Cardiac Exam
Content
CARDIOVASCULAR EXAMINATION
Steven A. Haist, MD, MS
Division of General Internal
Medicine
and Geriatrics
Department of Internal Medicine
CARDIOVASCULAR EXAMINATION
History
Physical Examination
Laboratory Tests (CPK, LDH, cholesterol, etc.)
Electrocardiography
Cardiac imaging—
Echocardiography
CT Scan
MRI
Cardiac Catheterization
Nuclear Imaging
CARDIOVASCULAR SYMPTOMS
• Chest Pain
• Shortness of Breath (dyspnea)
DOE (dyspnea on exertion)
Orthopnea
PND (paroxysmal nocturnal dyspnea)
Trepopnea
Wheezing
CARDIOVASCULAR SYMPTOMS
(continued)
• Dizziness / Syncope
• Palpitations
• Fatigue
• Edema
• Intermittent Claudication
• Cyanosis
CHEST PAIN
Angina Pectoris
Esophageal Spasm
Myocardial Infarction
Cholecystitis
Pericarditis
Peptic Ulcer Disease
Pulmonary Embolus
Costochondritis
Aortic Dissection
Hyperventilation
Esophagitis
Mitral Valve Prolapse
HISTORY
• Location
• Quality
• Quantity
• Radiation
• Timing—Onset, duration, frequency
• Setting
HISTORY (continued)
• Aggravating Factors
• Alleviating Factors
• Associated Factors
• Pertinent Negatives
• Pertinent Past History
• Previous Laboratory Tests (prior to this visit)
• Risk Factors
HISTORY MYOCARDIAL INFARCTION
• Anterior mid-chest (substernal)
• Heavy, crushing, pressure-like pain
• 9/10 with 10 being the worst pain of their life
• Radiates into L arm or neck
• > 30 minutes, < 12-24 hours
• Awoke this morning with the pain
HISTORY - MI (continued)
• Any activity
• None
• Associated diaphoresis, dyspnea, and nausea
• Denies history of MI, murmur, palpitations,
orthopnea, DOE,PND
• Similar pain not as severe in past lasting 5-10
minutes,relieved with rest, brought on by walking
• ECG in ER 1 yr. ago reportedly normal
• Smokes 1 PPD, hypertension for 10 years
• Father MI age 45, chol 300, no hx DM
CARDIOVASCULAR PHYSICAL
EXAMINATION
• General Appearance
• Vital Signs
• Jugular Veins
• Heart
• Peripheral Pulses
PHYSICAL EXAMINATION
• Is the patient in acute distress?
• Always use a hospital gown. Never palpate or
auscultate through clothing.
• Is the patient comfortable?
• Be concerned with the patient's privacy.
• Bed at 30°
• Must have quiet room !
• Examine from the right side.
Vital Signs
•BP
both arms
hypertension
hypotension
orthostatic hypotension
•HR
tachycardia
bradycardia
•Rhythm
regular
regularly irregular
irregularly irregular
•Respirations
tachypnea
•Temperature
fever
INSPECTION
• Jugular veins / jugular venous pressure
• Right side, head tilted to L
• Adjust angle of bed to see pulsation at midneck.
• Record distance from R atrium to top of
pulsation (sternal angle is 5 cm above RA)
INSPECTION (continued)
• Lips, nail beds
• Heart:
apical impulse
point of maximal impulse
• Extremities: (edema, venous or arterial
insufficiency)
CARDIAC EXAMINATION
• Inspection
• Palpation
• Percussion
• Auscultation
PALPATION
• Impulses - finger pads
• Thrills (vibrations palpated secondary to a
murmur—turbulent blood flow through a heart
valve) - Bony part of hand, ball of hand
PALPATION (continued)
• Apical impulse (normally 5th ICS and medial to
mid-clavicular line)
• Point of maximal impulse (PMI)
• Left lateral decubitus position (heart closer to
chest well) apical impulse more easily palpable
AUSCULTATION
•
Diaphragm – medium and high frequency sounds
•
Bell – low frequency sounds
•
Normally hear closure of valve
•
Sounds from left side of heart louder than
equivalent sounds from right side of heart
AUSCULTATION
•
S1 – closure of mitral and tricuspid
valves
•
S2 – closure of aortic and pulmonic
valves
•
Low pitched sounds S3, S4, mitral
stenosis, and Korotkoff sounds
•
S1 systole S2 diastole S1
•
Simultaneous palpation of carotid pulse
can help in differentiating S1 and S2
FIRST AND SECOND HEART SOUNDS
•
Aortic component (A2) normally louder than
pulmonic component (P2)
•
Mitral component (M1) normally louder than
tricuspid component (T1)
FIRST AND SECOND HEART SOUNDS
(continued)
•
T1 and P2 normally heard only over their
respective area (LLSB and L2ICS)
•
Normally left-sided sounds occur first M 1T1 (S1)
and A2P2 (S2)
•
S2 changes with respiration, S1 does not
Inspiration S1 systole A2 P2
Expiration S1 systole A2 P2
•
DIAPHRAGM
•
Right 2nd intercostal space
Aortic Area
•
Left 2nd intercostal space
Pulmonic Area
•
Third intercostal space
Erb’s point
•
Left lower sternal border
Tricuspid area
•
Apex – over apical impulse
Mitral area
BELL
•
Left lower sternal border
•
Apex
•
Apex with patient in left lateral decubitus
position
•
Light pressure only!
