.

Funduscopy • Hypertensive retinopathy ○ Grade I  Minimal irregularity of the arterial lumen and narrowing with increased light reflex ○ Grade II  AV nicking with more marked narrowing and irregularity of the arterioles and distention of veins ○ Grade III  Flame shaped hemorrhages and fluffly cotton wool exudates ○ Grade IV  Papilledema with another changes from grades I through III Below: Grade II

Inspection (see diagram on last page) • Anatomical landmarks ○ Midsternal line ○ Parasternal borders ○ Midclavicular line ○ Anterior axillary line ○ Midaxillary line ○ Posterior axillary line ○ Suprasternal notch: visible aortic pulsations and aortic aneurysms may be visible here ○ Subxiphoid area: enlargement of left ventricle can be appreciated upon palpation ○ Aortic area: 2nd ICS, midclavicular line ○ Pulmonic area ○ Mitral area: 5th ICS, midclavicular line ○ Tricuspid area: 3rd and 4th ICS left parasternal border ○ Point of Maximal Impulse (PMI)  5th ICS left midclavicular line  In 50% of individuals, it may not be visible. In which case, palpate for apex beat (next) ○ Apex beat  Determined by palpation  5th ICS LMCL ○ Parasternal borders ○ Midclavicular line Palpation • Pulsations of the heart and great arteries are transmitted to the chest wall • Precordial movements should be timed with simultaneously palpated carotid pulse or auscultated heart sounds • Examination carried out with the chest completely exposed and elevated to 30 degrees Examination of precordial pulsations • Best performed in patients in supine position with head and trunk elevated 45 degrees • Examiner positioned in the right side of the supine patient • Rotating the patient in the left lateral decubitus position with the left arm elevated over the head causes the heart to move laterally

Below: Grade III

Below: Grade IV

and increases the palpability of both normal and pathological thrusts of the left ventricle

Thrills ○ The flat of the hand or the fingertips usually best appreciate thrills which are vibratory sensations that are palpable manifestations of loud harsh murmurs having low to medium frequency components seen in stenotic valves.

Above: Structures that can be palpated • Short arrow: aortic arc • Arched arrow: pulmonary artery • Straight and long arrow: left atrial appendage • Open arrows: area of left ventricle Palpation • The left ventricular impulse ○ Apex beat normally produced by left ventricular contraction and is the lowest and most lateral point on the chest at which the cardiac impulse is appreciated ○ 5th ICS, LMCL (left midclavicular line) ○ May not be palpable in the supine position in as many as half of all normal subjects, apex beat is palpable in the left lateral decubitus position. Abnormal Precordial Pulsations • Pronounced epigastric or subxiphoid pulsation ○ Right ventricular failure ○ Abdominal aortic aneurysm • A visible pulsation over the right 2nd ICS or right sternoclavicular joint ○ Aneursym of the ascending aorta • Suprasternal pulsation ○ Aneurysm of the arch of the aorta • A visible pulsation over the left 2nd or 3rd ICS ○ Dilated pulmonary artery Palpation • Right ventricle ○ Subxiphoid area • Pulmonary artery ○ 2nd ICS, LMCL (left midclavicular line)

Percussion • Palpation is far more helpful than is percussion in determining cardiac size • Useful in the absence of apical systolic beat ○ Pericardial effusion ○ Dilated cardiomyopathy ○ Heart failure ○ Marked displacement of the hypokinetic apical beat • Percussion carried out from mid to lateral or vice versa within the intercostals spaces • Normal cardiac area of dullness is within 10 cm from midsternal line to the lowest most lateral border of the heart Examination of the arterial pulse • Arterial pulses ○ Carotid: do one at a time please lest the patient should faint or stroke ○ Brachial, radial, and ulnar ○ Femoral, popliteal, posterialtibial, and dorsalispedis (absent 40% of the time) • Assess ○ Rigidity and elasticity of the arteries ○ Done by rolling the vessel under underlying tissue  The more rigid the artery, the less compressible Arterial pulses rate and rhythm • Arrhythmias ○ Sinus bradycardia, junctional rhythm, complete AV block ○ Ventricular premature beats  Bigeminies ○ Atrial fibrillation  Irregularly irregular pulses Arterial pulses: variations in the character of the pulse • Pulsusalterans ○ Alternating strong and weak pulses in the presence of a regular pulse ○ Commonly caused by left ventricular systolic failure ○ Other causes:  Aortic stenosis

Hypertrophic obstructive cardiomyopathy  Ischemia Pulsusparadoxus ○ Substantial reduction in the amplitude of the pulse during inspiration ○ Inspiratory decrease in arterial pressure exceeding 12 to 15 mmHg ○ Causes:  Cardiac tamponade  COPD  Rarely in PE, pregnancy, marked obesity, partial obstruction of the SVC. 

Above: A: Normal. Brisk and rapid upstroke that occurs at systole.Dicrotic notch represents aortic valve closure. B: Aortic stenosis. Because the aortic valve does not open up all the way, there is a delay in the upstroke and the amplitude of the stroke is diminished. They pulse is delayed and weak, hence, pulsustardus. C: Aortic regurgitation: pulsusbisferiens. There are 2 systolic peaks. D: Hypertrophic cardiomyopathy: Also exhibiting pulsusbisferiens during systole, but lower in amplitude than with AR. E: Chronic heart failure: 2 peaks, one in systole and one in diastole.

