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INSPECTION OF CARDIOVASCULAR SYSTEM

Dr. Ch.VIJAY

Patient must be stripped to waist. Examined in good light. Examined in both upright and in lying down position. Examiner should sit or stand directly facing the patient.

The examination includes 2 parts :-

A) INSPECTION OF NECK B ) INSPECTION OF CHEST

VENOUS PRESSURE ARTERIAL PULSE ENGORGEMENT OF LEFT EXTERNAL JUGULAR VEIN DETECTION OF GOITRE WEBBING OF NECK

Venous pressure measured >3 cm above the sternal angle is considered elevated

NORMAL JUGULAR VENOUS WAVES

a wave - atrial systole x descent onset of atrial relaxation c wave - small positive notch in the 'x' descent due to bulging of the AV ring into the atria in isovolumetric ventricular contraction. v wave - after the x' descent - slow positive wave due to right atrial filling from venous return y descent - rapid emptying of the RA into RV due to TV opening

VENOUS PULSATIONS

ARTERIAL PULSATIONS Medial to SCM

b/w SCM 2 heads & clavicle Superficial ,widespread Visibility>>>palpability Obliterable Multiple pulsations Changes with -respiration -position -abd.pressure Upper limit visible 2 peaks/heart beat 2 descents,rapid

Deeper,localised <<< Not obliterable Single No change

Not visible 1 peak/heart beat 1 descent,slow **seen in AR,hyperkinetic states

CAROTID PULSATIONS

Carotid shudder A coarse vibration at the height of carotid pulse said to be diagnostic of combined AS+AR. Dancing carotids(Corrigans Sign) Massive pulsation of neck carotid arteries observed in AR. These pulsations are severe enough to cause visible movement of ears or head with each beat of heart(Alfred de Mussets sign). Pulsating carotids are usually indicative of wide arterial pulse pressure. Kinked carotid artery Males suggestive of coarctation of aorta. Females have a small pulsatile oval swelling in persons with hypertension, atheroma, and kyphoscoliosis. Prominent pulsation on right side of neck, in hypertension, is referred to as Rowntrees sign. contd

EPIGASTRIC PULSATIONS

Epigastric pulsation may be cardiac, aortic, or hepatic in origin.


Cardiac pulsations
Synchronus with apex More of retraction High up in epigastrium MS Lt sided pleural effusion

Character
Relation to apical thrust Thrust or retraction Location Causes

Aortic pulsations
Soon after apex More of thrust Low down in epigastrium Nervousness Transmitted pulsations by abdominal lump Aneurysm of abdominal aorta

Hepatic pulsations
Soon after apex More of thrust Right of the midline Enlarged pulsating liver in TR or TS

DISTENDED SUBCUTANEOUS ARTERIES :

Dilated and tortuos superficial arteries under the skin of the chest and back are a characteristic feature of coarctation of the aorta. Suzmans sign?

Size, shape and type of chest Shape of the precordium Apical thrust Other pulsations of the precordium Other pulsations of the chest wall Suprasternal or episternal pulsation

They have a direct bearing on presence of atypical or abnormal physical signs in the chest as in funnel chest, rachitic chest, and scoliosis, or the straight back syndrome. It is also responsible for diseased condition of the heart, as in emphysema and severe kyphoscoliosis.

Bulging or retraction of the precordium may be due to diseases outside the heart; they should be ruled out first, before implicating heart as the cause. PRECORDIAL BULGING :- A good sign for recognizing bulge in male is lateral displacement and elevation of left nipple in comparison with right. Causes : 1) Skeletal deformities 2) Diseases of lung and pleura 3) Diseases of heart or precordium

BACKWARD BULGE :1) 2)

Pectus excavatum Shield chest

PRECORDIAL FLATTENING :1) 2)

Old pericarditis or adherent pericardium Fibrosis or collapse of lung Scoliosis or kyphoscoliosis

3)

APEX BEAT v/s PMI :


The term PMI is often used as a synonym for an apex beat. It actually means point of maximum impulse i.e. the site of the loudest murmur. The maximal precordial pulsations may be due to Dilated pulmonary artery Large RV Ventricular aneurysm Aortic aneurysm

Hence THE DEFINITION OF APEX BEAT is the lowermost and outermost point of definite cardiac impulse, which can be appreciated.

NORMAL VARIATIONS :A.

B.
C.

D.

Infancy or childhood, apex is in 4th intercostal space. In thin, narrow chested, and elderly subjects, seen in 6th intercostal space. In obesity, abdominal distension and during pregnancy, it may be displaced slightly outward and upward by the raised diaphragm. Apical thrust is normally invisible in few persons due to 1) Heart being situated behind a rib 2) Thick chest wall 3) Pendulous breast 4) Emphysematous chest

POSTURAL SHIFT :A.

B.

C.

