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CARDIAC ASSESSEMENT

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HISTORY.

Chest pain, tightness or discomfort. Shortness of breath Palpitation Syncope or dizziness Related cardiovascular history -Transient ischemic attack, -stroke, -peripheral vascular disease -peripheral edema

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Chest pain

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Chest pain is one of the important symptoms of heart disease. usually in the front of the chest (retrosternal). spread to the neck, jaw, back, left or right arm. chest pain due to cardiac ischemia is typically tight and crushing in quality.

Location:

Radiation:

Nature:

Patients may refer to angina pain as 'indigestion'.

Other

features include duration, aggravating and relieving factors, and associated symptoms (e.g. nausea and/or

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Chest pain

BREATHLESSNESS
Cardiac

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causes include

severe

pulmonary oedema

acute MI, cardiac arrhythmia pericarditis

pericardial effussion

q
q

Cont.

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Dyspnea on exertion may be the Breathlessness on lying flat

evidence of heart failure.

q

(orthopnea
q

Any attacks waking the patient from

sleep (paroxysmal nocturnal dyspnoea) or at rest?

q

Cheyne-Stokes or periodic breathing

PALPITATIONS
Palpitations- presentation of a cardiac arrhythmia. Rhythm: tap out the rate and regularity; -a missed beat suggests extra systoles. Duration:- sudden short episodes suggest paroxysmal tachycardia; -longer duration with irregularities suggests Arial dysrhythmia. Associated symptoms: pain, dyspnoea, feeling faint or syncope.

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OTHER HISTORY

Drugs/medication: Associated cough. Limb ischemia, intermittent cloudication. .Gastrointestinal symptoms: Failure to thrive in children or weight loss Urinary symptoms- oliguria.. Cerebral symptoms:-Dizziness, head ache

in in adults.

and mental changes

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EXAMINATION

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Examination General

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tBuild (obesity or wasting); shortness of breath; difficulty in talking; do they look ill? for pallor, jaundice,, sweatiness and clamminess, for any evidence of syndromes or non-cardiovascular conditions associated with cardiovascular abnormalities.

Look

Look

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Cyanosis-Central, peripheral

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Face
Malar

flush - redness around the cheeks (mitral stenosis,). yellowish deposits of lipid around the eyes, palms, or tendons (hyperlipidaemia). arcus - a ring around the cornea (normal aging or hyperlipidaemia). - forward projection or displacement of the eyeball (graves disease)

Xanthalasma-

Corneal

Proptosis

Malar flush

xanthalasma

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Corneal arcus

proptosis

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Hands
Finger

clubbing. refill. haemorrhage (infective

Capillary

Splitncter

endocarditis).
Oslers

nodes- tender nodules in the

fingertips (infective endocarditis).

Sweaty Visible

palms, tremor (thyrotoxicosis)

capillary pulsations in the nail

FINGERS clubbing
ONTENT

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NORMAL ONTENT

CLUBBED

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Splinter haemorrhage

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Oslers nodes-

- Assess Visible capillary pulsations in the nail bed (Quincke's sign

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PULSES
-Palpate both radial pulses and assess rate and rhythm.. - Palpate carotid pulse and assess volume and character. Bruits -Palpate the femoral, - popolitial (located at the back of the knee with a flexed knee) -posterior tibia (located below the medial alveolus, lateral to the extensor hillocks longus) - dorsalis pedis.

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RADIAL PULSE

CAROTID PULSE SITE

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Carotid pulse pulses

femoral

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Dorsalis pedis

poplitial.

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posterior tibia

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Peripheral oedema

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Degree of edema

palpate the skin over the tibia for edema bySquzeeing the skin for 30-60 sec. from --trace -4+. is slight indentation dissappear in a short time. Mild pitting, slight indentation, no perceptable swelling of the leg 2+ Moderate pitting, indentation subsides rapidly 3+ Deep pitting, indentation remains for a short time, leg looks swollen 4+ Very deep pitting, indentation lasts a long time, leg is very swollen

Graded Trace

1+

ASSESSMENT OF PITTING EDEMA

Pitted edema is tested by pressing & holding finger into the swollen tissue over a bony area for 5 seconds. If there is an indentation left behind when you remove finger it is pitted edema 2mm or less 2-4mm = 2 4-6mm = 3 6-8mm = 4 = 1+ Edema + Edema + Edema + Edema

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Slight pitting Somewhat Pit is No visible deeper pit noticeably distortion No deep Disappears readably May last rapidly detectable more than 1 distortion minute Disappears Dependent

Pit is very deep Lasts as long as 2-5 minutes Dependent extremity is

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ASSESSMENT OF PRECORDIUM

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INSPECTION PALPATION PERCUSSION AUSCULTATIO N

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INSPCTION

INSPECTION:
Shape Barrel

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of the chest chest

Pectrus excavatm (funnel shaped ) chest chest Carinatum (pigeon shaped & Scoliosis.

