Peripheral Exam - Physical Exam

Physical Exam

·        Position patient at 45 degrees

·        General appearance, including cachectic state, Marfan‟s, Down‟s or Turner‟s Syndromes

·        Dextrocardia = heart on right hand side (1 in 400??).  Need right-sided heart leads

Peripheral Exam

Hands

·        Check for clubbing (congenital cyanotic heart disease), warmth (perfusion), capillary refill, anaemia (palmar creases), peripheral cyanosis, splinter haemorrhages

Pulse

·        Radial pulse: assess rate, rhythm, and delay from radial to femoral pulse (radio-femoral delay)

·        Brachial or Carotid pulse: Character and volume

·        Rate:

o   Sinus Tachycardia:

§  = Sinus rhythm > 100 bpm. 120 bpm could be physiological, > 140 – 150 bpm more likely to be an aberrant rhythm

§  Causes: fever, exercise, emotion, anxiety, pain, pregnancy, anaemia, hypoxia, thyrotoxicosis, HF, catecholamine excess, constrictive pericarditis, myocarditis, shock, MI, drugs, smoking, coffee, autonomic neuropathy (eg in DM), PE

o   Sinus bradycardia:

§  = Sinus rhythm < 60 bpm

§  Causes: athlete, during sleep, drugs (b-blockers, digoxin, amiodarone), hypothyroidism, hypothermia, severe jaundice (due to bilirubin in conducting system), 3^rd degree heart block, MI, paroxysmal bradycardia (eg vasovagal syncope)

·        Rhythm:

o   Regular

o   Irregular:

§  Irregularly irregular: usually atrial fibrillation

§  Regularly irregular: Sinus arrhythmia (rate ­ with respiration and ¯ with expiration) or 2^nd degree heart block (Mobitz type 1)

·        Quality:

o   If „thin‟ then ¯ volume

o   Slow rising, low volume Þ aortic stenosis

o   Radial/femoral delay Þ aortic stricture e.g. coarctation,

o   Bounding pulse = a pronounced pulse – big difference between systolic and diastolic pressure (i.e. large pulse pressure). If bounding then always do a collapsing check

o   Collapsing pulse = bounding pulse + thumping pulse felt over wrist with palm of your hand when patient‟s arm raised - ?aortic regurgitation (higher column of blood ® ­regurgitation)

·        Pulse deficit = difference between the radial pulse rate and heart rate. If rapid or irregular contraction then no time for ventricular filling Þ there may not be a corresponding radial pulse beat

Measuring Blood Pressure

·        Ways of measuring blood pressure:

o  Mercury sphygmomanometer: listen for Kortokoff sounds 

o  Oscillotonometer: detects arterial pulsations transmitted by the cuff. Tend to over-read very low pressures (oscillations diminish in amplitude)

o  Ultrasound sphygmomanometer: uses Doppler shift

o  Direct measurement: intra-arterial pressure with transducer

·        How to measure with a sphygmomanometer:

o  Patient relaxed/seated for 5 minutes

o  Arm at heart level 

o  Hold their hand under your right arm, straighten their arm and support under elbow. Use right thumb to feel brachial pulse as cuff is inflated (so you don‟t over-inflate). Inflate to 30 mmHg above point where pulsation stops 

o  Don‟t push stethoscope diaphragm too hard (otherwise ® bruit)

o  Start of Kortokoff sound 1 = systolic.  Disappearance of Kortokoff sound 5 = diastolic

o  In obese people a normal width cuff will over-estimate blood pressure – must use a large one

o  Repeat several times, and on several occasions before deciding to treat

o  Sources of operator error:

§  Wrong sized cuff

§  Poor positioning of the patient

§  Too rapid release of cuff pressure

§  Use of non-standard diastolic end points

§  Rounding to 5‟s or 10‟s

·        Watch for:

o  Pulsus paradoxus: Normally inspiration ® ¯systolic and diastolic blood pressure (more negative intrathoracic pressure ® pooling in pulmonary vessels ® ¯filling). Pulsus paradoxus = this decrease is exaggerated (ie fall of > 10 mmHg). Can occur in constrictive pericarditis, pericardial effusion or severe asthma

o  Postural hypotension:

§  Fall of more than 15 mmHg systolic or 10 mmHg diastolic on standing

§  Causes: hypovolaemia, drugs (vasodilators, antidepressants, diuretics), Addison‟s disease, hypopituitarism, autonomic neuropathy

§  ­ Pulse on standing.  For vasovagal syncope pulse ¯

·        Hypertension

 Face

·        Eyes:

o  Jaundice from liver congestion secondary to heart failure

o  Anaemia

o  Roth‟s spots on retina: areas of retinal infarction and haemorrhage caused by septic emboli in bacterial endocarditis

·        Xanthelasma: intracutaneous yellow cholesterol deposits around the eye. Normal variant or ?hyperlipidaemia

·        Mitral facies: rose cheeks with dilated blue veins and cyanosed tongue. Due to pulmonary hypertension and ¯cardiac output (eg as in severe mitral stenosis)

·        Mouth: diseased teeth (cause of infective endocarditis), tongue for central cyanosis, and mucosa for petechiae

 Carotid Arteries

 ·        Never palpate both at once ® occlude blood supply to brain

·        Information about aorta and left ventricular function , 

Pulse wave forms:

Jugular Venous Pressure (JVP)

·        Information about right atrial and right ventricular function

·        ­ in RVF, volume overload, impaired RV filling, SVC syndrome

·        Positioning:

o   Patient should be at 45 degrees

o   Internal jugular is medial to the superior end of sterno-mastoid then runs behind it as it descends

o   External is lateral, is easier to see, but is more tortuous and therefore less reliable 

o   Sternal angel is the zero point – pulsations are visible above this point at 45 degrees (centre of the right atrium is 5 cm lower). Normal is pulsations just above the clavicle (+3 cm)

·        Differentiating from carotid pulse.  The JVP is:

o   Visible but not palpable

o   Flickers twice with each cardiac cycle

o   Usually decreases with respiration

o   Is obliterated then filled from above following light pressure at the base of the neck

·        Pressure waves in atria:

o   a wave: atrial contraction at end of diastole ® ­atrial pressure. Coincides with first heart sound and precedes carotid pulse. Closely followed by …

o   c point: bulging of AV valves into atria during systole ® ­atrial pressure.  Not usually visible

o   x descent: atrial relaxation between S1 and S2

o   v wave: End of atrial filling during systole – venous inflow into atria with AV valve closed ® ­atrial pressure

o   y descent: rapid ventricular filling following opening of the AV valve

·        Height (the easy bit – ha ha!):

o   If > 3 cm above the zero point then right heart filling pressure is raised

o   Rises with 10 seconds pressure on the liver (hepatojugular reflex). A rise is normal. If it remains raised then ventricular failure

o   Causes of ­ height: Right ventricular failure, tricuspid stenosis or regurgitation, pericardial effusion or constrictive pericarditis, SVC obstruction (no waves), fluid overload, hyperdynamic circulation

o   Should normally fall on inspiration. If it rises then ?constrictive pericarditis.  Investigate with echo

·        Character (the hard part):

o   Causes of a dominant a wave: tricuspid stenosis (also causes a slow descent), pulmonary stenosis, pulmonary hypertension

o   Causes of cannon a waves (­­wave - right atrium contracts against closed tricuspid valve): intermittently in complete heart block (two chambers beating independently), retrograde conduction 

o   Cause of dominant v wave: tricuspid regurgitation (should never miss this, watch for movement of ear lobe)

o   x descent: absent in AF, exaggerated in cardiac tamponade, constrictive pericarditis

·        y descent: Sharp: severe tricuspid regurgitation, constrictive pericarditis, slow in tricuspid stenosis, right atrial myxoma