cardiac assement.1

7/31/2019 Cardiac Assement.1

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Chest pain, tightness ordiscomfort.Shortness of breath

PalpitationSyncope or dizzinessRelated cardiovascular history -

-Transient ischemic attack,-stroke,-peripheral vascular disease

-peripheral edema

HISTORY.


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Chest pain

Chest pain is one of the important

symptoms of heart disease. Location: usually in the front of the chest

(retrosternal).

Radiation: spread to the neck, jaw, back,left or right arm.

Nature: chest pain due to cardiacischemia is typically tight and crushing inquality.

Patients may refer to angina pain as'indigestion'.

Other features include duration,

aggravating and relieving factors, andassociated s m toms e. . nausea and/or


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Chest pain


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BREATHLESSNESS

Cardiac causes include

severe pulmonary oedema

acute MI, cardiac arrhythmia

, pericarditis

pericardial effussion


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qCont.

qDyspnea on exertion may be the

evidence of heart failure.

qBreathlessness on lying flat

(orthopnea

qAny attacks waking the patient from

sleep (paroxysmal nocturnal

dyspnoea) or at rest?

qCheyne-Stokes or periodic breathing


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PALPITATIONSPalpitations- presentation of acardiac arrhythmia.Rhythm: tap out the rate andregularity; -a missed beat suggestsextra systoles.Duration:- sudden short episodessuggest paroxysmal tachycardia;-longer duration with irregularities

suggests Arial dysrhythmia.Associated symptoms: pain,dyspnoea, feeling faint or syncope.


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8/9/12OTHER HISTORY

Drugs/medication:

Associated cough.

Limb ischemia, intermittent cloudication.

.Gastrointestinal symptoms:

Failure to thrive in children or weight loss

in in adults.

Urinary symptoms- oliguria..

Cerebral symptoms:-Dizziness, head ache

and mental changes


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EXAMINATION


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tBuild (obesity or wasting);

shortness of breath; difficulty intalking; do they look ill?

Look for pallor, jaundice,,

sweatiness and clamminess,

Look for any evidence of

syndromes or non-cardiovascularconditions associated withcardiovascular abnormalities.

ExaminationGeneral


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8/9/12Cyanosis-Central, peripheral


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Malar flush - redness around thecheeks (mitral stenosis,).

Xanthalasma- yellowish depositsof lipid around the eyes, palms, or

tendons (hyperlipidaemia).Corneal arcus - a ring around the

cornea (normal aging orhyperlipidaemia).

Proptosis - forward projection ordisplacement of the eyeball(graves disease)

Face
http://www.patient.co.uk/DisplayConcepts.asp?WordId=GRAVES%20DISEASE&MaxResults=50


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Malar flush xanthalasma


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Corneal arcus proptosis


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Finger clubbing.

Capillary refill.

Splitncter haemorrhage (infective

endocarditis).

Oslers nodes- tender nodules in the

fingertips (infective endocarditis).

Sweaty palms, tremor (thyrotoxicosis)

Visible capillary pulsations in the nail

Hands


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FINGERSclubbing

ONTENT


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ONTENT

NORMAL CLUBBED


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Splinter haemorrhage


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8/9/12Oslers nodes-

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


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8/9/12PULSES

-Palpate both radial pulses and assess rateand rhythm..- Palpate carotid pulse and assess volumeand character. Bruits

-Palpate the femoral,

- popolitial (located at the back of the kneewith a flexed knee)

-posterior tibia (located below the medialalveolus, lateral to the extensor hillocks longus)

- dorsalis pedis.


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RADIAL PULSE CAROTID PULSE SITE


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Dorsalis pedis poplitial.


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8/9/12posterior tibia


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8/9/12Peripheral oedema


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8/9/12Degree of edema-

palpate the skin over the tibia for edema by-Squzeeing the skin for 30-60 sec.

Graded from --trace -4+.

Trace is slight indentation dissappear in ashort time.

