Cardiovascular examination
(SZCZEKLIK& MOSBY'S& NET)
Possible causes of chest pain:
-typical angina pectoris
-atypical angina pectoris
-variant (Prinzmetal) angina
-unstable angina
-coronary insufficiency
-myocardial infarction
-nonobstructive, nonspasmic angina
-mitral valve prolapse
-dissection of aorta
-pericarditis
-pleurisy
-pneumothorax
-mediastinal ephysema
-GI diseases ( reflux, esophageal spasm, cholecystitis, peptic ulcer disease, pancreatitis)
-pulmonary diseases ( pulm.hypertension, pneumonia, pulm.embolus, bronch.hyperactivity)
-musculoskeletal ( shoulder disorder: bursitis, rotator cuff injury)
-psychoneurotic
Types of pain:
anginal: SUBSTERNAL, provoked by effort, emotion, eating. Relieved by rest or/by nitroglycerin. Often accompanied by diaphoresis ( increased perspiration)
pleural: precipitated by breathing or coughing; usualy described as SHARP; absent when breath holding
esophageal: BURNING, SUBSTERNAL, may radiate to the shoulder, noctural uccurrence, usually when lying flat
from peptic ulcer: INFRADIAPHRAGMATIC, epigastric, nocturnal occurrance, relieved by food ; unrelated to activity
biliary: USUALLY UNDER R. SCAPULA! prolonged in duration, often uccurs after eating; will trigger angina more often than mimic it!
arthritis/bursitis: lasts for hours, local tenderness and pain with movement
cervical: associated with injury, provoked bya ctivity, pesists after activity, painful on palpation
musculoskeletal: provoked by movement, twisting or costochondral bending; long lasting, often associated with focal tenderness
neurotic: associated with beeing anxious, intramammary region!
HISTORY OF PRESENT ILNESS:
* CHEST PAIN
a) onset and duration : sudden, gradual, lenght of episode, cyclic nature ( if so), related to physical exertion/rest/emotions/eating/coughing/ cold temp./ exposure to trauma; if can awake patient from sleep
b) character: sharp, aching, tingling, burning, pressure, stabbing, crushing, clenched fist sign
c) location: radiating down/to arms/to mandible/to scapula; relieved with position change?
d) severity: interference with activity, need to stop all activities, disrupts sleep
e) symptoms association: anxiety, dyspnea, diaphoresis, dizzines, nausea, vomiting, faintness, cold, clammy skin, cyanosis, pallor, swelling, edema, cough
plus recent treatment and medications!!: : nitroglycerine, digoxin, diuretics, beta blockers, ACE inhibitors, calcium channel blockers, NSAIDS
*PAST MEDICAL HISTORY plus FAMILY HISORY: cardiac surgery, rhythm disorder, acute rheumatic fever, unexplainced fever, swollen joints, inflammatory rheumatism, chronic ilnesses ( diabetes, hypertension, bleeding disorders, hyperlipidemias, thyroid dysfunction, coronary artery disease, obesity, congenital heart defects) , sudden deaths in family
* PERSONAL AND SOCIAL HISORY: employment, work type, tobacco smoking, alcohol, hobbies, physical activitys tatus
EXAMINATION:
1) INSPECTION:
-apical pulse should be visible in 5th L inercostal space in midclavicular line ( but easily obscured by breasts, obesity, muscularity)
-may be visible in 4th intercostal space
-chest patterns
2) PALPATION:
-apical pulse and its location, estimate width of area it can be felt; characterize it ( heave or lift): displacement to the right may indicate dextrocardia, diaphragmatic hernia, disteded stomach, pulmonary abnormality
-feel the thrill: fine, palpable, rushing vibrations, a palpable murmur ( over the base of the heart in the area of right or left 2nd intercostal space) ; can be appreciated in systole or diastole:
systole
#in aortic stenosis: located in suprasternal notch and/or 2nd and 3rd right intercostal spaces
