|Written by Dr.Md.Redwanul Huq (Masum)|
|Sunday, 23 December 2012 14:18|
I) General assessment:
anemia or polycythemia,
Details of pulse:
1) Radial pulse- rate, rhythm & volume
2) Compression of radial artery against lower end of radius to see condition of the vessel wall
3) Examination for collapsing pulse by radial artery
4) Radial symmetry
5) Radio-femoral delay
6) Brachial symmetry
7) Carotid artery (not simultaneously on two sides) – to see volume & character of pulse
8) Femoral symmetry
9) Popliteal arteries on both sides (one by one)
10) Arteria dorsalis pedis of both sides to see presence & symmetry
11) Posterior tibial arteries of both sides to see presence & symmetry
Details of JVP:
Two scales & a pencil.
Patient is reclined at 45° and examined for Jugular vein between two heads of sternocleidomastoid muscle. If not seen then normal right artial pressure is confirmed by doing abdomino-jugular reflux or hepato jugular reflux. If JVP is raised, height of JVP is measured vertically by two scales in cm (of H2O) from sternal angle to the top of venous pulsation.
II) Examination of the precordium:
a) Appearance:Shape, skin condition (scar, superficial vein, lump, lesion]
b) Visible cardiac impulse.
c) Apex beat- Location.
i) Apex beat:
Location of the apex beat is determined at first by palm of the right hand
(at the level of heads of metatarsal bones) & then by right index finger.
Then counting the intercostal space & measuring the distance from midline
by measuring tape in cm.
ii) Tapping: Just touch the finger & then fade away. It is found in mitral stenosis.
iii) Heaving: Forceful & sustained pressure on the index finger. It is found in
left ventricular hypertrophy due to aortic stenosis or systemic hypertension
or coarctation of aorta.
iv)Thrusting: Forceful pressure (but not sustained) on the index finger. It is
found in volume overload due to aortic regurgitation or mitral regurgitation.
Palpable murmur is called thrill.
The areas are: Mitral area, tricuspid area, pulmonary area and aortic area.
iii) Left parasternal heave–
It is felt at left sternal margin in 3rd or 4th intercostal space with breath holding on
expiration by heel of right hand.
iv) Palpable A2 & P2: These are felt in aortic & pulmonary areas respectively.
It is done in examination of the precordium for determination of area of the heart-
i) From right side of the chest horizontally for right border.
ii) From upper left side of the chest obliquely downwards for base.
iii) From lower left side of the chest obliquely upwards for inferior border.
Auscultation sounds are-
i) In four areas (mitral area, tricuspid area, pulmonary area and aortic area) for:
a) 1st & 2nd heart sounds
b) 3rd & 4th heart sounds
c) Additional sounds, e.g. clicks & snaps
e) Bilateral basal crepitation.
(At first all the four areas are auscultated for 1st & 2nd heart sounds, then all these
areas are again auscultated for other findings)
ii) Pericardial rub.
iii) Aortic bruits.
[Areas of best hearing of heart sounds:1st heart sound in mitral & tricuspid areas, 2nd heart sound in aortic & pulmonary areas, 3rd sound in mitral area (auscultated by bell)]
Details of murmur:
For auscultation in above described four areas for murmur at first left thumb is pressed transversely against right carotid artery then- murmur is auscultated by diaphragm of the stethoscope in four areas.
If the murmur coincides with carotid pulsation, it is systolic murmur, so for radiation- auscultation is done in-
* Axilla- if systolic murmur is in mitral area.
* Right to tricuspid area- if systolic murmur is in tricuspid area.
* Below left clavicle- if systolic murmur is in pulmonary area.
* Over right neck- if systolic murmur is in aortic area.
If the murmur doesn’t coincide with carotid pulsation, it is diastolic murmur.
* Mitral diastolic murmur (i.e. in mitral stenosis) bell of the stethoscope is used at mitral area in left lateral position (breath holding on expiration).
* In all other diastolic murmur- diaphragm of the stethoscope is used.
