Intro CVS System Notes

Notes Compiled by Abdullah Bohairi, Faisal Alkharji, Faris Alsomih

Inspection

Face/Neck Inspection

• Malar flush (Mitral Stenosis)
• Lips and tongue - Central cyanosis
• Dental Caries (Infective Endocarditis)
• High Arched Palate (Marfan’s Syndrome)
• Neck - JVP, carotid pulse
• Thoracicectomy scars
• Down Syndrome
• Obesity, Cachexia
• Eyes; Exomphalos, XANTHELASMATA, CORNEAL ARCUS, Roth spot, Petechial Haemorrhage on the conjunctiva, Jaundice

Upper Limb inspection

• Splinter Haemorrhage; hard labour, Infective endocarditis
• Peripheral Cyanosis- Tetralogy of Fallot, VSD, ASD (VSD & ASD complicated with ezinminger syndrome, Tetralogy of Fallot)
• Clubbing - may be complicated by Tetralogy of fallot
• Osler Nodules; painful
• Janeway lesion; painless
• Arachnodactyly - Marfan's syndrome relation to regurgitation of aorta

Clubbing grading 1-4

• Fluctuation Test (Grade 1) - Press down on the nail and observe the opposite side for fluctuation, which indicates increased sponginess of the nail bed.

• Window Test (Grade 2) - By placing the nails of the same fingers against each other, a small diamond-shaped window appears if there is no clubbing. The absence or reduction of this window indicates the presence of clubbing.

• Increased Anteroposterior Curvature (Grade 3) - The nails show increased curvature both longitudinally and transversely, which is more pronounced and visible.

• Drumstick Appearance (Grade 4) - The terminal phalanges of the fingers enlarge, and the nails curve around the fingertips, resembling drumsticks.

Other signs

Aortic reaggregation; check axilla for Ehlers-Danlos syndrome (EDS) - elastic falling down from axilla

Lower Limb Inspection

• Unilateral Cyanosis - DVT
• Bilateral Cyanosis - Cortication of AORTA -
• If unilateral hairless, painful, Cyanosed - Ischemia PAD
• Hoof-mans Sign; DVT; though not highly specific
• Edema -
• Search for scar saphenous vein graft - -Saphenous Vein Graft Scar: This scar results from harvesting the saphenous vein in procedures like coronary artery bypass grafting (CABG). Look for a linear scar along the inner thigh or leg where the vein was removed.

Chest Inspection

• start by inspecting for scars -Mediastinotomy Scar: This is a scar on the chest, typically vertical, resulting from a mediastinotomy, which is a surgical procedure to access the mediastinum (the central compartment of the thoracic cavity). -Valve Replacement/CABG Scar: For patients who have undergone valve replacement or CABG (often referred to colloquially as “cabbage”), expect to find a sternotomy scar, which is a vertical scar down the middle of the chest. - though they are very rare

• Gynecomastia; chronic spironolactone usage

• Clear Deformity; pect excv- others

• 1 = pacemaker scar
• 2 = median sternotomy scar
• ==3 + 4 = right and left lateral thoractomy scars,==
• 5 + 6 = surgical drain scars

Peripheral Pulses Examination

Rate;

placing three fingers without moving patient arm upon bony prominence of radial artery

Rhythm;

• Irregular; Mitral Stenosis

Volume

• Large; Pulse on superficial touch, collapsing pulse - Aortic/Mitral Regurgitation
• Small; Aortic Stenosis, Mitral Stenosis - not necessary to do
• Normal;

Character

Collapsing Pulse - Ask if theres pain on shoulders - collapsing pulse; press four fingers against brachioradialis - normal if arm is above head - Bounding pulse - normally in preganancy

Grading per finger - 1st normal - 2nd bounding pulse - anemia, thyrotoxicosis, - 3rd +ve collapsing pulse - 4th water hammer pulse severe aortic regurgitation

synchronization

• Radio Radial, Radio femoral delay
• all cardiovascular exam mostly 45 degree

Sync Radio Radial

• Trauma is the most common
• Recurrent Arterial blood gasses testings; DM, Atherosclerosis
• Takayasu disease - This is a rare form of vasculitis that predominantly affects Asian women and can involve the subclavian and aortic arch arteries. It leads to narrowing, occlusion, or aneurysms of the affected arteries.

Sync Radio femoral delay Mid inginual point; typically located from the anterior superior iliac spine (ASIS) to the pubic symphysis.

patient should stand, test for femoral artery

• Cortication of descending aorta

Arterial Examination Points of Lower Limb

1. Dorsalis Pedis Artery:

   • Origin: This artery originates from the anterior tibial artery. It is located on the dorsum (top) of the foot.
   • Location for Palpation: It can typically be felt by palpating the foot just lateral to the extensor tendon of the big toe.

2. Peroneal Artery (possibly meant by “Perinoeum”):

   • This artery, also known as the fibular artery, runs along the lateral aspect of the lower leg and supplies blood to the lateral compartment of the leg.
   • It does not travel below the feet but can be challenging to palpate as it lies deep between the muscles of the lower leg.

