The Cardiovascular Exam Sources: UST-FMS Med1 Lecture (October 8, 2014), Mosby s, KaiMM notes, Netter s Anatomy, Berne and Levy Physiology

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1 MED 1: Cardivascular Exam Bambam2017 The Cardivascular Exam Surces: UST-FMS Med1 Lecture (Octber 8, 2014), Msby s, KaiMM ntes, Netter s Anatmy, Berne and Levy Physilgy MOSBY S NOTES Heart: ANATOMY AND PHYSIOLOGY Cne-shaped 12 cm lng, 8 cm wide, 6 cm AP diameter Brader upper prtin: BASE Narrwer lwer tip: APEX Area verlying the heart: PRECORDIUM Lies in the mediastinum, t the left f midline, just abve the diaphragm, and is cradled between the medial and lwer brders f the lungs Psitined behind the sternum and the cntiguus parts f the 3rd t 6th cstal cartilages In a tall persn: heart tends t hang vertically and psitined mre centrally In a stcky r shrt persn: heart tends t be mre left and hrizntally Dextrcardia: heart n the right Situs Inversus: heart and stmach n the right, liver n the left Structure Fur chambers: tw atria and tw ventricles Pericardium: tugh, duble-walled, fibrus sac encasing the heart; has 2 layers with fluid inside prviding fr easy, lw frictin mvement Epicardium thin utermst muscle layer Mycardium thick muscular layer Endcardium innermst layer, lines the chambers and valves Cardiac Septum divides the heart int left and right Atrium small, thin-walled Ventricle large, thick-walled Primary muscle mass f the heart: ventricles Surface Anatmy Anterir: RV Left: LV Right: RA Psterir: LA Valves AV Valves: Mitral and Tricuspid Mitral (left): 2 cusps Tricuspid (right): 3 cusps Semilunar Valves: Artic and Pulmnary (bth have 3 cusps) Artic: between Left ventricle and Arta Pulmnary: between right ventricle and pulmnary artery UST-FMS Batch 2017 Sectin D [amfv] 1

2 Ask patient t lie dwn and remve his/her T-shirt. Intrduce yurself t the patient. We shuld always d CV exam with the patient lying. We stay n the right side f the patient. WE DO IT IN THIS SEQUENCE: 1. General Survey 2. Vital signs 3. JVP 4. Cartid pulse 5. Peripheral pulse 6. Precrdial Exam Just fr this afternn, we ll start with precrdial exam. We expse nly the area we want t examine. The heart is in the middle, pinting t the left. QRS cmplex the spread f stimulus t the ventricles (ventricular deplarizatin), usually less than 0.10 s ST segment and T wave the return f stimulated ventricular muscle t a resting state (ventricular replarizatin) U wave a small deflectin smetimes seen just after the T wave QT interval the time elapsed frm the nset f ventricular deplarizatin until the cmpletin f ventricular replarizatin. Interval varies with cardiac rate R cardiac brder: RA Mst anterir prtin: RV L cardiac brder: LV Mst psterir chamber: LA (when it enlarges, it will push anterir structures frward) The Flw f Bld 1. SVC and IVC 2. RA 3. Tricuspid valve 4. RV 5. Pulmnic valve 6. Pulmnary artery 7. Lungs (t be xygenated) 8. Pulmnary veins 9. LA 10. Mitral valve 11. LV 12. Artic valve 13. Arta In essence, there are 2 simultaneus circulatin: (1) pulmnary and (2) systemic. Our heart as a pump has t be deplarized. There is electrical and mechanical event. Cnductin f Impulse SA nde (pacemaker): lcated in the wall f RA AV nde: lcated at the atrial septum Bundle f His Purkinje fibers: in the ventricular mycardium Ventricular cntractin starts at the apex t the base MOSBY S NOTES ECG The heart is autnmus An intrinsic electrical cnductin system enables it t cntract within itself Electrcardigram: graphic recrding f the electrical activity f the heart; deplarizatin and replarizatin P wave the spread f stimulus thrugh the atria (atrial deplarizatin) PR interval the time frm initial stimulatin f the atria t initial stimulatin f the ventricles, usually 0.12 t 0.20 s UST-FMS Batch 2017 Sectin D [amfv] 2

