ASSESSMENT CARDIOVASCULAR

SYSTEM
DR. VAISHNAVI YADAV,ASSISSTANT PROFESSOR ,RNPC,DMIMS DU
 SPECIFIC LEARNING OBJECTIVE
• AT the end of the lecture student should be
able to understand and
• Explain inspection in CVS system
• Explain heart sounds
• Enlist the investigations
 CARDIOVASCULAR
EXAMINATION(PERIPHERAL)
• BP
• Always measure in both arms sitting
• Then take BP standing
• ORTHOSTATIC HTN-Have the patient lie down for 5
minutes and measure BP and pulse
• Have patient stand and repeat reading immediately.
Allow 90 seconds for maximum orthostatic changes
• A drop in systolic BP of 20 mmHg or more when
standing is orthostatic
• There is usually an increase in HR
• Supravalvular Aortic Stenosis
• If there is hypertension in the right arm, take BP in the
left arm as well
• supravalvular aortic stenosis, there will be hypertension
in the right arm and hypotension in the left arm
• Coarctation of the Aorta-If the patient is hypertensive in
both arms, have patient lie on abdomen, put cuff around
lower thigh, listen to BP at the popliteal artery
• A leg blood pressure lower than the arm BP suggests
coarctation
• Normally BP higher in leg arteries than arm
• ARTERIAL PULSE
• RATE, RHYTHM,PULSE DEFICIT,PERIPHERAL
PULSATIONS.
• Grasp both radial arteries, count for 30 seconds,
and multiply by 2
• Determine rhythm. The slower the rate, the
longer you should palpate.
• If the rhythm is irregular, is there a pattern to
the irregularity?
 CARDIOVASCULAR EXAMINATION
INSPECTION
A. PRECORDIUM
• Bulging( enlarged heart, pericardial effusion,
mediastinal tumour, pleural effusion)
• Flattened( fibrosis of lung, old pleural and
pericardial effusion, congenital deformity)
B. APEX IMPULSE
C. PULSATIONS
• Left and right parasternal
• Epigastric
• Suprasternal
• Neck
D. DILATED VEIN OVER CHEST WALL
 E. SCAR
Horizontal scar-closed mitral commissurotomy, repair
of coarctation of aorta or correction of PDA)
Vertical midline scar- coronary artery bypass,open
mitral commisurotomy or valve replacement)
• LENGTH
• signs of INflammation
F. DRAINAGE- pleural and mediastinal drain post
cardiac surgery.
G.POSTURE
 PALPATION
A. APEX BEAT
• Heaving apex beat left ventricular hypertrophy,
impulse sustain throughout systole or
exaggerated in amplitude.
• Well sustained heave systolic overload e.g aortic
stenosis.
• Ill sustained heave- diastolic overload eg aortic
and mitral regurgitation
• Absent –(dextrocardia , Left pleural
effusion,emphysema,thick chest wall, obesity)
 PERCUSSION
HEART BORDER
B. PARASTERNAL HEAVE
Systolic impulse in the left parasternal region-right
ventricular enlargement is parasternal heave.
Ulnar border of the hand on left parasternal
area,with patient in supine.
C. THRILLS
• Thrills are superficial vibratory sensations felt on
the skin overlying an area of turbulence
• The presence of a thrill indicates that you will
hear a loud murmur (grade 4-6)
 AUSCULTATION
• Close your eyes when listening
• Never listen through any kind of clothing
• Listen at all 4 cardiac areas:
• Aortic --2nd ICS, RS
• Pulmonic---2nd ICS, LS
• Mitral--cardiac apex, 5th ICS, MCL
• Tricuspid---left lower sternal border
• Normally only the closing of valves can be heard.
• Closure of the tricuspid and mitral valves (AV valves) produce the 1st
heart sound.
• Closure of the aortic and pulmonic valves produce the 2nd heart sound.
• Opening of valves can only be heard if they are very damaged (opening
“snap” “click”)
• To interpret heart sounds correctly, you must
clearly identify what sound is S1. To do this,
palpate the carotid artery while you listen.
• The sound that you hear when you feel the
carotid pulse is S1.
• S2 will follow the pulse
• Third Heart Sound-When AV valves open, the
period of rapid filling of ventricles occurs. 80%
of ventricular filling occurs now. At the END of
rapid filling, a 3rd heart sound may be heard
• S-3 is normal in children and young adults, but
not in people over age 30. It means there is
volume overload of ventricle
• Fourth sound -At the end of diastole, atrial
contraction contributes to the additional 20%
filling of the ventricle
• If the left ventricle is stiff and non-compliant,
you will hear an S4.
• Gallop Rhythms
• The presence of an S3 and an S4 creates a
cadence resembling the gallop of a horse.
• Hence the term “gallop rhythm”
MURMURS
• They are produced when there is turbulent blood flow within
the heart
• Turbulence may be due to a narrowed opening of a valve
(stenosis) or a valve that does not close completely, allowing
blood to slosh backwards (regurgitation or insufficiency)
• When in the cardiac cycle do you hear the murmur? Systole?
Diastole? Pan-systolic?
• Location (in which of the 4 cardiac areas do you hear it the
loudest?)
• Radiation (does the sound travel throughout the chest?)
• Duration of the murmur
• SYSTOLIC MURMUR
• These are ejection murmurs
• May be caused by turbulence across the aortic
or pulmonic valves if they are stenosed
• May be caused by turbulence across the mitral
or tricuspid valves if they are incompetent
(regurgitant)
• The murmur falls between S1 and S2
• Sounds like, LUB-shhh-dub
Diastolic Murmurs
• Mitral and tricuspid stenosis can cause a
diastolic murmur
• Aortic or pulmonic regurgitation can cause a
diastolic murmur
• Sounds like this: Lub-dub-shhh
• Investigations- ECG , 2D echo, CAG,
• Posture
• MMT
• ICF
• Quality of life- WHO QOL
• FUNCTIONAL CAPACITY-Six minute walk test
 SUMMARY
• Explain inspection in CVS system
• Explain heart sounds
• Enlist the investigations
 REFERENCE
• PRACTICAL MEDICINE :PJ MEHTAAPI
• TEXTBOOK OF MEDICINE
THANK YOU