Heart/Neck Vessels & Peripheral Vascular/Lymphatics

1. Heart/Neck Vessels &Peripheral Vascular/Lymphatics

2. Anatomy Review • 4 chambers • Right/left atrium • Right/left ventricle • 4 valves • Tricuspid • Mitral • Pulmonic • Aortic

3. Anatomy and Physiology • Cardiac output (L/min) determined by: • Heart rate (beats/min) • Stroke volume (L/beat) • CO = SV x HR

4. Health History • Chest pain • Do you have any chest pain or discomfort? • OLDCART • Do you do you use any recreational drugs? • Do you have any increased life stress/anxiety? • Dyspnea • Do you have any labored or difficulty breathing (dyspnea)? • OLDCART • Related to exercise (exertional dyspnea)? • Quantify: Have far can you walk before getting short of breath? • Related to position/lying supine (orthopnea)? • How many pillows do you sleep on at night?

5. Health History • Palpitations • Ever have palpitations/or unpleasant awareness of heartbeat? (“fluttering/ pounding”) • Dizziness or Syncope • Have you felt dizzy or ever lost consciousness/passed out (syncope)? • Fatigue • Do you seem to tire easily? • Cyanosis or pallor • Ever noted your facial skin turn blue or ashen gray?

6. Health History • Cough • Any pink or blood tinged frothy sputum? • Edema • Do you have any swelling in your feet or legs? • Nocturia • Do you awaken at night with an urgent need to urinate?

7. Health History • Past Cardiac History • CHF, angina, MI, murmurs, rheumatic fever, congenital heart disease • Assess for risk factors of coronary artery disease • Hypertension, hyperlipidemia, diabetes, physical inactivity, obesity, smoking, stress, increasing age. family history of CAD (especially in 1st degree relatives F<65, M<55) • Additional for women: Menopause or use of oral contraceptives

8. What the History Can Tell You • Angina (pain resulting from ischemia) • Onset: Abrupt, often precipitated by event such as emotion, exertion, cold or eating. • Location: Substernal or retrosternal pain. • Duration: Usually lasts a few minutes and then subsides. • Characteristic: Described as squeezing or heavy pressure • Radiation: May radiate to the neck, jaw, or arms • Relieving Factors/Treatments Tried: Often relieved with sublingual nitroglycerin

9. What the History Can Tell You • Myocardial Infarction • Onset: Abrupt, often unrelated to precipitating event. • Location: Substernal or over precordium. • Duration: Prolonged • Characteristic: Severe, described as viselike or crushing • Associated Symptoms: dyspnea, dizziness, nausea, diaphoresis, palpitations, anxiety (sense of doom) • Radiation: May radiate to neck, jaw, arms or hands. • Treatments Tried: Sublingual nitroglycerin without relief

10. What the History Can Tell You • Congestive Heart Failure • Right-sided • Dependent Edema • Nocturia • Left-sided • Coughing/Hemoptysis (pink frothy) • Orthopnea • Dyspnea with exertion • Cyanosis or ashen color • Cold, moist extremities • Oliguria • Restlessness/anxiety

11. Carotid Artery • Inspect for pulsation • Absent pulse wave with arterial occlusion or stenosis • Palpate lightly & one at a time for: • Contour • Smooth with rapid upstroke • Amplitude • 4+ Bounding • 3+ Full • 2+ Normal • 1+ Weak • 0 Absent • Diminished or unequal with atherosclerosis or other arterial disease • Auscultate • Over angle of jaw, mid-cervical, & base of neck with bell • For presence of bruit • Blowing, swishing sound indicating turbulence http://www.youtube.com/watch?v=yq74c6KhPuo Carotid arteries 2+ bilaterally without bruits.

12. Jugular Venous Pressure • Assessment of jugular veins gives estimation of heart function • Ie. CHF • Internal Jugular Vein • Position patient supine at 45 degrees without a pillow • Use Angle of Louis to read CVP at highest level of pulsation • Normal-Pulsation <2.5cm • Abnormal- Pulsation >2.5cm • Indicates increased CVP associated with heart failure http://www.youtube.com/watch?v=yq74c6KhPuo • If you cannot find internal jugular veins, use the external and note point where look collapsed

13. Jugular Venous Pressure • External jugular veins are lateral to sternomastoid muscle above the clavicles • Assess if: • Visible (distended) @ 45 ° External jugular veins flat @ 45 °

14. Hepatojugular Reflux • Very sensitive in detecting right-sided heart failure • Elevate to 30 degrees • Press firmly in right upper quadrant • Observe neck for elevation in JVP • Rise of >1cm is abnormal http://www.youtube.com/watch?v=X9fKPIe6nDQ

