Tag: assessing the JVP

In patient assessment, following the process of history-taking, we’ll be looking into performing a thorough examination of the cardiovascular system.

Examination of the Cardiovascular System Outline

1. general considerations
2. examining the hands
3. examining the radial pulse, rhythm & rate
4. measuring the blood pressure
5. examining the face
6. examining the neck
7. examining the chest wall
8. examining the bases of the lungs
9. examining the abdomen
10. examining the lower limbs

1. General Considerations

1. If you haven’t done so already, introduce yourself and shake hands with your patient
2. Note the patient’s age and general state
3. Ensure that the examination room is quiet enough to perform auscultation
4. The patient should be properly undressed for this examination
5. The patient should be positioned adequately i.e. reclining at 45° with the head resting comfortably on pillows

2. Examining the Hands

FINGER CLUBBING

• caused by interstitial oedema and dilation of the arterioles and capillaries
• assess for finger clubbing by checking for the loss of the normal angle between the nail and the nail bed, and fluctuation of the nail bed
• advanced finger clubbing may be featured through swelling of the subcutaneous tissues over the base of the nail causing the overlying skin to become tense, shiny and red, increase in the curvature of the nail especially in its long axis, and swelling of the pulp of the finger
• finger clubbing causes may include cardiac issues such as cyanotic heart disease (heart disease that is caused by lack of oxygen) and infective endocarditis (inflammation of the endocardium, the inner lining of the heart, as well as the valves that separate each of the four chambers within the heart), respiratory issues such as bronchial carcinoma (a malignant cancerous tumour of the bronchi and the lung tissue), lung abscess (a type of liquefactive necrosis of the lung tissue and formation of cavities containing necrotic debris or fluid caused by microbial infection), bronchiestasis (a long-term condition where the airways of the lungs become widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection), empyema (pus-filled pockets that develop in the pleural space), and fibrosing alveolitis (a disease involving the gas-exchanging portions of the lungs), and gastrointestinal issues such as inflammatory bowel disease (a term for two conditions – Crohn’s disease and ulcerative colitis, that are characterized by chronic inflammation of the GI tract), and liver cirrhosis (scarring of the liver caused by continuous, long-term liver damage).

PERIPHERAL CYANOSIS

• can be physiological eg. due to a surrounding cold environment, reduced cardiac output eg. shock causes central cyanosis
• featured through bluish discolouration of the nail beds
• usually starts showing when patient is at <85% SPO2

SPLINTER HAEMORRHAGES

• featured as small dark subungual petechiae
• may be symptoms of infective endocarditis (inflammation of the endocardium, the inner lining of the heart, as well as the valves that separate each of the four chambers within the heart) as well as trauma

TAR-STAINED FINGERS

• caused by smoking – smoking accellerates build-up of atherosclerosis which leads to CVA and/or peripheral vascular disease and ischaemic heart disease. Complete occlusion by athersclerosis causes a Myocardial Infarction.

TEMPERATURE

• warm hands signify vasodilation
• cold hands signify vasoconstriction
• note if hands are dry or moist
• clammy hands may be a sign of anxiety or sympathetic activation

3. Examining the Radial Pulse, Rhythm & Rate

ASSESSING THE RADIAL PULSE

• the radial pulse can be located just lateral to the flexor carpi radialis
• assess the rhythm – sinus (normal – controlled by the sino-atrial node)? irregular (due to atrial or ventricular extrasystoles, atrial fibrillation or heart block)?
• assess the rate – 60-100bpm at rest = normal; >100bpm = sinus tachycardia (due to fever, exercise, anxiety, heart failure); fast arrhythmias (due to atrial fibrillation, supraventricular tachycardia, or ventricular tachycardia); <60bpm = bradycardia (due to high vagal tone in athletes, sleep, or certain medication eg. beta blockers or calcium antagonists)
• assess the condition of the vessel wall – if vessel wall feels stiff and tortuous, atherosclerosis is probably present

4. Measuring the Blood Pressure

TAKING THE PATIENT’S BLOOD PRESSURE

• the patient should not eat, smoke, take caffeinated products, or perform vigorous exercise for 30 minutes prior to the examination
• the room should be quiet and adequately prepared so that the patient is comfortable
• the patient’s arm should be positioned in a way so that the antecubital fossa is level with the heart
• the bladder of the cuff should be centered over the brachial artery about 2cm above the antecubital fossa; the bladder length should not be less than 80% of the patient’s arm circumference
• patient’s arm should be slightly flexed at the elbow
• palpate the radial pulse and inflate the cuff until the pulse cannot be palpated any more, take note of the number displayed and deflate the cuff
• place the stethoscope over the brachial artery
• inflate the cuff to 30mmHg over the estimated systolic pressure
• release the pressure slowly at about 5mmHg/second
• note the measurement where you start hearing the korotkoff sound as the systolic pressure
• note the measurement where you stop hearing the korotkoff sound as the diastolic pressure
• record the patient’s blood pressure as systolic over diastolic
• retake blood pressure measurement by repeating the same process on the other arm if the patient is visiting for the first time; if there is a difference in blood pressure of more than 10mmHg in one arm, record the highest reading

