Cardiology History & Physical

1. Cardiology History & Physical Dr. Gwen Hollaar, Lanice Jones & Dr. Robert Lee Lao FMS September 26 2006

2. Cardiac History: 8 questions • Chest pain • Dyspnea (shortness of breath) • Edema (dependent - i.e. gravity edema) • Fainting (syncope) • Fatigue • Irregular heart beat • Cyanosis (turning blue) • Hemoptysis (coughing up blood)

3. Chest Pain – think WWQQAAAB • Where is the pain • When does the pain occur (What activities) • Quality of pain – crushing, stabbing • Quantity of pain – a little, or more,1 – 10 • what makes the pain worse (exertion? How many steps, blocks, flights of stairs • what makes it better? Rest, Nitrospray? • Associated symptoms: diaphoresis, nausea, vomiting, dyspnea, radiating pain • Belief: what does the patient think is going on?

4. Dyspnea – think WWQQAAA • When = How long have you been short of breath? • Quality = Did the shortness of breath occur suddenly or gradually? • Quantity = How far can you walk before you become short of breath (one a flat surface, going up stairs)? • What makes it worse? Do you ever wake up at night feeling short of breath (paroxysmal nocturnal dyspnea)?Has your shortness of breath been stable or progressive? • What makes it better = How many pillows do you sleep on at night? • Associate = Edema, swelling in the legs or feet • Associate = Chest pain associated with shortness of breath?

5. Edema • Where do you have swelling? • When did you first notice the swelling? • Quality - Did it appear suddenly or gradually? • Quantity – Are both legs equal in swelling • Is the swelling worse in the morning or evening? • What makes it better? Does it decrease after a night's sleep? Does elevating the legs improve the swelling? • Associated - shortness of breath? • Associated - change in your weight? • Associated – leg pain? • Are you taking any medications, if so, which ones?

6. Fainting (syncope) • How often do you faint (or feel like you are going to faint)? (Quantity) • What are you doing when you faint (or feel like you are going to faint)? (When?) • Have you ever lost consciousness? (Quantity) • Does the fainting (or feeling like you are going to faint) occur suddenly? (Quality) • In what position were you when you fainted (or felt like you were going to faint)? (Associate) • Have you noticed anything that seem to be associated with the fainting (feeling like you are going to faint), for example, chest pain, irregular heart beat, nausea, confusion, hunger, tingling, or numbness?

7. Fatique • When did you feel tired? • Quality: Did the fatigue come on suddenly or gradually? • Quantity: Do you feel tired all day or only in the morning or evening • Quantity How far can you walk before you become short of breath (one a flat surface, going up stairs)? • Do you feel more tired at home or at work? • Is your fatigue relieved by rest? • Associate – hypothyroid, dyspnea, chest pain, etc

8. Irregular heart beat (palpitations • When do you feel your heart beating fast or irregular)? • When did you first notice the irregular heart beats? • Quantity: How long did the irregular heart beats last? • Quality: What did the irregular heart beats feel like? • Could you count your pulse during the episode? (Quality) • Can you tap on the table what the rhythm felt like? (Quality) • Did the irregular heart beats stop abruptly? (Quality) • Alleviate Did anything you do stop the irregular heart beats? • Associate: Chest pain • Associate: with exercise • Associate: sweating, flushing, or headaches Any you taking any medications, if so, which ones? • Associate: thyroid symptoms: heat intolerance, sweating, weight loss, diarrhea • Associate: smoke or use any other recreational or street drugs, if so, how much and how often? • How much caffeine do you drink a day (coffee, tea, soft drinks)?

9. Hemoptysis • How long have you been coughing up blood? • How often do you cough up blood? • Do you have chest pain when you cough up blood? • How much blood do you cough up?

10. General Cardiac History • Have you ever had any problems with your heart? • Have you ever had angina or a heart attack? • Do you have high blood pressure? • Do you smoke (tobacco), if so how much and for how long? • Do you have high cholesterol? • Have you ever been told you had a heart murmur or had rheumatic fever? • Have you ever had phlebitis (pain) or swelling in your legs?

