CARDIOVASCULER ASSESSEMENT

8/10/2019 CARDIOVASCULER ASSESSEMENT

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Cardiovascular Patient Assessment

A. A. Gede Budhitresna, MD, PhD,FINASIMSANJIWANI GENERAL HOSPITAL

WARMADEWA SCHOOL MEDICINE

2013


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Objectives :Outline a systematic approach tocardiovascular assessment.Differentiate normal from abnormalfindings when assessing thecardiovascular system.Relate the events of the cardiac cycle toauscultatory findings.


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Assessing Patients CV Status History & Subjective Data

Past Medical historyPrevious IllnessDiagnostic/interventional cardiac proceduresHospitalizations

Surgeries Allergies

AMPLE


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Assessing Patients CV Status CCCommon signs and symptoms of CVdisease

Chest pain (most common CV symptom) Angina

often described as pressure rather than pain Usually brought by physical/emotional stressLast: 2-5 minutes ; rarely > 20Relieved with rest / NTG


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Assessing Patients CV Status Dyspnea

Subjective sensation of being unable to breath

Usually cause by congestion from LVFTypes:

Dyspnea on exertion (DOE)Orthopnea : inability to breathe while lying flat

Paroxysmal nocturnal dyspnea (PND): nightimeepisodes of SOB due to lying flat which increasesvenous return (preload)


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Assessing Patients CV Status Fatigue / WeaknessSymptom of decreased forward COUsually seen as unusual fatigue at end ofnormal day previously toleratedExertional fatigue : sense of weakness orheaviness of extremitiesMedications that can cause fatigue:

Diuretics : orthostatic hypotension , hypokalemiaBeta Blockers, Calcium Channel Blockers, Digoxin,antihypertensive medications


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Assessing Patients CV Status Fluid retention

Fluid accumulation in tissues

Common cardiac causesHeart failureConstrictive pericarditisRestrictive cardiomyopathies

Weight gain of 2 lbs in 4 days or 3-5 pounds over amonth may be indicative of heart failureMore severe in evening


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Assessing Patients CV Status Syncope/Presyncope

Temporary loss of consciousness,lightheadedness, dizzinessCardiac cause most commonly result ofinadequate cardiac output from arrythmias


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Assessing Patients CV Status Palpitations

Awareness of heart beat with sudden

changes in rate, rhythm, increased strokevolume Associated with : tachycardias,bradycardias, atrial fibrillation, PVCs, aortic

and mitral regurgitation, signs of heartfailure


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Assessing Patients CV Status Other symptoms

Decreased urine outputIndicative of heart failure and hypovolemiaLook for concomitant weight gain due to CHF

Nocturia

Sign of heart failureCaused by increased preload to heart


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Assessing Patients CV Status Risk FactorsNon-modifiable

Age

SexFamily historyRace

ModifiableCigarette smoking

HypertensionHyperlipidemiaPhysical inactivityDiabetesStressObesity


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FAT : Adipose Tissueendocrine function

adipokines Leptin

Pro-thrombotic Anti-inflammatorySatiety to hypothalamus

ResistinHormone making tissueinsulin resistant

Type II DM AdiponectinCounteracts negativeeffects of otherhormones


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Brown Fat vs. White Fat


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Cholesterol Level :

AHA RecommendationTotal Cholesterol

< 200 mg/dL

best200 239

borderline high

240 mg/dL and

above 2X risk of CAD


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Cholesterol Level :

AHA RecommendationHDL Cholesterol

< 40 mg/dL (men)

< 50 mg/dL(women)> 60 mg/dL

cardioprotective


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Cholesterol Level :

AHA RecommendationLDL Cholesterol

< 100 mg/dLOptimal

100 129 mg/dLNear or above optimal

130 159 mg/dLBorderline

160 189 mg/dLHigh190 mg/dL

Very high


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Cholesterol Level :

AHA RecommendationTriglyceride

< 150 mg/dL

Normal150 199 mg/dL

Borderline high

200 499mg/dL

High500 mg/dL andabove

Very high


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Know youre A -B-C NumbersHemoglobin A1c

Measures an average BSover 3 months

Goal : under 7%Prefer under 6.5%Blood Pressure

< 130/80 mmHgCholesterol

Total : < 200 mg/dlHDL : > 45 mg/dl in men ;55 mg/dl in womenTriglycerides : < 150 mg/dl


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Assessing Patients CV Status Social History

Alcohol intake

Dietary pattern: caffeine , salt intakeCocaineEducational level

Medication HistoryPrescribed drugsOTC


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Salty FoodsSalty Foods


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Physical ExaminationInspection

General appearanceColor

Cyanosis 5 gm desaturated hemoglobinCentral Cyanosis

Decreased SaO2 usually < 80%Indicates cardiopulmonary diseaseSeen in buccal mucosa, conjunctiva

Peripheral CyanosisReduced blood flow to extremitySeen on tip of nose, ears, distal extremitiesIndicates low CO as in late heart failure or shock


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Physical ExaminationJaundice

