2023 Cardiac Physical Exam basic knowledge

cardiac physical exam

1. CARDIAC PHYSICAL EXAMINATION 1

2. Examining the Heart and Circulation History Taking General Appearance Feel the pulses, rate and rhythm Inspect the neck veins Palpate and auscultate the carotids Palpate the precordium and apex Auscultate the precordium and apex Palpate the peripheral pulses Examine the extremities for venous insufficiency 2

3. Taking Patient’s History Sacred 7 and Fundamental 4 Chest Pain : OPQRST Breathlessness: DOE ? PND? OP? + calculate 10-year and lifetime CVD risk factor for patients ages 40-79 Constant, J. 2002. Essentials of Bedside Cardilogy Second Edition . New Jerseys : Humana Press Bickley, LS. 217. Bates’ Guide to Physical Examination Twelfth Edition . Wolters Kluwer 3

4. Vital Signs - HR Rate Normal rate 60-100 bpm Bradycardia < 60 bpm Tachycardia > 100 bpm Regularity Arrhythmia- varies with respiration Intermittent irregularity –ectopic beats Continuously irregular (irregularly irregular – atrial fibrillation) Volume: Normal/increased/decreased 4

5. Vital Signs - BP 5

6. Establish the Stability of the Patient A - Airway – patent/obstructed B - Breathing – rate/pattern C - Circulation – HR/PR/BP D - Describe the patient Comfortable/distressed Dyspneic /fatigued Pale/cyanosed Diaphoretic Dehydrated/volume depleted Congested/edematous/ volume overloaded 6

7. General Appearance Cyanosis -> central? Peripheral? Differential? clubbing finger skin sign of infective endocarditis, skin and sign of hepatic failure Congenital and Acquired Facies (Down Syndrome (ASD,VSD), William syndrome(supravalvular aortic stenosis), et Frank sign (diagonal earlobe crease) Constant, J. 2002. Essentials of Bedside Cardilogy Second Edition . New Jerseys : Humana Press 7

8. Cardiac Examination 8

9. Inspection - Eyes jaundice : severe HF  high venous pressure  liver damage , sign of infective endocarditis ( roth spots) yellowish corneal arcus, xanthelasma hipercholesterolemia Exofthalmus -> thyrotoxicosis heart disease, advanced CHF with high venous pressure and weight loss Constant, J. 2002. Essentials of Bedside Cardilogy Second Edition . New Jerseys : Humana Press 9

10. Inspection - Chest Apical impulse? pectus excavatum ( marfan syndrome  MR ), cheyne stokes respiration (patient with CHF) Constant, J. 2002. Essentials of Bedside Cardilogy Second Edition . New Jerseys : Humana Press 10

11. Inspection - Chest Apical impulse? pectus excavatum ( marfan syndrome  MR ), cheyne stokes respiration (patient with CHF) Constant, J. 2002. Essentials of Bedside Cardilogy Second Edition . New Jerseys : Humana Press 11

12. Inspection - Extremities Rule out edema cause: Normal venous pressure : less likely cardiac cause unless diuretics have been given Face and hand edema: less likely cardiac cause except in infant Noncardiac bilateral leg edema Low albumin Premenstrual edema (hormonal) Obesity ( obstruksi limfatik ) Constant, J. 2002. Essentials of Bedside Cardilogy Second Edition . New Jerseys : Humana Press 12

13. Abdomen – Hepatojugular reflux 13 To check a venous pressure that below the upper limit of normal that actually high for RV failure patients. Abdominal compression will cause and maintain a rise in the top level of pulsations only if the venous pressure is relatively high. Sustained elevation of JVP by more than 3 cm is considered a positive hepatojugular reflux.