1+ Mild pitting, slight indentation, noperceptable swelling of the leg

2+ Moderate pitting, indentation subsidesrapidly3+ Deep pitting, indentation remains for ashort time, leg looks swollen4+ Very deep pitting, indentation lasts a longtime, leg is very swollen


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ASSESSMENT OF PITTING EDEMA

2mm or less= 1+ Edema

2-4mm = 2+ Edema

4-6mm = 3+ Edema

6-8mm = 4+ Edema

Slight pitting

No visibledistortion

Disappearsrapidly

Somewhat

deeper pit No

readablydetectable

distortion Disappears

Pit is

noticeablydeep

May lastmore than 1

minute Dependent

Pit is very

deep Lasts as

long as 2-5minutes

Dependentextremity is

Pitted edema is tested by pressing & holding fingerinto the swollen tissue over a bony area for 5seconds. If there is an indentation left behind whenyou remove finger it is pitted edema


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ASSESSMENT OFPRECORDIUM


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INSPECTION

PALPATION

PERCUSSIONAUSCULTATIO

N


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INSPCTION


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Shape of the chest

Barrel chest

Pectrus excavatm (funnel shaped )chest

Pectus Carinatum(pigeon shapedchest

Kyphosis & Scoliosis.

chest scars and deformity

Note the respiratory rate.

Expansion of the chest

INSPECTION:


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Shape of the chest

Normal: bilaterally symmetrical /Elliptical


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Abnormal :

Barrel Shaped Chest

NT

PECTUS EXCAVATM (FUNNEL SHAPED


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PECTUS EXCAVATM (FUNNEL SHAPEDCHEST)

ONTENT


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PECTUS CARINATUM (PIGEONSHAPED CHEST)

CONTENT


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SHAPE OF SPINE

Kyphosis

ScoliosisTENT


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Chest expansion


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8/9/12PALPATION


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Method of examine jugular venous pressure

Use the right internal jugular vein (IJV).

The patient should be at a 45 angle.The patient's head should be turned slightly to

the left.

If possible, have a tangential light source that

shines obliquely from the left.

Locate the JVP - look for the double waveformpulsation

Measure the level of the JVP by measuring thevertical distance between the sternal angleand the top of the JVP. Measure the height -usually less than 4 cm)


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Apex Beat

Ape Beat


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Locate and palpate the apex beat .

usually the 5th/6th intercostal spacemid-clavicular line.

. Decide if the apex beat is normal ordisplaced Lateral displacement

suggests an enlarged heart. . A normalapex beat is short and sharp.

Causes of absent apical impulse:Emphysema

ObesityDextrocardiaLt. pleural effusion or pneumothoraxSevere pericardial effusion.

Apex Beat


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PERCUSSION

Percussion of cardiac borders.

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 theleft sternal border- Pulmonic region )

LLSB left lower sternal border-


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AUSCULTATION.


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AUSCULTATION.

four classical auscultation areas: -

mitral/apex area, (5th intercostalspace, ICS, mid clavicular line)S1

tricuspid area, (left of lower part of

sternum 4th and 5th left ICSs, )S1

pulmonary area-left to the sternum(2nd left ICS) S2

Aortic area right of the sternum (2ndright ICS lateral to sternum)S2


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Additional areas of auscultation.

Auscultate in left axilla for radiation of a

murmur, and auscultate carotids forradiation and bruits.

Interscapular area for pansystolicmurmur of MR.

Anterior chest-3rd intercostals space onthe left side for murmur of AR)

Left intraclavicular areafor MRmumur,PDA murmur.

Left 3rd and 4th intercostals space formumur of VSD.


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first heart sound (S1) . Normal

second heart sound (S2

Extra heart sounds

S3and S4

Murmurs

Other abnormal sounds-clicks and

rubs.

HEART SOUNDS

f di l i


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sequence of cardiac auscultation.

Start from apex..

Proceed along the left sternal border below(tricuspid area) and pulmonary(above).

Then auscultate the right 2nd space(aortic area).

Auscultate additional areas whenever necessary.

. move stethoscope in an S-shape, starting at theapex beat.

Listen systematically to the auscultatory events in

the cardiac cycle i.e. (S1 and s2) and for addedsounds and murmurs..

Use both the bell and diaphragm appropriately inthe 4 areas the bell should only be placed lightly

on the skin


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Roll your patient slightly onto his left side andlisten in the 5th ICS with the bell for the lowfrequency mid diastolic murmur of mitral

stenosis..)

Auscultate in the axilla with the diaphragmfor radiation and comparative loudness of asystolic murmur.

auscultate with the diaphragm over bothcarotids for bruits and radiation of murmurs,.)

Next sit your patient forwards and listen withthe diaphragm at the lower left sternal edge,in expiration, for the high frequency diastolicmurmur of aortic regurgitation.

Finally, with the diaphragm, auscultate at thelung bases for the crackles of left ventricularfailure.


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cardiac assement.1

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