POSITIONS
•
Lying at 30°, standard position
•
Apex with the patient in the left lateral
decubitus position, with bell (mitral stenosis)
•
At LLSB with patient sitting, leaning
forward, fully exhaled with diaphragm(aortic
regurgitation)
Normal S1 S2
Splitting of S2
Aortic Stenosis
Mitral Regurgitation
Aortic Insufficiency
Observe, record, tabulate, communicate. Use your five senses. The art of
the practice of medicine is to be learned only by experience ; 'tis not an
inheritance ; it cannot be revealed. Learn to see, learn to hear, learn to
feel, learn to smell, and know that by practice alone can you become
expert. Medicine is learned by the bedside and not in the classroom. Let
not your conceptions of the manifestations of disease come from words
heard in the lecture room or read from the book. See, and then reason and
compare and control. But see first. No two eyes see the same thing. No
two mirrors give forth the same reflection. Let the word be your slave and
not your master. Live in the ward. Do not waste the hours of daylight in
listening to that which you may read by night. But when you have seen,
read. And when you can, read the original descriptions of the masters
who, with crude methods of study, saw so clearly. Record that which you
have seen ; make a note at the time ; do not wait. * The flighty purpose
never is o'ertook, unless the deed go with it.' . . ,1
TERMINOLOGY
•Stenosis - forward obstruction
•Regurgitation (insufficiency) - backward flow
•Aortic Stenosis - during systole forward flow through
obstructed aortic valve from left ventricle
•Mitral Stenosis - during diastole forward flow through
obstructed mitral valve from left atrium
•Aortic regurgitation - during diastole backward
flow through aortic valve from aorta
Steven A. Haist, MD, MS
Division of General Internal
Medicine
and Geriatrics
Department of Internal Medicine
CARDIOVASCULAR EXAMINATION
History
Physical Examination
Laboratory Tests (CPK, LDH, cholesterol, etc.)
Electrocardiography
Cardiac imaging—
Echocardiography
CT Scan
MRI
Cardiac Catheterization
Nuclear Imaging
CARDIOVASCULAR SYMPTOMS
• Chest Pain
• Shortness of Breath (dyspnea)
DOE (dyspnea on exertion)
Orthopnea
PND (paroxysmal nocturnal dyspnea)
Trepopnea
Wheezing
CARDIOVASCULAR SYMPTOMS
(continued)
• Dizziness / Syncope
• Palpitations
• Fatigue
• Edema
• Intermittent Claudication
• Cyanosis
CHEST PAIN
Angina Pectoris
Esophageal Spasm
Myocardial Infarction
Cholecystitis
Pericarditis
Peptic Ulcer Disease
Pulmonary Embolus
Costochondritis
Aortic Dissection
Hyperventilation
Esophagitis
Mitral Valve Prolapse
HISTORY
• Location
• Quality
• Quantity
• Radiation
• Timing—Onset, duration, frequency
• Setting
HISTORY (continued)
• Aggravating Factors
• Alleviating Factors
• Associated Factors
• Pertinent Negatives
• Pertinent Past History
• Previous Laboratory Tests (prior to this visit)
• Risk Factors
HISTORY MYOCARDIAL INFARCTION
• Anterior mid-chest (substernal)
• Heavy, crushing, pressure-like pain
• 9/10 with 10 being the worst pain of their life
• Radiates into L arm or neck
• > 30 minutes, < 12-24 hours
• Awoke this morning with the pain
HISTORY - MI (continued)
• Any activity
• None
• Associated diaphoresis, dyspnea, and nausea
• Denies history of MI, murmur, palpitations,
orthopnea, DOE,PND
• Similar pain not as severe in past lasting 5-10
minutes,relieved with rest, brought on by walking
• ECG in ER 1 yr. ago reportedly normal
• Smokes 1 PPD, hypertension for 10 years
• Father MI age 45, chol 300, no hx DM
CARDIOVASCULAR PHYSICAL
EXAMINATION
• General Appearance
• Vital Signs
• Jugular Veins
• Heart
• Peripheral Pulses
PHYSICAL EXAMINATION
• Is the patient in acute distress?