14. Assessment of Carotid Pulse Bickley, LS. 217. Bates’ Guide to Physical Examination Twelfth Edition . Wolters Kluwer Amplitudo & variation with respiration Contour of the pulse wave -> upstroke and downstroke Timing of carotid upstroke in relation to S1 and S2 Pulsus alternans ? Paradoxical ? Thrills and bruits -> proceed to auscultation 14

15. Assessment of Carotid Pulse Gentle tap : normal No tap but only a push : aortic stenosis probably present Sharp tap (brisk pulse) : Normal pulse volume or pressure : MR, VSD, HCM Increased pulse amplitude : AR, PDA, Coarctatio aorta 15

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17. Inspection - JVP 17

18. Jugular Venous Pressure To assess the volume status of the circulation Level Waveform Differentiate from carotid Multiple wave forms Compressible Varies with inspiration and abdominal pressure 18

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20. Normal JVP Waveform 20

21. Palpation Apex: Palpable in 1 of 5 adults age 40 Best felt with fingertips or finger pads Normal Location: generally felt at the fifth intercostal space in the midclavicular line Normal Size: approximately the size of a quarter (2.5–3.0 cm in diameter)(about 2 finger breadths) 21

22. Palpation 22 Look for: Heaves and lifts using palm Thrills -> vibratory sensation, if present -> ausculate

23. Palpation - Apex 23 APICAL IMPULSE/ POINT MAXIMAL IMPULSE Evaluate: Location Diameter Ampltudo Duration

24. Percussion 24 Starting well to the left on the chest, percuss from resonance toward cardiac dullness in the 3rd, 4th, 5th, and, possibly, 6th interspaces.

25. Auscultation Use the diaphragm for high pitched sounds (S1 S2), murmur -> AR MR, pericardial friction rub Use the bell for low pitched sounds (S3 S4), murmur -> MS 25

26. Auscultation - Maneuvers MITRAL STENOSIS 26 AORTIC REGURGITATION

27. Identify Heart Sounds S1 – closure of mitral and tricuspid valve S2 – closure of aortic (A2) and pulmonary valves (P2) S3 – rapid ventricular filling S4 – pre-systolic sound atrial contraction filling non-compliant ventricle 27

28. Identify Heart Sounds 28

29. Heart Sound – S1 S1 – closure of mitral and tricuspid valve High Frequency sound  diaphragm of stethoscopes. Loudest near the apex of the heart 29

30. Altered Intensity of The S1 Shortened PR interval  valve leaflets have less time to drift back together, forced shut from a relatively wide distance Mild mitral stenosis  impeded flow causes prolonged diastolic pressure gradient between LA and LV, mobile portions of mitral leaflets farther apartforced shut loudly when LV contracts. High cardiac output / tachycardia  diastole is shortened. Leaflets have less time to drift back together before the ventricles contract DIMINISHED S1 Lengthened PR interval : first-degree AV Block  delays the onset of ventricular contraction Mitral Regurgitation  mitral leaflets may not come into full contact as they close Severe Mitral Stenosis  the leaflets are nearly fixed in position, and reduced movement “Stiff” left ventricle (e.g. LVH due to systemic hypertension)  Atrial contraction generates a-higher-than-normal ventricular pressure at the end of diastole  leaflets drift together more rapidly ACCENTUATED S1 30

31. Heart Sound – S2 S2 – closure of aortic (A2) and pulmonary valves (P2) 31

32. Splitting S2 32

33. Heart Sounds S2 TRANSIENT SPLIT 33

34. Heart Sounds S2 SPLIT 34

35. Listen for Murmurs 35

36. Seven S: Characteristics of a “functional” murmur Soft murmur Short duration S1 and S2 sounds are normal Systolic murmur Symptomsless Special test normal ( ekg , chest x-ray) Standing/sitting (changes with position) 36

37. Characteristic of Pathologic Murmurs Diastolic murmur Loud murmur - grade 4 or above Regurgitant murmur Murmurs associated with a click Murmurs associated with other signs or symptoms e.g. cyanosis Abnormal 2 nd heart sound – fixed split, paradoxical split or single 37

38. Assessing Murmur Intensity SYSTOLIC MURMURS 38 DIASTOLIC MURMURS

39. SYSTOLIC MURMUR 39

40. SYSTOLIC MURMUR - maneuvers 40

41. DIASTOLIC MURMUR AR : high-pitched decrescendo blowing murmur at along the LLSB, with the patient sitting, leaning forward, exhale. PR : due to PAH. Inspiration increase intensity. MS / TS : mid to lat low frequency rumbling murmurs and follow a sharp OS. Atrial contraction ↑ Flow  intense murmur Severe MS / TS : prolonged murmur 41

42. THANK YOU 42