11. Cardiac Physical Examination • Vitals • Inspection • Palpation • Auscultation • (Percussion – not done in N. America)

12. Inspection • Nails, color, shape, capillary filling • Skin color – pale, white palm creases • Conjunctiva color • Jugular Venous Distention • (Jugular Venous Pulsation – very difficult, not done well even by experienced clinicians)

13. Jugular Venous Distention • Internal Jugular Vein is in a straight line with the R atrium – distention shows elevated central venous pressure • It is difficult to do: Soft tissue lies over the jugular vein, and carotid pulse is stronger, making Jugular Vein harder to assess

14. Hunting for the Internal Jugular Venous Pulsation • Think anatomically. The right IJ runs between the two heads (sternal and clavicular) of the sternocleido-mastoid muscle (SCM) and up in front of the ear. • This muscle can be identified by asking the patient to turn their head to the left and into your hand while you provide resistance to the movement. The two heads form the sides of a small triangle, with the clavicle making up the bottom edge. You should be able to feel a shallow defect formed by the borders of these landmarks. • Note, you are trying to identify impulses originating from the IJ and transmitted to the overlying skin in this area. You can't actually see the IJ.

15. Jugular Vein Anatomy • Remember! We are not seeing the Jugular vein! We are looking for a pulsation transmitted through the neck soft tissue • Look between Sternal head and Clavicular head. • The External Jugular is more obvious but not reliable • Keep practicing!

16. Jugular Vein Anatomy Sternocleidomastoid muscle removed

17. JVP hints • Patient must be at 30 degrees – 45 degrees (lying with 2 or 3 pillows under his head and shoulders) • Take your time! • Check the entire course of the vein – it can be hidden up above the angle of the jaw • Use a light to shine tangentially across the neck • Assess Hepato-jugular reflux: press over liver for 10 seconds and observe if the wave rises

18. JVP measurement

19. Measuring JVP • identify JVD • estimate how high in cm the top of the column is above the Angle of Louis • identify the supra-sternal notch, a concavity at the top of the manubrium. • move your fingers downward until you detect a subtle change in the angle of the bone • approximately 4 to 5 cm below the notch. • roughly at the level of the 2nd intercostal space. • The vertical distance from the top of the column to this angle is added to 5cm, the rough vertical distance from the angle to the right atrium with the patient lying at a 45 degree angle. The sum is an estimate of the CVP. • Normal is 7-9 cm. (2 to 4 cm above the Angle – over 5 cm is abnormal

20. Measuring JVD

21. Palpation: Point of Maximal Impulse • Point of Maximum Impulse (PMI) identify the rough position with the palm of your hand, try to pin down the precise location with the tip of your index finger. • mid-clavicular line, 5th intercostal space. • Enlarged heart moves the PMI laterally • How strong is the impulse? Mitral Regurgitation and Aortic insufficiency increase the PMI • Check for a thrill, a vibratory sensation produced by turbulent blood flow. Usually secondary to valvular abnormalities. Not common.

22. Palpating PMI

23. Palpation – Carotid Arteries • First auscultate carotids, if you hear a murmur, palpate • Palpate only 1 side at a time • Decreased pulsation may be caused by atherosclerosis, aortic stenosis, or severely impaired ventricular performance.

24. Palpation other pulses • Palpate radial pulse, dorsalis pedis, posterior tibial, femoral.

25. Auscultation of the heart • Aortic Valve = 2nd right intercostal space, • Pulmonic Valve = 2nd left intercostal space, Tricuspid Valve = left 4th intercostal space, • Mitral Valve = 4th intercostal space, left midclavicular line to examine the mitral area.

