Cardiac assessment

Cardiac assessment

1. Cardiovascular system assessment

2. A careful and detailed clinical assessment is essential in order to assess the likely cause and severity of symptoms, arrange appropriate investigations and referral, avoid unnecessary investigations, and to assess individual risk of cardiovascular disease or cardiomyopathy .

3. ARTICLES REQUIRED A watch with a second hand Stethoscope with diaphragm & bell Centimeter ruler, Penlight Tape measure Sphygmomanometer

4. STEPS History collection Physical examination

5. HISTORY COLLECTION Socio demographic data Symptoms & history of present illness Dyspnea onset & duration Orthopnea Wheeze/abnormal breath sound Paroxysmal nocturnal Dyspnea (PND) Severity / grade

6. Grading of dyspnea Grade I – No limitation of any physical activity but occur on more than ordinary exertion Grade II – Dyspnea on less than ordinary daily activity Grade III - Dyspnea on less than ordinary daily activities Grade IV – limitations of all activities (Dyspnea at rest )

7. Chest pain O- ONSET L- LOCATION D- DURATION C- CHARACHTERISTICS A- ASSOCIATED SYMPTOMS A- AGGREVATING FACTORS R- RELIEVING FACTORS

8. Palpitation Syncop e Sudden onset Gradual onset Significance of associated symptoms Cough with expectoration

9. PAST HISTORY Rheumatic fever Recurrent attacks of lower respiratory infections since childhood Enquire about dental carries, the recent dental extraction Previous history of DM & HTN Previous history of angina ,MI,CABG

10. FAMILY HISTORY Marriage : Consanguineous History of coronary artery disease,HTN,DM Sudden cardiac death in family

11. PERSONAL HISTORY Sleep Smoking : Alcoholism Exercise pattern / activity pattern Dietary habits

12. GENERAL EXAMINATION Body Built Nourishment: Cyanosis

13. central cyanosis is seen in the following cardiac condition cyanosis congenital heart disease reversal of left to right shunt Pulmonary edema peripheral cyanosis occur in peripheral vascular disease

14. Pedal edema Clubbing Clubbing is caused by prolonged hypoxemia of the extremities. Hypoxemia causes structural changes in the distal phalanges over time. Cyanotic Congenital heart disease Reversal of left to right shunts Infective endocarditis

15. Inspection... Inspect nails. Splinter hemorrhages are associated with infective endocarditis Inspect the face. People with supravalvular aortic stenosis have wide-set eyes, low-set ears, upturned nose, hypoplasia of the mandible Moon face suggests pulmonic stenosis

16. More inspection... Expressionless face with puffy eyelids and loss of the outer 1/3 of the eyebrow is seen in hypothyroidism Inspect eyes. Yellow plaques on eyelids ( xanthelasma ) may be due to hyperlipoproteinemia

17. Assessment of Blood Pressure Always measure in both arms sitting, standing,lying down Normal-15 mg reduction of systolic from lying to standing HR- should not increase 20 b/min from supine to standing

18. Jugular Venous Pulse Assesing the internal jugular vein provides information about right atrial pressure The pulsation of the internal jugular vein are beneath the sternocleidomastoid muscle and are visible as they are transmitted through surrounding tissue The vein itself cannot be seen JVP> 4cm from sternal angle at 45’ patient position is said to be raised

19. JVD

20. JUGULAR VENOUS DISTENTION

21. Heapatojuglar reflex patient in 45 degree inclination . The examiner standing on the right side of the patient should apply firm pressure over the mid abdomen for 20 seconds Patient should be asked to breathe normally (not to strain . In normal individual JVP rise is not more than 4 cm it is not sustained . In RH sustained elevation of more than 4 cm is noted .

22. EXAMINATION OF THE PRECORDIUM Inspection The heart and chest develop at the same time in embryo, so anything that interferes with development of the chest may interfere with the heart Pectus Excavatum (caved-in chest) is seen in Marfan’s syndrome and sometimes MVP Pectus Carinatum (pigeon chest ) also seen in Marfan’s syndrome

23. Palpation a. Apical impulse b. Pulsation Heaves-Sustained lifts of chest wall in precordial area c. Thrills - Thrills – vibratory sensations - Thrills are best palpated with head of metacarpal bones - Thrills suggest presence of a murmur - Thrills are common with obstructive lesion with narrow orifice - Diastolic thrills – MS - Continuous thrill – PDA

24. Percussion The right and left sides of the heart can be estimated by percussion.The curve of the rib in the fourth and fifth intercoastal space starting at midaxillary line is percussed

25. Auscultaion Auscultatory areas : Aortic area - Right of the sternum (in the 2 nd intercostal space ) Pulmonary area – left of the sternum (2 nd intercostal space ) Erb’s point —3rdintercostal space to the left of the sternum tricuspid area —fourth intercostal spaces to the left of the sternum mitral area —the PMI , 5 th intercostal space midclavicular location on the chest where heart contractions can be palpated

26. Principles of Auscultation Normally only the closing of valves can be heard. Closure of the tricuspid and mitral valves (AV valves) produce the 1st heart sound. Closure of the aortic and pulmonic valves produce the 2nd heart sound. Opening of valves can only be heard if they are very damaged (opening “snap” “click”)

27. Third Heart Sound When AV valves open, the period of rapid filling of ventricles occurs. 80% of ventricular filling occurs now. At the END of rapid filling, a 3rd heart sound may be heard S-3 is normal in children and young adults, but not in people over age 30. It means there is volume overload of ventricle

28. Fourth Heart Sound At the end of diastole, atrial contraction contributes to the additional 20% filling of the ventricle If the left ventricle is stiff and non-compliant, you will hear an S4. It sounds like this: a- STIFF- wall, a- STIFF -wall, a- STIFF -wall Or sounds like TEN-ne-see

29. Murmurs They are produced when there is turbulent blood flow within the heart Turbulence may be due to a narrowed opening of a valve (stenosis) or a valve that does not close completely, allowing blood to slosh backwards (regurgitation or insufficiency)

30. The Intensity of Murmurs Grade I = lowest intensity, not heard by inexperienced listener Grade II = low intensity, usually audible to everyone Grade III = medium intensity but no palpable thrill Grade IV = medium intensity with a thrill

31. Intensity of murmurs, con’t Grade V = loudest murmur audible when stethoscope is on the chest. Has a thrill Grade VI = loudest intensity, audible when stethoscope is removed from the chest. Has a thrill

32. Systolic Murmurs These are ejection murmurs May be caused by turbulence across the aortic or pulmonic valves if they are stenosed May be caused by turbulence across the mitral or tricuspid valves if they are incompetent ( regurgitant ) The murmur falls between S1 and S2 Sounds like, LUB - shhh -dub

33. Diastolic Murmurs Mitral and tricuspid stenosis can cause a diastolic murmur Aortic or pulmonic regurgitation can cause a diastolic murmur Sounds like this: Lub -dub- shhh

34. Pericardial Friction Rub These are extra-cardiac sounds of short duration that have a sound like scratching on sandpaper May result from irritation of the pericardium from infection, inflammation, or after open heart surgery Best heard when patient sits and holds breath

35. Assessment of the Peripheral Vascular System

36. INSPECTION Edema cyanosis thrombophlebitis clubbing of nails varicosities lesions or ulcers

37. PALPATION Assess the different pulse sites Temperature Edema of limbs Rigidity of vessels Homan’s sign Allens test