The WiggersDiagram PHYSICAL EXAMINATION …

1 1 PHYSICAL EXAMINATION cardiovascular SYSTEMPHYSICAL EXAMINATION PHYSICAL EXAMINATION cardiovascular cardiovascular SYSTEMSYSTEMM ervyn Gotsman of cardiology , Hadassah University Hospital, Hebrew University -Hadassah Medical School, Jerusalem, IsraelMervynMervynGotsman of cardiology , Hadassah Department of cardiology , Hadassah University Hospital, Hebrew University University Hospital, Hebrew University --Hadassah Medical School, Jerusalem, Hadassah Medical School, Jerusalem, IsraelIsraelThe Wiggers Diagramxy General examinationGeneral EXAMINATION Arterial pulse Arterial pulse brachial, brachial, carotids, peripheralcarotids, peripheral Jugular Venous PressureJugular Venous Pressure The heartThe heart InspectionInspection Palpation Palpation PercussionPercussion AuscultationAuscultationPHYSICAL EXAMINATION PHYSICAL EXAMINATION cardiovascular SYSTEMCARDIOVASCULAR system Walking and gaitWalking and gait Sitting or lyingSitting or lying OrthopnoeaOrthopnoea Cyanosis (central or peripheral), anaemia, Cyanosis (central or peripheral)

2 , anaemia, jaundicejaundice Fever and embolic signsFever and embolic signs Right heart failure (JVP, dependent oedema, Right heart failure (JVP, dependent oedema, hepatomegaly, ascites, pleural effusions)hepatomegaly, ascites, pleural effusions) Left heart failure (dyspnoea, tachypnoea, Left heart failure (dyspnoea, tachypnoea, orthopnoea, cough, basal crepitationsorthopnoea, cough, basal crepitations Pulmonary diseasePulmonary disease SytemicSytemicdisease: disease: thyrotoxicosisthyrotoxicosis, , sclerodermascleroderma, , lupus lupus erythematosiserythematosis, etc, etcCARDIOVASCULAR SYSTEMCARDIOVASCULAR SYSTEMG eneral examinationGeneral examinationLeftHeart Failure Elevated LVEDP LAP PVP Pulmonary congestion Dyspnoea Orthopnoea Cough Tiredness and lethargyRight Heart FailureJVPJVPH eparHeparAscitesAscitesAnkle EdemaAnkle EdemaWeightWeight2 Arterial pulseArterial pulse Jugular Venous PressureJugular Venous Pressure Cardiac EXAMINATION : Cardiac EXAMINATION .))

3 InspectionInspection PalpationPalpation Percussion Percussion AuscultationAuscultationPHYSICAL EXAMINATION PHYSICAL EXAMINATION cardiovascular SYSTEMCARDIOVASCULAR SYSTEMA rterial pulseArterial pulseRadial arteryRadial artery Heart rate:Heart rate:( 60( 60--100 ).100 ). Rhythm:Rhythm:RegularRegularIrregularIrr egular: Sinus arrhythmia: Sinus arrhythmiaOccasionalOccasional--Prematur e beatsPremature beats--Dropped beatsDropped beatsTotallyTotally--irregularirregularA rterial pulseArterial pulseRadial arteryRadial arteryAmplitude/Contour:Amplitude/Contou r: HypokineticHypokinetic ( weak ) ( weak ) --HypovolemiaHypovolemiaHeart failureHeart failureAortic stenosisAortic stenosis Hyperkinetic Hyperkinetic increased stroke volumeincreased stroke volumeFever, anemia, hyperthyroidismFever, anemia, hyperthyroidismAR, bradycardia, atherosclerosisAR, bradycardia, atherosclerosisArterial pulseArterial pulseCarotid arteryCarotid artery120801208012080 Amplitude/Contour:Amplitude/Contour.

4 BisferiensBisferiens--HOCUMHOCUM CollapsingCollapsing ARAR ParvusParvuset et tardustardus--AS AS AlternansAlternans--Heart failure Heart failure BigeminalBigeminal--Premature beatsPremature beats Paradoxical Paradoxical --Pericardial Pericardial tamponadetamponade--Constrictive Constrictive pericarditispericarditis DicroticDicrotic CardiomyopathyCardiomyopathy FiliformFiliform--shockshockArterial pulse: Carotid arteryArterial pulse: Carotid arteryPulsus parvus et tardusThe phono-carotid pulse tracing: Phono Long systolic ejection murmur Paradoxical split of the 2ndheart sound Carotid pulse tracing Pulsus parvus et tardus3 Arterial pulseArterial pulse Jugular Venous PressureJugular Venous Pressure The heartThe heart InspectionInspection Palpation Palpation PercussionPercussion AuscultationAuscultationPHYSICAL EXAMINATION PHYSICAL EXAMINATION cardiovascular SYSTEMCARDIOVASCULAR SYSTEMJ ugular Venous PressureJugular Venous Pressure4545ooangleangleJugular Venous PressureJugular Venous PressurePatient at 30 degrees and oblique lightingPatient at 30 degrees and oblique lightingDifferentiation from arterial

5 PressureDifferentiation from arterial pressure Two waves ( if not in A fib)Two waves ( if not in A fib) Changes with positionChanges with position Obliterated with pressureObliterated with pressure Decreases with respirationDecreases with respirationJugular Venous PressureJugular Venous Pressure ReflectsReflects Right atrial pressureRight atrial pressure Blood volumeBlood volume Tricuspid valveTricuspid valve Diastolic events in the right ventricleDiastolic events in the right ventricle Estimate CVPE stimate CVPM aximal 3cm from Maximal 3cm from sternalsternalangle angle + 5cm from atrium (Right atrial + 5cm from atrium (Right atrial pressure)pressure)

