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CVS and abdomen.pptx

  1. 1 By: Beker A. (BSc, MSc )
  2. Objective ♀At the end of this unit students will be able to: Identify the surface- land marks for cardiac assessment Differentiate normal and abnormal heart sounds Demonstrate the techniques of cardiac assessment 2 By: Beker A. (BSc, MSc )
  3. 3 By: Beker A. (BSc, MSc )
  4. • Diseases of the CVS are common at any level & diagnosis of diseases requires thorough history taking and meticulous physical exam. Symptoms Dyspnea – shortness (difficult) of breathing. The degree of dyspnea is graded based on the New York Heart Association Class (NHAC): Class I: No limitation of physical activity No symptoms with ordinary exertion Class II: Slight limitation of physical activity Ordinary activity causes symptoms Class III: Marked limitation of physical activity Less than ordinary activity causes symptoms Asymptomatic at rest Class IV: Inability to carry out any physical activity without discomfort or symptoms at rest 4 By: Beker A. (BSc, MSc )
  5. Paroxysmal Nocturnal Dyspnea: Is shortness of breath that occurs during sleep. The pt suddenly wakes up due the shortness of breath and then sits up or rush to open a window/door to get fresh air. Orthopnea: Shortness of breath that occurs during recumbent position. It is gauged by the number of pillows that are used to relieve the symptom Pain (Angina pectoris) is a cardiac pain. It usually on the retrosternal region and radiates to the left neck, shoulder and left upper arm. It has piercing character which is aggravated by exertion and relieved by rest Body swelling: Usually this starts from the leg Palpitation: Is subjective unpleasant perception of one’s own heart beat. Cough: This usually occurs at night (nocturnal) Syncope: Sudden episode of fainting related to hemodynamic derangement. 5 By: Beker A. (BSc, MSc )
  6. Physical Examination • Observe the pt for general signs of CVS disease - Breathing pattern - Cyanosis - Finger clubbing - Edema Arterial Pulses Note Rate, Rhythm, Character & Volume (amplitude) of pulse - The radial artery is more preferred - Compress the artery with your index and middle fingers - Count the pulse for one full minute. 6 By: Beker A. (BSc, MSc )
  7. Cont.… Major Arteries: Major arteries  Radial  Brachial  temporal  Carotid  Femoral  Popliteal  Posterior Tibial,  Dorsalis pedis. By: Beker A. (BSc, MSc ) 7
  8. By: Beker A. (BSc, MSc ) 8
  9. Pulse classification in adults Based on the rate - Normal = 60 - 100 beats / min - Bradycardia = < 60 beats / min - Tachycardia: > 100 beats / min Based on rhythm - Regular or Irregular Character and Volume - Normal (full) or weak (fible) 9 By: Beker A. (BSc, MSc )
  10. Blood Pressure  The pt should not smoked, taken caffeine or engaged in vigorous exercise within the last 30 mins.  The room should be quiet and the pt comfortable.  Position the pt's arm so that the anticubital fold is level with the heart.  Center the bladder of the cuff over the brachial artery approximately 2-3 cm above the anticubital fold.  Proper cuff size is essential to obtain an accurate reading  Place the stethoscope over the brachial artery.  Inflate the cuff 20-30mmHg above the estimated systolic pressure after the pulse disappears  it is acceptable in adults to inflate the cuff to 200 mmHg and go directly to auscultating the BP.  Release the pressure slowly, no greater than 5 mmHg/sec. 10 By: Beker A. (BSc, MSc )
  11. Jugular Venous Pressure (JVP) - is a reflection of the right atrial pressure and it is the most important part of venous system examination - Position the pt supine - Look for a rapid, double (sometimes triple) wave with each heartbeat. 11 By: Beker A. (BSc, MSc )
  12. ♀Position the person any where from a 30-45 degree angle, where ever you can best see the pulsations. ♀Turn the person’s head slightly away from the examined side. ♀Note the external jugular vein overlying the sternomastoid muscle. 12 By: Beker A. (BSc, MSc )
  13. ♀In some persons, the veins are not visible at all; where as in others, they are full in the supine position. ♀As the person is raised to a sitting position, these external jugulars flatten and disappear, usually at 45 degree. ♀Full distention of external jugular veins above 45 degree signify increased CVP. 13 By: Beker A. (BSc, MSc )
  14. ♀The internal jugular veins lie deep and medial to the sternocleidomastoid muscle. ♀The external jugular veins are more superficial; they lie lateral to the sternocleidomastoid muscle and above the clavicle. ♀You must be able to distinguish internal jugular vein pulsation from that of the carotid artery. ♀It is easy to confuse because they lie close together 14 By: Beker A. (BSc, MSc )
