Harrison's 19e Cardiovascular System

Harrisons PE of the CV System
Introduction
1. Directed history and targeted physical examination
2. General appearance of the patient, with notation of age, posture,
demeanor, and overall health status
Sign
May avoid certain
positions
Dyspnea, barrel chest
with increased AP
diameter, tachypnea,
pursed-lip breathing,
use of accessory
muscles
Chronically illappearing emaciated
Genetic diseases with
cardiovascular
involvement
Central cyanosis
Peripheral cyanosis or
acrocyanosis
Cyanosis affecting
lower but not upper
extremities
Spider nevi and can
cause R-to-L shunting
when in the lungs
Malar telangiectasia
Tan or bronze
discoloration of skin
Jaundice
Cutaneous
ecchymoses
Subcutaneous
xanthomas
Xanthelasma
Eruptive
xanthomatosis
Possibility
Pericarditis
Obstructive lung disease
Long standing heart failure

Malignancy
Trisomy 21
Marfan syndrome
Holt-Oram syndrome
R-to-L shunting at level of heart or lungs
Reduced extremity blood flow d/t small vessel
constriction (severe heart failure)
Large PDA
Secondary pulmonary hypertension with right
to left shunting at the great vessel level
Hereditary telangiectasias of lips, tongue,
mucous membranes as part of Osler-WeberRendu syndrome (Hereditary Hemorrhagic
Telangiectasia)
Advanced mitral stenosis
Scleroderma
Hemochromatosis as cause of systolic heart
failure
Advanced R heart failure
Congestive hepatomegaly
Cardiac cirrhosis
Taking vitamin K antagonists or antiplatelets
like aspirin or theinopyridines
Lipid disorders
Severe hypertriglyceridemia
Lipemia retinalis
Palmar crease
xanthomas
Leathery
cobblestoned
appearance of skin in
axilla and neck
creases
Angioid streaks on
fundoscopy
Extensive lentiginoses
Lupus pernio
Erythema nodosum
With associated
dilated
cardiomyopathy, AV
blocks,
intraventricular
conduction delay,
ventricular
tachycardia
Dentition and oral
hygiene
High arched palate
Bifid uvula
Orange tonsils
Hypertelorism, low set
ears, micrognathia
Blue sclerae
Arcus senilis
Fundoscopic exam
abn
Fundoscopy
Acute visual change
Branch retinal artery
occlusion
Hollenhorst plaque
Inflamed pinna
Type III hyperlipoproteinemia

Pseudoxanthoma elasticum
Developmental delay-Cardiovascular
syndromes like Carney syndrome (multiple
atrial myxomas)
Sarcoidosis
Source of possible infection

Marfan syndrome
Loeys-Dietz Syndrome
Tangier disease
Congenital heart disease
OI
Lacks specificity as index of coronary heart
disease risk
Atherosclerosis, HTN, DM
IE
Relapsing polychondritis
In later stages,
saddle-nose deformity
Saddle nose deformity Wegener or granulomatosis with polyangiitis
Midline sternotomy
Left posterolateral
thoracotomy
Infraclavicular scars
Prominent venous
collateral patterns
Dusky or slightly
cyanotic head and
neck
Venous pressure is
highly elevated
without visible
pulsations
Thoracic cage
abnormalities
Pectus
carinatum/excavatum
Severe kyphosis
Compenstory lumbar,
pelvic, knee flexion
Loss of normal
kyphosis of thoracic
spine
Asymmetric chest wall
Anterior displacement
of left hemithorax
Maximal cardiac
impulse in
epigastrium
Liver is enlarged and
tender
Systolic pulsations
over liver
Splenomegaly
Ascites
ICD
Pacemaker
Subclavian or vena caval obstruction
SVC syndrome
Connective tissue disorders
Ankylosing spondylitis
Check for aortic regurgitation
Straight back syndrome
Check for MVP
Cyanotic congenital heart disease
Obstructive lung disease

Chronic heart failure
Tricuspid regurgitation
Infective endocarditis, esp when symptoms
have been present for months
Advanced chronic R heart failure
Constrictive pericarditis
Hepatic cirrhosis
Elevated JVP
Between epigastrium
and umbilicus
Intraperitoneal malignancy
Cardiovascular etiology
Abdominal aorta
Ultrasound
Listen for bruits (presence means high-grade
atherosclerosis)
Note:
Clubbing
Unopposable
fingerized thumb
Arachnodactyly
Positive wrist to
thumb sign
Non tender Janeway
lesions (slightly raised
hemorrhages)
Temperature, color
Presence of clubbing (Ischemic
osteoarthropathy)
Arachnodactyly
Pertinent nail findings
Central L-to-R shunting
Endocarditis
Appearance:
Range from cyanosis and softening of root of
nail bed to classic loss of normal angle
between base of nail and skin to the skeletal
and periosteal bony changes of hypertrophic
osteoarthropathy, which is seen rarely in
advanced liver or lung disease
Holt-Oram Syndrome
Marfan
Infective endocarditis
Tender Osler nodes