15. Inspection & Palpation • Inspect & palpate precordium for: • Lifts/Heaves • Thrills • Use ball of your hand firmly on the chest • Apical impulse • http://www.youtube.com/watch?v=FkM6muqmve0&feature=related Apical impulse @ 5thintercostal space midclavicular line. No lifts, heaves, or thrills noted. • Note location of heart may also be determined by percussing for borders of dullness

16. Apical Impulse • AKA: Point of maximal impulse (PMI) • Apical impulse specifically for apex beat. • Localize apical impulse using one finger. Ask to exhale and hold breath may help find. May need to roll midway to left. • Note: location, size (1cm x 2cm), amplitude (short gentle tap), duration (short, occupies only first half of systole • Not palpable in obese, thick chest wall • Increased size or location with volume overload, hypertrophy (HTN, CAD, CHF, cardiomyopathy) • Increased amplitude & duration with high cardiac output states (anxiety, fever, hyperthyroidism, anemia

17. Auscultation • Wth the diaphragm auscultate @ the apex of the heart for: • Rate • Normal Adult Rate: 60-100 beats/min • Bradycardia–heart rate less than 60 • Tachycardia–heart rate greater than 100. • Rhythm • Regular vs. irregular • Sinus arrythmia (rhythm varies with breathing) • Regularly irregular, irregularly irregular • If pulse irregular assess for pulse deficit • Auscultate the apical beat while simultaneously palpating the radial pulse. Every beat hear should perfuse to periphery Apical pulse 80bpm and regular. No pulse deficit noted.

18. Auscultation • Proceed over precordium with bell • Best for low pitch • Auscultate over: • Aortic area • Pulmonic area • Erb’s point • Tricuspid area • Mitral area • Epigastric • For: • Gallops (best with bell) • Murmurs (depends) • Rubs

19. Normal Heart Sounds • S1 • “Lubb” • Sound of mitral & tricuspid valve closing simultaneously • Start of systole • Heard loudest at apex of heart • Approx 5th intercostal space, midclavicular line on left • S2 http://www.youtube.com/watch?v=2aO0HKIP3vI • “Dubb” • Sound of simultaneous closing of pulmonic and aortic valves • End of systole • Heard loudest at base of heart • Best over 2nd intercostal space on right

20. Gallops: S3 & S4

21. Murmurs • Swishing or blowing noises that occurs with turbulent blood flow in heart or great vessels. • Categorized as: • Innocent • Always systolic & without evidence of physiological/structural abnormalities • Functional • Associated with physiological alterations such as high cardiac output states • i.e. exercise, anemia, hyperthyroidism or increased blood volume associated with pregnancy • Pathologic • Caused by structural abnormalities in valves or chambers • Stenosis, regurgitation, patent ductus arteriosis

22. Structural Abnormalities in Valves and Chambers

23. Murmur Characteristics • Timing • Systolic: Heard during systole (between S1 and S2) • If possible note: early, late or mid systolic) • Diastolic: Heard during diastole (between S2 and S1) • If possible note: early, late or mid diastolic • Continuous: Heard in both systole and diastole http://www.youtube.com/watch?v=XvtBpnV_lOE

24. Valvular Disease & Murmur Locations http://www.merckmanuals.com/professional/resources/multimedia/name/audio.html

25. Murmur Characteristics • Quality (Shape/Pattern & Sound) • Shape/Pattern • Crescendo/Decrescendo • AKA- Diamond shaped murmur; ejection type murmur • Primary causes: Stenotic valves • Holosystolic • AKA- Pansystolic • Decrescendo • Primary causes: Aortic and pulmonic regurgitation, Mitral and tricuspid stenosis http://www.merckmanuals.com/professional/resources/multimedia/name/audio.html

26. Murmur Characteristics • Quality • Sound • Musical, blowing, harsh, or rumbling • Pitch • High, medium, or low; Loud or soft • Location • Area of maximal intensity • Radiation • May be heard in another place on precordium or neck, back or axilla

27. Murmur Characteristics • Intensity (loudness) • 1 - Very faint, heard only after listener has “tuned in;” may not be heard in all positions • 2 - Quiet, but heard immediately after placing the stethoscope on the chest • 3 - Moderately loud • 4 – Loud, with palpable thrill • 5 - Very loud, with thrill. May be heard when stethoscope is partly off the chest • 6 – Very loud, with thrill. May be heard with stethoscope just removed from and not touching the skin.