  15. ♀N.B: Identify the highest point of pulsations in the internal jugular vein and with a centimeter ruler measure the vertical distance between this point and the sternal angle. Normally this distance is less than three cm. ♀Increased pressure (> 3cm) when it is bilateral suggests right-sided heart failure or less commonly tricuspid stenosis, superior vena cava obstruction or rarely constrictive pericarditis. By: Beker A. (BSc, MSc ) 15
  16. JVP By: Beker A. (BSc, MSc ) 16
  17. Differentiation of the jugular & carotid pulse wave 17 By: Beker A. (BSc, MSc )
  18. Palpate for a point of maximal impulse (which usually is located at the same area to the apical impulse,). It is normally located in the 4th or 5th intercostals space just medial to the mid clavicular line. Auscultate with stethoscope: Diaphragm: preferred to auscultate high pitched sounds e.g. S1 (lub), S2 (dub), systoic murmur, etc Bell: preferred to auscultate low pitched sounds e.g. S3, S4, diastolic murmur of Miteral stenosis 18 By: Beker A. (BSc, MSc )
  19. Areas of auscultation: 1. The right 2nd interspace near the sternum (aortic area). 2. The left 2nd interspace near the sternum (pulmonic area). 3. 3rd intercostal space left of sternal boarder- erb’s point 3. The left 4th & 5th interspace near the sternum (tricuspid area) 4. At the apex (mitral area) * Apical impulse should occupy only one inter space, the 4th or 5th at or medial to the midclavicular line. 19 By: Beker A. (BSc, MSc )
  20. To distinguish S1 from S2 S1 is louder than S2 at the apex; S2 is louder than S1 at the base S1 coincides with the carotid artery pulse Feel the carotid gently as you auscultate at the apex; the sound you hear as you feel each pulse is S1 Listen for murmurs A murmur is a blowing swooshing sound that occurs with turbulent blood flow in the heart or great vessels. 20 By: Beker A. (BSc, MSc )
  21. If you hear a murmur describe the intensity in terms of six grades  Grade 1- barely audible, heard only in a quite room and with difficulty  Grade II- clearly audible but faint  Grade III- moderately loud  Grade IV- loud associated with a trill palpable on the chest wall  Grade V- very loud, heard with one corner of the stethoscope lifted off the chest wall  Grade VI- loudest, still heard with entire stethoscope lifted just off the chest wall 21 By: Beker A. (BSc, MSc )
  22. 22 By: Beker A. (BSc, MSc )
  23. 23 By: Beker A. (BSc, MSc )
  24. Surface Landmarks: Abdomen is a large cavity extending from the diaphragm to the pelvic brim. It is divided in to four quadrants by a vertical & horizontal line bisecting the umbilicus. 24 By: Beker A. (BSc, MSc )
  25. By: Beker A. (BSc, MSc ) 25
  26. 26 By: Beker A. (BSc, MSc )
  27. Guideline  Good light, a relaxed patient, and full exposure of the abdomen from above the xiphoid process to the symphysis pubis  Patient should not have a full bladder  Position -patient should be supine  Before Palpation, ask the patient to point to any areas of pain, and examine painful or tender areas last. By: Beker A. (BSc, MSc ) 27
  28. Cont.… Monitor your examination by watching the patient's face for sign of discomfort Have a warm hand, a warm stethoscope, and short fingers nails Make a habit of visualizing each organ in the region you are examining. Proceed in an orderly fashion, Inspection, auscultation, By: Beker A. (BSc, MSc ) 28
  29.  Inspects the contour, symmetry, umbilicus, skin, pulsation or movement, skin markings and hair distribution is performed best in good light.  abdominal distension (6 Fs - fat, fluid, faeces, foetus, fibroids, flatus)  A scaphoid abdomen can occur in a pt with upper gastrointestinal obstruction or as a result of starvation. 29 Method of examination 1. Inspection By: Beker A. (BSc, MSc )
  30. Subjective data Indigestion or anorexia Nausea/vomiting Hematemesis Abdominal pain Dysphagia Change in bowel function Constipation or diarrhea Past abdominal surgery 30 By: Beker A. (BSc, MSc )
  31. Objective data  Equipment needed  Stethoscope Small centimeter ruler Skin marking pain Order of abdominal examination Inspection Auscultation Percussion Palpation Order of exam is critical. Auscultate before percussing and palpating By: Beker A. (BSc, MSc ) 31
  32. 32 By: Beker A. (BSc, MSc )
