Comprehensive Guide to Cardiovascular Examination and Diagnosis Techniques

 

Heart and Circulatory System

The Cardiovascular System (CVS) is a particularly pleasant clinical examination since it typically results in an accurate diagnosis. Studies are conducted in order to support the clinical impression or to distinguish between several options.

Symptoms

Thorough history taking is essential for the early detection of major cardiac conditions such as heart failure and ischemic heart disease.
Dyspnea and chest discomfort are the two hallmark signs of cardiovascular disease.

Main Signs and Symptoms of Heart Illness

Dyspnea

• Orthopnea,
• Paroxysmal nocturnal dyspnea
• Exertional dyspnea

Chest Pain

• Angina infarction
• Ischemic heart disease
• Pericarditis
• Aortic dissection

Dyspnea

Breathing difficulties is referred to as dyspnea or breathlessness. It might happen while you're at rest or while you exert yourself.

Dyspnea Exertional

It is a sign of cardiac failure that appears early. In the beginning, it might happen after an unusually high or intense exercise, but as the illness worsens, the patient might run out of breath even after taking a few steps.

Dyspnea Nocturnal Paroxysmal

The patient usually has a cough and frothy sputum when they wake up in the middle of the night from severe dyspnea that becomes better after sitting upright for a few minutes. Paroxysmal nocturnal dyspnea is the term for this. This is because, while in a recumbent position, there is an enhanced venous return to the heart, which causes temporary pulmonary edema. This characteristic of left heart failure is caused by severe left ventricular disease (cardiomyopathy, ischemic heart disease), hypertension, mitral/aortic valve disease, and left ventricular pressure/volume overload.

Orthopnea

Orthopnea is the term for people with severe heart failure whose dyspnea gets worse when they lie flat.

Edema pulmonary

The primary source of the fluid transudation into the pulmonary alveoli is left heart dysfunction. The symptoms include severe dyspnea, prolonged dyspnea, and large amounts of frothy, watery, blood-stained sputum from the cough.

Chest Pain

It is a significant heart disease symptom. Its traits change depending on the underlying condition.

Heart Ischemic Disorder

It indicates that the myocardium is not receiving enough blood from the coronary arteries. It could show up as an infarction or angina.

Pectorile Angina

There is momentary heart blockage. When the patient exerts themselves, they have chest pain, which is quickly resolved with rest and sublingual nitroglycerin. Retrosternal pain spreads across the chest, causing radiating pain to the left arm and mouth. The patient reports it as feeling heavy or like a tight band around their chest. Sweating, palpitations, and dyspnea may be linked to it. The agony lasts for less than half an hour in total.

Myocardial Ischemia

One or more coronary artery branches completely close, resulting in the death of the reliant myocardium. The pain is comparable to angina pectoris, but it lasts longer than 30 minutes and is not reduced by rest or sublingual nitrates.

Pericarditis

Ischemic heart disease pain is comparable to the symptoms of pericarditis. Exercise, rest, or nitrates have no effect. Leaning forward helps ease it, and coughing and hard breathing might make it worse.

Cutting open the Aorta

The pain is felt in front of the chest, behind the scapulae, or at both locations. It has a rapid onset, is intense, and has a tearing quality.

Heart Attack

Pulmonary infarction is caused by peripheral embolism. Pleuritic discomfort is addressed under the respiratory system. An ischemic heart disease-related discomfort cannot be distinguished from that of a major central pulmonary embolism.

Precordial Catch

It is a common, brief, sharp pain reported by normal persons at the location of the heart apex. It is meaningless. Cardiac illness is not the cause of persistent precordial pain that is unrelated to exertion.

Palpitation

It is a common symptom of anxiety and is the awareness of one's heartbeat. It also happens in heart failure and tachycardia.

Analyzation

Unless instructed otherwise, always begin the examination with a broad physical examination before moving on to a more detailed evaluation of a patient's system.

