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—

EchocardiographyCT ScanMRICardiac CatheterizationNuclear Imaging

CARDIOVASCULAR SYMPTOMS

• Chest Pain

• Shortness of Breath (dyspnea)

DOE (dyspnea on exertion)OrthopneaPND (paroxysmal nocturnal dyspnea)TrepopneaWheezing

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 mid-neck.

• 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

AUSCULTATIONAUSCULTATION

• Diaphragm – medium and high frequency soundsDiaphragm – medium and high frequency sounds

• Bell – low frequency soundsBell – low frequency sounds

• Normally hear closure of valveNormally hear closure of valve

• Sounds from left side of heart louder than Sounds from left side of heart louder than equivalent sounds from right side of heartequivalent sounds from right side of heart

AUSCULTATIONAUSCULTATION

• SS11 – closure of mitral and tricuspid – closure of mitral and tricuspid valvesvalves

• SS22 – closure of aortic and pulmonic – closure of aortic and pulmonic valvesvalves

• Low pitched sounds SLow pitched sounds S33, S, S44, mitral , mitral stenosis, and Korotkoff soundsstenosis, and Korotkoff sounds

• SS11 systole S systole S22 diastole S diastole S11

• Simultaneous palpation of carotid Simultaneous palpation of carotid pulse can help in differentiating Spulse can help in differentiating S11 and Sand S22

FIRST AND SECOND HEART SOUNDSFIRST AND SECOND HEART SOUNDS

• Aortic component (AAortic component (A22) normally louder than ) normally louder than pulmonic component (Ppulmonic component (P22))

• Mitral component (MMitral component (M11) normally louder than ) normally louder than tricuspid component (Ttricuspid component (T11))

FIRST AND SECOND HEART SOUNDS FIRST AND SECOND HEART SOUNDS (continued)(continued)

• TT11 and P and P22 normally heard only over their normally heard only over their respective area (LLSB and Lrespective area (LLSB and L22ICS)ICS)

• Normally left-sided sounds occur first MNormally left-sided sounds occur first M11TT11 (S (S11) ) and Aand A22PP22 (S (S22))

• SS22 changes with respiration, S changes with respiration, S11 does not does not Inspiration SInspiration S11 systole A systole A22 PP22

• Expiration SExpiration S11 systole A systole A22 P P22

DIAPHRAGMDIAPHRAGM

• Right 2Right 2ndnd intercostal space intercostal spaceAortic AreaAortic Area

• Left 2Left 2ndnd intercostal space intercostal spacePulmonic AreaPulmonic Area

• Third intercostal spaceThird intercostal spaceErb’s pointErb’s point

• Left lower sternal border Left lower sternal border Tricuspid areaTricuspid area

• Apex – over apical impulseApex – over apical impulseMitral areaMitral area

BELLBELL

• Left lower sternal borderLeft lower sternal border

• ApexApex

• Apex with patient in left lateral decubitus Apex with patient in left lateral decubitus positionposition

• Light pressure only!Light pressure only!

POSITIONSPOSITIONS

• Lying at 30Lying at 30°, standard position°, standard position

• Apex with the patient in the left lateral Apex with the patient in the left lateral decubitus position, with bell (mitral stenosis)decubitus position, with bell (mitral stenosis)

• At LLSB with patient sitting, leaning At LLSB with patient sitting, leaning forward, fully exhaled with diaphragm(aortic forward, fully exhaled with diaphragm(aortic regurgitation)regurgitation)

Normal S1 S2Normal S1 S2

Splitting of S2Splitting of S2

Aortic StenosisAortic Stenosis

Mitral RegurgitationMitral Regurgitation

Aortic InsufficiencyAortic 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 throughobstructed aortic valve from left ventricle

•Mitral Stenosis - during diastole forward flow throughobstructed mitral valve from left atrium

•Aortic regurgitation - during diastole backward flow through aortic valve from aorta