  33. Umbilicus Normally it is midline and inverted with no signs of inflammation or hernia. It becomes everted and pushed upward with pregnancy. Umbilical hernias frequently are present in the infant, toddler, and younger child, particularly in black children. Abnormal findings on inspection  Visible or distended veins- ascites  Visible peristalsis- obstruction  Asymmetry/ Distention- mass or intestinal obstruction  Color changes- jaundice, bluish/cyanotic 33 By: Beker A. (BSc, MSc )
  34. 2. Auscultation Auscultate bowel sounds and vascular sounds Auscultate abdomen next because percussion and palpation can increase peristalsis. Use the diaphragm – end piece because bowel sounds are relatively high pitched. • Hold the stethoscope lightly against the skin, pushing too hard may stimulate more bowel sounds. • Begin in the RLQ at the ileocecal valve because bowel sounds are always present here normally. 34 By: Beker A. (BSc, MSc )
  35. Bowel sounds originate from the movement of air & fluid through the small intestine They are high pitched gurgling occurring from 5-30 times Do not bother to count it. • Bowel sounds may be altered in  diarrhea, intestinal obstruction, paralytic ileus, and  peritonitis. 35 By: Beker A. (BSc, MSc )
  36. Judge for presence, hypoactive or hyperactive One type of hyperactive bowel sounds which is common is hunger or diarrhea which is hyperperistalsis known as “borborygmi” Borborygmus is a rumbling noise in the abdomen, caused by gas in the intestine. Active bowel sounds usually are decreased or absent in pts with appendicitis, intestinal obstruction, following abdominal surgery or with inflammation of the peritoneum Perfectly “silent abdomen” is uncommon; you must listen for 5 mins before saying absent bowel sounds.  Stenosis involving the aorta or iliac, femoral, or renal arteries may give rise to an audible abdominal bruit. Hyperactive sound are loud, high pitched, rushing 36 By: Beker A. (BSc, MSc )
  37. 3. Percussion  - abdomen is normally tympanic (gas-filled loops of bowel produce tympany), liver span and splenic areas are dull.  Percuss to assess the relative density of abdominal contents to locate organs and to screen for abnormal fluid or masses.  first percuss lightly in all four quadrants to determine the prevailing amount of tympany and dullness.  Tympani should predominate because air in the intestine rises to the surface when the person is supine.  Abnormal dullness occurs over a distended bladder, adipose tissue, fluid or a mass.  Hyper resonance is present with gaseous distention. 37 By: Beker A. (BSc, MSc )
  38.  If you suspect ascites, begin percussion peripherally. At first dullness will be noted.  As percussion advances centrally, the air-filled loops of intestine, forced to the midline by ascitic fluid, will emit a tympanitic sound. When the pt turns to one side or the other, the locations of tympany and dullness shift as the fluid moves into dependent areas.  A fluid wave can be produced when the examiner strikes one flank area with the tips of the fingers of one hand and detects gentle pressure with the other hand on the opposite flank.  This finding is better demonstrated by employing the aid of an assistant who at the same time has placed the ulnar surfaces of both fully extended hands pointing toward one another along the midline of the abdomen. 38 By: Beker A. (BSc, MSc )
  39. 4. Palpation  Palpation is extremely beneficial for determining of certain organs (liver, kidney & spleen) size, location & consistency and for detecting abdominal masses or tenderness.  An examiner's warm hands & initial gentle, soft touch may go a long way in gaining the cooperation of the pt for deeper, more thorough palpation.  Instruct pt to take a deep breath and then exhale slowly while you applies firm steady pressure to the abdomen.  A fairly complete examination can be achieved by repeating the procedure in all four quadrants. 39 By: Beker A. (BSc, MSc )
  40. 40 By: Beker A. (BSc, MSc )
  41. To enhance complete muscle relaxation  Bend the person’s knees.  Take deep inhalation & slow breath out  Keep your palpation gentle  Begin with light palpation with fingers close together.  make a gentle rotary motion, sliding the fingers and skin together.  Then lift the fingers and move clockwise to the next location around the abdomen.  An objective of superficial palpation is not to search for organs but to form an overall impression of the skin surface and superficial musculature 41 By: Beker A. (BSc, MSc )
  42. Abnormal: involuntary rigidity is a constant board like hardness of the muscles as in peritonitis.  In case of very large or obese abdomen use a bimanual technique.  Place your two hands on top of each other.  The top hand does the pushing, the bottom hand is relaxed and can concentrate on the sense of palpation 42 By: Beker A. (BSc, MSc )