# in pulmonic stenosis: located in suprasternal notch and/or 2nd to 3rd left intercostal spaces
# in ventricular septal defect: 4th left intercostal space
#in mitral regurgitation: apex
# tetralogy of Fallot: left lower sternal border
# petent ductus arteriosus: left upper sternal border often with extensive radiation
diastole
# in aortic regurgitation/ aneurysm of asc. aorta: in right sternal border
# mitral stenosis: apex
-palpating precordium: one hand to palpate carotid artery, other to palpate precordium ( to describe carotid pulse in relation to cardiac cycle). Carotid pulse an S1 are practically synchronous
3) PERCUSSION:
-limited value in defining the borders of the heart
4) AUSCULTATION
There are 4 major areas of auscultation:
a) aortic : right 2nd intercostal space
b) pulmonary: left second intercostal space
c) mitral: 5th left intercostal space in midclavicular line
d) tricuspid: 4th right intercostal space close to the sternum
e*) Erb's point: 3rd or 4th left intercostal space close to the sternum: the best point to aucultate systolic murmur in case of mitral regurgitation ( niedomykalność)
Hear sounds:
a)S1: 'lub' composed of components M1( closure of mutral valve) and T1(closure of tricuspid valve ). Normally M1 precedes T1 slightly. It is caused by the sudden block of reverse blood flow due to closure of the atrioventricular valves, i.e. tricuspid and mitral (bicuspid), at the beginning of ventricular contraction, or systole.
For the loudness of the S1, the M1 is responsible. BEST HEARD AT THE APEX
b)S2:'dub' closure of semilunar valves: aortic ( A2 component) and pulmonary ( P2 component); A2 is louder and precedes P2 slightly. Heard as an unite when expiration, while inspiration it can be heard splitted ( physiologic splitting of S2) ; BEST HEARD OVER THE BASE OF THE HEART ( in the aortic area)
c)S3: also called protodiastolic gallop: "lub-dub-ta"; It occurs at the beginning of diastole after S2 and is lower in pitch than S1 or S2 as it is not of valvular origin. The third heart sound is benign in youth, some trained athletes, and sometimes in pregnancy but if it re-emerges later in life it may signal cardiac problems, such as a failing left ventricle as in dilated congestive heart failure (CHF). S3 is thought to be caused by the oscillation of blood back and forth between the walls of the ventricles initiated by blood rushing in from the atria.
d)S4: S4 when audible in an adult is called a presystolic gallop or atrial gallop. This gallop is produced by the sound of blood being forced into a stiff or hypertrophic ventricle.
"ta-lub-dub" or "a-stiff-wall". It is a sign of a pathologic state, usually a failing or hypertrophic left ventricle, as in systemic hypertension, severe valvular aortic stenosis, andhypertrophic cardiomyopathy
Ejection clicks:
- they are audible while ventricles are contracting
a) protosystolic (wczesnoskurczowy):
-caused by ejection of blood from ventricles to the dilated vessel, often through the stenotic orifice
-causes: dilation of aorta ( hypertension, atherosclerotic dilation of ascending aorta) or pulmonary trunk (pulmonary hypertension), defect in aortic valve, stanosis of pulmonary trunk stenosis
-best audible: base of the heart, in the places of valve auscultation
b)mezosystolic ( midsystolic-śródskurczowy) and telesystolic ( latesystolic-późnoskurczowy):
-caused by rapid tension of elongated chorda tendinae and convex ( 'baloony') cusps of atrioventricular valves
-main cause: mitral valve prolapse ( wypadanie)
-best audible: over the apex, they worsen during expiration, while lying on the left side or being seated but during physical excercise.
*Valsalvas maneuvr: when venous return is diminished, clicks appear during systole.
