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Physical Examination: Difference between revisions
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The peripheral pulsations should be assed by both palpitation of the pulse and auscultation for bruits. Pulse abnormalities and bruits increase the likelihood of peripheral arterial disease. Pulsations should be assessed and documented in several arteries in the body in order to get an idea of the state of peripheral vasculature. Easily and fast palpable pulses in healthy individuals include the brachial, radial, and ulnar arteries of the upper extremities and the femoral, popliteal, dorsalis pedis, and posterior tibial arteries of the lower extremities. Minor or absent pulsations suggest a severe stenotic lesion proximal of the palpation site. To asses the cardiac (dys)function through the pulse generally an artery close to the heart should be selected, such as the carotid. Bounding high-amplitude carotid pulses suggest an increase in stroke volume and should be accompanied by a wide pulse pressure on the blood pressure measurement. A weak carotid pulse suggests a reduced stroke volume. [Figure 1] | The peripheral pulsations should be assed by both palpitation of the pulse and auscultation for bruits. Pulse abnormalities and bruits increase the likelihood of peripheral arterial disease. Pulsations should be assessed and documented in several arteries in the body in order to get an idea of the state of peripheral vasculature. Easily and fast palpable pulses in healthy individuals include the brachial, radial, and ulnar arteries of the upper extremities and the femoral, popliteal, dorsalis pedis, and posterior tibial arteries of the lower extremities. Minor or absent pulsations suggest a severe stenotic lesion proximal of the palpation site. To asses the cardiac (dys)function through the pulse generally an artery close to the heart should be selected, such as the carotid. Bounding high-amplitude carotid pulses suggest an increase in stroke volume and should be accompanied by a wide pulse pressure on the blood pressure measurement. A weak carotid pulse suggests a reduced stroke volume. [Figure 1] | ||
[[Figure 1. Body locations for examining the pulse. | [[Image: |thumb|right|400px|'''Figure 1.''' Body locations for examining the pulse. | ||
source: homemade from http://commons.wikimedia.org/wiki/File%3ACirculatory_System_no_tags.svg]] | source: homemade from http://commons.wikimedia.org/wiki/File%3ACirculatory_System_no_tags.svg]] | ||
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Additionally, the characteristics of the right internal jugular pulse should be assessed, because they can be reveal clinical signs of right-heart function and rhythm disturbances. The distinctive waves of the jugular vein are summarized in Table 7 and visualized in Figure 2. | Additionally, the characteristics of the right internal jugular pulse should be assessed, because they can be reveal clinical signs of right-heart function and rhythm disturbances. The distinctive waves of the jugular vein are summarized in Table 7 and visualized in Figure 2. | ||
[[Image:Jugular Venous Pulse.png|right|thumb|400px|Figure 2. Jugular venous pulse waveform.]] | [[Image:Jugular Venous Pulse.png|right|thumb|400px|'''Figure 2.''' Jugular venous pulse waveform.]] | ||
{| class="wikitable" border="0" cellspacing="0" cellpadding="0" width="600px" | {| class="wikitable" border="0" cellspacing="0" cellpadding="0" width="600px" | ||
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===Cardiac Auscultation=== | ===Cardiac Auscultation=== | ||
[[Image:Gray1216 modern locations.svg.png|thumb|right|400px|Figure 3. Locations for cardiac auscultation]] | [[Image:Gray1216 modern locations.svg.png|thumb|right|400px|'''Figure 3.''' Locations for cardiac auscultation]] | ||
The acceleration and deceleration of blood and the subsequent vibration of the cardiac structures during the phases of the cardiac cycle are causing heart sounds. In healthy adults, there are two normal heart sounds often described as a lub and a dub (or dup), that occur in sequence with each heart beat. These are the first heart sound (S1) and second heart sound (S2), produced by the closing of the atroventricular valves and semilunar valves respectively. In addition to these normal sounds, a variety of other sounds may be present including heart murmurs, adventitious sounds, and gallop rhythms S3 and S4.To hear cardiac sounds, use a stethoscope with a bell and a tight diaphragm. The bell is best used to hear low-frequency sounds which are associated with ventricular filling. The diaphragm is best used to appreciate the medium-frequency sounds that are associated with valve opening and closing. Cardiac murmurs are caused due to turbulent blood flow and are usually high-to-medium frequency. In most cases the diaphragm is best used to hear cardiac murmurs. An important exception to this is the low-frequency atrioventricular valve inflow murmurs, such as that produced by mitral stenosis, which are best heard with the bell. Murmurs may be physiological or pathological. Abnormal murmurs can be caused by stenosis restricting the opening of a heart valve, resulting in turbulence as blood flows through it. Abnormal murmurs may also occur with valvular insufficiency (or regurgitation), which allows backflow of blood when the incompetent valve closes with only partial effectiveness. | The acceleration and deceleration of blood and the subsequent vibration of the cardiac structures during the phases of the cardiac cycle are causing heart sounds. In healthy adults, there are two normal heart sounds often described as a lub and a dub (or dup), that occur in sequence with each heart beat. These are the first heart sound (S1) and second heart sound (S2), produced by the closing of the atroventricular valves and semilunar valves respectively. In addition to these normal sounds, a variety of other sounds may be present including heart murmurs, adventitious sounds, and gallop rhythms S3 and S4.To hear cardiac sounds, use a stethoscope with a bell and a tight diaphragm. The bell is best used to hear low-frequency sounds which are associated with ventricular filling. The diaphragm is best used to appreciate the medium-frequency sounds that are associated with valve opening and closing. Cardiac murmurs are caused due to turbulent blood flow and are usually high-to-medium frequency. In most cases the diaphragm is best used to hear cardiac murmurs. An important exception to this is the low-frequency atrioventricular valve inflow murmurs, such as that produced by mitral stenosis, which are best heard with the bell. Murmurs may be physiological or pathological. Abnormal murmurs can be caused by stenosis restricting the opening of a heart valve, resulting in turbulence as blood flows through it. Abnormal murmurs may also occur with valvular insufficiency (or regurgitation), which allows backflow of blood when the incompetent valve closes with only partial effectiveness. | ||
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*Shape – Several shapes can be distinguished as shown in Figure 4. | *Shape – Several shapes can be distinguished as shown in Figure 4. | ||
[[Figure 4. Murmur sound shapes. | [[Image: |thumb|right|400px|'''Figure 4.''' Murmur sound shapes.]] | ||
*Radiation – Some of the underlying pathologic disease cause murmurs to radiate. The distinctive pattern follows the blood flow from the point of maximal intensity: | *Radiation – Some of the underlying pathologic disease cause murmurs to radiate. The distinctive pattern follows the blood flow from the point of maximal intensity: | ||
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====Murmurs categorized by time in cardiac cycle==== | ====Murmurs categorized by time in cardiac cycle==== | ||
[[Image:441px-Phonocardiograms from normal and abnormal heart sounds.png|thumb|right|300px|Figure 5. Representation of the sound waves of murmurs associated with heart disease.]] | [[Image:441px-Phonocardiograms from normal and abnormal heart sounds.png|thumb|right|300px|'''Figure 5.''' Representation of the sound waves of murmurs associated with heart disease.]] | ||
A schematic scheme of the heart sounds and heart murmurs are shown in Figure 5. | A schematic scheme of the heart sounds and heart murmurs are shown in Figure 5. | ||