  43. Liver  For the obese pt, a two-hand technique with the fingers of one hand applying pressure on top of the fingers of the other hand may be required.  stand on the pt's right side when attempting to feel the liver  Place your left hand under the person back parallel to the 11th & 12th ribs & lift up to support the abdominal content.  Place your right hand on the RUQ with fingers parallel to the midline in a somewhat oblique position. 43 By: Beker A. (BSc, MSc )
  44.  Push deeply down and under the right costal margin.  Palpation should progress in a superior direction until the lower edge of the liver is detected.  It is normal to feel the edge of the liver  Often the liver is not palpable and you feel nothing firm  Abnormal liver palpated more than 1-2 cm below the right costal margin is enlarged. 44 By: Beker A. (BSc, MSc )
  45. Spleen • Normally, the spleen is not palpable  Rich your left hand over the abdomen and behind the left side at the 11th &12th ribs  lift up to support place your right hand obliquely the LUQ with the fingers pointing to ward the left axillae and just inferior to the rib margin.  Push your hand deeply down and under the left costal margin and ask the person to take a deep breath. Abnormal - enlarged the spleen slides out and bumps your fingertips  - if you feel an enlarged spleen return the person but do not continue to palpate. It is friable and can rupture easily with over palpation  - It can grow so large that it extends in to the lower quadrant. 45 By: Beker A. (BSc, MSc )
  46. Cont.… Costo vertebral angle tenderness to assess the kidney, place one hand over the 12th rib at the costo vertebral angle on the back. Thump that hand with ulnar edge of your other fist. The person feels no pain. Abnormal: - sharp pain occurs with inflammation of the kidneys By: Beker A. (BSc, MSc ) 46
  47. Cont.… Findings: The patient should perceive a thud but no pain. CVA tenderness or severe pain may indicate pyelonephritis, glomerulonephritis, or nephrolithiasis (kidney stones). By: Beker A. (BSc, MSc ) 47
  48. Kidneys  For the right kidney, place your hands together at the person’s right flank.  Press your two hands together firmly and ask the person to take a deep breath.  In most people, you will feel no change.  The left kidney sits 1cm higher than the right kidney and is not palpable normally  Search for it by reaching your left hand across the abdomen and behind the left flank for support.  Push your right hand deep in to the abdomen and ask the person to breath deeply.  You feel no change with inhalation 48 By: Beker A. (BSc, MSc )
  49. Tests: 1. Rebound tenderness  Pain induced or increased by quick withdrawal.  It results from the rapid mov’t of an inflamed peritoneum.  Hold your hand  Push down slowly and deeply perpendicular to the site, then lift up quickly  No pain on release of pressure in normal case  Do at the end of the examination b/c it causes sever pain and muscle rigidity 49 By: Beker A. (BSc, MSc )
  50.  When peritonitis is suspected, rebound tenderness may be elicited by pressing firmly and slowly on the abdomen and then quickly releasing pressure 2. Inspiratory arrest (Murphy's sign) – Normally, palpating the liver causes no pain. – In a person with inflammation of the gall bladder or cholecystitis, pain occurs. – Hold your fingers under the liver border. – As the descending liver pushes the inflamed gallbladder on to the examining hand, the person feels sharp pain and abruptly stops inspiration mid way. 50 By: Beker A. (BSc, MSc )
  51. 3. Iliopsoas muscle test  Perform this test when acute abdominal pain or appendicitis is suspected  With the person supine, lift the right leg straight up, flexing at the hip; then push down over the lower part of the right thigh as the person tries to hold the leg up.  When the test is negative, the person feels no change Abnormal - pain in the RLQ indicates appendicitis 51 By: Beker A. (BSc, MSc )
  52. 4. Obturator Test  When appendicitis is suspected with the person supine, lift the right leg, flexing at the hip and 90 degrees at the knee.  Hold the ankle and rotate the leg internally and externally  Negative or normal response is no pain 5. Rovsing’s sign  when LLQ is palpated pain will be felt in the RLQ 52 By: Beker A. (BSc, MSc )
  53. ASSESS the abdomen for fluid. If fluid is suspected within the abdomen, perform the following tests: Shifting Dullness Fluid Wave Shifting dullness When ascites is suspected and tympany will be changed to dullness By: Beker A. (BSc, MSc ) 53