3 PRECORDIAL EXAMINATION INSPECTION Lk at the chest and check fr any defrmity: Pectus excavatum Sternum naka-uka papalb Pectus carinatum sternum prtruding ut These defrmities may be assciated with heart prblems PALPATION MOSBY S NOTES PALPATION Suggested sequence: apex left sternal brder base dwn t the right sterna brder epigastrium r axilla (depending n circumstances) Apical Impulse: n mre than 1cm, gentle and brief, nt lasting as lng as systle Check the back, there is usually slight thracic Kyphsis If there s n kyphsis Straight back syndrme (assciated with heart prblems) Check the precrdium fr visible pulsatins. Adynamic: n visible pulsatins Dynamic: 1 visible pulse Hyperdynamic: 2 r mre visible pulse Check visible pulsatins at eye level r use white light (flash it tangentially) Apex L lwer parasternum and Epigastrium Midprecrdium 2 nd ICS, left parasternum 2 nd ICS, right parasternum Thrills Fr thrills, sensatin is like the ball f yur hand. Thrill is a palpable murmur (at least grade 4) turbulent flw Landmarks Midsternum Parasternum Midclavicular line (d nt use the nipple) Anterir axillary line Midaxillary line Psterir axillary line Angle f Luis (palpate frm suprasternal ntch, slide yur finger dwn): 2 nd rib is attached MOSBY S NOTES THRILL fine, palpable, rushing vibratin, a palpable murmur; usually ver the base r right r left 2 nd ICS; lcate in terms f ICS, relatinship t midsternal, midclavicular, r axillary lines While palpating precrdium, use the ther hand t palpate the cartid artery just medial r belw the angle f the jaw. The cartid pulse and S1 are practically synchrnus. UST-FMS Batch 2017 Sectin D [amfv] 3

4 The murmur f grade IV level r mre can be felt. The sensatin is called the thrill, It can be appreciated in systle r diastle. The fllwing are cmmn: Timing Lcatin Prbable Cause Systle Suprasternal ntch Artic stensis and/r 2 nd and 3 rd right ICS Suprasternal ntch Pulmnic stensis and/r 2 nd and 3 rd left ICS 4 th left ICS Apex VSD Mitral regurgitatin Left lwer sternal Tetralgy f Fallt brder Left upper sternal PDA brder, ften with extensive radiatin Diastle Right sternal brder Artic regurgitatin Aneurysm f ascending arta Apex Mitral stensis Apex beat When the heart cntracts, it will rtate cunterclckwise, hitting the chest t prduce the apex beat. Characterize the apex beat: lcatin, amplitude, diameter, duratin Ask the patient t exhale, then hld his/her breath; s that the lungs wn t cver the apex beat Or put the patient n left lateral decubitus Hw t reprt Apex beat: The apex beat is palpable ver the 5 th ICS MCL, 8.5 cm frm MSL. Fund n nly 1 ICS, apprx. 1cm in diameter. Amplitude is very small. If yu can feel the apex beat during the whle systle, that is a sustained apex beat. This means that LV is hypertrphied. If LV is dilated, the apex beat will g t left and dwn. Lifts LA lift (at the 3 rd ICS L parasternum): dilated LA PA lift (at the 2 nd ICS L parasternum): dilated PA Dilated arta (2 nd ICS, R parasternum) Fr apex beat, d nt use PMI. It s nt always LV that prduces the PMI. Apex beat Heaves RV heave (left lwer parasternum r ver epigastrium): dilated/hypertrphied RV LV heave (apical area, very strng): dilated RV Mst lateral palpable ventricular impulse Patient shuld be sitting Mid left thrax (10 cm frm MSL) Level f 4 th t 5 th ICS, LMCL Only feel it within ne ICS (< 2.0 cm); if mre than 1, the apex beat is diffuse Nt mre than 1 ½ fingertips wide Small and feels like a gentle tap Only feel it transiently UST-FMS Batch 2017 Sectin D [amfv] 4