3. Anterior Tibial Artery:

   • This artery passes down the front of the leg. It originates from the popliteal artery and travels down to become the dorsalis pedis artery at the ankle.

4. Posterior Tibial Artery:

   • Location for Palpation: This artery can be palpated behind (posterior to) the medial malleolus, which is the bony prominence on the inner aspect of the ankle.
   • It does not specifically involve the calcaneum (heel bone), but it runs down the inner aspect of the ankle close to the medial malleolus.

5. Popliteal Artery:

   • This artery is found at the back of the knee and is the continuation of the femoral artery. It is best palpated with the knee slightly flexed and relaxed.

6. Common Femoral Artery:

   • Location for Palpation: This artery is palpated in the groin at the mid-inguinal point, which is halfway between the anterior superior iliac spine and the pubic symphysis.

7. Aorta:

   • Palpating the aorta itself through the abdominal wall is challenging and usually only possible in thin individuals or when an abdominal aortic aneurysm is present.
   • Bruit: If there is aortic stenosis or an aneurysm, a “bruit” can often be heard using a stethoscope. A bruit is a whooshing sound made by turbulent blood flow.
   • Other Sounds: In the case of other vascular closures or narrowing, similar bruits can be heard at different sites along the arteries, depending on the location of the narrowing.

Lower Limb edema test

• Greet patient - take consent -

• Before proceeding with the physical examination, ask the patient if they are currently experiencing any pain in their limbs. This can help differentiate between edema due to fluid overload and edema due to inflammation or injury

• Using your thumb, apply firm pressure to the soft tissue of the area. Press down until the pressure of your finger causes a noticeable indentation.

• Maintain the pressure for about 10 seconds before releasing. This duration allows adequate time to displace the fluid and create a visible indentation if edema is present.

Grade the pitting edema if present:

• 1+ Mild pitting, slight indentation, no perceptible swelling of the limb
• 2+ Moderate pitting, indentation subsides rapidly
• 3+ Deep pitting, indentation remains for a short time, leg looks swollen
• 4+ Very deep pitting, indentation lasts a long time, leg is very swollen

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Palpitation

Palpation of Apex

Localization

Areas of maximum pulsation - Typically located in the left fifth intercostal space at the midclavicular line.

• Technique: Place your flat of your hand gently in this area to feel the pulsation. If the pulsation is not palpable, ask the patient to lean forward or turn to their left side, which may make the apex beat more apparent.

• Angle of Louis: Can be used as an anatomical landmark to help locate the intercostal spaces accurately; it is the protrusion formed by the joint of the manubrium and the body of the sternum.

Characterization

• tapping - mitral stenosis;
• raised finger ± heave apex = mostly likely aortic stenosis, Hypertension
• thrusting - Aortic/Mitral Regurgitation
• Implalpable
  • Poor technique
  • Obesity
  • Emphysema
  • Apex is Under the Rib
  • Shifted apex to the axilla; due Dilated Cardiomyopathy/Mitral Regurgitation
  • Pericardial effusion = Pericarditis // Friction rub sounds
  • Dextrocardia

Thrill

diastolic thrill, apex you hear mitral - thrill = palpable murmur after grade 3

parasternal heave

Location: Immediately lateral to the sternum.

Technique: Lightly place your hand over the left parasternal area to feel for any heaving motions.

Positive test Indicates

• Right ventricular hypertrophy, typically due to conditions like pulmonary hypertension or tricuspid regurgitation

Pulmonary Area

The pulmonary area is primarily used for auscultation (listening) rather than palpation (feeling). Heart sounds in this area are best heard in the second intercostal space at the left sternal border. This location is crucial for evaluating certain cardiac functions and sounds, such as those related to the pulmonary valve.

Aortic Area

aortic stenosis is typically assessed by auscultation (hearing for a murmur), in severe cases, a thrill (a palpable vibration) might be felt in the right second intercostal space near the sternum indicating Palpable Aortic Stenosis

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Auscultation

Heart Sounds

S1 -(Systolic)- S2 —> (Diastolic) —> S3,S4 —> S1 heard after S1 is systolic, after S2 is diastolic

Systole Murmur - aorta open Valvular stenosis

• Aortic stenosis or pulmonary stenosis (crescendo-decrescendo)
• heard best over the aortic area and often radiating to the carotids.

Diastolic Murmur -

• Mitral stenosis - characterized by a mid-diastolic rumbling murmur, best heard at the apex with the patient in the left lateral decubitus position.

• Aortic Regurgitation and Tricuspid Stenosis: Aortic regurgitation typically results in a “blowing” early diastolic murmur heard best along the left sternal border.

