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Cardiovascular Examination (Jugular veins (Abnormal JVP Waves (Increase a…
Cardiovascular Examination
Blood pressure
Determined in
Both Arm
Both legs
Abnormal
Difference between arms >10 mmHg
Cause of discrepancy
Arterial occlusion or stenosis
Dissecting aortic aneurysm
Coarctation of aorta
Supravalvular aortic stenosis
Thoracic outlet syndrome
Palpation
Position
Supine
Left lateral decubitus
Apical impulse
Normal
Occurs early systole
Outward motion imparted to chest wall
Mid-Late systole, apical moves away from chest wall
Point of maximal impulse not= with apical impulse
If not palpable + Hemodynamically unstable = TAMPONADE
Location
Apex
Systolic precordial retraction
Constrictive pericarditis
Tricuspid regurgitation
Apical impulse of LV enlargement
Widened or diffuse
3cm in diameter
Palpated in 2 interspaces
Displaced leftward
A Wave - LV hypertrophy
Characteristic
Subtle
Presystolic
Preventricular rapid filling wave
Observed the motion with stethoscope on chest wall
Cause
Aortic stenosis
Hypertrophic obstructive cardiomyopathy
Systemic hypertension
Lower sternal area
Reflects the RV motion
Overload
Systolic
Sustained outward lift
Caused by
Pulmonary stenosis
Diastolic
Vigorous nonsustained motion
Left upper sternal
Pulmonic area
Due to DIlated pulmonary artery
Poststenotic dilation in pulonary valve stenosis
Idiopathic dilaton of the pulmonary artery
Increased pulmonary flow
ASD
Pulmonary hypertension
Type of pulsation
Dynamic + Quick = Increase blood flow
Sustained impulse = Pressure overload
Right upper sternal
Aortic area
Suggest = Aortic aneurysm
Jugular veins
May reflect the condition of right heart
Normal: decrease while inspiration
If paradoxically increase while inspirate
A.K.A Kussmaull Sign
Reference
Clue to:
Constrictive pericarditis
Pulmonary embolism
RV infarction
Normal sinus rhythm
2 positive (outward) wave
Wave A
Just before S1
Wave V
Near S2
2 negative (descent) wave
Wave X
Follows after S1
Wave Y
After V wave in early diastole
Should be checked while using stethoscope
Hepatojugular reflux sign
A.K.A. Abdominojugular
Procedure
Abnormal
Distended (>=4 cm) and descent abruptly
Happens in
LV failure + pulmonary hypertension
Elevated Pulmonary capillary wedge pressure
Mistral stenosis
Engorged not pulsatile = SVCS
Abnormal JVP Waves
Increase a Waves
Tricuspid stenosis
Pulmonary stenosis
Pulmonary vascular diseases
Bernheim effect
HOCM
Rapid X descent
Cardiac tamponade
Increased v Waves
Rapid y Descent (Friedrich sign)
Constrictive pericarditis
Arterial pulse
Abnormalities carotid pulse
Hyperdynamic
Consistent with AR
Examples
May be caused by
High cardiac output
Wide pulse pressure in elderly
Dicrotic and Bisferious
In myocardial failure with
Hypotension
Decrease CO
Increase peripheral resistance
Twice beating
Dicrotic pulse = early diastole
Systolic and Diastolic impulse
In
Cardiomyopathy
Left Ventricular failure
Bisferiens pulse = late systole
Occurs in AR + AS
Mostly occurs in pure AR
HOCM
Characteristic - 2 systolic impulses
Aortic stenosis
Pulsus parvus (soft or weak pulse)
Aortic stenosis
severe stenosis of any cardiac valve
Low CO
Pulsus tardus (slowly increasing delayed pulse)
Severe aortic stenosis
Transmitted murmurs
Due to
Aortic stenosis
Coarctation
PDA
Pulmonary stenosis
VSD
Carotid bruit high in neck
Pulsus Paradoxus
<=10 mmHg inspiratory decrease of arterial pressure
Caused by
Constrictive pericarditis
Pericardial tamponade
Severe emphysema
Severe asthma
Severe heart failure
Pulmonary embolism
Morbid obesity
Pulsus alternans
NOT Electrical alternans
Alteration stronger-weaker beats
Severe myocardial failure
Abnormalities of femoral pulse
Aortic coarctation
Delayed femoral to radial pulse
Relative weakening femoral<radial
Heart sounds
S1
Component
Audible
M1
Before T1
T1
Wide splitting
Ebstein anomaly
RBBB
Intensity influenced by
PR interval
Long PR - S1 Soft
Short PR - S1 loud
Mitral valve disease
MS - Loud S1
MS severe - S1 decrease
Severe AR - S1 Soft
LV pressure
Hypercontractile state - S1 loud
Fever
Exercise
Thyrotoxicosis
Pheochromocytoma
LV failure - S1 soft
S1 in lower left sternal border > S1 in Apex
ASD
Tricuspid stenosis
S2
Systolic Ejection click
Origin
Left side of the heart
Right side of the heart
Sound
Possible mechanism
Intrinsic abnormality of aortic/pulmonic valve
Congenital bicuspid aortic valve
Latter, the click buried under systolic murmur
Pulsatile distension of a dilated great artery
Truncus arteriosus
Aortic click
ASD
Pulmonic click
Idiopathic dilatation of pulmonary artery
Increased pressure in great vessel
Aortic/pulmonary hypertension
Imply --> mobility of cusp
Absent in
Subvalvular stenosis