Category	Systolic	Diastolic
Normal	<130	<85
High Normal	130-139	85-89
Mild Hypertension	140-159	90-99
Moderate Hypertension	160-179	100-109
Severe Hypertension	180-209	110-119
Crisis Hypertension	>210	>120

ASSESSING THE PULSE PRESSURE

• pulse pressure is the difference between the systolic and diastolic blood pressure
• a normal value of the pulse pressure falls somewhere between 30-40mmHg
• a narrow pulse pressure may be a sign of reduced cardiac output such as in a haemorrhagic shock, as well as in severe aortic stenosis (prevents aortic valves from opening and closing properly, leading to stress on the heart to work harder to pump blood to the rest of your body), constrictive pericarditis (a condition in which granulation tissue formation in the pericardium results in loss of pericardial elasticity leading to restriction in the ventricular filling), and pericardial effusions (acute or chronic accumulation of fluid within the pericardial space)
• a wide pulse pressure may be a sign of increased cardiac output and low vascular resistance, common in aortic insufficiency (heart valve disease where the aortic valve no longer functions adequately to control the flow of blood from the left ventricle into the aorta), anaemia (a condition in which the number of red blood cells or the haemoglobin concentration within them is lower than normal), and thyrotoxicosis (a clinical state of inappropriately high levels of circulating thyroid hormones T3 and/or T4 in the body)

PULSUS PARADOXUS

• pulsus paradoxus is the difference between where the Korotkoff sounds are first heard on expiration only and where they are heard on both inspiration and expiration is normally 10mmHg
• pulsus paradoxus is present when the difference exceeds 10mmHg
• pulsus paradoxus is associated with pericardial effusion (acute or chronic accumulation of fluid within the pericardial space) and severe acute asthma

5. Examining the Face

CENTRAL CYANOSIS

• can be easily noted when looking at the patient’s tongue
• happens when the oxygen saturation of arterial blood falls below 80-85%; central cyanosis indicates lack of oxygen in the brain
• may be a sign of congenital heart disease (conditions present at birth which affect the structure of the heart and the way it works) or chronic obstructive airways disease or COPD

ANAEMIA

• anaemia is characterised by a reduction of haemoglobin concentration in the blood, which usually are <13.5g/dl in adult males and <11.5g/dl in adult females
• anaemia can be noticed as pallor of the mucous membranes eg. the conjunctival mucosa (happens when the haemoglobin level is <9-10g/dl

CORNEAL ARCUS

• corneal arcus is characterised by a greyish line in the periphery of the cornea, concentric with the edge but separated from it by a clear zone, consisting of cholesterol crystals
• corneal arcus is typically seen in the elderly, but when seen in young people, it may be a sign of hypercholesterolaemia

XANTHELASMA

• xanthelasma is characterised by intracutaneous yellow cholesterol deposits around the eyes
• xanthelasma can be noted in normal people as well as in those with hypercholesterolaemia

MALAR FLUSH

• malar flush is characterised by redness of the cheeks
• malar flush is commonly seen in patients with mitral stenosis (narrowing of the valve between the two left heart chambers) as well as in normal individuals

6. Examining the Neck

JUGULAR VENOUS PRESSURE (JVP)

• the jugular veins, which are located adjacent to the superior vena cava, directly reflect right arterial pressure
• assessing the right internal jugular vein is better since it is more proximal to the superior vena cava than the left; the right external jugular vein has venous valves between it and the superior vena cava, hence it is less preferred for assessment; ideal patient placement is at 45 degree angle, looking to his left
• jugular venous pressure (JVP) can be noted as a double flicker above the clavicle parallel to the anterior border of the sternocleidomastoid muscle (remember that a venous pulse is never palpable)
• note the height by measuring the vertical height in cm between the top of the jugular venous pulsation and the sternal angle
• normal JVP height = <4cm
• high JVP height is a sign of increased pressure in the right atrium, and so, may be a sign of congestive heart failure, fluid overload (which may be due to nephrotic syndrome) or superior vena cava obstruction
• note the waveform: a wave signifies right atrial systole whilst an absent waveform may be due to atrial fibrillation; c wave, which is rarely noted, is due to tricuspid valve closure; x descent (systolic collapse) is a sign of atrial relaxation and downward displacement of the tricuspid valve towards the right ventricular apex in ventricular systole; v wave is due to right atrial filling; y descent (diastolic collapse) is a sign of a fall in right atrial pressure when the tricuspid valve opens
• giant a waves happen when the right atrium is contracting against resistance as in tricuspid stenosis; cannon a waves happen when the right atrium is contracting against a closed tricuspid valve as in complete heart block
• the hepatojugular reflux helps in re-checking an already raised jugular venous pressure; it is done by pressing with the flat of the hand over the liver and watching the rise of the JVP