• left atrial myxoma & tricuspid

Opening snap; indicating leaflet is still moving and is still not calcified

Radiation

• Aortic stenosis; Typically causes a systolic murmur that can radiate to the carotid arteries. The presence of aortic calcification, which can be associated with aortic stenosis, does not necessarily cause pain but can contribute to the severity of the stenosis detectable via imaging or echocardiography.

• Mitral regurgitation; have pansystolic murmur that radiates to the axilla. The murmur starts with S1 and extends up to S2, indicating the backward flow of blood from the left ventricle to the left atrium throughout systole.

Sound Differentiation

• Tricuspid Regurgitation - swoosh dub murmur - RT. V. Hypertrophy

• Mitral Stenosis - LUB dub -

• Localization of Heart Sounds

• Mitral Stenosis:

• This condition is best evaluated by listening over the mitral area, which is generally found over the apex of the heart, toward the left side of the chest.

• Austin Flint Murmur of Aortic Regurgitation:

• S1 (first heart sound) is typically best heard in the aortic area, which is the right second intercostal space near the sternum. It is best felt in the pulmonary area, which refers to the left second intercostal space adjacent to the sternum.

• Tricuspid Stenosis:

• This is best heard over the tricuspid area, located at the lower left sternal border of the chest.

• Left Atrial Myxoma:

• Suspected when a tumor in the left atrium causes a sound, which can often be best detected near the heart’s apex.

• Diastolic Murmurs:

• These murmurs are generally quiet and can be challenging to hear. It is advisable for the patient to sit forward and hold their breath after exhaling to enhance the audibility of these murmurs.

Systolic Murmurs	Diastolic Murmurs/Sounds
AS = aortic stenosis	AR = aortic regurgitation
MR = mitral regurgitation	MS = mitral stenosis
HCM = hypertrophic cardiomyopathy	S3 = third heart sound
PS = pulmonary stenosis	PR = pulmonary regurgitation
VSD = ventricular septal defect	PDA = patent ductus arteriosus (continuous murmur)
I = innocent murmur	-

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JVP

• 45 degrees - don’t touch the patient
• Tell patient to look away from your side
• Between two heads of sternocleidomastoid, and arise till lobe of the ear
• 2-3cm then its normal JVP

Observe the level of the jugular venous pulse in the neck.

A positive abdominojugular reflux test suggests elevated central venous pressure, which can be due to right heart failure or constrictive pericarditis, among other conditions.

Watch the jugular vein as you apply pressure. A positive test is indicated by a sustained rise in the JVP of more than 3 cm that persists as long as pressure is applied and then quickly returns to normal when the pressure is released.

Locate the Sternal Angle (Angle of Louis): This is the bony prominence at the junction between the manubrium and the body of the sternum. It’s typically in line with the second rib and is a key landmark for assessing JVP.

Identify the highest point of the distended jugular vein pulsation. In cases of high venous pressure, this might be visible above this angle.

Place a ruler vertically on the sternal angle. Then use another ruler or straight edge to form a right angle with the first ruler at the level of the highest visible pulsation. This second ruler will help you measure the vertical distance from the sternal angle to the top of the JVP.

Calculating CVP:

• Measure the vertical height of the JVP above the sternal angle in centimeters. This height is added to a baseline pressure assumed to be approximately 5 cm H₂O, which is the vertical distance from the right atrium to the sternal angle when the patient is lying at 45 degrees

• For example, if the JVP is observed 3 cm above the sternal angle, the estimated CVP would be 3 cm (height of JVP above the sternal angle) + 5 cm (baseline pressure) = 8 cm H₂O.

Timing and Observation:

• The ‘A’ wave occurs after the P wave of the ECG and just before the carotid pulse.
• The ‘V’ wave occurs later in the cardiac cycle and peaks after the carotid pulse.

Causes for raised JVP

• Right sided heart failure
• Constrictive Pericarditis
• Restrictive cardiopathy
• Mitral Regurgitation; ---- A / V Wave
• Bronchogenic Carcinoma; without any waves - rest on this list has waves

JVP & Carotid Identification

JVP

• Visible but not palpable
• Two pulses - A and V
• hepatojugular reflux
• Change in respiration
• Between two heads of sternocleidomastoid, and arise till lobe of the ear

Carotid

• V + D, One pulse systemic
• Palpable, may be visible in some pathologies
• No hepatojugular reflex
• No Change in respiration
• medial to sternocleidomastoid - lateral to trachea

Hepatojugular Reflux

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Right Sided Heart Failure

Signs

• SVC; Raised JVP
• IVC; Tender hepatomegaly + acities + bilateral pitting edema

Left sided heart failure

• Bi-basal crackles; indicate pulmonary edema
• Pulmonary edema
• Audible S3,S4 Gallop Rhythm - usually not heard until heart strain

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Other notes

• Puts stethoscope in pocket whilst examining if finished with it
• To assess rate (bring your watch and put it in the pocket)
• Regurg not palpable
• Move Z with heart exam
• Heart with bell; low pitch for diastolic murmurs
• Hearing a turbulence blood flow (Bruits) narrow artery; athero