Pectus

Kyphosis

chest scars and deformity

Note

the respiratory rate. of the chest

Expansion

Shape of the chest

Normal:

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bilaterally symmetrical / Elliptical

Abnormal :
Barrel

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Shaped Chest

NT

PECTUS EXCAVATM (FUNNEL SHAPED CHEST)

ONTENT

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PECTUS CARINATUM (PIGEON SHAPED CHEST)

CONTENT

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SHAPE OF SPINE
Kyphosis Scoliosis

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TENT

Chest expansion

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PALPATION

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 Method Use The The

of examine jugular venous pressure

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the right internal jugular vein (IJV). patient should be at a 45 angle.

patient's head should be turned slightly to the left. possible, have a tangential light source that shines obliquely from the left. the JVP - look for the double waveform pulsation the level of the JVP by measuring the vertical distance between the sternal angle and the top of the JVP. Measure the height usually less than 4 cm)

If

Locate

Measure

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Apex Beat

Apex Beat
Locate

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and palpate the apex beat . usually the 5th/6th intercostal space mid-clavicular line. Decide if the apex beat is normal or displaced Lateral displacement suggests an enlarged heart.. A normal apex beat is short and sharp. of absent apical impulse: Emphysema Obesity Dextrocardia Lt. pleural effusion or pneumothorax Severe pericardial effusion.

Causes

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PERCUSSION

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PERCUSSION
of cardiac borders.

Percussion

Right

upper cardiac border(between

the 2nd and 3rd intercostal spaces- Aortic region -)

left

upper cardiac border. (between

the 2nd and 3rd intercostal spaces at the left sternal border- Pulmonic region )
LLSB

left lower sternal border-

AUSCULTATION.

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AUSCULTATION.
four classical auscultation areas: mitral/apex tricuspid

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area, (5th intercostal space, ICS, mid clavicular line)S1 area, (left of lower part of sternum 4th and 5th left ICSs, )S1 area-left to the sternum (2nd left ICS) S2 area right of the sternum (2nd right ICS lateral to sternum)S2

pulmonary Aortic

Additional areas of auscultation.

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Auscultate

in left axilla for radiation of a murmur, and auscultate carotids for radiation and bruits. area for pansystolic murmur of MR.

Interscapular Anterior Left Left

chest -3rd intercostals space on the left side for murmur of AR) intraclavicular area for MR mumur,PDA murmur. 3rd and 4th intercostals space for mumur of VSD.

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HEART SOUNDS
first

heart sound (S1) . heart sound (S2

Normal

second Extra

heart sounds

S3and S4

Murmurs Other

abnormal sounds-clicks and

rubs.

sequence of cardiac auscultation.

Start

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from apex..

Proceed

along the left sternal border below (tricuspid area) and pulmonary(above). auscultate the right 2nd space(aortic area). additional areas whenever necessary.

Then

Auscultate .

move stethoscope in an S-shape, starting at the apex beat. systematically to the auscultatory events in the cardiac cycle i.e. (S1 and s2) and for added sounds and murmurs.. both the bell and diaphragm appropriately in the 4 areas the bell should only be placed lightly on the skin

Listen

Use

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Roll

your patient slightly onto his left side and listen in the 5th ICS with the bell for the low frequency mid diastolic murmur of mitral stenosis..) in the axilla with the diaphragm for radiation and comparative loudness of a systolic murmur. with the diaphragm over both carotids for bruits and radiation of murmurs,.) sit your patient forwards and listen with the diaphragm at the lower left sternal edge, in expiration, for the high frequency diastolic murmur of aortic regurgitation. with the diaphragm, auscultate at the lung bases for the crackles of left ventricular failure.

Auscultate

auscultate

Next

Finally,

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abnormal sounds

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