1. Examining the cardiovascular system includes the following:
2. Checking the pulse
3. Blood pressure measurement
4. Neck vein examination
5. Precordium examination using the following methods:

• inspection
• palpation
• percussion
• auscultation

Analysis Of Pulse

The left ventricle contracts, sending a wave into the blood column that is ten times quicker than the blood itself. This wave is known as the pulse. Wherever an accessible artery can be applied pressure to a bone beneath it, a pulse can be felt. The radial, brachial, carotid, femoral, popliteal, posterior tibial, and dorsalis pedis pulses are frequently felt. When an adult's systolic blood pressure drops below 50 mmHg, their pulse becomes impalpable.

Radial Pulse

The most accessible and frequently felt pulse is the radial pulse. The patient's hand ought to be pronated and slightly flexed. Apply pressure to the head of the radius with the radial artery.

Brachial Pulse

Extend the patient's arm and feel for the biceps tendon. Using the thumb of your other hand, press on the tendon's medial side.

Carotid Pulse

Press backwards while placing your thumb or fingers of the other hand along the anterior border of the sternomastoid, at the level of the laryngeal cartilage. Remember that stimulation of the carotid sinus, which is located near the common carotid artery's bifurcation, may cause bradycardia or syncopy. Avoid palpating both carotid arteries at the same time since this could severely restrict the blood supply to the brain. Feel the left carotid from the left side and the right from the right.

Femoral Pulse

Place your thumb or finger midway along the inguinal ligament, between the pubic tubercle and the anterior superior iliac spine.

Popliteal Pulse

The popliteal artery is difficult to palpate because it is located deep within the popliteal fossa. With the thumb on the patella, flex the knee to a 120° angle and press both hands' fingers into the popliteal fossa.

Dorsalis Pedis Pulse

Palpate in the proximal region of the first intermetatarsal gap to release the dorsalis pedis pulse. Step behind the medial malleolus to feel the posterior tibial pulse.
When examining the pulse, take note of the following characteristics:

1. Velocity
2. Harmony
3. Volume
4. Character
5. Evaluation in relation to other pulses
6. The state of the wall of the vessel

Rate

Complete a minute-long pulse count. Seventy-two beats per minute is the typical pulse rate. With the exception of some arrhythmias like atrial fibrillation, it is identical to the heart rate.

Tachycardia

A tachycardia is defined as a pulse rate more than 100 beats per minute.

Bradycardia

A pulse rate of less than fifty beats per minute is indicated.

Compared to Bradycardia

Typically, the pulse increases by 10 beats per minute for every degree Fahrenheit (0.5°C) as the body temperature raises. Relative bradycardia is the term used to describe a pulse rate that is lower than expected given the body temperature.

Beat

Normally, the rhythm is regular and the beat interval is consistent. Its pulse becomes erratic if it is disrupted.

Sinus Arrhythmia

Pulse rate is quicker during inspiration and slower during expiration in a sinus arrhythmia. This is a common occurrence that manifests itself more strongly in some people. In cardiac failure and autonomic neuropathy, it vanishes.

Sporadic Irregularity

Premature beats are to blame. A premature beat is a weak beat that starts earlier than the typical beat and ends with a lengthier pause. In healthy persons, occasional premature beats are typical and of no consequence. When a patient has underlying cardiac disease, frequent premature beats need to be handled seriously.

Inconsistently Irregular

The beats are erratic and lack regularity. If the rate is rapid, detection is simpler.

Reasons For a Wildly Erratic Heartbeat

1. Heart arrhythmia
2. Several early beats that occur frequently
3. Varying block in atrial flutter

Pulse Deficit

The heart rate measured by auscultation is higher than the pulse rate in atrial fibrillation because part of the weak left ventricular contractions are not carried to the arteries. Pulse deficit is the term used to describe the ensuing discrepancy between heart rate and pulse rate.

Atrial Fibrillation Causes include

1. Mitral stenosis
2. Hyperthyroidism
3. Ischemic heart condition
4. High blood pressure.

The Pulse's Volume

The degree of displacement of the fingers used for palpation determines the pulse wave's amplitude. The pulse may be low (heart failure, hypovolemic shock), high (e.g., fever, aortic regurgitation), or normal (learned by experience). Stroke volume is seen in younger individuals. The vessel wall stiffens with age, and the pulse volume exceeds the predicted stroke volume.