Above: • Pulsusalternans: Alternating strong and weak pulses. • Pulsusparadoxus: substantial reduction in the amplitude of the pulse during inspiration. It is elicited using a sphygmomanometer. Take not of the 1stKorotkoff sound. There shouldn’t be an inspiratory decrease of >10 mmHg. If there is >10mmHg decrease during normal respiration that is a (+) pulsusparadoxus. Seen in cardiac tamponade, severe COPD, sometimes pulmonary embolism and pregnancy or partial obstruction of SVC.

Arterial Pulses Changes in Contour • Pulsustardus ○ Delayed upstroke in the ascending limb of the carotid pulse ○ Aortic stenosis

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Pulsusparvus ○ Aortic stenosis ○ Small amplitude pulse Pulsusbisferiens ○ Presence of 2 positive impulses near the peak of the arterial pulse  Aortic regurgitation

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Systolic murmur heard over the femoral artery when the artery is compressed proximally; a diastolic murmur heard when the artery is compressed distally Quincke sign ○ Phasic blanching of the nailbeds Hill sign ○ Systolic pressure in the lower extremity exceed that in the arms by more than 20 mm Hg Becker sign ○ Visible pulsations of the retinal arterioles Mueller sign ○ Pulsating uvula ○

Altered Characteristic of the Arterial Pulse and their Clinical Significance • Pulsusalternans ○ Suspect acute or chronic reduction in left ventricular systolic function • Pulsustardus ○ Suspect fixed left ventricular outflow tract obstruction such as valvular aortic stenosis • Pulsusbisferiens ○ Suspect aortic regurgitation, large PDA, HOCM, complete heart block, hyperkinetic heart syndrome • Pulsusparadoxus ○ Suspect tamponade, emphysema • Dicrotic pulse ○ Suspect low output syndrome with increased systemic vascular resistance ○ Commonly seen in patients with severe heart failure. Sign characteristic of severe aortic regurgitation • Corrigan or Water – hammer pulse ○ Abrupt upstroke followed by rapid collapse • Traube sign ○ Pistol shot sounds heard over the femoral artery when the stethoscope is placed on it • Duroziez sign

Examination of the Jugular venous pulse and pressure • Essential to assess hemodynamic changes in the right side of the heart • Done with the patient in a 45 degree semirecumbent position • IJV pulse located medial to the mandibular portion of the sternocleidomastoid muscle • IJV is valveless so is more representative of right atrial pressure than EJV, which has a valve. Difference between venous and carotid artery pulsation • Venous pulse ○ Sharp inward movement ○ Double undulation character during sinus rhythm ○ Gentle compression obliterates the venous pulse ○ Venous pulse amplitude decreases on inspiration • Carotid arterial pulse ○ Sharp outward movement ○ Arterial pulse remain visible on gentle compression ○ Arterial pulse amplitude does not change on respiration JVP • Normal right atrial pressure is 9 cm of water

Jugular venous pulse wave recordings Take note of the uppermost visible pulsation of the jugular vein and the landmark used is the sternal angle of Louis. The measurement that is obtained will have 5 cm added to it. (eg, measurement obtained is 3 cm3cm + 5cm = 8cm). • Positive waves ○ A wave

Caused by transmitted right atrial pressure to the jugular veins during right atrial systole  Cannon waves seen in complete heart block ○ C wave  Recognized with the onset of right ventricular systole and occurs from bulging of the tricuspid valve into the right atrium ○ V wave  Caused by the rise of in right atrial and jugular venous pressure due to continued inflow of blood to the venous system during right ventricular systole when the tricuspid valve is still closed  Tricuspid regurgitation Negative waves ○ X descent  Results from right atrial relaxation  Prominent in patients with cardiac tamponade ○ Y descent  Caused by opening of the tricuspid valve and the rapid flow of blood from the right atrium to the right ventricle  Rapid and deep in patients with constrictive pericarditis ○ Kussmaul sign  Increase in JVP during inspiration  Seen in:  Constrictive pericarditis  Right ventricular infarction  Severe right heart failure 

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with the palm of the hand to the RUQ of the abdomen for at least 10 seconds Normal patients exhibit slight increase in JVP with rapid return to baseline in less than 10 seconds The abnormal hepatojugular reflux is defined when there is a rapid increase in JVP that remains elevated by 4 cm or more until abdominal compression is released.

Hepatojugular Reflux Test • With the patient breathing normally in the semirecumbent position, firm pressure is applied

Abnormalities of the venous pressure and pulse and their clinical significance • Positive hepatojugular reflex ○ Suspect CHF, particularly left ventricular dysfunction • Elevated systemic venous pressure without obvious X or Y descent and quiet precordium and pulsusparadoxus ○ Suspect cardiac tamponade • Elevated systemic venous pressure with sharp Y descent, Kussmaul sign, and quiet precordium ○ Suspect constrictive pericarditis because right ventricle is so stiff so it gives rise to a sharp Y descent. • A prominent A wave with or without elevation of mean systemic venous pressure ○ Exclude tricuspid stenosis, right ventricular hypertrophy due to pulmonary stenosis, and pulmonary hypertension • A prominent V wave with a sharp Y descent ○ Suspect tricuspid regurgitation ○ Sometimes in severe tricuspid regurgitation there will be merging of the C and V waves to create a CV wave.

Above: Landmarks __________________________________________________________________________________ End of transcription

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