* In aortic diastolic murmur (i.e., in aortic regurgitation)- diaphragm of the stethoscope is used at tricuspid area & then aortic area with the patient leaning forward & holding breath on expiration.
- Breath hold on expiration is needed to auscultate the murmur produced by valves of left side of the heart i.e. by mitral (in mitral stenosis) & aortic (in aortic regurgitation) valves, as filling of left heart is more in expiration.
- Breath hold on inspiration is needed to auscultate the murmur produced by valves of right side of the heart i.e. by tricuspid & pulmonary valves, as filling of right heart is more in inspiration.
Description of a typical murmur of mitral stenosis:
It is a mid-diastolic murmur in mitral area, which is low-pitched, localized, rough, rumbling (hints:LLRR), best heard with bell of the stethoscope, in the left lateral position with the breath holding on expiration, with pre-systolic accentuation.
Pan-systolic murmur is audible throughout the systole from 1st to 2nd heart sound.
Loud & blowing
d) Mitral valve prolapse
Causes of abnormal pulse:
1. Rate & rhythm:
a) Increased pulse rate- See causes of tachycardia
b) Decreased pulse rate- See causes of bradycardia
c) Pulsus bisferiens- In aortic stenosis concomitant with aortic regurgitation
d) Pulsus alternans- In LVF
e) Pulsus bigeminy- In Digitalis toxicity
f) Anacrotic pulse- In aortic stenosis
g) Pulsus paradoxus- In constrictive pericarditis, pericardial effusion
h) Pulsus deficit- This abnormal pulse is found in atrial fibrillation.
a) High volume pulse- See causes of high volume pulse.
b) Low volume pulse- See causes of low volume pulse.
3) Condition of vessel wall–
Vessel wall becomes hard in case of atherosclerosis.
4) Radio femoral delay–
seen in coarctation of aorta.
5) Absence of pulse:
Found in peripheral vessels in cases of peripheral vascular diseases.
Difference between systolic murmur & diastolic murmur:
1) Heard between 1st & 2nd heart sound
2) Coincides with carotid pulse
3) Radiation- present
4) Time of occurrence- during systole
5) Thrill- more obvious
6) Causes- MR, AS, TR, PS
1) Heard between 2nd & 1st heart sound
2) Dose not coincide
4) During diastole
6) MS, AR, TS, PR
Three important features of Right heart failure:
1) Engorged neck vein
2) Enlarged, tender lever.
3) Dependent edema.
Features of left ventricular failure:
Left Ventricular Failure has the following features-
1) Tachycardia with low volume pulse
2) Shifted apex beat
3) Bilateral basal crepitations
4) Pulsus alternans
5) Gallop rhythm: Tachycardia with audible 3rd & / or 4th heart sound.
* In proto-diastolic gallop- 3rd heart sound audible.
* In pre-systolic gallop- 4th heart sound audible.
* In summation gallop- 3rd & 4th heart sounds audible
Differences between Jugular venous pulse (JV pulse) & carotid pulse:
1) Can be compressed
2) Usually visible
3) Two waves per beat
4) Hepato-jugular reflux is found.
5) Varies with respiration
6) Varies with posture
7) Rapid inward movement
1) Cannot be compressed
2) Usually palpable
3) One wave per beat
4) Not found
5) Does not vary
6) Does not vary
7) Rapid outward movement
Differentiation of dyspnea of cardiac origin from respiratory origin-
Dyspnea of cardiac origin (in LVF)
Dyspnea of respiratory origin
1. Previous H/O heart disease – yes
2.Previous H/O dyspnea-Usually – No
3. Allergic history- No
4. Frothy sputum- Yes
1. Usually -No
3. Usually -Yes
Rapid & shallow breathing,
Cardiomegaly, Vulvular murmur Bilateral basal crepitation
Vesicular breath sound with prolonged expiration, Bilateral widespread respiratory rhonchi
CXR: Cardiomegaly, pulmonary
Verbal description of normal Pulse:
Pulse of the patient is 72 beats/min, regular, normal of no definite character, symmetrical on both sides with no radio-femoral delay, condition of the arterial wall is neither thickened nor tortuous.