“CVS Examination & Physiological Changes in CVS System During PREGNANCY”
Apprehensive facies produced by pain, anxiety and respiratory distress (MI, angina, PE, arrhythmias as VT, fast AF)
A ) Skin Color and Texture
Malar flush: long-standing MS,
Brick red color of polycethemia (may cause HTN, thrombosis, MI)
Central cyanosis (right to left intracardiac shunt or lung disease.
B ) Eyes and Lids
Xanthelasma (hypercholesterolemia, DM)
Lid edema (myxedema, nephrotic syndrome, SVC syndrome…)
Exophthalmos, lid retraction in thyrotoxicosis (A.F, high output failure)
Corneal arcus in young people indicates severe hypercholesterolemia.
C ) Bony Developmental Abnormality
Marfan syndrome (with long narrow face,lens sublaxation, long arm, arachnodactyly) (AR,aortic dissection, MVP)
Williams syndrome (small elf-like forehead,turned up nose, egg shaped teeth, low set ears)
Noonan’s sydrome (widely set eyes, webneck) associated with PS
D ) Hands
Tremor may indicate thyrotoxicosis (AF, CHF)
Clubbing of the fingers (cardiac cause: CHD, IE)
Capillary pulsation (AR, thyrotoxicosis, pregnancy)
Splinter hemorrhage (IE , acute GN)
Osler’s nodes (0.5-1 cm painful reddish-brown subcutaneous papules occur on the tip of the fingers or toes, palm of the hand, planter aspect of the feet (IE)
Is not apparent till Hb < 5g/dl (central)
In CHD cyanosis is observed if R to L shunt is > 25% of CO and not improved by 100% of O2
Good examination of tongue, lips, earlobes, fingers, toes is recommended
1. Collapsing pulse (water hammer pulse) jerky pulse with full expansion followed by sudden collapse (AR, PDA, A-V
fistulas, pregnancy, paget’s disease, thyrotoxicosis, anemia)
2. Alternating pulse pulses alternans (regular rate, amplitude
varies from beat to beat) seen in LVF
3. Pulses bisferiens (two strong systolic peaks separated by a
midsystolic dip) seen in HOCM, AS/AI
4. Anacrotic pulse slow rising pulse in A.S. (Parvus et tardus)
5. Dicrotic pulse, two systolic and diastolic peaks (sepsis,
hypovolemic, cardiogenic shock)
6. Paradoxic pulse (amplitude decreases with inspiration and
increases during expiration) seen in cardiac tamponade,
COPD, massive P.E.
The Normal JVP consist of 3 +ve pulse waves (a,c and v) and 2 –ve pulse wave (x and y)
A — Atrial systole –Coincide with 4th H.S.
X — Atrial relaxation
C — Bulging of TV into RA during V systole — begins at the end of 1st H.S.
V — filling of RA while TV is closed
Y — Decline in RA pressure when TV opens– corresponds with 3rd H.S.
X´– descent: systolic
Y — descent: diastolic
a) Absent in AF
b) Diminished in:- i)Tachycardia
ii) Increased PR Interval
c) Large a waves:- i) TS
iii) Pulm. HTN
d) Canon a waves Complete ht block.
b) Cardiac tamponade
d) SVC obst.
e) Hyperkinetic Circulatory state
f) Increased bld. Vol.
1. APEX BEAT:
a) Patient should be examined in the supine, sitting, and left lateral decubitus position.
b) Normal apex beat is palpable as brief outward impulse
(intersection of left mid clavicular line and 5th ICS)
c) Apex beat > 2cm indicate LV enlargement.
d) Double apical impulse caused by LVH and forceful LA contraction.
2. LEFT PARASTERNAL LIFT
a) Best appreciated by the distal palm or with the finger tip.
b) Palpable anterior systolic movement sustained up to S2 indicate RVH.
c) Giant presystolic lift seen in HCM.
a) Abdominal aorta (aneurysm)
b) Liver (hepatomegaly, pulsatile liver)
4. Diastolic shock
a) Palpable murmur
b) Definite evidence of presence of organic ht ds.
Grading of intensity of murmurs:
Grade I – So faint and heard only with special effort
Grade II – Soft but readily detected
Grade III – Prominent but not loud
Grade IV – Loud usually with palpable thrill
Grade V – Very loud with thrill
Grade VI – Heard without stethoscope on the chest wall
Classification of Murmurs: (Systolic, Diastolic and Continuous)
a) Mid Systolic Ejection Murmur:
b) Pansystolic MI, TI, VSD
c) Late Systolic MVP, PS, HOCM.
2. Diastolic Murmurs:
a) Early Diastolic:
Graham Steell’s Murmur
b) Mid Diastolic:
Carey Coomb’s Murmur
Austin Flint’s Murmur
c) Late Diastolic:
Lt and Rt Atrial Myxona
3. Continuous Murmurs
Surgically Produced shunts in TOF