  54. Cont.…  Procedure: Ask the patient to lie supine so any fluid pools in the lateral (flank) area.  Percuss the abdomen.  Draw lines on the abdomen to indicate the midline tympany (the expected tone) in contrast to lateral dullness (tone created by fluid).  Then have the patient turn to the right side and repeat percussion.  Listen for the tympanic tone to shift to the upper (left) side and the area of dullness rises toward the midline.  Finally have the patient turn to the left lateral position and percuss. Listen as the dullness rises toward the midline. By: Beker A. (BSc, MSc ) 54
  55. By: Beker A. (BSc, MSc ) 55
  56. Cont… Findings: Normally tympany is heard throughout the abdomen, except over the bladder when it is distended. Movement of the area of dullness as the patient shifts position reflects the shift of fluid in the peritoneal cavity (ascites). By: Beker A. (BSc, MSc ) 56
  57. Obstetric Examination Abdominal examination: • Inspection: the four ”s”& fetal movement S- size of the abdomen ( proportional, small and large to GA) S- shape of the abdomen( oval in primi gravida, round in multi para, broad in multiple pregnancy and mal presentation) S- scar( any previous C/S or myomectomy) S- skin • Palpation (Leopold’s maneuver):- to determine uterine size (symphysis fundal height), fetal lie, presentation, attitude and engagement By: Beker A. (BSc, MSc ) 57
  58. Steps of leopold maneuver 1. Fundal palpation 2. Lateral palpation 3. Pawlk’s grips 4. Deep pelvic palpation • Auscultation: fetal heart beat By: Beker A. (BSc, MSc ) 58
  59. The first Leopold’s maneuver By: Beker A. (BSc, MSc ) 59
  60. Leopold I: – Fundal palpation. - Has two purposes: 1) Determination of fundal height, and 2) What occupies the fundus? Fundal height measurement - should be after correcting for dextrorotation. There are two methods of measuring the fundal height: 1. Finger method: - below the umbilicus, 1 finger = 1 weeks and - Above the umbilicus, 1 finger = two weeks Body marks: - Uterus at symphysis pubis = 12 weeks - At the umbilicus = 20 weeks - At Xiphisternum = 36 weeks - Midways between symphysis & umbilicus = 16 Weeks - Midways between umbilicus & Xiphisternum = 28 Weeks By: Beker A. (BSc, MSc ) 60
  61. CONT.. 2. Tape measurement: - Symphysis to fundal height measurement in centimeters with tape meter. - At 18 – 34 weeks of gestation, tape measurement is accurate to +2 weeks of actual Gestational age. - McDonald rule & Johnson formula for GA & Fetal weight estimation What occupies the fundus? Soft irregular bulky mass - the breech Hard round ballotable mass – Head By: Beker A. (BSc, MSc ) 61
  62. The second Leopold’s maneuver By: Beker A. (BSc, MSc ) 62
  63. Leopold II: – Lateral palpation - Has two purposes: 1) To know the lie 2) To determine side of the back 1. Lie: - is the longitudinal axis of the fetus in relation to the longitudinal axis of the mother. - It can be longitudinal, transverse or oblique. 2. Side of the back – to auscultate the FHR on that side. - FHR can be auscultated at 20 weeks by using the De Lee /Pinard stethoscope or at 10 - 12 weeks using Doppler Ultrasound By: Beker A. (BSc, MSc ) 63
  64. The third Leopold’s maneuver By: Beker A. (BSc, MSc ) 64
  65. Leopold III – pelvic palpation – It has three purposes: to know the 1) Presentation 2) Descent of presenting part. 3) Attitude of the fetal head. Presentation: – is the part of the fetus that occupies the lower uterine pole. E.g. Cephalic presentation, breech presentation, shoulder presentation Descent is measured after identifying the anterior shoulder with rule of 5th in fingers above pelvic brim. 5/ 5th – floating 2/5th – engaged at the pelvic inlet. Attitude: is the relationship of the fetal parts to each other particularly the fetal head to its trunk. - Cephalic prominence on the side of the back- Extended attitude = > abnormal - Cephalic prominence opposite to the side of the back - Flexed attitude = > normal - Military Attitude: - neither flexed nor extended By: Beker A. (BSc, MSc ) 65
  66. The fourth Leopold’s maneuver By: Beker A. (BSc, MSc ) 66
  67. Leopold IV – Pawlik’s grip: – It has two purposes. To know the 1) Presentation and 2) Descent or mobility of the fetal head – floating or fixed By: Beker A. (BSc, MSc ) 67
  68. Quiz 1. List steps of leopold maneuver 2. List at least 4 area of pulse 3. List the common area of auscultation to hear different heart sound 4. What is Rovsing’s sign 5. List at least 4f that cause abdominal distension By: Beker A. (BSc, MSc ) 68