Examination of the heart
and the circulatory system
Complaints
• Chest pain
– Angina pectoris
– Pericarditis
– Aortic aneurysm dissection
– Extracardial causes
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Esophagus
Lung, pleura
Chest wall (muscle, neural, bone, joint)
Anxiety
Complaints
• Angina pectoris
– Features
• Constricting, pressing pain
• Radiates to the left shoulder, arm
– But can be radiate to the neck, mandibule, back,
epigastrium
• Reversible – few minutes
• Provoked by
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Physical activity
Smoking, hypoxia
Cold
Big meal
• Relieving factor - nitrates
Complaints
• Angina pectoris subtypes
– Effort angina
– Status anginosus
– Crescendo angina
Complaints
• Pain from other arteries
– Intermittent claudication
– Abdominal angina
Complaints
• Pain in other localisation
– Raynaud’s-phenomenon
Complaints
• Arrythmia
– Palpitation
– Tachycardia
– Bradycardia
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– Extrasystolia
Syncope
Complaints
• Dyspnea
– Inspiratory dyspnea
– Subtypes
• Effort dyspnea
• Dyspnea on rest
– Orthopnea
dyspnea relieves in
vertical position
– Paroxysmal nocturnal dyspnea
Complaints
• Edema
according to the gravitaion
• In laying patients: sacral edema
Complaints
• Other complaints
– Nycturia v. nocturia
– Coughing
– Weakness, decreased loadability
Complaints
• Important anamnestic data:
– In the family history
• Hypertension
• Early heart death, sudden death, ischemic heart
disease
– Factors
• Smoking
• Alcohol consumption
Inspection
• Cyanosis
• Gärtner’s-sign - the blood filled vein can’t
became empty during elevation of the hand
• Drumstic fingers
clubbed fingers
• Aortic valve insufficiency
– Capillary pulsation
Palpation
• Pulse
– Radial, ulnar artery
– Dorsalis pedis artery
– Tibial posterior artery
– Popliteal artery
– Femoral artery
– Carotis
behind the inner ankle
Palpation
• Pulse features
– 1. Frequency
• Frequent or rare
– 2. Amplitudo
• High or small
– 3. Compressibility
• Hard or soft
– 4. Speed of increasing
• Quick or slow
– 5. Palpability
Palpation
– 6. Rythm
• Regular or irregular
– Irregular – arrhythmia
» Phasic sinus arrhythmia – respiratory arrhythmia
» Extrasystole „premature beat”
Episodic or frequent
» Bigeminy,
trigeminy
Palpation
Atrial fibrillation - absolute arrhythmia
irregular and inequal pulse
• Apical impulse
Palpation
– Normal: 1-2 cm medially to the left midclav. line
in the V. intercostal space
surface: 1 cm2
– Alterations
• Goes to the left – dilatation, hypertrophy
• Goes to the right – small heart
• Goes up - pushed up
– Quality
• Higher – hypertrophy
• Wider - dilatation
Palpation
• Murmurs
Percussion
• Rules
– Must to do it in the intercostal spaces
– The percussioned finger is always parallel to the
checked border
• Order
– Lower border right side, mc.line
VI. intercostal sp.
– Right border
– Upper border
– Left border
Auscultation
• Sound : short (0,2 sec), sharp bordered
• Murmur : longer, borders are blurred
Auscultation - Sounds
• Sounds
– I. sound – systolic – longer
it comes after the longer interval
– II.sound – diastolic – shorter
• Development of sounds
– Closure of valves
• Systolic: mitral and tricuspidal
• Diastolic: aortic and pulmonal
– Opening of the other valves
– Muscle contraction
– Blood flow
Auscultation – I. sound – S1
• Alterations
– Loud
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tachycardia
strong physical activity
extrasystole
stenotic mitral valve
– Soft
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heart failure
emphysema
pericardial effusion
thick chest wall
Auscultation – II.sound – S2
• Normally the loudness of the S2 sounds of
the aortic and pulmonal valve are equal
(the aortic valve is more deeper)
– Alterations
• S2 soft – hypotony
• S2 is louder somewhere
– Above the aortic valve
hypertension
– Above the pulmonal valve pulmonar hypertension
• S2 is absent – aortic valve insufficency
Auscultation - Murmurs
Subgroups
– Extracardial – pericardial friction rub
– Intracardial
Auscultation –
Intracardial murmurs
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Development of murmurs – turbulent flow
– Organic
valvular diseases
irregular surface of the vessel
– Functional - no organic alteration
papillar muscle insufficiency, heart dilatation
– Accidental - no organic or functional alteration
increased blood flow,
decreased blood viscosity
Intracardial murmurs
• Place in the cardiac cycle
–Systolic or diastolic
• Location of maximal intensity punctum maximum
• Radiation of the murmur
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Shape plateau, crescendo, descrescendo
Intensity
Pitch
high, medium, low
Quality blowing, harsh, musical, rumbling
Auscultation - Murmurs
• Cardiac cycle
– Systole
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Pansystolic
Protosystole - early
Mesosystole - mid
Telesystole - late
– Diastole
• Protodiastole
• Mesodiastole
• Praesystole
Auscultation - Murmurs
• Radiation of murmurs – always in the
direction of the blood flow
Examples:
– Mitral insufficiency – to the axilla
– Aortic stenosis – to the carotid artery
Auscultation – murmurs shape
Plateau – mitral regurgitation
Crescendo-decrescendo –
aortic stenosis - ejection
Auscultation – murmurs shape
• Decrescendo – aortic
regurgitation
• Crescendo – mitral
stenosis