Mere shifting in bed from left lateral to the right lateral position may shift the apex as much as 11/2 to 2 inches. A change from recumbent to the upright position or even taking a deep breath may alter the position of the thrust. Failure of apical thrust to shift in this manner(with change in posture or on inspiration) is a sign of adherent pericardium.

APICAL THRUST MUST BE OBSERVED FOR : Presence or absence Location, whether normal or displaced Extent, whether localized or diffuse Direction of movement during systole, whether outward or inward (thrust or retraction) Lack of mobility or fixation Other characteristics

Displacement of apical thrust :- Due to

A) Extrinsic or Extra cardiac causes I) Extra thoracic scoliosis, straight back syndrome II) Intra thoracic Displaced i. sideways pleural effusion, pneumothorax ii. downwards aortic aneurysm, mediastinal new growth III) Intra abdominal ascites, meteorism, massive abdominal tumour or advanced pregnancy. B) Intrinsic or cardiac causes I) Congenital dextrocardia II)Acquired hypertension, aortic and mitral valve disease

Extent of apical thrust :A)

B)
C) D) E)

F)
G)

seen in Thin chest wall Hyperdynamic heart conditions Severe valvular regurgitation Left to right shunts Complete AV block Hypertrophic obstructive cardiomyopathy Retraction of lung from fibrosis or collapse

Diffuseness of thrust is

A double systolic outward thrust is characteristic of HOCM. It is also seen in mitral valve prolapse and LV dyskinesia as in acute MI.

Force of apex thrust :- force is visibly increased in


A)
B) C) D)

Thin chest wall Retracted lung Hyperdynamic heart LV hypertrophy as in hypertension or AR

Cardiac causes of invisible apex :A) B) C)

D)

Weak action of heart as in MI or acute myocarditis Pericardial effusion Dilation of heart Dextrocardia

Skodas sign :- (Negative cardiac impulse)


It is sucking in or retraction during systole of the apical region. It may be due to A) Hyperdynamic heart with apex situated behind a rib B) Hypertrophied right ventricle, with forward thrust in the midprecordial area and retraction of apex C) Adhesive pericarditis, a diagnosis justified only when retraction involves both ribs and interspaces (BROADBENTS SIGN)

Best observed by tangential inspection of precordial area, preferably with patient recumbent with lowering his eyes level to anterior wall of patients chest. Physiological diffuse pulsation (wavy or peristaltic cardiac impulse) : Seen in Thin chest individuals Hyperdynamic hearts During fever or after exercise Retracted lungs

Physiological para-apical retraction : A systolic retraction of

chest wall between the apical region and sternum, due to the sucking in effect of RV systole It may be mistaken for abnormal apex. It is however situated medial to true apex and is a retraction rather than a outward movement. Contd

Left parasternal pulsation :

A systolic heaving of the mid precordial area, maximal between 3rd and 6th ribs is characteristic of massive RV hypertrophy. A central lift may be due to systolic expansion of left atrium from mitral regurgitation. A heave in the left parasternal region may be due to LV hypertrophy.

Rocking or see saw movements : seen in massive


hypertrophy of right or left ventricle. In RV hypertrophy, an inward movement of the apex is associated with an outward movement of the midprecordium during systole In LV hypertrophy, the phenomenon is reversed

Diffuse systolic retraction : A diffuse retraction of

precordial area, involving ribs and interspaces is due to the Tricuspid regurgitation Adhesive pricarditis Aortic regurgitation

Lateral retraction in lateral decubitus position due to

Large RV or severe TR (with initial outward movement) Constrictive pericarditis: systolic retraction (with initial outward movement), followed by diastolic thrust

High thoracic pulsations : Observed in 2nd right

intercostal space or behind the upper part of the sternum indicative of Aneurysm of the ascending or transverse part of aortic arch Dilatation of the aorta AR Pulsations involving the 2nd or 3rd left interspace due to : Dilatation of pulmonary artery as in PDA or septal defects,MS or aneurysmal dilatation of P.artery. Retraction of left lung from fibrosis or collapse. Aneurysm of descending thoracic aorta

Pulsations of sternoclavicular joint: Due to


Right side suggests right sided aortic arch Either side occurs in aortic dissection or aneurysm Systolic outward pulsation of upper half of sternum is due to aneurysm of ascending aorta Pulsation to right of sternum is due to dilated and unfolded ascending thoracic aorta and rarely due to large right atrium

Pulsations in atypical situations


CAUSE
Empyema necessitates Lymphosarcoma Descending thoracic aorta aneurysm Innominate artery aneurysm Coactation of aorta

LOCATION
Pulsatile swelling in lateral aspect of chest wall Highly vascular tumour in mid sternum Back Supraclavicular region or upper part of thorax Interscapular and intercostal regions

It may be seen in Hyperdynamic heart. Anemia. Aneurysm of aorta. Dilatation of aorta as in atheroma or syphilitic aortitis. Raised or uncoiled aorta as in hypertension. Elongation and flexion of the innominate artery. Anomalous right subclavian artery. Thyroidea ima artery.

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