Cardiac Examination
A. General
- observe for central or peripheral cyanosis (pinkish/bluish nail beds), clubbing of fingers and toes,
xanthomas, xanthelasmas, splinter hemorrhages, diaphoresis (MI)
B.
Vital Signs
- check blood pressure (both arms {normal diff bet 2 sides is < 10 mm Hg}, supine and upright)
- check arterial pulse (radial)
1. rate (over 15 sec x 4)
2. rhythm (ex. Regular, regularly irregular {PAC’s, PVC’s}, irregularly irregular(Afib})
3. volume/amplitude (ex. weak {heart failure}, bounding pulse {thyrotoxicosis})
4. symmetry on both sides
C. Neck Inspection
1. Elevate the bed at 30-45 degrees before asking the patient to lie down
2. palpate carotid pulsation on both sides with your thumb
3. check jugular venous pulsation
- head slightly turned away from the midline, use tangential lightning (“look away from me”)
- comment on how high JVP (normally upto 2-3 cm from the sternal angle) and
the timing of the a wave & v wave with respect to the heart sounds
- know how to differentiate between an arterial vs venous pulsation
3. listen for carotid bruit..
D. Precordial Inspection (do so from the foot of the bed)
- observe for any thoracic cage deformities, venous dilatation of the skin, respiratory difficulties check for
visible apex beat, heaves, lifts, retractions
E. Precordial Palpation
- palpate the precordium at four sites with your index finger:
1. aortic site
2. pulmonic site
3. Erb’s point (3rd ICS RSB where both aortic and pulmonic sounds are audible)
4. tricuspid site
5. mitral site
comment on any palpable thrills, lifts, pulsations
- comment on the apex beat: (apex beat is the lateral most pulsation vs PMI)
1. location (should not be > 4 inches lateral to the LMCL)
2. size (should not be > 2 cm in diameter)
3. quality (strong or weak)
4. duration (<2/3 of systole) (done while simultaneously listening at the heart sounds at the base)
- palpate the epigastrium for the abdominal aorta
F.
Auscultation
- listen to the heart in the ff locations (rub the stethoscope with your hands to warm it up):
1. aortic site
2. pulmonic site
4. Erb’s point (3rd ICS RSB where both aortic and pulmonic sounds are audible)
5. tricuspid site
6. mitral site
- listen to the heart sounds with both diaphragm (S1,S2, systolic murmurs) ( move from point 1 to 5) and bell
(S3, S4, diastolic murmurs) (from point 5 to 1)
- comment on S1, S2, S3, S4
- location, where is it loudest
- splitting
- intensity
- comment on the murmur
A. grading:
1. soft murmur, faintly heard
2. soft murmur, readily heard
1
-
3. loud murmur, w/o thrill
4. loud murmur w/ thrill
5. murmur heart with only edge of stet touching the chest
6. murmur heart with stet not touching the chest wall
B. radiation
- AS radiates to the neck
- MR radiates to the axilla
C. timing (systolic, diastolic, continuous)
D. location
E. effect of manuevers on intensity of heart sounds
AR inc when sitting upright
inc on expiration
MS inc when turning to LLD
Right sided murmurs – inc with inspiration
AS - dec with valsalva’s (blow hard at back of your hand)
F. Shape (blowing, crescendo, diamond shaped)
G. Quality
H. Pitch
Maneouvers:
1. LLD: “I’d like to listen to your heart in a different position, can you turn to your left side please”
and ask patient to “breathe in deeply, breathe out and hold it” listen with the bell from a mid
diastolic events murmur of Mitral Stenosis at apex
2. upright, : “I’d like you to lean forward” “take a deep breath and hold it”: listen with diaphragm
over the aortic area and L sternal edge for high pitched blowing early diastolic murmurs of Aortic
Regurgitation.
