SEMIOLOGY BLOOD :
Clinical examination of the arteries includes 4 time :
- The systematic palpation of all peripheral pulses.
- Auscultation of the major arterial routes.
- The taking of the blood pressure and measurement of systolic pressure index (IPS).
1/- L’INSPECTION :
In the normal state : peripheral arteries are invisible.
At the condition : They become visible
- In atherosclerosis : humeral arteries are visible to the inner arm and the fold of the elbow ; we can, their level, find the sign of the bell which makes a movement of crawling of the’sinuous and very beating humeral artery at each systole.
- In aortic regurgitation : carotid pulses are further, they are visible at the base of the neck ; they can make the sign of Musset that are rhythmic jerking of the head when it is slightly bent.
review the capital Time, it must be systematic and symmetric. Must feel :
- the posterior tibial.
- the dorsalis pedis
Technique : pulp 2th, 3th and 4th gentle fingers.
The peripheral arterial palpation will always bilateral and comparative to find the amplitude differences. on specify :
The palpable pedal pulses to the back of the foot next to the 20116 space is absent in inter métatarsien.il 5 at 10 % of the population and without pathological.
– The presence or absence of a pulse (disappearance in case of atheromatous occlusion e.g.).
- The regularity of the heartbeat (if arrhythmias).
- The amplitude of the pulse (small or large) which gives an idea of the stroke volume (eg wide pulse and surging aortic insufficiency).
- The regularity of accessible arterial routes (Search aneurysm suspected in the loss of parallelism of the edges of the artery) and flexibility (arteries can be rigid, in "pipe stem" if such atheroma).
Results of palpation :
A/- to & rsquo; normal :
- The arteries are flexible and depressibles.
All peripheral pulses must be normally found except, sometimes pedal pulses.
- 2 symmetrical arteries have equal and synchronous beats.
- The carotid pulse is synchronous B1.
- The radial pulse and the femoral pulses are synchronous.
- The pulse is steady, its frequency is the same as the heart rate.
B/- Abnormalities of arterial pulse :
a/- cardiac rhythm disorders : This is either :
In case of irregular rhythm taking the pulse underestimate FC : be based on cardiac auscultation.
b/- Changes in the amplitude of the arterial pulsation :
– The general weakening of the pulse : microsphygmie (decreased cardiac output) :
- Aortic stenosis.
- Congestive heart failure.
- Lipothymies, syncopations.
- Coarctation of aorta F.
- Thrombosis terrninale portion F aorta.
- thrombosis 2 iliac arteries.
– The weakening or disappearance of an elective arterial pulse :
total or subtotal obstruction of an artery : artérite, thrombosis or embolism.
– The widespread increase of amplitude of arterial pulse :
- heart erethism.
Aortic insufficiency : Pulse Corrigan.
– L’pulse amplitude may vary with respiratory movements : paradoxical pulse Kussmaul : Pericardial effusion of great abundance and constrictive pericarditis.
c/- The perception of tremor or thrill : Maybe systolic or systolic-diastolic : in arterial aneurysms or arteriovenous.
3/- AUSCULTATION :
A/- to & rsquo; normal : Arteries are silent on condition not to compress.
B – the condition : Appearance of a systolic murmur or systolic-diastolic breath or a continuous murmur is pathologic.
a/- In the carotid arteries :
- Thrombosis or carotid stenosis.
- RAO (irradiation of the breath of the carotid RAO).
- Atheromatous arterial narrowing : SS.
- arterial aneurysm : SS.
- Aneurysm, arteriovenous : S continu.
c/- renal artery :
- renal stenosis : unilateral SS, latero-umbilical or umbilical addition.
d/- femoral artery :
- IAO : Double femoris breath Duroÿez (On compressing the femoral artery by using a stethoscope and then gradually decreasing the pressure : systolic and diastolic S S).
- femoral stenosis.
4/- MEASURING BLOOD PRESSURE :
A/- The auscultatory method :
- This is the reference method and the oldest.
- Based on auscultation of arterial Korotkov noises, heard downstream of’a pneumatic cuff that is gradually deflated.
- In practice, the cuff is inflated to a pressure level above the systolic pressure, what is verified by the disappearance of the radial pulse, then slowly deflated.
- The stethoscope is placed immediately downstream of the cuff, at the brachial artery.
- Systolic blood pressure (NOT) F corresponds to appearance of noise (phase 1).
- Then the sounds change according to the time that the artery is opened during each heartbeat : they become intense, dry (phase 2), then longer and often with a blast (phases 3), then deafen (phase 4), and disappear (phase 5).
- The disappearance of sounds (start of phase 5) corresponds to the diastolic blood pressure (PAD).
+ The palpation method (palpation of the pulse during deflation of a cuff placed upstream) is only an approximate method, in addition, provides only systolic blood pressure (appearance of the pulse).