5 AUSCULTATION Auscultatry Areas MOSBY S NOTES CARDIAC CYCLE 1. Mitral Valve: Apex, 5 th ICS MCL 2. Tricuspid Valve: Left lwer parasternum, 4 th ICS 3. Pulmnic Valve: Left parasternum, 2 nd ICS 4. 2 nd Pulmnic Valve: Left sternal brder, 3 rd ICS 5. Artic Valve: Right parasternum, 2 nd ICS Ideal Stethscpe Largest ear tips pssible Adjustable head pieces Vinyl tubing Nt mre than 25 cms 3/16 internal diameter Shallw large diameter bell Smth stiff, thin diaphragm The Cardiac Cycle 1. Isvlumetric cntractin a. Because systemic pressure is always HIGHER than ventricular pressure, ventricles build pressure by cntracting b. N mvement f bld c. Cntractin against clsed valve = builds up pressure 2. Rapid ejectin a. Rapid mvement f bld upn pening f artic valve b. LV pressure drps -> artic & pulmnic valve will clse (S2) 3. Isvlumetric relaxatin a. Atria cannt build up pressures as high as ventricles Nt pressure builders b. They need the ventricles t actively relax c. When ventricular pressure drps and becmes less than atrial pressure, mitral & tricuspid valves pen 4. Rapid filling phase a. During ventricular systle, large amunts f bld accumulate in the right and left atria because f the clsed A-V valves. b. Therefre, as sn as systle is ver and the ventricular pressures fall again t their lw diastlic values, the mderately increased pressures that have develped in the atria immediately push the AV valves pen and allw bld t flw rapidly int the ventricles. 5. Slw filling phase a. When pressures between atria and ventricles equilibriate 6. Atrial deplarizatin a. Cause atrial cntractin and eject any residual bld Systle: ventricles cntract, ejecting bld frm the LV int the arta and frm the RV int the pulmnary artery Diastle: the ventricles dilate, an energyrequiring effrt that draws bld int the UST-FMS Batch 2017 Sectin D [amfv] 5

6 ventricles as the atria cntract Heart Sunds S1, lubb : clsure f AV valves S2, dubb : clsure f semilunar valves, has 2 cmpnents; A2(artic valve clsure) and P2 (pulmnary valve clsure) S3: ventricular filling/ diastle S4: atrial cntractin Generalities Pressures in the RV, RA and PA are LOWER than the left side f the heart The events ccur slightly LATER n the right side than n the left side; thus heart sunds smetimes have tw cmpnents E.g. A2 and P2: split S2 (physilgic) The simultaneus muscular tensin and flw f bld give bdy t the sunds The sunds are best heard in the directin f bld flw S1 (1 st Heart Sund) Etilgy Clsure f mitral valve Clsure f tricuspid valve Ejectin int the artic rt Quality (apex) Lud High pitch Timing Cincides with the apex beat Hw t Identify S1 frm S2 S1 Cincides with apex upstrke S1 is heard immediately befre cartid upstrke S1 with shrter interval frm S2 Apex - S1 luder than S2 Base - S2 luder than S1, S2 splits n inspiratin Factrs affecting the ludness f S1 Rate f rise f LV pressure Timing f MV clsure in relatin t nset f ventricular cntractin Psitin f the MV at the beginning f ventricular cntractin The mre pen the mitral valve is at the end f diastle, the luder the S1(parang pint. Kapag binuksan m ng malaki, malakas ang kalabg pag padabg mng sinara) The strnger the LV cntracts, the luder the S1 Splitting f S1: usually ver tricuspid area S2 (2 nd Heart sund) Etilgy Initiatin f diastle Sudden deceleratin f frward flw during artic and pulmnary valve clsure Best heard at the base f the heart Nrmally widens n inspiratin Physilgic Splitting When a persn inhales, the intrathracic pressure becmes mre NEGATIVE increases the bld returning t the right side f the heart. Therefre in SYSTOLE, mre bld is present in the right atrium LONGER time is needed fr bld t empty frm the right atrium t the right ventricle Cmpnent delayed is the pulmnic cmpnent UST-FMS Batch 2017 Sectin D [amfv] 6

7 JUGULAR VENOUS PULSE Use internal jugular vein which is behind SCM (external jugular vein may als be used) S3 (3 rd Heart sund) Rapid filling sund Early filling gallp sund Occurs at the end f the rapid expansin phase f the ventricle Heard best at r near the apex Heart best with bell applied with light pressure Physilgic S3: due t increase in velcity f ventricular expansin (tachycardia, nervusness) Pathlgic S3: lss f cmpliance/distensibility (heart failure) Lk fr maximal mvement f that clumn f bld In getting JVP, use the RIGHT jugular vein because it reflects right atrial pressure REMINDERS IN TAKING THE JVP: 1. Patient must be seated at Measure the highest angulatin 3. Put ruler hrizntally 4. Put ruler vertically at angle f Luis 5. Height will be yur JVP 6. Use cm mark 7. Use white light S4 (4 th Heart Sund) Atrial gallp, presystlic gallp, S4 gallp rarely physilgical cmmnly pathlgical - decreased distensibility r cmpliance f the LV During atrial Cntractin best heard with the use f bell at the apex with the patient n left lateral decubitus Murmurs Abnrmal sunds Pericardial frictin rub Prsthetic Valve sunds Pacemaker sunds UST-FMS Batch 2017 Sectin D [amfv] 7