6 Increased pressureIncreased pressureRight sided heart failureRight sided heart failureConstrictive Constrictive pericarditispericarditisTricuspid stenosisTricuspid stenosisObstructed SVCO bstructed SVCI ncreased Increased intrathoracicintrathoracicpressurepressu reJugular Venous PressureJugular Venous PressureJugular Venous PressureJugular Venous PressureVenous PressureVenous PressureExternal jugular External jugular veinveinInternal jugular Internal jugular veinvein4 Jugular Venous PressureJugular Venous PressureAngle of LewisAngle of LewisJugular Venous PressureJugular Venous PressureavyxS1S2S2S1 Systole Diastolewavedescent Amplitude of pulsationsAmplitude of pulsationsa wave, x descent, v wave, y descenta wave, x descent, v wave, y descentAtrial contraction, relaxation, atrial filling, emptyingAtrial contraction, relaxation, atrial filling, emptying Absent Absent aa wavewave--atrial fibrillationatrial fibrillation Giant Giant aa wavewave--tricuspid Stenosis, PHTtricuspid Stenosis.

7 PHT Cannon Cannon aa waveswaves--AV dissociationAV dissociation Large Large vv wavewave--tricuspid regurgitationtricuspid regurgitation Slow Slow yy descentdescent tricuspid stenosistricuspid stenosisJugular Venous PressureJugular Venous PressureJugular Venous PressureJugular Venous PressureDiagnosis ?Diagnosis ? '1 A V 'Y ' Jugular Venous PressureJugular Venous PressureDiagnosis ?Diagnosis ?5 '2 : .. - .. - HepatojugularHepatojugularrefluxreflux-- Sustained rise of Sustained rise of JVP JVP Heart failure.

8 KussmaulKussmaul sssignsign--Increase with inspirationIncrease with inspirationConstrictive Constrictive pericarditispericarditisHeart failureHeart failureJugular Venous PressureJugular Venous Pressure Arterial pulseArterial pulse Jugular Venous PressureJugular Venous Pressure Cardiac ExaminationCardiac EXAMINATION InspectionInspection PalpationPalpation Percussion Percussion AuscultationAuscultationPHYSICAL EXAMINATION PHYSICAL EXAMINATION cardiovascular SYSTEMCARDIOVASCULAR SYSTEM6 Cardiac EXAMINATION : Cardiac EXAMINATION : InspectionInspectionCardiac pulsationsCardiac pulsationsPMIPMIP arasternal liftParasternal liftS3, S4S3, S4 DyskinesisDyskinesisAneurysmAneurysmCard iac EXAMINATION : Cardiac EXAMINATION : InspectionInspection Arterial pulseArterial pulse Jugular Venous PressureJugular Venous Pressure Cardiac ExaminationCardiac EXAMINATION InspectionInspection PalpationPalpation Percussion Percussion AuscultationAuscultationPHYSICAL EXAMINATION : PHYSICAL EXAMINATION .

9 cardiovascular SYSTEMCARDIOVASCULAR SYSTEMA reas of palpationAreas of palpation Apical impulse (PMI)Apical impulse (PMI) Left Left sternalsternalborderborder Left and right 2nd Left and right 2nd interspaceinterspace EpigastricEpigastricareaarea ThrillsThrillsCardiac EXAMINATION : Cardiac EXAMINATION : PalpationPalpation Apical impulse (PMI)Apical impulse (PMI)Cardiac EXAMINATION : Cardiac EXAMINATION : PalpationPalpation Apical impulse (PMI)Apical impulse (PMI)Cardiac EXAMINATION : Cardiac EXAMINATION : PalpationPalpation7 Apical impulse (PMI)Apical impulse (PMI)Cardiac EXAMINATION : Cardiac EXAMINATION : PalpationPalpationLeft Left parasternalparasternalliftlift Right ventricular volume load Right ventricular volume load ASD ASD Pulmonary incompetencePulmonary incompetence Tricuspid incompetence Tricuspid incompetence --seesee--saw motionsaw motion Right ventricular pressure loadRight ventricular pressure load Pulmonary hypertensionPulmonary hypertension Pulmonary stenosisPulmonary stenosis Left atrial liftLeft atrial lift Mitral incompetenceMitral incompetenceCardiac EXAMINATION Cardiac EXAMINATION --PalpationPalpation Left Left sternalsternalborderborder--Right ventricleRight ventricleCardiac EXAMINATION .

10 Cardiac EXAMINATION : PalpationPalpation Left 2nd Left 2nd interspaceinterspace--Pulmonic: PHT Pulmonic: PHT Right 2nd Right 2nd interspaceinterspace--Aortic: HTNA ortic: HTN EpigastricEpigastricareaarea--Right ventricle in Right ventricle in hyperinflatedhyperinflatedlungslungs Thrills Thrills --Murmurs grade 4+Murmurs grade 4+Cardiac EXAMINATION : Cardiac EXAMINATION : PalpationPalpationThe normal apex-cardiogramThe normal apex cardiogram: Normal outward motion fills the first third of systole Small presystolic outward motion Rapid filling waveRFWA pexcardiogramin aortic stenosis Prominent outward presystolic motion Prolonged sustained outward motion fills all of systole a 8 Apexcardiogram in aortic stenosis Prominent outward presystolic motion Prolonged sustained outward motion fills all of