Best seen in scleraSeen in late heart failure caused by hepatic impairment

PallorIndicates anemia or increased SVRInspect palm of hands

Jugular Venous PressureExtremities

Arterial insufficiency4 Ps of blocked arteries

PulselessPallorPain

Paralysis


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Physical ExaminationSkin Changes

Taut, skinny, scaly, atrophiedUlcerations common above lateral malleolus, paleextremely painfulLoss of hair especially lower leg

Delayed capillary fillingProvides estimate of peripheral blood flowNormal return < 2 seconds ; if more indicates low CO, lowvolume, low SVR

Nails Venous insufficiencyThrombophlebitis

Homans Sign calf pain with dorsiflexion


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Physical ExaminationPalpation

EdemaUsually not detectable until interstitial fluidvolume is 30% above normal (7-10lbs)Bilateral edema

Progression from ankles,legs,thighs,genitalia,and

abdomen, presacral for bedrestIndicative of heart failure or bilateral venousinsufficiency (unilateral seen in venous thrombosisand lymphatic blockage of extremity)


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Physical Examination Anasarca

Generalized edemaSeen in severe heart failure, hepatic cirrhosis, andnephrotic syndrome

Edema scale : evaluated by pressing thumb for 5seconds

0 = absent+1 = slight indentation : disappears rapidly+2 = indentation readily noticeable : disappears

within 10-15 seconds+3 = deep indentation ; disappears within 1-2

minutes+4 = marked, deep indentation ; may be visible in >5min


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Physical ExaminationSkin Turgor

Arterial PulsesRate and rhythm

Pulse volumeSimultaneous bilateral evaluation requiredCommon abnormalitiesWeak, thready pulseBounding pulsePulsus alternansBigeminal pulsePulsus Paradoxus strong on expiration, weak oninspiration ; present if difference in systolic pressurevaries > 15 mm Hg between inspiration and expiration


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Physical ExaminationPulse Rating

0 = absent, may be heard with doppler1 = feeble, difficult to palpate, fades in and out2 = faint, easily obliterated3 = normal, easily palpated, not easily obliterated4 = bounding, strong, hyperactive, not obliterated

by pressure

D = doppler only


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Physical Examination Auscultation

Blood pressure

Overall reflection of LV functionSystolic represents force of contractionDiastolic represents vascular resistance (afterload)Pulse pressure difference between systolic and diastolic

Widening

NarrowingOrthostatic changes minimum 3 minutes wait ;>10mm Hg drop


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Physical ExaminationHeart BordersSpecific areas for examination

Aortic area: 2 nd ICS, RSBPulmonic area: 2 nd ICS, LSB Tricuspid area: 5 th ICS, LSBMitral or Apical area: 5 th ICS, MCLErbs point: 3 rd ICS, LSBEpigastric : over xyphoid process


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Physical ExaminationHeart Sounds

Closure of valvesS1

first heart sound lub; closure of AV valves heardloudest at mitral and tricuspid areas; usually lowerpitch than S2

S2 second heart sound dub; closure of semilunarvalves; heard best at aortic and pulmonic areas


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S3 Ventricular gallopHeard in early diastole, just after S2

Ken-tuc -ky Due to rapid, early ventricular fillingIndicates loss of ventricular compliance, diastolicoverloading, heart failure

Heard best : bell, mitral area if produced by leftheart ; along sternal borders if produced by rightheart

Physical Examination


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Physical ExaminationS4

Atrial gallopHeard in late diastole, just before S1

Ten -nes- see Results when ventricular resistance to atrial fillingincreased from decreased ventricular compliance orincreased ventricular volumeSeen in: ventricular hypertrophy, ischemic heart disease,MI, hypertension, mitral regurgitation

Summation GallopPresence of all four sounds. S3 and S4 merge into onesoundOccurs at rates > 100Occurs in heart failure


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Physical ExaminationMurmursProduced by increased or turbulent blood flowOften imply significant disease of heart valves, greatvessels, or septal defects

Classified by the following characteristicsTiming: systolic or diastolicPitch: high or lowQuality: blowing, harsh, musical, rumblingIntensity: graded from I-VII = barely audibleII= faint, but immediately available

III= easily audibleIV= loud, usually accompanied by thrill V= very loud, always accompanied by thrill

VI= very loud, can be heard with stethoscope off chest


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Physical ExaminationHeart Murmurs Shape/Configuration

HolosystolicReferred to as plateau or pansystolicOccurs in systole

CrescendoDecrescendoCrescendo-Decrescendo

Innocent MurmursHemodynamically insignificant, physiologicNot associated with cardiac diseaseCommon in children and pregnant womenFound in hyperthyroidism, anemia


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Physical ExaminationExtracardiac Sounds

Pericardial Friction RubsCaused by inflammation of pericardiumRough, scratchy, squeaky sound like two pieces of leatherrubbing against each otherBest heard with patient leaning forward, holding breath infull expiration

C licks

Mediastinal crunchSystolic snap Venous hum


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Thank You !

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CARDIOVASCULER ASSESSEMENT