EXAMINATION OF CARDIOVASCULAR SYSTEM
EXAMINATION OF CARDIOVASCULAR SYSTEM
To examine and report on the cadiovascular system of the subject.
Requirements: Stethoscope, Sphygmomanometer, Scale
1. General Examination:
Any systemic examination should be preceded by a general examination.
The points relevant in cardiovascular system should be examined in a more detailed manner.
Foreg: dyspnoea, cyanosis, clubbing, oedema, pulse, blood pressure, JVP. pallor
2. Systemic Examination: This should be done in the following order.
1. Arterial pulse
2. Measurement of blood pressure
3. Examination of neck veins
4. Examination of precordium
Arterial pulse is a pressure wave transmitted along the systemic arteries, when blood is pumped into an already filled aorta during systole. It can be felt in the superficial peripheral arteries.
Usually arterial pulse is palpated at the wrist over the radial artery due to its superficial position. It is best felt with the tip of the middle three fingers, the patients forearm being semipronated and the wrist slightly flexed.
The following points regarding the arterial pulse should be noted:
a. Rate of the pulse: It denotes the number of beats per minute. The pulse rate should be counted for 1 minute (at least 30 seconds) while counting the pulse rate, the subject should be well relaxed.
Normal pulse rate is 60-100/minute. Average - 72/mm.
Pulse rate is higher in children, after meals, exercise and emotion
Tachycardia: An increase in pulse rate above 100
Seen in conditions like high fever, thyrotoxicosis, septic infections.
Bradycardia: An decrease in pulse rate below 60
Causes include typhoid, jaundice, hypothyroidism, heart block. It is also seen in atheletes. In cases of atrial fibrillation, the pulse rate counted at the wrist will be less than the heart rate. This difference is referred to as pulse deficit. This is detected by simultaneous examination of pulse and heart rate by two persons.
b. Rhythm of the pulse: It is the regularity with which one beat follows another. Irregularity is unequal spacing between beats. Note whether the rhythm is regular or irregular, if it is irregular, note whether it is irregularly or regularly irregular. Regularly irregular pulse is seen in extrasystole and irregularly irregular pulse is seen in atrial fibrillation.
c. Character of the pulse:
This is best studied by palpation of the carotid pulse with the thumb, pressed backwards at the medial border of sternocleidomastoid at the level of thyroid cartilage. A normal arterial pulse tracing has an upstroke and a downstroke. On the peak there is a percussion wave followed by a tidal wave and a dicrotic notch on the down stroke. In certain disease the character of the pulse is detected as abnormal.
Some examples are
1. Anacrotic pulse or slow rising pulse: This is typically a small volume pulse with a late systolic peak. Seen in aortic stenosis.
2. Collapsing pulse or water hammer pulse: This is characterised by rapid upstroke and downstrole. Most often seen in aortic regurgitation.
3. Bisferiens pulse: It is combination of slow rising and collapsing pulse. This occurs when aortic stenosis and aortic regurgitation occur together.
4. Pulsus alternans: Strong ventricular beats alternate with weak beats. It indicates severe left ventricular damage.
d. Volume of the pulse: This gives a rough guide to the pulse pressure which depends on strong volume and the compliance of the arteries. Note whether the colume is normal, low or high and equal on both sides.
e. Condition of the vessel wall: See whether the vessel wall is palpable or not. Normally it is not palpable, but in old age and atherosclerosis, the vessel wall becomes palpable.
f. Radio femoral delay: Normally radial and femoral pulsations are felt synchronously. Delay of the femoral pulse after the radial pulse is found in coarctation of the aorta.
g. Other peripheral pulsations: Note whether all the peripheral pulsations are normal and equal on boh sides i .e, carotid, brachial, radial, femoral, popliteal, posterior tibial, anterior tibial and dorsalis pedis pulsations.
Measurement of blood pressure: The blood pressure is recorded using the sphygmomanometer by palpatory and auscultatory methods and expressed in mm of Hg.
Examination of neck veins:
Examine the neck veins for any pulsation, the right internal jugular vein reflects the arterial pressure, as it is in direct line with the right atrium.
The subject is seated, propped up at an angle of 45°.The neck is supported so that the muscles, especially the sternocleidomastoids are relaxed. Look for the upper level of jugular vein pulsation, in good light. Normally it is not visible as the upper level is located behind the sternal angles. The vertical height from the angle of Louis to the upper level of the pulse wave is measured in centimeters and expressed as jugular venous pressure.
When jugular venous pressure is raised thejugular venous pulsations become visible in the neck. Jugular venous pressure is raised in right sided cardiac failure, superior vena cava obstruction, pregnancy etc.
Differences between arterial and venous pulsations in the neck
Jugular Venous pulse
More lateral in position
Better seen than felt
Definite upper level present
The level falls during inspiration
Different waves seen
More wavy, less sharp
Hepatojugular reflux seen
More medial in position
Better felt than seen
No definite upper level
Not affected by respiration
Single wave pattern
Sharp and expansible
No change during the procedure
i .e, the upper level rises with gentle abdominal pressure.