CARDIOVASCULAR EXAMINATION Steven A. Haist, MD, MS Division of General Internal Medicine and Geriatrics Department of Internal Medicine

CARDIOVASCULAR EXAMINATION History Physical Examination Laboratory Tests (CPK, LDH, cholesterol, etc.) Electrocardiography Cardiac imaging— Echocardiography CT Scan MRI Cardiac Catheterization Nuclear Imaging

CARDIOVASCULAR SYMPTOMS Chest Pain Shortness of Breath (dyspnea) DOE (dyspnea on exertion) Orthopnea PND (paroxysmal nocturnal dyspnea) Trepopnea Wheezing

CARDIOVASCULAR SYMPTOMS (continued) Dizziness / Syncope Palpitations Fatigue Edema Intermittent claudication Cyanosis

CHEST PAIN Angina Pectoris Esophageal Spasm Myocardial Infarction Cholecystitis Pericarditis Peptic Ulcer Disease Pulmonary Embolus Costochondritis Aortic Dissection Hyperventilation Esophagitis Mitral Valve Prolapse

HISTORY Location Quality Quantity Radiation Timing—Onset, duration, frequency Setting

HISTORY (continued) Aggravating Factors Alleviating Factors Associated Factors Pertinent Negatives Pertinent Past History Previous Laboratory Tests (prior to this visit) Risk Factors

HISTORY MYOCARDIAL INFARCTION Anterior mid-chest (substernal) Heavy, crushing, pressure-like pain 9/10 with 10 being the worst pain of their life Radiates into L arm or neck > 30 minutes, < hours Awoke this morning with the pain

HISTORY - MI (continued) Any activity None Associated diaphoresis, dyspnea, and nausea Denies history of MI, murmur, palpitations, orthopnea, DOE,PND Similar pain not as severe in past lasting 5-10 minutes,relieved with rest, brought on by walking ECG in ER 1 yr. ago reportedly normal Smokes 1 PPD, hypertension for 10 years Father MI age 45, chol 300, no hx DM

CARDIOVASCULAR PHYSICAL EXAMINATION General Appearance Vital Signs Jugular Veins Heart Peripheral Pulses

PHYSICAL EXAMINATION Is the patient in acute distress? Always use a hospital gown. Never palpate or auscultate through clothing. Is the patient comfortable? Be concerned with the patient's privacy. Bed at 30° Must have quiet room ! Examine from the right side.

Vital Signs BP both arms hypertension hypotension orthostatic hypotension HR tachycardia bradycardia Rhythm regular regularly irregular irregularly irregular Respirations tachypnea Temperature fever

INSPECTION Jugular veins / jugular venous pressure Right side, head tilted to L Adjust angle of bed to see pulsation at mid- neck. Record distance from R atrium to top of pulsation (sternal angle is 5 cm above RA)

INSPECTION (continued) Lips, nail beds Heart: apical impulse point of maximal impulse Extremities: (edema, venous or arterial insufficiency)

CARDIAC EXAMINATION Inspection Palpation Percussion Auscultation

PALPATION Impulses - finger pads Thrills (vibrations palpated secondary to a murmur—turbulent blood flow through a heart valve) - Bony part of hand, ball of hand

PALPATION (continued) Apical impulse (normally 5th ICS and medial to mid-clavicular line) Point of maximal impulse (PMI) Left lateral decubitus position (heart closer to chest well) apical impulse more easily palpable

AUSCULTATION Diaphragm – medium and high frequency sounds Diaphragm – medium and high frequency sounds Bell – low frequency sounds Bell – low frequency sounds Normally hear closure of valve Normally hear closure of valve Sounds from left side of heart louder than equivalent sounds from right side of heart Sounds from left side of heart louder than equivalent sounds from right side of heart

AUSCULTATION S 1 – closure of mitral and tricuspid valves S 1 – closure of mitral and tricuspid valves S 2 – closure of aortic and pulmonic valves S 2 – closure of aortic and pulmonic valves Low pitched sounds S 3, S 4, mitral stenosis, and Korotkoff sounds Low pitched sounds S 3, S 4, mitral stenosis, and Korotkoff sounds S 1 systole S 2 diastole S 1 S 1 systole S 2 diastole S 1 Simultaneous palpation of carotid pulse can help in differentiating S 1 and S 2 Simultaneous palpation of carotid pulse can help in differentiating S 1 and S 2

FIRST AND SECOND HEART SOUNDS Aortic component (A 2 ) normally louder than pulmonic component (P 2 ) Aortic component (A 2 ) normally louder than pulmonic component (P 2 ) Mitral component (M 1 ) normally louder than tricuspid component (T 1 ) Mitral component (M 1 ) normally louder than tricuspid component (T 1 )

FIRST AND SECOND HEART SOUNDS (continued) T 1 and P 2 normally heard only over their respective area (LLSB and L 2 ICS) T 1 and P 2 normally heard only over their respective area (LLSB and L 2 ICS) Normally left-sided sounds occur first M 1 T 1 (S 1 ) and A 2 P 2 (S 2 ) Normally left-sided sounds occur first M 1 T 1 (S 1 ) and A 2 P 2 (S 2 ) S 2 changes with respiration, S 1 does not Inspiration S 1 systole A 2 P 2 S 2 changes with respiration, S 1 does not Inspiration S 1 systole A 2 P 2 Expiration S 1 systole A 2 P 2 Expiration S 1 systole A 2 P 2

DIAPHRAGM Right 2 nd intercostal space Right 2 nd intercostal space Aortic Area Left 2 nd intercostal space Left 2 nd intercostal space Pulmonic Area Third intercostal space Third intercostal space Erb’s point Left lower sternal border Left lower sternal border Tricuspid area Apex – over apical impulse Apex – over apical impulse Mitral area

BELL Left lower sternal border Left lower sternal border Apex Apex Apex with patient in left lateral decubitus position Apex with patient in left lateral decubitus position Light pressure only! Light pressure only!

POSITIONS Lying at 30°, standard position Lying at 30°, standard position Apex with the patient in the left lateral decubitus position, with bell (mitral stenosis) Apex with the patient in the left lateral decubitus position, with bell (mitral stenosis) At LLSB with patient sitting, leaning forward, fully exhaled with diaphragm(aortic regurgitation) At LLSB with patient sitting, leaning forward, fully exhaled with diaphragm(aortic regurgitation)

Normal S1 S2

Splitting of S2

Aortic Stenosis

Mitral Regurgitation

Aortic Insufficiency

Observe, record, tabulate, communicate. Use your five senses. The art of the practice of medicine is to be learned only by experience ; 'tis not an inheritance ; it cannot be revealed. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone can you become expert. Medicine is learned by the bedside and not in the classroom. Let not your conceptions of the manifestations of disease come from words heard in the lecture room or read from the book. See, and then reason and compare and control. But see first. No two eyes see the same thing. No two mirrors give forth the same reflection. Let the word be your slave and not your master. Live in the ward. Do not waste the hours of daylight in listening to that which you may read by night. But when you have seen, read. And when you can, read the original descriptions of the masters who, with crude methods of study, saw so clearly. Record that which you have seen ; make a note at the time ; do not wait. * The flighty purpose never is o'ertook, unless the deed go with it.'.., 1

TERMINOLOGY Stenosis - forward obstruction Regurgitation (insufficiency) - backward flow Aortic Stenosis - during systole forward flow through obstructed aortic valve from left ventricle Mitral Stenosis - during diastole forward flow through obstructed mitral valve from left atrium Aortic regurgitation - during diastole backward flow through aortic valve from aorta