Assessment of Heart Failure – Advanced Assessment

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.