Heart murmurs:
- are produced when the laminar flow of blood changes into turbulent flow as a result of
*increased blood flow through unchanged/changed orifice or vessel
*blood flow through stenotic vessel/orifice or flow into dilated one( ex. aortic aneurysm)
* backflow of blood caused by regurgitation
*leakage of blood through some 'connections' ( ex. septal deffects)
- murmur must be localized-> areas of auscultation: where it is the loudest
- relation to the heart cycle: sytolic/diastolic must be estimated
-loudness, radiation, factors increasing/decreasing loudness must also be stimated
-DIASTOLIC MURMURS NEVER OCCUR AS A PHYSIOLOGICAL NORM!!!!!!!!
#LEVINE's scale: estimates loudness of the murmur ( from 1 to 6 [6= audible without stethoscope placed in the chest])
#PROTO=EARLY #MEZO= MID #TELE= LATE #PAN=WHOLE duration
Presystolic murmurs:
-increased blood flow through stenotic valve in the end of ventricular filling ( just before S1) as a result of atrial systole
-causes: tricuspid stenosis, mitral stenosis
-auscultation: silent, crescendo-decrescendo/ crescendo. Does not occur during atrial fibrillation
*****SYSTOLIC MURMURS*******
a) protosystolic ( earlydiastolic):
-causes: regurgitation of tricuspid valve without pulmonary hypertension; regurgitation of mitral valve; can be innocent in young people
-auscultation: starts along with S1 and ends in the middle of systole
b) mezosytolic ( midsytolic):
-blood flowing through the stenotic aretrial (pulmonary/aortic) orifices or when ejection fraction is increased along with unchanged area of outflow; not frequently when blood is flowing to the dilated vessel
-causes: regurgitation of aortic or pulmonary valves, aneurysm of ascending aorta, hiperkinateic circulation ( fever, pregnancy, anemia), septal defect, mitral regurgitation; in young people can be innocent when heard over the pulmonary valve area
c) telesystolic (latesystolic):
-causes: ischaemia or infarction of mitral pappilary muscle or its dysfunction due to left ventricular dilation
-ausculation: starts in late systole and end just before S2 or together with it. Usually crescendo type, of high frequency, localized over the apex.
-if accompanied by midsytolic murmur-->mitral prolapse
d) holosytolic (pansystolic= wholesystolic):
-causes: regurgitation of mitral/tricuspid valve ( backflow of blood from ventricle to atrium), septal defect at the level of ventricular septum (shunt of blood from right to left ventricle or vice versa)
-auscultation: audible during whole systole ( no pause between S1 and murmur)
******DIASTOLIC MURMURS********
a) protodiastolic :
-backflow of blood through aortic or pulmonary valve, when the pressure in ventricle decreases (becomes lower than pressure inside aorta/pulmonary trunk)
-causes: regurgitation of aortic valve/pulmonary valve
-auscultation: high frequency murmur, soft, decrescendo, puffy ('pfffff')
b) mezodiastolic:
-disproportion between area of outflow to the volume of blood passing through it during the phase of rapid filling of ventricles
-causes: mitral stenosis, tricuspid stenosis, increased flow through mitral/tricuspid orifice ( inborn regurgitation), regurgitation of pulmonary valve without pulmonary hypertension, septal defect, myxoma ( śluzak- tumour of CT)
-auscultation: low frequency, low loudness, starts after S2
Continuous murmurs:
-leak high or low-pressure cause by innapropriate anastomoses (venous, areterio-venous fistulas)
- causes: patent ductus aretriosus (Botall's), arotico-pulmonary window, arterio-venous maformations
-auscultation: audible through whole cardiac cycle
- venous hum (buczenie żylne): best audible in the angle between clavicle anc SCM, frequently more on the right side; the loudest in the diastole
Pericardial friction rub:
- friction of pericardium covered by fibrin
-caused by pericarditis
-auscultation: grasping, scratching, fresh-snow-walking, composed of 2-3 sounds during whole cardiac cycle; best audible in the 2nd and 3rd intercostal space close to the left sternal angle