cardiovascular

DONE BY MASOHA
 General examination of the CVS

▪ In the head we will look for

Hyperlipidemia :-
_corneal arcus Malar rash jaundice Roths
Central cyanosis Pallor
_xanthelasma spot
*important risk of seen by
heart disease opthalm
oscope

Causes :-
-Respiratory (pnemonia , Causes :-
Caused
asthma , COPD ) -Chronic
Caused by by right
-Cardiac Disorders congested
mitral stenosis heart
-congenital heart heart failure
failure Caused by
disease infective
-heart failure endocarditis
 ▪ In the hands we will look for :-

Peripheral cyanosis Pallor in palmar creases recapillary

Splinter hemorrhage Finger clubbing
filling

Cause :-
Cause :- Infective endocarditis
Causes :- Infective
- Cold exposure
Chronic congested endocarditis
-causes of central cyanosis ( HF )
-Arterial obstruction heart failure
-venous obstruction
▪ In the neck we will look for :-
▪ Distended neck veins
 Arterial pulses

▪ When taking a pulse, assess : -

• Rate ( normal heart rate 60 _ 100 beats per minute )
• Rhythm ( regular or irregular ? , if its irregular , there is regular irregularity as in
ectopic and irregular irregularity as in the atrial fibrillation )
• Volume ( large , small , normal )
• Character ( collapsing pulse ? )
• nature of the blood vessel
*note :- if the pulse is regular  for 15 sec  *4
If the pulse is irregular  it must be taken for 1 minute
 1- radial pulse
▪ Assess rate, and rhythm
▪ ■ To detect a collapsing pulse: first, check that the patient has no
shoulder or arm pain or restriction on movement. Feel the pulse with the
base of your fingers, then raise the patient’s arm vertically above the
patient’s head
▪ ■ Palpate both radial pulses simultaneously, assessing any delay radio
radial delay
▪ ■ Palpate the radial and femoral pulses simultaneously for radiofemoral
delay ( normally the femoral pulse comes befor the radial pulse )
 2- Brachial pulse

▪ To Assess mainly the volume.

▪ The Elbow joint must be extended
▪ The brachial artery is located medial to the biceps tedon
 3- carotid pulse

▪ Gently place the tips of your fingers or the tip of your thumb between
the larynx and the anterior border of the sternocleidomastoid
muscle and feel the pulse
▪ never assess both carotids simultaneously , because you may stimulate
carotid body and induce vagal reflex ( Bradycardia )
▪ Listen for bruits over both carotid arteries, using the diaphragm of
your stethoscope during held inspiration
 JVP

▪ The internal jugular vein enters the neck behind the mastoid process. It runs deep to
the sternocleidomastoid muscle before entering the thorax between the sternal and
clavicular heads and should be examined with the neck muscles relaxed .
▪ The JVP level reflects right atrial pressure which is normally 8-9 cmH2O
▪ The sternal angle is approximately 5 cm above the right atrium, so the JVP in health
should be ≤4 cm above this angle when the patient lies at 45°
 The JVP has two peaks A & V

▪ The A  atrial that comes with the diastole

▪ The V  ventricular that comes with the systole
abnormalities of JVP
Precordium examination

▪Inspection
▪Palpation
▪Percussion
▪Auscultation
 Inspection

▪ We will look for scars like midline sternotomy scar usually indicates previous
coronary artery bypass surgery or aortic valve replacement , A left submammary
scar is usually the result of mitral valvotomy , Infraclavicular scars are seen after
pacemaker or defibrillator implantation, and the bulge of the device may be
obvious .

left submammary scar

sternotomy scar Infraclavicular scar
 Inspection

▪ We will look for chest deformity :- Pectus excavatum (funnel chest) , a posterior
displacement of the lower sternum, and pectus carinatum (pigeon chest) may displace
the heart and affect palpation and auscultation

pectus carinatum
Pectus excavatum (funnel chest)
Percussion

▪ In the cardiovascular , the percussion is negligible may be used in

the state of cardiomegaly only
Palpation

The tips of the finger is to palpate the

apex beat which is the most lateral and
inferior position where the cardiac
impulse can be felt

The base of the fingers for the thrill

which is palpable murmurs that can be
felt as a palpable vibration.
* The thrill done at the 4 sites of 4
valves

For heave which is a palpable impulse

that noticeably lifts your hand.
 The site of the apex beat

▪ The apex beat is normally in the fifth left intercostal space at, or medial to,
the mid-clavicular line
▪ The apex beat may be impalpable in overweight or muscular people or in patients with
asthma or emphysema because the lungs are hyperinflated
▪ Or may be displaced due to some pathological conditions ( causes of displacement )
Thrill

The most common thrill is that of aortic stenosis which may be palpable at the
apex, at the lower sternum or in the neck. The thrill caused by a ventricular septal
defect is best felt at the left and right sternal edges .
 Heave

▪ The heave indicates ventricle hypertrophy , (right ventricular heave) indicates

right ventricular hypertrophy or dilatation, most often accompanying pulmonary
hypertension
 Auscultation

▪ Normal heart sounds are S1 which is due the closure of the mitral
and tricuspid valvles and S2 which is due to the closure of aortic and
pulmonary vavles  “ lub _ Dub “
▪ In the auscultation , we must notice if there are any murmur ( systolic
or diastolic ) or any added sounds like rub friction in pericarditis or S3
, S4 or click sound in the state of mechanical valves
▪ You must auscultate the mitral , tricuspid , pulmonary , aortic valvles
respectively
Auscultation
 Listen for the murmur of mitral stenosis with the
lightly applied bell with the patient in the left
lateral position
 Listen for the murmur of aortic regurgitation with
the diaphragm with the patient leaning forward
Findings after the auscultation ???

