THE CARDIOVASCULAR SYSTEM

ANATOMY AND PHYSIOLOGY B. THE HEART C. THE ARTERIAL PULSE D. BLOOD PRESSURE
A.

A. ANATOMY AND PHYSIOLOGY

1. SUFACE PROJECTION OF THE HEART AND GREAT VESSELS
Right Ventricle : ( + ) the pulmonary artery A Wedgelike structure behind and to the left f the sternum Inferior border : below the junctional of the sternum and the Xiphoid Process Meets The pulmonary artery : 3rd left costal cartilage close to the sternum

Left Ventricle : Lying to the left of and behind to the right ventricle Forms the left border of the heart and produces the apical impulse ( 5th interspace, 7-9 cm from the midsternal ) Right Atrium : Forms the right border of the heart Not usually identifiable on physical examination

Left Atrium : Mostly posterior and cannot be examined directly

The Aorta : Curves upward from the left ventricle to the level of the sternal angle arches backward down The superior Vena Cava : on the right, empties into the right atrium
The Inferior Vena Cava : Base : the right and the left 2nd interspace close to the sternum

2. CARDIAC VALVES

Tricuspid left atrioventricular valve mitral right atrioventricular valve Aortic and Pulmonic semilunar valve As the heart valve close normal heart sounds

3. CARDIAC CYCLE

Systole Diastole

the period of ventricular contraction the period of ventricular contraction

4. HEART SOUND

S1

2 COMPONENTS : Mitral sound : much louder, can be heard best at the cardiac apex Tricuspid sound : softer, heard best at the louder left sternal border

S2

2 OMPONENTS : The Aortic valve closure ( A2 ) The pulmonic value closure ( p2 )

S3 Rapid ventricular filling as blood flows early in diastole rom left atrim to left ventricle

S4

ATRIAL CONTRACTION

EARLY SYSTOLIC EJECTION SOUND ( EJ ) Accompanied the opening of the aortic valve OPENING SNAP ( OS ) mitral stenosis ) The mitral valve opens ( in

5. HEART MURMURS LONGER DURTION ATRIBUTED TO TURBULENT BLOOD FLOW MAY INDICATE SERIOUS DISEASE THE MEANING OF MURMUR MUST BE ABLE TO TIME THEM IN THE CARDIAC CYCLE AND IDENTIFY WHERE THEY CAN BE HEARD BEST 6. RELATION OF AUSCULTATORY FINDINGS TO THE CHEST WALL SOUND AND MURMUR THAT ORINATE IN : The Mitral valve at and around the cardiac apex The Tricuspid valve the lower left sternal border The Pulmonic valve the 2nd and 3rd left interspace close to the sternum The Aortic valve may be heard anywhere from the right 2nd interspace to the apex

B. THE HEART
1. INSPECTION AND PALPITATION

THE CARDIAC APEX ( LEFT VENTRICULAR AREA )

At or medial to th midclavicular line in the 5th or posibbly

the 4th interspace May not visible in the supine patient Often is most easly felt in the letf lateral decubitus position Search for it first with the palmar surface of several fingers If ( - ) ask patient to exhale fully and stop breathing for a few second

 If ( - )

ask patient to exhale fully and stop breathing for a few second

If ( + )

make finer assessments with fingertips and then withone finger ( location, diameter, amplitude and duration )

THE LEFT STERNAL BORDER IN THE 3RD , 4TH AND INTERSPACE ( RIGHT VENTRICULAR AREA )
The patient should rest supine at 30o Place the tips of your curved finger in the 3rd , 4th ,and 5th

interspace and try to feel the systolic impuls of the right ventricle Improves your observation asking the patient to breath out and then briefly stop breathing Location, amplitude and duration

THE EPIGASTRIC ( SUB XIPHOPID ) AREA Useful when examine a person with an increased anteroposterior diameter of the chest

2. PERCUSSION

IN MOST CASES, PALPITATION HAS REPLACED PERCUSION IN THE ESTIMATION OF THE CARDIAC SIZE PERSUS FROM RESONANCE TOWARD CARDIAC DULLNESS IN THE 3RD , 4TH , 5TH AND POSSIBLY 6TH INTERSPACES ( THE LEFT ON THE CHEST )

3.AUSCULTATION

LOCATION : 2nd interspace close to the sternum ( right aortic, lelt pulmonic ) Along the left sternal border in each interspace from 2nd through 5th interspaces ( tricuspid ) The apex ( mitral ) if the heart is enlarged or displaced, you
should alter your pattern accordinely

SEQUENCE : BASE APEX OR APEX BASE STETOSCOPE : THE DIAPRAGHM S1 AND S2 ; MURMUR OF AORTIC AND MITRAL REGURTATION THE BELL S3 AND S4 ; MURMUR OF MITRAL STENOSIS

POSITION : Supine entire precordium Roll partly ontothe left side the apical impulse ( bell ) Sit up, lean forward, exhale completely and stop breathing along the left sternal border and at the apex ( diaphraem ). Pausing periodically so the patient may breath .
WHAT TO LISTEN FOR ? S1 intensity, spliting ? S2 intensity, spliting ? Extra sound in systole ( ejection sound or systole click ) Extra sound in diastole ( S3, S4, or opening snap ) Systolic murmurs Diastolic murmurs

C. ARTERIAL PRESSURE

HEART RATE The Radial Pulse The pads of your index and middle fingers a maximal pulsation is detected Rhythm is regular and the rate seems normal 15 seconds and multiply by 4 The Rate is unusual , fast or slow 60 seconds The rhythm is irregular the rate should be evaluated by cardiac auscultation

D. BLOOD PRESSURE

CHOICE OF SPHYGMOMANOMETER Choose a cuff of appropriate size The inflatable bladder of the cuff : - Width about 40 % of limbs circumference - Length about 80 % of limbs circumference
Aneroid or Mercury Type

An aneroid instrument often becomes inaccurate repeated use so it should be recalibrated periodically

with

TECHNIQUE - Avoid smoking or ingesting caffeine for 30 minutes - Rest for at least 5 minutes - The room should be quiet and comfortably warm - The arm selected should be resting and free of clothing - Free of : a. Arteriovenous fistules for dyalisis b. Scarring from Brachia Artery cutdown c. Lymphedema

- The Brachial Artery should at the heart level

( 4th interspace at its junction with the sternum ) - The patients arm so that it is slightly flexed at the elbow - The inflatable bladder over The Brachial Artery - The lower border of the cuff should be about 2,5 cm above The Antecubital Crease

1. Feel The Radial Artery with the fingers of one hands rapidly inflate the cuff until the radial pulse disappears 2. Read this pressure on the manometer and add 30 mmHg to it 3. Deflate the cuff promptly and completely and wait 15 30 minutes 4. Place the bell of a stethoscope lightly over The Brachial Artery 5. Inflate The Cuff rapidly again to the level just determined and then deflate it slowly at a rate of about 2-3 mmHgg / seconds

6. Note the level at which you hear the sounds of at least two consecutive beats ( Systolic Pressure ) 7. Continue to pressure slowly until the sounds become muffled and then disappear ( Diastolic Pressure ) 8. To confirm the disappearance of sounds, listen as the presure falls another 10-20 mmHg then deflate the cuff rapidly 9. Wait 2 or more minutes and repeat and take the average. If the first two readings differ by more than 5 mmHg, take the additional readings