The Nature of the Pulse

The pulse wave has a particular wave structure or character in some disorders. For this reason, a significant pulse near the heart (brachial, carotid, or femoral) should be felt.

Pulse That Rises Slowly (Pulsus Plateau)

It rises gradually, has a low loudness, and lingers on the palpating finger for a prolonged period of time. The pulse pressure is limited. In aortic stenosis, it happens.

Collapsing Pulse

Water hammer pulse, also known as a collapsing pulse, is a high volume pulse that has a typical upstroke and a quick downstroke.
Using your right palm, grasp the patient's wrist so that the radial pulse may be felt along the prominences of the metacarpophalangeal joint. Using your left hand to hold the patient's fingers rather than your right, quickly raise his arm. Due to the effect of gravity, there is a brief increase in blood flow towards the heart, and the pulse's compressing nature becomes more noticeable for a few beats.
Wide pulse pressure (>60 mmHg) is reflected in the collapsing pulse. The most common cause is aortic regurgitation, although arteriovenous fistula, ventricular septal defect, chronic ductus arteriosus, and severe anemia can all cause it.

Pulsus Bisferiens

A single pulse has two discernible systolic peaks. Diastole is the second peak in a dicrotic pulse. It is only visible when the pulse is directly recorded and is not tactile. It can occasionally be observed when regurgitation and aortic stenosis coexist.

Jerky Pulse

Blood ejection is initially normal in hypertrophic obstructive cardiomyopathy. The aortic outflow tract's band of muscle then abruptly contracts, obstructing it. It gives the pulse a choppy quality.

Pulsus Paradoxus

During inspiration, the pulse either weakens or becomes impalpable. This is a heightened version of a common occurrence. Systolic pressure normally drops during inspiration by 5 mmHg or less; in pulsus paradoxus, this drop is greater than 10 mmHg. It happens in cases of acute severe bronchial asthma, constrictive pericarditis, and large pericardial effusion (cardiac tamponade).
By measuring the blood pressure during inspiration and expiration, pulseus paradoxus can be verified. Request that the patient breathe calmly. The cuff should first be inflated above systolic level and then gently deflated. Take note of the volume at which the first Krotokoff noises arise. These will only be audible when they expire. Once the sounds are audible throughout the breathing cycle, keep deflating the cuff and record this level as well. The difference in pulsus paradoxus between these two values is greater than 10 mmHg.

Pulsus Alternans

The rhythm is consistent and the beat interval is constant as a strong and weak beat alternate. It manifests in supraventricular tachycardia and left ventricular failure. Systolic pressure is high during strong beats and low during weak beats; this aids in utilizing a BP apparatus to validate the presence of pulsus alternans. As indicated by the palpatory approach, inflate the cuff above the systolic blood pressure level. Gradually release the pressure inside the cuff; initially, loud beats will cause Krotokoff sounds to arise. Take note of how many Krotokoff noises there are in a minute. Reduce the cuff's pressure even more. The rate of Krotokoff sounds will abruptly double when the level of systolic pressure for weak beats is achieved. This phenomenon will verify that pulsus alternans is present.

Pulsus Bigeminus

It resembles pulsus alternans but has a variable beat-to-beat interval. Strong and weak beats are paired when they happen near to one another, creating a lengthy delay before repeating the cycle. A typical beat is a strong beat. Premature beats that start earlier than anticipated and are followed by compensating pauses are referred to as weak beats. The ECG confirms the diagnosis and reveals ventricular bigeminy. Toxicology from digoxin is the primary factor.

In Contrast to other Pulses

Compare the volumes of the matching pulses on both sides, excluding the carotids, by palpating them concurrently. Avoid palpating both carotids at the same time. Comparing the radial and femoral pulses, one finds that the femoral pulse is weaker and delayed than the radial pulse in cases of aortic coarctation (radiofemoral delay). The most significant clinical characteristic of aortic coarctation is radiofemoral delay.

State of the Vessel Wall

Use three fingers to feel the radial pulse. Feel the vessel wall with the middle finger after applying pressure with the proximal finger to occlude the pulse. It is not usually perceptible. It can seem like a wire connecting the finger to the underlying bone in cases of severe atherosclerosis.