28. Murmur Characteristic Example • Aortic Stenosis • Timing: Midsystolic • Pitch: Loud • Quality: Harsh • Location: Loudest @ 2nd right interspace • Radiation: Widely to side of neck, down left sternal border, or apex http://www.merckmanuals.com/professional/resources/multimedia/name/audio.html

29. Auscultation • Pericardial friction rub • Membranous sac surrounding heart becomes inflamed • Differentiate pericardial from pleural friction rub by having patient hold breath http://www.merckmanuals.com/professional/resources/multimedia/name/audio.html

30. Physical Exam Findings for CHF Right-Sided Failure Left-Sided Failure Pulmonary Edema Coughing Hemoptysis Orthopnea Dyspnea/Tachypnea Crackles in lungs Cyanotic nail beds, ashen color Cold, moist extremities Restlessness/anxiety S3 gallop rhythm Tachycardia • Distended neck veins • Dependent edema • Ascites • Hepatomegaly • Nocturia http://www.youtube.com/watch?v=QODCQHwSfOU&feature=related

31. Peripheral Vascular & Lymphatics http://images.google.com

32. Peripheral Vascular System • Arteries • Supply oxygenated blood to the body from the heart • Veins • Return unoxygenated blood to the heart • Contain one-way valves that keep the blood from flowing backwards • Muscles help squeeze the blood in the veins to the heart

33. Health History • Common or concerning symptoms • Pain in the arms or legs • Intermittent claudication: leg or arm pain that is exercise induced • Cold, numbness, pallor in the legs; hair loss • Color change in fingertips or toes in cold weather • Swelling in calves, legs or feet • Swelling with redness or tenderness • High risk: Tobacco use, diabetes, HTN, Hyperlipidemia, CV disease • Severity of peripheral vascular disease closely parallels the risk for heart attack, stoke, and death from vascular causes

34. Inspection • Inspect upper and lower extremities for: • Color • Symmetry • Lesions • Clubbing • Edema • Capillary refill • Pitting Edema- Apply pressure with finger for 5 seconds. • 1+: Slight pitting, 1cm or less, disappears rapidly • 2+: Deeper pitting, 1.5cm, disappears 10-15 sec. • 3+: Deep pitting, 2cm, disappears more than 1 minute • 4+: Very deep pitting, 2.5cm, disappears 2-5 minutes No pitting edema noted

35. Inspection • Inspect lower extremities for • Hair distribution • Varicosities • Muscle atrophy

36. Palpation • Palpate upper and lower extremities for: • Temperature • Texture • Capillary refill • Lymph nodes • Epitrochlear, Inguinal

37. Lymph Nodes • Epitrochlear • In antecubital fossa and drains: • Hand • Lower hand • Inguinal • In groin and drains most of the lymph • Lower extremities • External genitalia • Anterior abdominal wall

38. Palpation • Peripheral Pulses • Brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis • Assess for symmetry in limbs • Force • 4+ Bounding • 3+ Full, increased • 2+ Normal • 1+ Weak • 0 Absent • If pulse is difficult to palpate use a Doppler (ultrasound stethoscope) to amplify sound of pulse wave

39. Peripheral Pulses- Brachial • Located medial to biceps tendon • Grade force bilaterally

40. Peripheral Pulses-Radial • Note: • Rate • Rhythm • Force

41. Peripheral Pulses-Ulnar • Modified Allen Test • Evaluate adequacy of collateral circulation prior to cannulating radial artery • Firmly occlude both ulnar and radial arteries • Release pressure on ulnar artery • Normal- return of color in 2-5 seconds

42. Peripheral Pulses-Femoral • Located just below inguinal ligament halfway between the pubis and anterior superior iliac spine. • Grade force bilaterally • If weak auscultate for bruit

43. Peripheral Pulses-Popliteal • Located just lateral to medial tendon • Grade force bilaterally

44. Peripheral Pulses-Posterior Tibial • Located behind the groove between the malleolus and Achilles tendon • Grade force bilaterally

45. Peripheral Pulses-Dorsalis Pedis • Located just lateral to & parallel with the extensor tendon of the big toe. • Force should be symmetrical

46. Assess for Deep Vein Thrombosis • Assess for: • Erythema • Calf Edema • Increased warmth No calf erythema, edema, warmth No longer widely practiced • Tenderness with palpation • Homan’s sign No calf erythema, edema, or warmth.

47. Venous vs. Arterial Insufficiency

48. Arterial Venous

49. Is that all?  MIDTERM 40 points all multiple choice GOOD LUCK!!!!