B/- other methods :
These methods for the evaluation of blood pressure level outside the medical presence, namely the’self-measurement and ambulatory blood pressure measurement (MAP)
a/- ambulatory blood pressure (MAP) : It evaluates by repeated measurements 24 hours level and blood pressure variability.
b/- L’automesure : Used to have a potentially large number of measurements over a sufficiently long period. It avoids particularly the increased pressure associated with the alarm reaction in the office (indeed "white coat").
C/- Precautions crumb reliable measurement of blood pressure :
For BP measurement by the conventional method, the following recommendations are to be met for a measure of quality :
- Adjust the size of the cuff to the circumference of the analyzed member (child, obese subject).
- Position the cuff, without bothersome garment its implementation. this recommendation, as previous, The same applies to self-measurement and ABPM.
- Able to rest, in a quiet room, after 10 minutes while lying or sitting
- Initial measurement of blood pressure in both arms. If asymmetry, then take always blood pressure in the arm where the numbers are the highest.
- Deflation slow if method "manual" auscultation, about 2 mm Hg / beat.
- Three measures to at least two consultations before the diagnosis of hypertension.
- Knowing the effect of "white coat" related to the doctor-patient interaction, increasing numbers of about 10 %. This effect is particularly common in the elderly or emotional Avoid talking or to talk during the measurement.
- In case of full arrhythmia by atrial fibrillation, the blood pressure levels are more difficult to measure and must be the average of several measurements.
- At the & rsquo; child, noises are heard to 0 and then consider Phase 4 (noise lower and more deaf) diastolic blood pressure.
- Blood pressure when standing must be compared to blood pressure while sitting or lying. It should be taken immediately and after two minutes of orthostatic.
D/- Normal blood pressure :
- The definition of hypertension is necessarily arbitrary, since, in fact, cardiovascular risk increases continuously with the blood pressure level, without clearly individualized threshold.
- In adults, the experts propose as normal BP the definition under 140 mmHg systolic and less 90 mmHg diastolic.
- Optimal blood pressure is < 120/80 mmHg
- Of course the proposed thresholds to define hypertension are not the same as the method used. They are lower for self-measurement and ABPM, which are not affected by the white coat effect.
INDEX PRESSURE STROKE :
- Interest in search of a lower limb arténopathie.
- A pneumatic cuff placed at the ankle is deflated, while the systolic pressure is measured with a Doppler probe at the dorsalis pedis artery or tibial posténeure.
- This systolic pressure at the ankle is attached to the humeral systolic pressure, for I index of systolic (IPS) that is considered abnormal if
less than 0,9 : ??? = ??????????? / ??????? = ?.? at ?.?.
Hypotension : rarely should be sought :
- Collapse cardiovasculaire.
- slow adrenal insufficiency.
- Hypotension young subjects and / or sports.
Abnormalities of the differential : difference between the SBP and DBP
- Enlargement : characteristic IAO.
- pinch : is seen especially in severe heart failure.
SEMIOLOGY VEIN :
- Examination of the jugular veins.
- Examination of leg veins.
- The search for signs of phlebitis (TVP).
1/- Examination of the jugular veins :
Its appearance reflects the pressure variations of OD.
A/- to & rsquo; normal :
venous pulse more visible than the arterial pulse but not palpable.
B/- the condition :
a/- The permanent distended jugular : spontaneous jugular :
Results in visible swelling on’inspection of the external jugular vein at the level of the neck (is more generally inspect the right jugular vein being located at the vertical of the vena cava), secondary to retention of blood in the venous territory.
Ringer's alliance cardiaque fonction droite :
- Right ventricular failure.
- Pericardial effusion abundant.
- Péricardite constrictive.
It is placed in supine patient, back positioned 30 degrees upward from l’horizontal, the patient is asked to look to the left to the right side of the neck is discovered.
Finally, we strongly press on the liver which is in the right hypochondrium and we look at s’it n’there is no reflux in the right external jugular vein.
The sign is positive if reflux.
It reflects a right heart failure.
c/- Systolic expansion of the jugular : Systolic jugular pulse of IT
In tricuspid insufficiency right atrium fills during systole due to IT that meets the cellar veins and so therefore the jugular veins.
Often associated with systolic expansion of the liver.
d/- Dissociation radio jugular :
Pulse independent jugular arterial pulse :
– Is faster than the arterial pulse : B AV complet, atrial tachycardias.
– Is slower than the arterial pulse : ventricular tachycardia.
A/- to’normal state :
The leg veins are not visible except at the level of the medial malleolus and the back foot.
B/- to’pathological state :
we are looking for :
a/- The varicose veins : (reaching the surface grating)
– Standing position +++.
– Go when the member is raised.
– May thrombose and thus cause a superficial thrombophlebitis.
b/- Deep vein thrombosis (TVP) lower limb : (reaching the deep network) : Obliteration of deep vein by a blood clot.
Course of Dr H Foudad – Faculty of Constantine