Cardiac Examination I

indications for a cardiac exam

- chest pain

- palpitations

- shortness of breath

- orthopnea/paroxysmal nocturnal dyspnea

- swelling/edema

- syncope

- *systemic complaint

important HPI information for a complaint of chest pain

exertional, radiation, associated symptoms (diaphoresis, nausea, vomiting, palpitations, SOB, lightheadedness, syncope, edema), treatment/medications

important HPI information for a complaint of palpitations

racing, irregular, skipping

important HPI information for a complaint of dyspnea (SOB)

sudden vs progressive, exertional, orthopnea, paroxysmal nocturnal dyspnea

orthopnea

difficulty breathing when lying down

How do you document orthopnea?

by quantifying the number of pillows used for sleeping

paroxysmal nocturnal dyspnea

SOB awakening from sleep, improved by sitting upright

important HPI information for a complaint of swelling

dependent edema, anasarca (severe generalized edema)

What cardiac pathology commonly causes fatigue?

common in chronic decreased cardiac output

What should you consider if syncope is sudden and without prodrome?

arrhythmia

What should you consider if syncope is exertional?

reduced cardiac output (CHF, valvular disease)

Cardiac PMHx

- cardiac surgery and hospitalization (catheterization, stenting, CABG)

- congenital heart disease

- rhythm disorder

- acute rheumatic fever, unexplained fever, swollen joints, inflammatory rheumatism

- Kawasaki disease

- chronic illness

Cardiac Family Hx

- long QT syndrome (watch medications!)

- Marfan syndrome

- Diabetes

- Heart disease

- Dyslipidemia

- Hypertension

- Congenital heart defects

- Family members with cardiac risk factors

Cardiac Personal/Social Hx

- employment (physical demands/stress, environmental hazards)

- nutritional status/diet/exercise

- weight

- alcohol consumption/illicit drugs/tobacco

- known hypercholesterolemia/triglycerides

- relaxation/hobbies

What are the main arteries to be evaluated during an exam?

carotid artery, internal carotid artery, external carotid artery

What are the two circulatory systems blood enters after it leaves the heart?

pulmonary and systemic

pulmonary circulation

right heart -> lungs -> left heart

purpose of pulmonary circulation

oxygenation

systemic circulation

left heart -> body -> right heart

purpose of systemic circulation

deliver oxygen/nutrients

Describe the pressures in pulmonary and systemic circulation.

Pulmonary circulation = lower pressure system

Systemic circulation = higher pressure system

How do veins change in response to significantly increased blood volume?

the veins can expand and act as a repository for extra blood

What are arterial pulses the result of?

ventricular systole (produces a pressure wave throughout the arterial system, arterial pulse)

How long does it take for the impact of the the pressure wave to be felt in the dorsalis pedis artery?

0.2 seconds

What can effect the characteristic of a pulse?

- volume of blood ejected

- distensibility of the aorta

- obstruction of blood flow

- peripheral arteriolar resistance

- viscosity of the blood

Intima of artery

lumen, regulates thrombosis and clotting

Media of artery

smooth muscle, can dilate/constrict to change blood flow

Adventitia of artery

connective tissue, contains nerve fibers

What must arteries be able to respond to?

variations that cardiac systole and diastole generate

How do anatomy and size of arteries vary?

varies according to distance from the heart (highly elastic arteries -> medium-sized arteries -> small arteries -> arterioles)

When are arterial pulses palpable?

when arteries lie close to body surface

brachial pulse

at bend of elbow, just medial to biceps tendon

radial pulse

lateral flexor surface at wrist

ulnar pulse

medial flexor surface (overlying tissues may obscure)

How many arterial arches are in the wrist/hand?

two, prevents arterial occlusion

What does the aorta branch into in the abdomen?

celiac trunk, superior mesenteric artery, inferior mesenteric artery (not palpable)

femoral pulse

below inguinal ligament, midway between ASIS and symphysis

popliteal pulse

passes medially behind the femur, palpable behind knee

dorsalis pedis

dorsum of foot; lateral to extensor tendon of big toe

posterior tibial

behind medial malleolus of ankle

Describe the structure of a vein

- thin-walled and highly distensible

- deep, superficial, and perforating veins have ONE-WAY VALVES

Purpose of one-way valves

propel blood toward heart, prevent pooling, venous stasis, and backward flow

Contraction of what muscle acts as a venous pump?

calf muscles (even if you aren't able to get up and walk around, doing calf raises in your seat cen be helpful to decrease swelling)

Deep veins carry ____% of venous return from lower extremities.