• Always use a hospital gown. Never palpate or
auscultate through clothing.
• Is the patient comfortable?
• Be concerned with the patient's privacy.
• Bed at 30°
• Must have quiet room !
• Examine from the right side.
Vital Signs
•BP
both arms
hypertension
hypotension
orthostatic hypotension
•HR
tachycardia
bradycardia
•Rhythm
regular
regularly irregular
irregularly irregular
•Respirations
tachypnea
•Temperature
fever
INSPECTION
• Jugular veins / jugular venous pressure
• Right side, head tilted to L
• Adjust angle of bed to see pulsation at midneck.
• Record distance from R atrium to top of
pulsation (sternal angle is 5 cm above RA)
INSPECTION (continued)
• Lips, nail beds
• Heart:
apical impulse
point of maximal impulse
• Extremities: (edema, venous or arterial
insufficiency)
CARDIAC EXAMINATION
• Inspection
• Palpation
• Percussion
• Auscultation
PALPATION
• Impulses - finger pads
• Thrills (vibrations palpated secondary to a
murmur—turbulent blood flow through a heart
valve) - Bony part of hand, ball of hand
PALPATION (continued)
• Apical impulse (normally 5th ICS and medial to
mid-clavicular line)
• Point of maximal impulse (PMI)
• Left lateral decubitus position (heart closer to
chest well) apical impulse more easily palpable
AUSCULTATION
•
Diaphragm – medium and high frequency sounds
•
Bell – low frequency sounds
•
Normally hear closure of valve
•
Sounds from left side of heart louder than
equivalent sounds from right side of heart
AUSCULTATION
•
S1 – closure of mitral and tricuspid
valves
•
S2 – closure of aortic and pulmonic
valves
•
Low pitched sounds S3, S4, mitral
stenosis, and Korotkoff sounds
•
S1 systole S2 diastole S1
•
Simultaneous palpation of carotid pulse
can help in differentiating S1 and S2
FIRST AND SECOND HEART SOUNDS
•
Aortic component (A2) normally louder than
pulmonic component (P2)
•
Mitral component (M1) normally louder than
tricuspid component (T1)
FIRST AND SECOND HEART SOUNDS
(continued)
•
T1 and P2 normally heard only over their
respective area (LLSB and L2ICS)
•
Normally left-sided sounds occur first M 1T1 (S1)
and A2P2 (S2)
•
S2 changes with respiration, S1 does not
Inspiration S1 systole A2 P2
Expiration S1 systole A2 P2
•
DIAPHRAGM
•
Right 2nd intercostal space
Aortic Area
•
Left 2nd intercostal space
Pulmonic Area
•
Third intercostal space
Erb’s point
•
Left lower sternal border
Tricuspid area
•
Apex – over apical impulse
Mitral area
BELL
•
Left lower sternal border
•
Apex
•
Apex with patient in left lateral decubitus
position
•
Light pressure only!
POSITIONS
•
Lying at 30°, standard position
•
Apex with the patient in the left lateral
decubitus position, with bell (mitral stenosis)
•
At LLSB with patient sitting, leaning
forward, fully exhaled with diaphragm(aortic
regurgitation)
Normal S1 S2
Splitting of S2
Aortic Stenosis
Mitral Regurgitation
Aortic Insufficiency
Observe, record, tabulate, communicate. Use your five senses. The art of
the practice of medicine is to be learned only by experience ; 'tis not an
inheritance ; it cannot be revealed. Learn to see, learn to hear, learn to
feel, learn to smell, and know that by practice alone can you become
expert. Medicine is learned by the bedside and not in the classroom. Let
not your conceptions of the manifestations of disease come from words
heard in the lecture room or read from the book. See, and then reason and
compare and control. But see first. No two eyes see the same thing. No
two mirrors give forth the same reflection. Let the word be your slave and
not your master. Live in the ward. Do not waste the hours of daylight in
listening to that which you may read by night. But when you have seen,
read. And when you can, read the original descriptions of the masters
who, with crude methods of study, saw so clearly. Record that which you
have seen ; make a note at the time ; do not wait. * The flighty purpose
never is o'ertook, unless the deed go with it.' . . ,1
TERMINOLOGY
•Stenosis - forward obstruction
•Regurgitation (insufficiency) - backward flow
•Aortic Stenosis - during systole forward flow through
obstructed aortic valve from left ventricle
•Mitral Stenosis - during diastole forward flow through
obstructed mitral valve from left atrium
•Aortic regurgitation - during diastole backward
flow through aortic valve from aorta
