8. Face :
⌠the facies of Williamâs syndrome; Downâs syndrome;
Moon face of Cushing syndrome; myxedema
⌠de Mussetâs sign of severe AR (âYES-YESâ sign)
⌠Malar rash vs butterfly rash
⌠Xanthelasma
⌠Diagonal earlobe crease (usually bilateral)
9.
10. * eyes : jaundice, anemic, exopthalmos ,roth spots,
blue sclera
* Pitting oedema : bilateral vs unilateral vs
anasarca
* Chest-Lungs:
- respiration pattern: Kussmaul vs rapid-shallow
breathing vs prolonged
expiration; Cheyne-stokes respiration
(CSA), orthopnoe, accessory respiratory
muscles work, etc
- auscultation: bibasilar late inspiratory rales?
wheezing?, etc
11. ď˝ JVP is related to body position & respiration
ď˝ Measure JVP indirectly:
⌠Use right internal jugular vein
⌠30â-45â position
⌠Patientâs head looks to the left side
⌠Not too bright room lighting
⌠Maneuver : tangential lighting or cross viewing
⌠Find the top level of pulsation at inspiration
⌠Measurement in cm with angulus sterni of Louis as
the zero point
ď difficulties: position, respiration, distinguish from
carotid beat
* Compare to abdomino-jugular reflux
15. ď˝ AbN jugular vein pulsation or pressure:
⌠Elevated JVP â abdominojugular reflux
⌠Kussmaulâs sign
⌠Prominent A wave; intermitten cannon A wave
⌠Prominent V wave ď characteristic of TR ď
+earlobes dancing or head shaking
16. ď˝ Measuring technique ď related to accuracy
- Patient position and condition
- Manometer and manset
- Inflation and deflation technique
# KOROTKOFF sounds:
- K.1 = tapping
- K.2 = beating
- K.3 = back to tapping
- K.4 = muffling
- K.5 = diminihed sound
ď Blood pressure = K.1/K.5 mmHg (or K.1/K.4/K.5)
ď Central arterial blood pressureď accurate?
17. ď˝ Palpate for rate, rhythm, amplitude,
configuration.
ď˝ Clues from peripheral (radial/femoral) palpation:
⌠Pulsus alternans (+S3, +abdominojugular reflux)
⌠Pulsus paradoxus (misnomer)
⌠Pulsus deficit
ď˝ Clues from carotid palpation:
⌠Pulsus corrigan/ water-hammer/seller : brisk rapid-rising
⌠Pulsus parvus et tardus : small, slow-rising, late peaking
⌠Small and weak pulse
⌠Pulsus bisferiens
⌠Pulsus dicrotic
ď˝ Radio/brachio-femoral delay
18. ď˝ Inspection & palpation
ď˝ Normal apical impulse:
ď 1 inch in diameter; ICS V (s)-line
midclavicularis (s); at early systole
ď˝ AbN apical impulse findings:
⌠Diffuse & weak apical impulse
⌠Displacement to the left & downward
⌠LV tapping
⌠LV heaving (over pressure)
⌠LV thrusting (over volume)
⌠Palpable thrill related to murmurs
19. ď˝ Position of patients ; semi-supine, LLD, upright
leaning forward ď to inhance hearing of some
heart sounds or murmurs
ď˝ Auscultatory area on the chest *(pic)
ď˝ Use diaphragm or bell ?
ď˝ Quality of stethoscope âcircumstances-patients
ď˝ Other maneuvers;
⌠clenching fistsď left sided
⌠deep inhalationď Right sided
⌠Full exhalation ď AR, pericardial friction rubs
⌠valsalva, nitrate, standing ď HOCM, MVP
20.
21. ď˝ S1 (M1T1); S2 (A2P2)
ď normal heard;
ď Accentuated, attenuated in some conditions
ď systolic time = S1 to S2; diastolic= S2 to S1
ď˝ Additional sounds:
# Systolic : - Ejection sound ď structural /functional
- midsystolic click ď MVP
# Diastolic: - S3 (ventricular gallop) ď CHF
- S4 (atrial gallop) ď HHD, MCI
- OS ď MS mild-moderate; flexible in
timing
ď˝ Splitting of S2; physiologic-wided-fixed
ď˝ Pericardial knock
22.
23.
24. ď˝ Caused by turbulent blood flow
ď˝ Assess :
⌠Timing (systolic or diastolic)
⌠Configuraton ( decressendo, cressendo, diamond shape,
holo, continuous)
⌠PM and referral points (left axilla, clavicle, carotid)
⌠Amplitude : systolic (1-6), diastolic (1-4); with thrill or
not
⌠Pitched/frequency ď diaphragm or bell of stethoscope
⌠Manuever: position, valsava, nitrat, inspiration
(Carvalloâs sign), clenched hands
ď˝ Physiologic heart murmur = systolic murmur,
midsystolic (not holosystolic), 1/6 or 2/6, with
normal heart sounds
25. ď˝ Systolic heart murmurs:
⌠Midsystolic murmur : AS, PS, ASD, hyperdynamic
Late systolic murmur : MVP with AR
Holosystolic murmur : MR, TR, VSD
ď˝ Diastolic heart murmur
⌠early decressendo murmur: AR, PR (in PH)
⌠Mid-diastolic & late diastolic murmur: MS
ď˝ To and fro murmur : AS with AR
ď˝ Continuous murmur: PDA
ď˝ Pericardial friction rub : acute pericarditis