(raised nodules on
pads of fingers or
toes)
Splinter hemorrhages
(linear petechiae at
midposition of nail
bed)
Lower ex or presacral
edema
Elevated JVP
Lower ex edema
Heart failure
Lymphatic or venous obstruction
Absence of jugular
venous hypertension
Pitting edema
Homan sign
-Posterior calf pain on
active dorsiflexion of
foot against
resistance)
Muscular atrophy
Absence of hair along
extremity
Venous insufficiency, further suggested by

presence of varicosities, venous ulcers
(typically medial), and brownish discoloration
from hemosiderin deposition (eburnation)
Use of Dihydropyridine CCBs
Neither specific nor sensitive for DVT
Severe arterial insufficiency

Primary neuromuscular disorder
JVP and Waveform

1. Single most important bedside measurement from which to
estimate volume status
2. IJV preferred
3. Important to distinguish the venous waveform from the carotid
pulse
4. Venous HTN sometimes can be elicited by performance of the
hepatojugular reflux or with passive leg elevation
a. (+) Hepatojugular reflux: Sustained rise of more than 3 cm
in JVP for at least 15 s after release of hands
5. JVP estimates RV filling pressure but has a predictable
relationship with the pulmonary artery wedge pressure
6. Elevated JVP = higher risk of subsequent hospitalization for HF,
death from heart failure, or both.
Prominent a wave
Cannon a wave
Absent a wave
Accentuated v wave
Prolonged or blunted
y wave
Kussmaul sign
Reduced right ventricular compliance

AV dissociation and RA contraction against a
closed tricuspid valve
Wide complex tachycardia
Atrial fibrillation
Tricuspid regurgitation
Severe TR: v wave merges with c wave so the
right atrial and venous waveforms become
ventricularized
RV inflow obstruction
Tricuspid stenosis
Pericardial tamponade
Rise or lack of fall of JVP with inspiration
Also in restrictive cardiomyopathy, massive
pulmonary embolism, RV infarction, Advanced
LV systolic HF
Also seen after cardiac surgery as an isolated
finding
Assessment of Blood Pressure
1. The length and width of the blood pressure cuff bladder should
be 80% and 40% of the arm circumference, respectively.
2. SBP and DBP are defined by the first and fifth Korotkoff sounds
3. BP should be measured in both arms and difference should be
less than 10 mm Hg
4. Systolic leg pressure are usually 20 mm Hg higher than systolic
arm pressures
5. Ankle-brachial index is a powerful predictor of long term
cardiovascular mortality
Very low (0 mm Hg) diastolic BP
Chronic Severe AR
Large AV Fistula
D/t enhanced diastolic run-off
> 10 mm Hg difference in right

and left arm BP
IN these cases, both phase 4 and

5 Korotkoff sounds should be
recorded
Atherosclerotic or inflammatory
subclavian artery disease
Supravalvular aortic stenosis
Aortic Coarctation
Greater leg-arm pressure

differences
White coat HTN
Aortic dissection
Chronic severe AR
Extensive and calcified lower
extremity PAD
At least three separate clinicbased measurements of >140/90
AND
At least 2 non-clinic-based
measurements of <140/90
Dont benefit from drug therapy
Masked HTN
Orthostatic hypotension
May develop HTN over time

Normal or even low BP in those
with advanced atherosclerotic
disease, esp. those with end organ
damage
Fall of >20 systolic or >10
diastolic in response to
assumption of upright position
from supine within 3 min
May lack compensatory
tachycardia as seen in Parkinson
Disease and diabetes
Exacerbated by:
Advanced age, dehydration,
certain meds, food,
deconditioning, and ambient
temperature
Arterial Pulse
1.

Harrison's 19e Cardiovascular System

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Harrisons PE of the CV System

Long standing heart failure

Type III hyperlipoproteinemia

Source of possible infection

Connective tissue disorders

Obstructive lung disease

Tender Osler nodes

Venous insufficiency, further suggested by

Severe arterial insufficiency

JVP and Waveform

Reduced right ventricular compliance

> 10 mm Hg difference in right

IN these cases, both phase 4 and

Greater leg-arm pressure

May develop HTN over time

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