00:00
Now, let's talk about a few specific
findings of some cardiac conditions.
00:06
First off, heart failure.
00:08
You're definitely going
to come across patients
with acute decompensated
heart failure
with whether systolic or diastolic,
or mix in nature.
00:17
And a few cardinal features
can really help us.
00:19
We already talked about
the third heart sound, the S3,
which again,
we're going to appreciate
with the bell of the stethoscope,
and the left lateral
decubitus position at the apex.
00:29
But another very important part
of the cardiovascular exam
when you're trying to assess
for heart failure
is to assess volume status.
00:36
And that's best done by looking
at central venous pressure
as estimated by
jugular vein distension,
by your jugular vein pressure.
00:46
And the way that
we're going to do that
is by tilting his head
off to the right,
just tilt your left to your left.
sorry, Shawn.
00:52
We can now visualize
the vessels of his great neck
underneath his skin.
01:01
Alright, so having talked about
Jugular Vein Distension,
and seeing how well
that can help to identify
acute congestive heart failure.
01:09
We're also going to want to look for
peripheral edema,
which can be
an important sign as well.
01:13
So, let's take a look
down here at the legs.
01:16
The most common place
to find peripheral edema
is gonna be
in your lower extremities,
particularly in,
if I may rotate the leg here,
the pretibial areas
in front of the shin,
the shin bone.
01:26
And down here in the pedal areas
so called pedal edema.
01:30
Assessing for edema is very simple.
01:32
You're going to push
on top of the skin,
hold for two or three seconds,
and then quickly release.
01:38
And you're going to look
and see if there's any pitting.
01:40
That is if there's an
indent left by your thumb,
after you pull your thumb away.
01:46
And typically if it
stays as a depression
for a longer span of time,
that may suggest more of a
proteinaceous kind of edema
like early lymphedema.
01:55
Whereas, if it resolves
within five seconds or so,
that may suggest more of a
hydrostatic type of edema
associated with heart failure,
or even an oncotic pressure
type of edema,
for example, from hypoalbuminemia,
or cirrhosis, etc.
02:12
The most common cause, though,
of edema in the lower extremities
is none of those very advanced
organ dysfunction problems.
02:22
It's actually just
chronic venous insufficiency,
which is a failure
of the valves in the veins
to return blood
effectively to the heart.
02:29
So all that is edema
is not heart failure.
02:32
And that's why
peripheral edema turns out
to not be a particularly useful
prognostic sign, or diagnostic sign
when you're trying to make
a diagnosis of heart failure.
02:42
That being said,
it's extremely useful
when you're tracking
a patient over time
as you're diuresing them,
for example.
02:48
In the same way that
tracking somebody's weight
can be helpful
when you're trying to see
if you've diurist them
or over diurist them, etc.
02:55
So, not useful to make a diagnosis
but useful to track patients
over time.
03:00
Importantly,
when you do push on the skin,
you may find that a patient
looks like the leg is
swollen and edematous.
03:07
But you push down and immediately
when you pull your thumb off,
the indent is gone.
03:13
And that can be suggestive of
lymphedema.
03:16
Advanced lymphedema.
03:18
When somebody has
acquired lymphedema,
or secondary lymphedema
that has been progressive
for a long span of time,
whether it's from a prior
lymph node dissection,
perhaps in the upper extremity,
or even folks who have
chronic venous insufficiency
for a long span of time
can develop this
lymphedematous process
a secondary lymphedema
or verrucous lymphedema,
you're going to find
that the skin is so
fibrost and thick
that when you push,
you can't push in very far,
and there's no indentation
that's left afterwards.
03:49
So the interpretation of edema
can be very nuanced.
03:52
And it's important to
realize that it's useful
but it's not going to make or break
a diagnosis of heart failure.
03:59
Since we're here
in the legs though,
it's worth us taking the look
at the at the pulses
that you can identify in the legs.
04:06
We're going to talk more in a moment
about the posterior tibial pulse.
04:09
It's right here behind
the medial malleolus
You can palpate it there.
04:13
The dorsalis pedis pluse
is going to be located here,
just a little bit lateral
to the very prominent
first MTP joint there.
04:23
Secondly,
there is a popliteal pulse,
very difficult to find,
for me at least.
04:28
But it's going to be found
in the popliteal fossa
between the semimembranosus and
semitendinosus tendons on the left
and or the medial and lateral
aspects of the back of the knee.
04:40
And then the femoral artery
is going to be up here.