THE CAROTID PULSE

• the carotid pulse is the closest point to the heart where the arterial pulse can easily be felt
• note the waveform of the pulse: slow rising pulse = moderate to severe aortic stenosis; collapsing pulse = aortic incompetence; double peak pulse a.k.a bisferiens = moderate aortic stenosis with severe incompetence
• assess the pulse volume: small volume = low cardiac output; large volume = anaemia or thyrotoxicosis

7. Examining the Chest Wall

SCARS FROM PAST SURGERIES

• left infra-mammary scar is a sign of past closed mitral valvotomy
• central sternal scar is a sign of past open heart surgery

APEX BEAT

• determine the position of the apex beat, which is the lowest and outermost point of definite cardiac pulsation; the apex is usually found in the 5th intercostal space within the mid-clavicular line
• the apex beat may be impalpable in individuals with COPD and in patients with obesity
• the apex may be displaced due to ventricular enlargement following cardiac failure, pneumothorax and scoliosis
• assess the quality of the cardiac impulse: normal = brief outward movement at the onset of left ventricular ejection; abnormal = thrusting displaced apex beat in volume overload due to active large stroke volume ventricle caused by mitral or aortic incompetence, sustained apex beat in pressure overload due to aortic stenosis and gross hypertension with a normal or reduced stroke volume; or parasternal heave in central thrust or lift in the sternal region or 3rd or 4th intercostal space indicating right ventricular hypertrophy
• assess for palpable murmurs a.k.a. thrills or palpable heart sounds at the apex and base of heart; systolic thrill at apex = due to a ventricular septal defect or mitral regurgitation; systolic thrill at base = due to aortic or pulmonary stenosis; diastolic thrill at the apex = mitral stenosis; diastolic thrill at the base = aortic regurgitation; palpable first heart sound (sounds like a tapping apex beat) = felt in mitral stenosis; palpable pulmonary sound = felt in pulmonary hypertension

PRAECORDIUM AUSCULTATION

• prior to auscultation of the parecordium, ensure surrounding area is quiet
• use the diaphragm of the stethoscope to filter out low pitched sounds and identify high pitched sounds eg. 2nd heart sound
• use the bell of the stethoscope to listen to low-pitched sounds eg. mitral stenosis murmur
• aortic valve = best heard at the right 2nd intercostal space close to the sternum; pulmonary valve = best heard at the left 2nd intercostal space close to the sternum; tricuspid valve = best heard at the left 3rd, 4th and 5th intercostal spaces close to the sternum; mitral valve = best heard at the apex
• heart sound S1 = closing mitral and tricuspid valves + upstroke of carotid pulse; loud S1 = mitral stenosis; faint S1 = mitral regurgitation; intensity variation = atrial fibrillation
• heart sound S2: loud S2 = systemic or pulmonary hypertension; soft S2 = calcified or immobile aortic or pulmonary valve; fixed splitting S2 = atrial septal defect; reversed splitting S2 on expiration = delayed aortic component follows pulmonary component; fixed splitting S2 on inspiration = aortic component superimposed on the normal pulmonary component, usually in left bundle branch block (delay in the activation of left ventricle)
• extra heart sounds: S3 = low-pitched sound following S2 which happens in rapid ventricular filling in early diastole (physiologically heard in children, healthy young adults, athletes, and in pregnancy; pathologically heard in patients with large poorly contracting ventricle or with increased ventricular stroke volume due to a leaking heart valve)
• extra heart sound: S4 = soft low-pitched sound occurring just before S1 in rapid emptying of a hypertrophied atrium, always abnormal, commonly associated with severe heart failure and/or hypertension

