examination of the heart and the circulatory system
TRANSCRIPT
Complaints
• Chest pain– Angina pectoris– Pericarditis– Aortic aneurysm dissection– Extracardial causes
• Esophagus• Lung, pleura• Chest wall (muscle, neural, bone, joint)• Anxiety
Complaints• Angina pectoris
– Features• Constricting, pressing pain• Radiates to the left shoulder, arm
– But can be radiate to the neck, mandibule, back, epigastrium
• Reversible – few minutes• Provoked by
– Physical activity– Smoking, hypoxia– Cold– Big meal
• Relieving factor - nitrates
Complaints
• Dyspnea– Inspiratory dyspnea– Subtypes
• Effort dyspnea• Dyspnea on rest
– Orthopnea dyspnea relieves in
vertical position– Paroxysmal nocturnal dyspnea
Complaints
• Important anamnestic data:– In the family history
• Hypertension• Early heart death, sudden death, ischemic heart
disease
– Factors• Smoking• Alcohol consumption
Inspection• Cyanosis
• Gärtner’s-sign - the blood filled vein can’t became empty during elevation of the hand
• Drumstic fingers
clubbed fingers
• Aortic valve insufficiency – Capillary pulsation
Palpation
• Pulse– Radial, ulnar artery– Dorsalis pedis artery– Tibial posterior artery behind the inner ankle
– Popliteal artery– Femoral artery– Carotis
Palpation• Pulse features
– 1. Frequency • Frequent or rare
– 2. Amplitudo• High or small
– 3. Compressibility• Hard or soft
– 4. Speed of increasing• Quick or slow
– 5. Palpability
Palpation– 6. Rythm
• Regular or irregular– Irregular – arrhythmia
» Phasic sinus arrhythmia – respiratory arrhythmia
» Extrasystole „premature beat”
Episodic or frequent
» Bigeminy, trigeminy
Palpation• Apical impulse
– Normal: 1-2 cm medially to the left midclav. line in the V. intercostal space surface: 1 cm2
– Alterations• Goes to the left – dilatation, hypertrophy• Goes to the right – small heart• Goes up - pushed up
– Quality• Higher – hypertrophy• Wider - dilatation
Percussion• Rules
– Must to do it in the intercostal spaces
– The percussioned finger is always parallel to the checked border
• Order– Lower border right side, mc.line
VI. intercostal sp.
– Right border
– Upper border
– Left border
Auscultation - Sounds
• Sounds– I. sound – systolic – longerit comes after the longer interval – II.sound – diastolic – shorter
• Development of sounds– Closure of valves
• Systolic: mitral and tricuspidal• Diastolic: aortic and pulmonal
– Opening of the other valves– Muscle contraction– Blood flow
Auscultation – I. sound – S1
• Alterations– Loud
• tachycardia • strong physical activity• extrasystole• stenotic mitral valve
– Soft• heart failure• emphysema• pericardial effusion• thick chest wall
Auscultation – II.sound – S2
• Normally the loudness of the S2 sounds of the aortic and pulmonal valve are equal (the aortic valve is more deeper)– Alterations
• S2 soft – hypotony• S2 is louder somewhere
– Above the aortic valve hypertension– Above the pulmonal valve pulmonar hypertension
• S2 is absent – aortic valve insufficency
Auscultation – Intracardial murmurs
• Development of murmurs – turbulent flow– Organic valvular diseases
irregular surface of the vessel– Functional - no organic alteration
papillar muscle insufficiency, heart dilatation– Accidental - no organic or functional alteration
increased blood flow,
decreased blood viscosity
Intracardial murmurs
• Place in the cardiac cycle–Systolic or diastolic
• Location of maximal intensity - punctum maximum
• Radiation of the murmur• Shape plateau, crescendo, descrescendo• Intensity• Pitch high, medium, low• Quality blowing, harsh, musical, rumbling
Auscultation - Murmurs• Cardiac cycle
– Systole• Pansystolic • Protosystole - early• Mesosystole - mid• Telesystole - late
– Diastole• Protodiastole• Mesodiastole• Praesystole
Auscultation - Murmurs
• Radiation of murmurs – always in the direction of the blood flow
Examples:– Mitral insufficiency – to the axilla
– Aortic stenosis – to the carotid artery
Auscultation – murmurs - shape
Plateau – mitral regurgitation
Crescendo-decrescendo –
aortic stenosis - ejection