G. Additional Tests
Pulsus Paradoxus
1. Determine the systolic BP by palpation
2. Inflate the BP cuff 30 mm Hg above the palpable systolic BP
3. Deflate the cuff slowly, as the cuff pressure is slowly lowered, the sounds appear to double
( they become audible in inspiration as well as expiration)
4. the difference in systolic BP recorded at the start of the Korotkoff’s sounds in inspiration and
is an estimate of pulsus paradoxus (it is significant if it is greater than 10 mm Hg
expiration
H. Auscultate the Lungs
in at least 4 places
I. Abdominal Exam
- check for hepatojugular reflux if suspecting CHF
1. warn px first before pressing
2. instruct px to breathe normally during pressure
3. place palm over the abdomen
4. compress abdomen steadily for 10 sec
5. note any change in JVP during abdl pressure and at the time of release
- check for abdominal bruits (if suspicious of abdominal aortic aneurysm)
- percuss for ascites
J. Inspect the Legs and sacral area
- check for pitting edema
- palplate peripheral pulses
- check for calf tenderness (people w/ heart failure have inc risk for DVT)
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Leg Pains
History
Onset, duration
Character ( crampy, dull ache)
Location (calf muscles, thighs, hips, buttocks, anywhere else)
What type of activities would cause the pain?
Is it present even with rest?
How much distance do you cover before pain sets in?
Does the pain always occur after walking that much distance?
Do you feel relief with rest? After how long?
Does the pain wake you up at night?
Does it help when you dangle your legs over the side of the bed?
Do you feel numbness or pins and needles in your feet?
Do you notice loss of hair on your toes and legs?
Do you have problems in attaining or maintaining erection?
Risk Factors for coronary heart disease
- Diabetes
- Hypertension
- Heart disease
- Smoking
- High cholesterol levels/dietary habits
- Stress (occupation or family problems)
- Exercise
- Alcohol intake/ Cocaine use
Past Medical History
Have you ever been diagnosed with diabetes, hypertension, high cholesterol levels
Medications
Physical Examination
A. Inspection
- Expose and examine the legs from the groin down the feet
(use bed sheet to cover patient’s genitals)
- size, symmetry, swelling
- abnormal venous pattern
- pigmentation, rash, scars, ulcers
- colour of skin, nail beds
- distribution of hair on lower legs, feet, toes
B. Palpation
1. Upper extremities
a. check the radial arteries on both sides and compare
b. check Temperature with back of your hands on both sides and compare (move rostrally)
c. Allen’s test in the hand
- compress both ulnar and radial arteries with your thumbs
- release compression at the radial artery and wait for flushing of the hand then do the same
for the ulnar artery and on the other hand
- normal response: return of color in 2-3 sec
2.
Lower extremities
a.
Pulses
i.
femoral artery
ii.
do a bimanual palpation of the popliteal artery (behind the knee)
with the knee slightly flexed
iii.
dorsalis pedis artery
iv.
palpate the posterior tibial artery (behind the medial maleolus)
with the foot dorsiflexed at a 90 degree angle
b.
check for bruit, thrill
c.
check for edema (press x 5 sec) at the foot, ankle and sheen
3
d.
e.
3.
press calf muscles and ask if there is tenderness
Elevation Dependency Test ( to estimate degree of ischemia)
- elevate the leg at 60 degrees for 30-60 sec, then ask pt to sit up and dangle
legs over the bed.
- normally color should come back in 10 sec , veins should fill up in 15 sec
Aorta
feel the aorta above the umbilicus
check for any bruit
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Chest Pain
History
-
-
-
Onset (sudden, gradual, recurrent, new)
Character/quality (pressure, heaviness)
Location
Radiation
Intensity/severity
Do you have recurrent episodes of pain?
How often do you have the pain?
Course (progressive or non-progressive)
- If unstable angina,
- Is the pain increasing in intensity
- Is the pain changing in character
- Does the pain occur with less physical activities
- Do you need more medication to ease the pain
- Does the pain last longer
What makes it worse? Breathing? Lying flat? Moving your arms or neck? Exercise? Stress? Coughing?
What do you do to make it better? (rest, nitroglycerine, food intake, antacids)
Does the pain occur at rest? With exertion? After eating? When moving your arms? With emotional strain?
While sleeping? During sexual intercourse?