AUSCULTATING FOR MURMURS

• heart murmurs are music-like sounds caused by turbulent blood flow in the heart; murmurs can result from normal blood volume passing through an abnormal valve, or from increased blood volume passing through a normal valve
• assess murmur timing – is it systolic or diastolic? (you may compare with the carotid pulse, and if murmur accompanies the pulse would be systolic, while if it follows the pulse it would be diastolic)
• ejection systolic murmurs start after the 1st heart sound, increase in amplitude to a peak around mid-systole, and quiet down towards the end of systole, stopping completely before the 2nd heart sound; causes include aortic stenosis, pulmonary stenosis (normal volume of blood flowing through a narrowed valve), and pregnancy (due to increased blood volume flowing through a normal valve)
• pansystolic murmurs extend throughout systole to the 2nd heart sound; causes include mitral or tricuspid valve leakage, or a ventricular septal defect
• late systolic murmurs are variants of the pansystolic murmurs, but these do not start right after the first heart sound but later on in systole; common in mitral valve prolapse
• early diastolic murmurs start right after the 2nd heart sound and quiet down as diastole proceeds; causes include aortic and/or pulmonary regurgitation
• mid-diastolic murmurs are low-pitched rumbling sounds best heard with the stethoscope bell at the apex of the heart while the patient is rolled onto the left hand side; occurs in mitral stenosis and rarely in tricuspid stenosis
• continuous murmurs are heard during systole and diastole; occur in patients with ductus arteriosus (channel connecting the aorta and pulmonary artery, which normally closes after birth)
• assess murmur intensity – murmur intensity is measured by grades…Grade 1 = heard by an expert in optimum conditions; Grade 2 = heard by a non-expert in optimum conditions; Grade 3 = easily heard, no thrill; Grade 4 = loud murmur with a thrill; Grade 5 = very loud, commonly heard over a wide area, with a thrill; Grade 6 = extremely loud, heard without a stethoscope
• assess murmur site and radiation – aortic stenosis = to the upper right sternal edge and neck; aortic rugurgitation = down the left sternal border and towards the apex; mitral stenosis = localised to the apex; pulmonary stenosis = to the upper left sternal border and beneath the left clavicle; pulmonary regurgitation = down the left sternal border; tricuspid stenosis = localised to the lower left sternal border; tricuspid regurgitation = lower left and right sternal border and epigastrium; ventricular septal defect = lower sternal edge
• assess murmur pitch – high pitch = greater pressure gradient; aortic incompetence murmur is high pitched so it is best heard with the diaphragm of the stethoscope; mitral stenosis murmur is low pitched so it is best heard with the bell of the stethoscope

AUSCULTATING FOR ADDED SOUNDS

• ejection click = opening sound caused by thickened aortic and pulmonary valves; happen right after first heart sound and before any ejection murmur
• prosthetic heart valves = usually have a quiet opening sound and a louder closing sound, seemingly metallic in character
• pericardial rub = friction sound common in acute pericarditis, usually heard by the diaphragm of the stethoscope left of the lower sternum with the patient breathing out, with intensity varying from hour to hour and with patient positioning

8. Examining the Bases of the Lungs

• crackes indicate pulmonary oedema, since they are produced by the explosive re-opening of collapsed airways

9. Examining the Abdomen

• palpate for the liver – enlarged liver is a sign of right heart failure; enlarged and pulsatile liver is a sign of tricuspid regurgitation
• palpate for aortic aneurysm – felt as a pulsatile mass over the epigastrium; a bruit may also be heard over it

10. Examining the Lower Limbs

PALPATE FOR THE PERIPHERAL PULSES

• femoral pulse = midway between the symphysis pubis and the anterior superior iliac spine
• popliteal pulse = deep in the popliteal fossa
• dorsalis pedis artery = along the cleft between the first two metatarsals
• posterior tibial artery = half-way along a line between the medial malleolus and the prominence of the heel
• NOTES: always compare left and right sides; always listen for bruits at all sites on both sides (heard over narrowed arteries); if peripheral pulses are impalpable, the problem may be peripheral vascular disease

ASSESS FOR SACRAL & LOWER LIMB OEDEMA

• oedema is the result of increased interstitial fluid that causes swelling of the tissues
• subcutaneous oedema can be determined by pitting of the skin following firm pressure applied by a finger or a thumb for a few seconds

Examination of the Cardiovascular System

Summary

Step-by-step instructions on how to perform an examination of the cardiovascular system:

1. assess hands for finger clubbing, peripheral cyanosis, tar staining
2. assess face for yellow lesions close to the inner eyes, malar flush, central cyanosis
3. assess neck: palpate the carotid artery & determine pulse rate, rhythm and volume; calculate CVP
4. assess chest: determine apex beat placement
5. auscultate for heart sounds and murmurs
6. check pedal pulses and for pitting oedema

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