How to Examine the Heart and Blood Vessels

1. How to Examine the Heartand Blood Vessels Joel Niznick MD FRCPC

4. Look at the patient • Sick/well • Comfortable/in distress • Cyanosed/plethoric • Wet/dry • Young/old • Male/Female • Establish probabilities of disease • History will have told you what to suspect

5. Younger people Functional murmur vs MVP vs bicuspid AV Older people Aortic sclerosis vs aortic stenosis Common Clinical Scenarios

6. Males more commonly have aortic valve disease Young – BAV Elderly - Degenerative Females more commonly have mitral valve disease MVP > rheumatic heart disease Probabilities

7. Inspect • Facies/body habitus • Cyanosis • Xanthelasma • Arcus senilis • Conjunctival hemorrhages • Syndromes • Marfan’s • Down’s

8. Hands • Clubbing • Capillary return • Digital ischaemia • Splinter hemorrhages • Osler’s nodes • Janeway lesions

9. Blood pressure • At rest 5” • Both arms • Legs if young hypertensive

10. Look at the Fundi OSU Interactive Physical Exam Guide

11. Look at the Fundi • Disc • Vessel • Hemorrhages • Exudates

12. Pulses • Rate • Rhythm • Volume • Quincke’s • Water hammer • Brachio-radial delay

13. Carotid • Upstroke-normal/brisk/delayed/anacrotic • Volume-normal/increased/decreased • Auscultate: • Bruit • Murmur • S2 audible ? Over carotid?

14. Carotid Tutorial

15. JVP • Height • Waveform • Specific patterns • Response to maneuvers • Inspiration • HJR

16. JVP Inspection

18. JVP Summary • Confirm it’s the JVP you are seeing • Compressibility • Waveform • Manoeuvers • Identify the height – start at 30o • Identify the waveform

19. If unable to see JVP-lie patient flat If still unable to see JVP-sit patient upright

20. Use the hand made ruler

21. Normal JVP Waveform a c v x y x

22. JVP Inspection • Look for descents not waves • Descents are easier to see due to greater amplitude and frequency • Time deepest descent with systole. This is the X’ descent

23. Specific JVP patterns

24. Precordium • Palpate: Aortic → Pulmonary → LSB → Apex → Left decubitus • Thrills • Palpable HS • Lifts • Apex: size/position/motion

25. Auscultation • Follow same sequence • Aortic → Pulmonary → LSB → Apex → Left decubitus → Upright lening forward • Diaphragm except for apex (use both here) • Identify HS, then extra sounds, them murmurs • Dynamic maneuvers

26. Palpation - Precordium Parasternal: • Palpable P2-pulmonary HTN • Thrill • VSD/HCM • RV lift • RVH • Severe MR

27. Palpation - Apex Apex: • Palpable in 1 of 5 adults age 40 • Best felt with fingertips or finger pads Normal Location: • No more than 10 cm from mid-sternal line in the supine position • Left decubitus position not reliable for apical location Normal Size: • No larger than 3 cm (about 2 finger breadths)

28. Apex–Dynamic Abnormalities Sustained Apex: • correlates with pressure overload or LVF • ( > 2/3 systole-hangs out to S2) • AS, LVH or LV systolic dysfunction Hyperdynamic Apex: • correlates with volume overload AR/MR • palpable S4 (atrial kick) • palpable S1 (MS) • palpable non-ejection click (MVP)

29. Apex–Dynamic Abnormalities Atrial kick: • Palpable S4 • Loss of LV compliance • LVH 2o Hypertension • Aortic Stenosis • Hypertrophic Cardiomyopathy

30. Auscultation

31. What are we listening for?

32. Normal First & Second Sounds

33. Normal First & Second Sounds 2

34. Splitting of the Second Sound

35. Timing of Cardiac Sounds

36. Fourth Heart Sound S4 Gallop

37. Third Heart Sound S3

38. Systolic Murmurs

39. Diastolic Murmurs

40. Common Murmurs Systolic Murmurs • Aortic stenosis • Mitral insufficiency • Mitral valve prolapse • Tricuspid insufficiency Diastolic Murmurs • Aortic insufficiency • Mitral stenosis S1 S2 S1

41. Auscultation Grading of Murmurs: Grade 1 - only a staff man can hear Grade 2 - audible to a resident Grade 3 - audible to a medical student Grade 4 - associated with a thrill or palpable heart sound Grade 5 - audible with the stethoscope partially off the chest Grade 6 - audible at the bed-side

42. Characteristics of a “functional” murmur • Short and soft SEM • Normal S1 and S2 • Normal cardiac impulse • No evidence for any hemodynamic abnormality

43. Functional (Innocent) MurmursCommon in asymptomatic adults • Characterized by • Grade I – II @ LSB • Systolic ejection pattern - no  with Valsalva/ upright • Normal precordium, apex, S1 • Normal intensity & splitting of second sound (S2) • No other abnormal sounds or murmurs • No evidence of LVH S1 S2

44. Characteristic of the NOT Innocent Murmur • Diastolic murmur • Loud murmur - grade IV or above • Regurgitant murmur • Murmurs associated with a click • Murmurs associated with other signs or symptoms e.g. cyanosis • Abnormal 2nd heart sound – fixed split, paradoxical split or single

45. Integrating Pulse with HS and Murmurs www.blaufuss.org

46. Examining the PeripheralPulses

47. Retinal Carotids Brachial Renal Ulnar Radial Femoral Popliteal Posterior Tibial Dorsal Pedis

48. Examination of Pulses • Grading: • Normal/Increased/Decreased/Absent • 2+/3+/1+/0 • Allen’s test • Trophic changes/Ulceration • Perfusion • Pallor on elevation • Rubor on dependency • Venous refill with dependency (should be less than 30 seconds) • Bruits

49. Trophic Changes Shiny, hairless skin, dystrophic nail changes and dependent rubor associated with peripheral arterialocclusive disease of the patient's right foot

50. Pallor on elevation Rubor on dependency