Is the pain associated with nausea or vomiting, SOB, sweating, palpitations, dizziness, coughing, sputum
production, fever, rashes, coughing up with blood, leg pain?
risk factors for Coronary artery disease
- Diabetes
- Hypertension
- Heart disease
- Smoking
- High cholesterol levels/dietary habits
- Stress (occupation or family problems)
- Exercise
- Family history of heart disease
- Alcohol intake/ Cocaine use
Medications
Past Medical Hx
Family Hx
Social Hx
Physical Examination
 General Appearance - level of distress, anxiety
 Vital signs – BP in both arms
 Skin – pallor, cyanosis, jaundice, herpetic rash
 Eyes – incl fundoscopy
 Neck – carotid pulse for bruits, lymphadenopathy, thyromegaly, midline trachea, jugular venous distention
 Heart – complete
 Chest Wall – herpetic lesions, signs of trauma, tenderness, swelling
 Lungs –
 Abdomen – tenderness, masses, organomegaly, bowel sounds, bruit, bounding pulses, ascites
 Lower Extremity – femoral pulses (absent in leaking AAA), cyanosis, diminished pulses, unilateral
swelling
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Hypertension Checklist
History
1. Blood Pressure
- duration
- levels of elevated BP
- successes/failures of previous treatment
- side effect of previous treatment
2. Any current symptoms:
(to check for any end organ damage)
- cardiovascular – chest pains, SOB, palpitations
- peripheral vascular - leg pains on walking, sexual dysfunction
- cerebrovascular - sever headaches, strokes, paralysis, loss of speech
- retinopathy - loss/blurring of vision, double vision
(to check for a secondary cause)
- nephropathy - SOA, flank pains, urinary frequency, blood in urine
- pheochromocytoma – sudden onset of palpitations, headaches, sweating
- hyperaldosteronism - weakness
3. Medication use (decongestants, OCP’s, estrogen, steroids, appetite suppressants, NSAIDs, tricyclic
antidepressant, MAO inhibitor, herbal medicines )
4. Family history - htn, stroke, diabetes, kidney disease, premature heart disease, high cholesterol levels
5. Social History:
- Alcohol, drugs (cocaine, crack), caffeine, smoking
- Lifestyle – exercise, stress, weight, diet (sodium intake, saturated fats)
- Psychosocial factors which may affect compliance, ability to afford meds, educational level
6. Past Medical History
- cholesterol levels
- thyroid, adrenal or pituitary problems
- renal disease
- diabetes
Physical Exam
1. Vital signs
- BP on both arms (coarctation of the aorta): sitting and standing (after 2 min)
- Distal pulses (radio-femoral delay and radial assymetry in coarctation of the aorta)
2. General
- cushing’s – buffalo hump, abdominal striae, cushingoid facies, thin limbs, hirsutism, acne
- acromegaly – coarse facial features
- polycythemia – flushing
- uremia – frosty skin
- myxedema – puffiness and dry skin
3. Head and Neck
- fundoscopy
- thyroid exam
4. Full Cardiovascular Exam
- including JVP, carotid bruit
- cardiomegaly (displaced PMI), murmur, gallop
- peripheral edema
5. Lung Exam
- check for bronchospasm, rales
6. Abdominal Exam
- abdominal bruits (renal artery stenosis, AAA)
- renal masses (polycystic kidneys are enlarged?)
- abdominal striae
- splenomegaly (polycythemia rubro vera)
7. Neurological
- CN deficits
- Motor/sensory deficits
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Possible Questions:
 Shows a picture of fundoscopy of different stages of hypertension
 Keith –Wagener-barker Classification
1.
Arteriolar narrowing
2.
+AV nicking
3.
+Hemorrhages & exudates
4.
+papilledema
 Laboratory Investigations:
 HCT
 Blood glucose
 ECG
 Urinalysis
 Serum creatinine
 Potassium, sodium
 Lipid profile
 Consider CXR
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Syncope
History
How did it happen?
Describe the sensation that you were feeling
Differentiate fainting from vertigo, imbalance, fatigue
Is there a sensation of movement or rotation? (vertigo)
Is the sensation similar to when you get our of bed too quickly? (orthostatic hypotension)
Does it feel like you can’t keep your balance? (disequilibrium)
Did this happen before ? How often?
Was there an abrupt onset to the fainting?
Did you lose consciousness?
How long were you out?
What were you doing before you fainted?
- were you urinating or moving your bowels?
- Were you coughing hard?
- Were you exercising?
- In what position were you when you fainted?
Was the fainting preceeded by any other symptom? Nausea? Chest pain? Palpitations? Confusion?
Numbness? Hunger?
Syncope vs Seizure
- Was there anybody who witnessed what happened?