8 JVP Wavefrms Murmurs 1. a wave -reflects the slight rise in atrial pressure that accmpanies atrial cntractin. a. It ccurs just befre the first heart sund and befre the cartid pulse. 2. x descent -starts with atrial relaxatin. It cntinues as the right ventricle, cntracting during systle, pulls the flr f the atrium dwnward 3. v wave - secnd elevatin a. The tricuspid valve is clsed, the chamber begins t fill, and right atrial pressure begins t rise again. 4. y descent -secnd trugh a. When the tricuspid valve pens early in diastle, bld in the right atrium flws passively int the right ventricle and right atrial pressure falls again. Lw JVP Dehydratin, Diarrhea, Bld lss High JVP Maneuvers Sme murmurs are affected by maneuvers t change intensity f murmurs. These are the fllwing maneuvers: 1. Respiratry variatins 2. Valsalva maneuver 3. Pstural changes 4. Exercise 5. Pharmaclgic agents 6. Pst premature beat 7. Transient arterial cclusin Vlume verlad Increased RV pressure Increased vascular resistance Obstructin t utflw Pulmnary hypertensin Any increase in pulmnary pressure Tricuspid stensis Increased pressure in RA which reflects RV pressure Right heart failure OPENING SNAP Occurs in mitral stensis Occurs earlier than S3 1st heart sund accentuated T distinguish if S3 r OS Sft S1 - S3 Lud S1 OS Valsalva maneuver frceful attempt t exhale a clsed glttis after taking a nrmal breath 2 part prcess: straining and relaxatin Mst murmurs diminish in intensity dut t decreased ventricular filling and cardiac utput except MVP UST-FMS Batch 2017 Sectin D [amfv] 8

9 Classificatin f Murmurs 1. Systlic Murmurs a. Systlic Ejectin murmurs i. Prduced by bld flwing frward thrugh a semilunar valve ii. starts with final cmpnent f S1 iii. crescend - decrescend iv. finishes befre S2 v. PULMONIC & AORTIC STENOSIS b. Systlic Regurgitant Murmurs i. Prduced by retrgrade flw frm a high pressure area thrugh sme abnrmal pening int an area f lwer pressure ii. always start with S1 if early iii. iv. always g t r beynd S2 if late predminantly high pitch and blwing when sft CAROTID PULSE Pulse: Remember RCV (rate, cntur, vlume) 2. Diastlic Murmurs a. Diastlic Atriventricular Valve Murmurs i. lw pitch ii. rumbling iii. starts with an pening snap iv. after shrt crescend, it is decrescend, fllwed by crescend t S1 (presystlic accentuatin) b. Diastlic Semilunar Valve Murmurs i. Begins with S2 ii. decrescend iii. blwing 1. Pulmnary Regurgitatin 2. Artic Regurgitatin a. Sit the patient up b. Lean patient frward c. Press hard with diaphragm during held expiratin d. "Lub kitah" UST-FMS Batch 2017 Sectin D [amfv] 9

10 PERIPHERAL PULSES Simultaneus Radial and Femral (t detect artic cartatin) Ppliteal: Use tw hands Brachial(d nt use thumb!) Drsalis Pedis Radial Psterir tibialis: encircle yu fingers n the medial mallelus Femral: press deeply belw the inguinal ligament midway between the ASIS and symphysis pubis UST-FMS Batch 2017 Sectin D [amfv] 10

11 The Auscultgram Whatever yu cannt draw, write (e.g. yung precrdium, lagay ny sa baba) At the apex, luder si S1 At the base, luder si S2 Between S1 and S2 are systlic events. S1 split heard best n tricuspid. Left has higher pressure, s M1 is taller than T1. S2 split heard best at pulmnic, heard at inspiratin (indicate). Pulmnic sfter than artic. Fr JVP, write the measurement. Nrmally the a-wave is higher. Fr CAP, nrmally upstrke is rapid and at S1. Gradually it will decline. UST-FMS Batch 2017 Sectin D [amfv] 11