▪ You should give the doctor an information about :-

▪ 1- intensity of the S1 , S2 ( normal , quiet , loud , split )
▪ 2- If there is a murmur ( systolic or diastolic ? , in the systolic
murmur there are two types ejection systolic murmur or
pansystolic murmur which is very common )
▪ 3- if there is any added sounds like S3 caused mainly by left
ventricular failure ( heart failure ) , mitral regurgitation its heard as
( lub _ da _ dub ) , S4 very common , rub friction caused by
pericarditis , click sounds , Mechanical heart valves sounds
Intensity of S1 and S2
Causes of S3 sound
Grades of intensity of murmur
 Radiation of the murmurs

▪ Murmurs radiate in the direction of the blood flow to specific

sites outside the precordium
▪ Murmurs in the mitral valve radiated to the left axilla , so the left
axilla must be examined with the stethoscope
▪ Murmurs of the aortic valve radiated to the carotid arteries in the
neck so must be examined with the stethoscope , if you find
murmurs on the aortic area
Respiratory

DONE BY MASOHA
 General examination of the respiratory system

▪ In the head we will look for

Dusky face due to ‘pursed lips’ breathing

Central cyanosis Co2 retention
Ptosis in COPD

In horners syndrome
The tumor of the
apex of the lung may
Causes :- press on the
-Respiratory sympathetic outflow
(pnemonia ,
asthma , COPD )
 ▪ In the hands we will look for :-

Peripheral cyanosis Tobacco ‘tar’-stained fingers flapping tremor Yellow nail

Finger clubbing
syndrome

caused by (lung is seen with severe

In heavy smokers cancer, ventilatory failure
Found in severe - bronchiectasis, and carbon dioxide
interstitial lung is associated with
Central cyanosis - retention
disease , lymphoedema and
pulmonary fibrosis an exudative pleural
in occupational effusion
lung disease)
 General examination of the respiratory system

▪ In the neck we will look for

JVP
enlargement of‘ the cervical,
Distended neck supraclavicular and scalene Thyroid
veins lymph nodes ) Retrosternal goitre(

elevated ( high ) in :-
Chronic hypoxia in COPD
, pneumothorax or severe acute asthma ,
due to lung cancer pulmonary embolism Due lung cancer
compressing the superior , in the SVC obstruction metastasis , Causes
vena cava the JVP is raised and non-pulsatile, and the tuberculosis tracheal
abdominojugular reflex is absent deviation
 General examination of the respiratory system

▪ In the thorax we will look for In the leg we will look for
Erythema nodosum on the
shins that occur in TB ,

Subcutaneous the dilated venous

lesions may be vascular channels
visible, including of SVCO
metastatic tumour
nodules

* Listen for hoarseness and stridor of the sounds

local examination

▪Inspection
▪Palpation
▪Percussion
▪Auscultation
 Inspection

▪ We will look for chest deformity : -

▪ ‘barrel-shaped’ associated with lung hyperinflation in patients with
severe COPD
▪ Pectus excaviatum
▪ Pectus carniatum
▪ kyphoscoliosis ( decreased lung volume )
▪ Scar
 Palpation

▪ With the patient looking directly forwards, look for any deviation of the
trachea
▪ Look for A ‘tracheal tug’ is found in severe hyperinflation; resting on the patient’s
trachea, your fingers move inferiorly with each inspiration.
Causes of tracheal deviation
 Palpation

Normally :- Both sides of the thorax should expand equally during normal (tidal) breathing and maximal inspiration
Abnormal :-
1- Reduced expansion on one side indicates abnormality on that side: for example, pleural effusion, lung or lobar
collapse, pneumothorax ,
2- Bilateral reduction in chest wall movement is common in severe COPD and diffuse pulmonary fibrosis.
3- emphysema produces a characteristic crackling sensation over gas-containing tissue
 Percussion

▪ Normal lung produces a resonant sound ( tympanic )

▪ Abnormal sounds hyperresonant , dull , stony dull
 Technique

* Note :- The percussion on the clavicle is done directly on it by you finger

 Auscultation

▪ Normal breathing sounds in all the areas of the chest is the vesicular breathing (
vesicular = alveolar )  the inspiratory phase > expiratory phase with no gap
(pause between the 2 phases )
▪ The intensity of breath sounds relates to airflow and the tissue through which the
sound travels.
Sites of auscultation
 abnormalities

▪ 1- Diminished vesicular breathing occurs in obesity, pleural effusion, marked

pleural thickening, pneumothorax, hyperinflation due to COPD
▪ 2- Bronchial breathing is a high-pitched breath sound with a hollow or blowing
quality similar to that heard over the trachea and larynx during tidal breathing ,
with a characteristic pause between the two phases and prolongation of
expiratory phase
Added sounds

▪ Crackeles that are examined at the base of the lung occur in

pulmonary edema ( in Rt heart failure ) , pulmonary fibrosis ,
bronchiectasis , …..
▪ Wheeze is characteristic of asthma and COPD
▪ Pleural Friction rub that occurs in inflammation of the pleura ,
pneumonia or pulmonary vasculitis , pulmonary embolism