26. Heart Sound Locations You are listening to WHERE the sound of the valve transmits best

27. Cardiac Cycle • S1 = closure of tricuspid and mitral valves, triggered by ventricle contracting, = SYSTOLE • S2 = closure of aortic and pulmonic valves triggered by ventricle relaxing, = DIASTOLE

28. Normal Splitting of S2 • S2 is made up of 2 components, aortic (A2) and pulmonic (P2) valve closure. • Inspiration is caused by lowered inter-thoracic pressure (by ribs raising, diaphragm lowering). Lowered pressure allows increased venous return to the heart • pulmonic valve closure is delayed • A2 closes first, then P2. • On expiration, the two sounds occur closer together and are detected as a single S2.

29. Extra Heart Sounds – S3 • Normal up to 20-30 years of age. • An S3 represents pathology in older patients. • It is caused by blood from the left atrium quickly going into an already overfilled ventricle during early diastolic filling. • S3 is most commonly associated with left ventricular failure

30. Extra Heart Sounds S4 • The S4 is a sound created by blood trying to enter a stiff, non-compliant left ventricle during atrial contraction. • It's most associated with left ventricular hypertrophy that is the result of long standing hypertension. • Use the bell of the stethoscope over the apex of the left ventricle • listen for low pitched "extra sounds" • These sounds are quite soft, so it may take a while before you're able to detect them. • Positioning the patient on their left side makes it easier

31. Cardiac Murmurs – Listen & Observe • Does it occur during systole or diastole? • What is the quality of the sound (i.e. does it get louder and then softer; does it maintain the same intensity throughout; does it start loud and become soft)? • What is the quantity of the sound? The rating system for murmurs is as follows: • 1/6┘ Can only be heard with careful listening • 2/6┘ Readily audible as soon as the stethescope is applied to the chest • 3/6┘ Louder then 2/6 • 4/6┘ As loud as 3/6 but accompanied by a thrill • 5/6┘ Audible even when only the edge of the stethescope touches the chest • 6/6┘ Audible to the naked ear • Most murmurs are between 1/6 and 3/6. Louder generally (but not always) indicates greater pathology.

32. Cardiac Cycle • There are 2 processes that affect heart valves – narrowing or dilation • Narrowing causes stenosis, dilation causes floppy valves that don’t close properly, causing regurgitant murmurs S1 = closure of mitral and tricuspid valves (Aortic and pulmonic are open) What 4 murmurs can you get in Systole? Which 2 are most common and why?

33. Systolic Murmurs • Aortic Stenosis • Upper sternal border • Diamond Shaped • Increase with sitting up and exhaling • Radiate to Carotids • Mitral Regurgitation • Louder in Axilla • Same through all of systole • Louder if patient makes 2 fists • Pediatric – VSD

34. Diastolic Murmurs 1. Aortic Regurgitation • Left sternal border, in the direction of the regurgitant flow. • Becomes softer towards the end of diastole • Accentuated by having the patient sit up, lean forward and exhale while you listen. • Occasionally accompanies aortic stenosis, so listen carefully for regurgitation in patients with AS. • carotid pulse feelsextraordinarily full 2. Mitral Stenosis (MS): • Heard best towards the axilla • Can be accentuated by having the patient role onto their left side while you listen with the bell of your sthethescope. • Associated with a soft, low pitched sound preceding the murmur, called the opening snap. This is the noise caused by the calcified valve "snapping" open. It can, however, be pretty hard to detect. Less Common Less Loud

35. Low Pressure versus high Pressure • The tricuspid and pulmonic valves on the R side of the heart are under much lower pressure than L heart valves • The murmurs are much softer, much harder to hear, and usually not as clinically important

36. An Orderly Approach to Auscultation • Try to focus on each sound individually and in a routine. • Ask yourself: Do I hear S1? Do I hear S2? • Is S2 split physiologically? • Are there extra sounds before S1or after S2 (i.e. an S4 or S3)? • Is there a murmur during systole? • Is there a murmur during diastole? • If a murmur is present, how loud is it? • What is its character? • Where does it radiate? • Are there any maneuvers which affect its intensity? • Listen for Cardiac Rubs • Listen for Carotid Bruits and Abdominal Bruits • *** Always have students listen to confirm after an echocardiogram report***