Clinical Examination Cardio - Vascular System

 Clinical Examination Cardio - Vascular System

 

Inspection: Chest and pericardium. 2) Neck veins. 3) Veins on the chest wall.

4) Cardiac impulse or Apex beat. 5) Other pulsations.

 

1) CHEST AND PERICARDIUM: Shape Normally the chest is bilaterally symmetrical and Elliptical in shape of the chest-varies with the build of the individual i.e. often being, broad and deep in the thick and long, flat and narrow in tall.

 

Chest Depor Mites:

1. Scoliosis (Lateral bending)
2. Kyphosis (Forward bending)
3. Pigeon - chest (Ricket)
4. Flattening of one apex (Apical fibrosis due to tuberculosis)
5. Barrel shaped chest [obstructive disease)

 

NECK VEINS: Neck veins should be examined with the patient in a good light and reclining at an angle of about 45⁰ veins normally show slight pulsation and 3 small waves can be distinguished in each cardiac cycle. There is mean level and the perpendicular height of this level in health is the same as that of mauu-brium sterni-i.e. in healthy person recycling at angle 45⁰ the mean level (definite upper level) will be invisible because it is below the clavicle but some slight pulsation may appear above the clavicle Arterial pulsation may also be visible in the neck. Neck should be supported so that the neck muscles are relaxed.

 

Vanous Pulse                                                                       Arterial Pulse

1. It is more sinous & less sharp                                        1. It is more sharp& thirsting in nature

2. Mean level falls during inspiration                               2. No. change

3. It is impalpable                                                                3. Easily palpable

4. Firm pressure (Gentle) on the                                        4. No. change

abdomen (rt) will rise level

 

                Raised venous pressure is usually indicative of Rt. heart failure. Slight rise in venous pressure also occurs with an increase in the circulation blood volume e.g. pregnancy and acutencphritis.

 

Veins on the Chest Wall: Veins will .be seen a) Normally seen when the patients skin is unusually transfarent when intra-thoacic growth or aneurysm obstructs the of blood to the heart.

 

c) When portal obstruation or inf. vena.cava obstruation is present.

 

Cardiac impulse: It is lowest and outer most impulse seen per felt, usually seen in the left 5^th  I C S about 9cm [3 ½]  away from midline or [1 ½] medial to the midclavicular line. It may be seen or felt in the ant, exillary line if the person is laying on his left side.

Displacement of apex beat

1. Commonest cause is thoracic diformities e.g. Scoliosis
2. Real displacement may be due to disease of the surrounding viscera which push or pull it from its usual site.

 

Pushing: Found in pleural effusion and pneumothorax.

Pulling: Found in pulmonary fibrosis, collapse of the lung diseases of the heart (left ventricular (hypertropy)

                Left ventricle normally produces the apex beat, one should also remember that it is left on the Rt side in congential dextrocardia.

 

Other Pulsations: Should be looked

i. In the nect

a)       Normally pulsations can be seen visibly on exertion and from mental excitent.

b)       Thyrotoxicosis

c)       Aortic incompetence

d)       Hypertension.

e)       Aneurusm of Aorta

 

ii. In the supre-sternal notch: seen in

a)       Hyper-tension

b)       Coarctation of the aorta

c)       Aneurysm of the arch of the aorta

 

iii. In the thorax : pulsation seen in

a)       Aneurysm of aorta              - Ascending

                                                        - Descending

                                                        - Transverse

b)       Coarotation of aorta.

 

iv. In the epigastrium :

a)       Pulsation is most commonly due to nervousness of excitement in a thin person.

b)       Less commonly seen due to transmission of aortic pulsation by a tumour such as carcinoma of the stomach.

c)       Occasionally due to distensible pulsation of the liver in heart failure with tricuspid regurgitation.

d)       Very rarely seen due to aneurysm of abdominal aorta.

 

Palpation: All the inspectory findings should be confirmed by palpation

1. Shape Of the chest
2. Neck veins
3. Veins over the chest wall
4. Cardiac impulse
5. Other pulsations in the neck, suprasternal notch over the chest and, in the epigastric region.
6. One should palpate the praecordium for the presence of thrill.

                Thrill is palpable murmur and on palpation it will give a sensation of a purring of a cat. It is due to abnormal load heart sounds.

 

Percussion: This Examination is done to know the limits of the heart i.e. to make out the borders of the heart especially left & right border.

 

Left Border: To precuss for the lef tborder of the heart one should localise the apical impulse i.e. left 5^th I.C.S. afterwards one should go to mid axilary line & start pecussing in left 5^th  I.C.S. and come towards heart. The moment you approach the heart there will be change in the note i.e. from resonant to dull note and mark a point by the skin surface marking pencil. Then you repeat the same procedure in the 4^th, 3^rd and 2^nd left I.C.S spaces and mark another three points. Now one should join these four points this is the. Limit of the heart on the left side.

 

                To percuss for the Rt. border: First percuss for the liver dullines on must go to one space above this i.e. Rt 5^th I.C.S. in the midaxilary line and start percussing and approach the sternum note down: the change of the percussion note from resonant to dull. Continue the precussion and approach the heart till one must get the more dull note that limits the Rt border of the heart in the Rt 5^th I.C.S. repeat the same procedure for R.t 4^th, 3^rd, 2^nd I.C spaces and mark the four points and join the. This is the Rt border of the heart.

 

Auscultation: It is done by using the stethoscope.

a) The following areas to be auscultated

1) Mitral area. 2) Tricuspid. 3) Aortic area. 4) Pulmonary area

 

I & II heart sounds are usually heard in all the four areas but I Heart sound is best heard in the Mitral and tricuspid areas and II Heart sound is best heard in the Aortic and pulmonary areas. One must differentiate between I & II heart sounds.

 

I.H.S	I.H.S
1) It is dull, prolonged and low pitched	1) Short, sharp & high pitched
2) Duration 0.l to 0.l7sec	2) Duration 0.14 sec
3) Best heard in Mitral tricuspid areas	3) Best heard in aortic and pulmonary areas
4) It coincides with apex best and coincides with carotid pulse	4) If comes after the commencement of the apex best and after carotid pulse
5) It coincides with R wave of ECG	5) It comes after T wave of ECG
6) It coincides with the C wave of the JVP	6) It coincides with the notch of the ascending limb of V wave

 

b) One must auscultate for the presence of any abnormal loud heart sounds i.e. murmus.