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 Myocardial Infarction Pericarditis Pulmonary Embolus Aortic Dissection Esophagitis Esophageal Spasm Cholecystitis Peptic Ulcer Disease Costochondritis Hyperventilation Mitral Valve Prolapse

HISTORY

Location Quality

Quantity
Radiation TimingOnset, 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 tachycardia bradycardia regular regularly irregular irregularly irregular tachypnea

HR Rhythm

Respirations

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 murmurturbulent 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 M1T1 (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 Erbs 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