BY HOSSAM HASSAN DEM CONSULTANT AND ASSISTANT PROFESSOR The Cardiac Exam BY HOSSAM HASSAN DEM CONSULTANT AND ASSISTANT PROFESSOR

History Taking

Introduction As with any part of the physical exam, a complete cardiac exam should begin with a detailed cardiac history.  A good historian should be able to predict the physical exam findings before attempting the actual physical exam.  A thorough cardiac history should include investigating for the following cardiac (8) symptoms.

Chest pain Where is the pain (s)? When did the pain first start (t)? How long does it last (t)? Does the pain radiate, if so where ? How often do you have the pain ? How would you describe the pain - burning, pressing, stabbing, crushing, dull, aching, throbbing, sharp, constricting ? Does the pain occur at rest, with exertion, with stress, after eating, when moving your arms, or during intercourse ? Do you have any other symptoms with the pain such as shortness of breath, palpitations, nausea, vomiting, coughing, fever, leg pain (as)?

Cyanosis (bluish color skin) Where is the bluish color skin? How long have you noticed it? Did it seem to happen suddenly or gradually? What type of work do you do? Does anyone else in your family has this condition? What makes the bluish skin color better or worse? Have you had any chest pain, cough, or bleeding associated with the bluish color skin?

Dyspnea (shortness of breath) How long have you been short of breath? Did the shortness of breath occur suddenly or gradually? Do you ever wake up at night feeling short of breath (paroxysmal nocturnal dyspnea)? How many pillows do you sleep on at night? How far can you walk before you become short of breath? Have you notice swelling in your legs associated with your shortness of breath? Have you had any chest pain associated with your shortness of breath?

Edema (dependent) Do you have swelling in your legs? When did you first notice the swelling? Did it appear suddenly or gradually? Is the swelling worse in the morning or evening? Does the swelling decrease after a night's sleep? Do your shortness of breath associated with the swelling? Have you noticed any change in your weight? Does elevating your feet make the swelling go down? Do you have pain in your legs associated with the swelling? Do both legs swell equally? Are you taking any medications, if so, which ones?

Fainting (syncope) How often do you faint (or feel like you are going to faint)? What are you doing when you faint (or feel like you are going to faint)? Have you ever lost consciousness? Does the fainting (of feeling like you are going to faint) occur suddenly? In what position were you when you fainted (or felt like you were going to faint)? periods?

Fainting (syncope) Have you noticed anything that seem to be associated with the fainting (feeling like you are going to faint), for example, chest pain, irregular heart beat, nausea, confusion, hunger, tingling, or numbness? Do you have any black, tarry bowl movements after the fainting episode.

Fatigue How long have you felt fatigued? Did the fatigue come on suddenly or gradually? Do you feel tired all day or only in the morning and/or evening? Do you feel more tired at home or at work? Is your fatigue relieved by rest? When do you feel least tired?

General Have you ever had any problems with your heart? Have you ever had angina or a heart attack? Have you ever had a cardiac catheterization or heart surgery? Do you have high blood pressure? Have you ever been told you had a heart murmur or had rheumatic fever? Have you ever had phlebitis (pain) or swelling in your legs?

Hemoptysis (coughing up blood) How long have you been coughing up blood? How often do you cough up blood? Do you have chest pain when you cough up blood? How much blood do you cough up

Irregular Heart Beat Do you have any problems with irregular heart beat or palpitations (when you can feel your heart beating fast or irregular)? How long have you had the irregular heart beats? When did you first notice the irregular heart beats? How long did the irregular heart beats last? What did the irregular heart beats feel like? Did anything you do stop the irregular heart beats? Did the irregular heart beats stop abruptly? Could you count your pulse during the episode?

Irregular Heart Beat Can you tap on the table what the rhythm felt like? Have you noticed the irregular heart beats during exercise? Did you experience any sweating, flushing, or headaches with your irregular heart beats? Are you taking any medications, if so, which ones? Has anyone ever told you that you had problems with your thyroid gland? Do you smoke or use any other recreational or street drugs, if so, how much and how often? How much caffeine do you drink a day (coffee, tea, soft drinks)? After the irregular heart beats, do you need to urinate?

EXAMINATION Inspection Like any part of the physical exam a thorough cardiac exam should begin with inspection. For the cardiac exam the patient should be supine at 30 degrees, ideally without any clothes on their chest or just a bra, or at the most a hospital gown. A thorough inspection for the cardiac exam involves not only looking at the area of the body in close proximity to the heart (chest), but also other areas of the body (eyes, mouth, skin), which although anatomically remote to the heart, give us a window into the cardiovascular system

Neck Look for raised JVP 4-11 cm

Chest Observe the chest for overall torso contour. Do you see pectus excavatum (caved-in chest)? Do you see pectus carinatum (pigeon chest)? Can you see any cardiac motion?

Pectus Exacavatum

Pectus Carinatum

Eyes The presence of yellowish plaques on the eyelids (xanthelasma) could indicate hyperlipoproteinemia, a risk factor for hypertension as well as arteriolosclerosis.

Mouth The presence of petechiae (small red or purple spots containing blood that appears in skin or mucous membrane), shown here on the skin, but which can also appear on mucous membranes, especially on the palate, can be a sign of subacute endocarditis.

Skin Clubbing The presence of clubbing (broadening of the extremities of the digits, accompanied by nails which are abnormally curved and shiny) indicates chronic poor oxygen perfusion to the distal tissues of the hand and feet.