90%

Describe the support of deep veins.

well-supported by surrounding tissues

Where are superficial veins located, and how are they supported?

subcutaneously, with poor tissue support

What superficial veins are important to know?

greater saphenous and small saphenous veins (anastomotic veins connect two saphenous veins)

Perforating veins

connect superficial (saphenous) system with deep system

How should you examine the patient?

inspect the patient from the end of the bed whilist at rest, looking for clinical signs suggestive of underlying pathology

Cyanosis

a bluish discoloration of the skin due to poor circulation (i.e., peripheral vasoconstriction secondary to hypovolemia) or inadequate oxygenation of the blood

What might SOB indicate?

underlying cardiovascular (i.e., CHF, pericarditis) or respiratory disease (i.e., pneumonia, pulmonary embolism)

Pallor

a pale color of the skin that can suggest underlying anemia (i.e., hemorrhage, chronic disease) or poor perfusion (i.e., congestive cardiac failure)

What does pallor of the hands indicate?

poor peripheral perfusion (i.e., congestive heart failure)

What does cyanosis of the hands indicate?

underlying hypoxemia

What is tar staining a sign of?

smoking, risk factor

Xanthomata

raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow, associated with hyperlipidemia

Arachnodactyly (spider fingers)

Marfan's - associated with mitral/aortic valve prolapse and aortic dissection

Finger clubbing

Congenital cyanotic heart disease

Endocarditis signs

splinter hemorrhages, Janeway lesions, Osler nodes

Splinter hemorrhages

longitudinal, red-brown hemorrhage under a nail that looks like a wood splinter

Causes of splinter hemorrhages

local trauma, infective endocarditis, sepsis, vasculitis, and psoriatic nail disease

Janeway lesions

non-tender, hemorrhagic lesions that occur on the thenar and hypothenar eminences of the palsm (and soles)

Osler nodes

red-purple, slightly raised, tender lumps, often with a pale center, typically found on the fingers or toes

Eye inspection

- conjunctival pallor (anemia)

- corneal arcus

- xanthelasma

- kayser-fleischer rings

Mouth inspection

- central cyanosis

- angular cheilitis

- high-arched palate

- dental hygiene

How to assess skin temperature

- assess at hands using the dorsal aspect of your hand

- the hands should be symmetrically warm, suggesting adequate perfusion

What do cool hands suggest?

poor peripheral perfusion (i.e., congestive cardiac failure, acute coronary syndrome)

What do cool and sweaty/clammy hands suggest?

acute coronary syndrome

How to perform a capillary refill test?

apply five seconds of pressure to the distal phalanx of one of a patient's fingers and then release

What is a normal capillary refill?

The initial pallor of the area you compressed should return to its normal color in less than two seconds

What does a capillary refill greater than 2 seconds suggest?

poor peripheral perfusion

Edema

accumulation of fluid in the interstitial space that occurs as the capillary filtration exceeds the limits of lymphatic drainage, producing noticeable clinical signs and symptoms

What type of edema are we looking for in the cardiac exam?

pitting edema

Where do we evaluate for edema?

- sacral edema

- peripheral edema (lower extremities, note pitting vs non pitting)

What type of edema is caused by right sided heart failure?

peripheral edema

What type of edema is caused by left sided heart failure?

pulmonary edema

SLIDE 34

What does amplitude of a pulse correlate with?

pulse pressure (difference between systolic and diastolic pressure)

Amplitude of pulse

- strength, force, or volume of the pulse

- often described as weak, thready, bounding, or normal

- you may have variations beat to beat

What might a high-amplitude (bounding) pulse indicate?

fever or anxiety

What might a low-amplitude (thready or hypokinetic) pulse indicate?

heart failure, shock, or severe dehydration

FINISH SLIDE 36

SLIDES 37-42

What is the diaphragm of the stethoscope used for?

high-pitched sounds (S1, S2, aortic and mitral regurgitation, pericardial friction rubs)

What is the bell of the stethoscope used for?

low-pitched sounds (S3, S4, mitral stenosis, bruits)

What type of pressure should you use when listening with the diaphragm?

firm, push down

What type of pressure should you use when listening with the bell?

light pressure

In a carotid examination, why do we auscultate before palpate?

assess for the presence of bruits

Bruit

a vascular sound, like a murmur, caused by turbulent blood flowing through an artery ("whooshing" sound)

What does a bruit indicate?

atherosclerosis, stenosis, or high-velocity flow

Where can a bruit be heard?

carotid arteries, abdomen, renal, or femoral arteries

What does an early systolic bruit indicate?

narrowing

What does a "pan-systolic" (throughout systole) bruit suggest?

more advanced narrowing (60% or more)

How do you differentiate a heart murmur radiating to the neck versus a bruit?

heart murmur radiating to the neck is usually louder below the clavicle, whereas a bruit is louder above it

Why should you never compress both carotids simultaneously?

avoid compromising cerebral blood flow

SLIDE 47

Why should you avoid palpation if you hear a bruit?

it may decrease the flow further or it may dislodge the plaque

Positioning for a carotid examination

supine with head of bed elevated to approx. 30-45 degrees

Palpation technique

- use the pads of your fingers

- use the index/middle finger in lower 1/3 of neck

Why is it important to avoid high neck palpation

to prevent stimulation of the carotid sinus, which can cause a sharp drop in heart rate or blood pressure