- Did you suffer any injuries after the event?
- Did you urinate in your pants?
- Did you have any warning that you were going to faint? Did you feel that something was going to
happen?
- Did you bite your tongue?
- Did you feel sore all over after?
Cardiovascular Disease
- Do you have any heart problems? How about in childhood?
- Any chest pains, SOB, palpitations, especially with physical exertion
- Do you have hypertension?
- Are you taking any medications for the heart?
Neurological
- Did you have any history of strokes or seizures?
- Did you sustain any fall (SAH esp in elderly)?
- Did you notice any weakness of half of your body, any changes in speech, imbalance?
Metabolic
- Are you diabetic?
Psychiatric
- Fear of dying
- Fear of going crazy or of losing control
- Feelings of unreality, strangeness, or detachment from the environment
Gastric
Did you have any black tarry bowel movements after the faint?
Physical Examination
1.
2.
3.
4.
Vital Signs
Cardiac
Neurological
Psychiatri
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Heart Failure
History
1. Previous heart disease
coronary artery disease, atherosclerosis
myocardial infarction
hypertension
valvular disease
myopathies
2. Difficulty of breathing
How far can you walk without developing SOB?
Do you wake up at night with SOB?
How many pillows do you use to sleep comfortably?
Do you wake up from sleep with a cough?
3. Chest pains
Explore
4. Weight gain
Rapid or gradual
5. Associated symptoms
Edema, abdominal pains, palpitations, fatigue, nocturia, change in exercise tolerance
6. Risk Factors for coronary heart disease
- Diabetes
- Hypertension
- Heart disease
- Smoking
- High cholesterol levels/dietary habits
- Stress (occupation or family problems)
- Exercise
- Alcohol intake/ Cocaine use
7. Family hx of heart disease, renal , hepatic, thyroid disease
8. Medication use
9. Others
Snoring in sleep
Sexual functions
Cognitive function
Coping behaviours
Social support
Physical Examination
-
General Appearance
Vital Signs
Skin – color, moisture, turgor, capillary refill
Weight
Eye - with fundoscopy
Neck – thyroid, jugular venous distention, hepatojugular reflux
Heart
Lungs
Abdomen – hepatomegaly, ascites
Extremities – edema, peripheral pulses
Mental status exam – esp in elderly
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Atrial Fibrillation
How long did it last? (duration)
What did it feel like? (palpitations, dizziness, calf pain, fatigue, leg edema, dyspnea)
Did any maneuvers or positions stop it?
Did it stop abruptly?
Was there any particular event that might have precipitated this (emotional stress, bath in
hot tub, activity, alcohol or drug use)?
Could you count your pulse during the attack?"
Can you tap out on the table what the rhythm was like?
If the patient had a previous attack of palpitations, ask the ff:
How was your previous attack terminated?
How often do you get the attacks?
Are you able to terminate them? If so, How?
Have you ever been told that you have wolf Parkinson white syndrome?
How did it happen?
For how long have you
had palpitations?
Do you have recurrent
attacks? If so, How
frequently do they
occur?
When did the current
attack begin? (onset)
Associated Sx
Have you noticed palpitations after strenuous exercise? On exertion? While lying on
your left side? after a meal? when tired?
During the palpitations, have you ever fainted? had chest pain? (ischemic heart disease, PE)
Was there an associated flush, headache, or sweating associated with the palpitations?
Have you noticed an Intolerance to heat? cold? Weight loss/gain? Tremors? (hyperthyroidism)
Medications
What kind of medications are you taking?
Do you take any medications for your lungs?
Are you taking any thyroid medications?
Past Medical Hx
Have you ever been told that you had a problem with your thyroid?
Did you have any previous heart disease? Lung problems? Strokes?
Family Hx
Is there a family history of heart disease?
Social Hx
How much tea, coffee, or cola sodas do you consume a day?
Do you smoke?
Do you drink alcoholic beverages?
Did you notice that after the palpitations you had to urinate?
Physical Examination
 General appearance - signs of respiratory distress, LOC,
 Vital Signs - HR, RR, BP (sitting and standing)
 Skin – pallor and flushing
 Eyes – lid lag
 Neck – thyroid, jugular venous distention, carotid artery bruits
 Cardiac
 Pulmonary
 Neurological
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