Cyanosis The presence of cyanosis (bluish color) also denotes chronic poor oxygen delivery to the peripheral tissues of the hands and feet.  Cyanosis can be found in patients with many different cardiac and pulmonary conditions.

Edema The presence of edema (tissue swelling) can be caused by several factors, although most commonly is associated with decreased cardiac function leading to decreased capillary flow.  This decreased flow in turns leads to increased fluid perfusion, especially in the gravity dependent areas of the body (e.g. arms and legs) which causes the swelling.

Xanthomas The presence of yellowish plaques under the skin (non-eruptive) excoriated through the skin (eruptive) could indicate hyperlipoproteinemia, a risk factor for hypertension as well as arteriolosclerosis

Palpation Point of Maximal Impact (PMI) The point of maximal impact (PMI) is the location on the anterior chest wall where the apex of the heart is felt most strongly. It can be felt in 70% of individuals in the sitting/standing position or in the left lateral decubitus position. Palpate for the PMI as follows:

Place the patient's chest so that the heart is thrust anteriorly either in the upright position (either sitting or standing) or left lateral decubitus position (NOT in the supine position). Place your fingertips in the fifth intercostal space and the left midclavicular line (PMI is normally within 10 cm of the sternum on the left side). Note the location of the PMI. Note the size of the PMI (PMI is normally 2-3 Cm in diameter). A large, laterally displaced, or diffuse PMI generally indicates some form of cardiomegaly.

Localized Motion Palpate for localized motion as follows: Place the patient in the supine position. Place your fingertips in each of the four precordial regions (aortic, pulmonary, tricuspid, and mitral). Note any impulses felt (e.g. a systolic impulse at the second left intercostal space could indicate pulmonary hypertension).

Generalized Motion Palpate for generalized motion as follows: Place the patient in the supine position. Place the proximal part of your hand (not fingers) in each of the four precordial regions. Note any heaves, lifts, or rocks (synonymous words indicating large cardiac pulsations felt on palpation).

Thrills Thrills are vibratory sensations caused by the heart and felt on the body surface. Thrills are always associated with murmurs. Palpate for thrills as follows: Place the patient in the supine position. Use the proximal part of your hand (not fingers)and press gently over the anterior chest wall over the heart. Note any thrills appreciated.

Percussion does have a small role in the cardiac exam, although its role in the cardiac exam is much less then in other parts of the physical exam such as the abdominal or pulmonary exam.

Cardiac percussion is performed at the third, fourth, and fifth intercostal spaces from the left axillary to the right axillary lines.  Normal cardiac percussion should show dullness to percussion from the sternum to approximately 6 cm lateral to the left of the sternum.

Auscultation Listening to the heart you can gather information about the  1)rate and rhythm, 2) value functioning (e.g. stenosis, regurgitation/insufficiency), and 3) anatomical defects (e.g. atrial septal defects, ventricular septal defect (VSD), hypertrophy).  

Auscultation In describing and documenting a murmur, you should be able to characterize 4 properties of an “abnormal” heart sound: The location of the heart sound on the chest (i.e. where is it heard loudest and where you can hear the sound at all). The timing of the heart sound (i.e. early diastolic, pan systolic, etc.) The grade or intensity of the heart sound (i.e.1-6 (see table below)) The quality and shape of the heart sound (i.e. musical crescendo, harsh snap, etc.)

Auscultation Where to place your stethoscope auscultation should proceed in a logical manner over 4 general areas on the anterior chest, beginning with the patient in the supine position. The 4 percordial areas are examined with diaphragm, including: Aortic region (between the 2nd and 3rd intercostal spaces at the right sternal border) (RUSB – right upper sternal border). Pulmonic region (between the 2nd and 3rd intercostal spaces at the left sternal border) (LUSB – left upper sternal border). Tricuspid region (between the 3rd, 4th, 5th, and 6th intercostal spaces at the left sternal border) (LLSB – left lower sternal border). Mitral region (near the apex of the heard between the 5th and 6th intercostal spaces in the mid-clavicular line) (apex of the heart).

Auscultation After this initial examination in the supine positions, several additional maneuvers should be accomplished in the thorough cardiac exam, as follows: Instruct the patient to turn onto their left side (left decubitus position) and listen with the bell of the stethoscope at the apex for mitral stenosis (low pitched diastolic murmur). Instruct the patient to sit upright and re-examine the 4 percordial regions, again with the diaphragm of the stethoscope. Instruct the patient to lean forward, exhale, and hold their breath. Listen with the diaphragm between the second and third intercostal spaces at the right sternal (aortic) and left sternal (pulmonic) areas for aortic regurgitation.

Murmurs Grade 1/6:very faint, only heard in ideal circumstance 2/6:loud enough to be generally hear 23/6:louder than grade 4/6:Louder than grade 3 5/6:heard with stethoscope partially off chest :Heardwith stethoscope entirely off chest 66/

Murmur Descriptions Description Possible Diagnosis Systolic ejection murmur Normal, pulmonic, or aortic stenosis Early diastolic murmur Aortic regurgitation Ejection Sound Aortic valve disease Pansystolic murmur Tricuspid or mitral regurgitationl Late diastolic murmur Tricuspid or mitral stenosis Systolic click with late systolic murmur Mitral valve prolapse

Auscultation Mitral stenosis Opening snap with diastolic rumble murmur Normal in children and occurs in heart failure s3 Physiological and in various diseas S4

Heart Sounds Normal sinus rhythm (at rates of ~60, ~90, and ~130beats per minutes).

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