Cardiac Assessment PDF

LESSON 2, Part 1 CARDIAC ASSESSMENT Learning Objectives: Describe assessment of chest pain Define palpitations, syncope, peripheral edema Describe findings of a normal cardiac assessment Identify and describe normal heart sounds Discuss assessment of the JVP Describe assessment of arterial pulses...

LESSON 2, Part 1 CARDIAC ASSESSMENT Learning Objectives: Describe assessment of chest pain Define palpitations, syncope, peripheral edema Describe findings of a normal cardiac assessment Identify and describe normal heart sounds Discuss assessment of the JVP Describe assessment of arterial pulses Lesson Introduction: Assessment is an important component of a cardiac patient’s physical exam. In this lesson, we will examine various causes of chest pain. We will also learn the significance of palpitations, syncope and edema, in the cardiac patient’s physical exam. We will learn what causes the heart sounds we normally hear, and learn the procedure for assessing JVP and arterial pulses. CHEST PAIN The vast majority of patients needing a cardiac assessment have an initial complaint of chest pain. Understanding the cause of chest pain requires questions about and information on: Location: - is the pain in a specific area or is it diffuse - are there areas of radiation Severity: - using a 1-10 pain scale is common practice Description: - tightness, squeezing, constriction, heaviness, pressure, burning, indigestion - is the pain sharp or dull - some patients use images such as: chest in a vise, elephant on the chest, ton of bricks on the chest Provoking and Alleviating Factors: - what makes the pain worse or better - are there predictable or reproducible factors Type of Onset: - gradual or sudden onset Occurrence and Duration: - what was the activity at time of onset - length of pain (minutes, hours) - is the pain constant or intermittent The following chart briefly examines various causes of pain Probable Common Location Worsening Alleviating Cause Description Factors Factors substernal, physical squeezing may radiate effort rest Angina aching to both arms, emotions oxygen pressure jaw, neck, or smoking nitroglycerine heaviness back hot or cold weather eating squeezing substernal, oxygen heaviness may radiate exertion opioids Acute MI tightness to both arms, anxiety (such as pressure jaw, neck, or smoking Morphine) burning back substernal, sitting up Acute sharp and may radiate lying down leaning forward Pericarditis continuous, with to neck and deep anti-inflammatory a sudden onset left arm breathing drugs retrosternal, epigastric or Dissecting sudden onset of upper surgery Aortic excruciating and abdomen n/a analgesics Aneurysm tearing pain may radiate to back, neck, shoulders Pulmonary sudden onset of over the analgesics Embolism stabbing pain affected lung inspiration anticoagulants area sudden onset of normal analgesics Pneumothorax severe and lateral thorax breathing chest tube sharp pain gradual or analgesics Chest-wall sudden onset of anywhere in movement heat syndrome sharp pain, often the chest palpation time tender to touch sudden onset of stress stress relief Acute Anxiety dull or stabbing anywhere in increased slowing of pain the chest respiratory respirations rate deep breathing Other conditions can also cause chest pain. Some other causes can include esophageal spasm, hiatus hernia, cholecystitis, peptic ulcer, endocarditis, myocarditis, chest trauma PALPITATIONS - palpitations are an awareness or sense of feeling one’s own heartbeat - they are usually felt over the precordium or in the throat - might be described as - heart skipping beats - fluttering or flopping - pounding or thumping - they can be of short duration or they may be sustained - the heart rate can be regular or irregular, fast or slow - palpitations are quite common and might be insignificant - they are often caused by stimulants (caffeine, alcohol, nicotine, bronchodilators, nasal decongestants) - palpitations can be a symptom of an arrhythmia - the presenting clinical picture determines the urgency of treatment SYNCOPE - a transient brief loss of consciousness due to cerebral anoxia - often referred to by patient as “fainting spell” - usually of short duration - not all patients are fully unconscious during syncopal episodes - some might feel “far away”, still hear sounds, still see blurred images of their surroundings - accompanying phenomena can include pallor, nausea, diaphoresis, slow and shallow respirations, slow and weak peripheral pulses, hypotension - syncope is often caused by vasodilatation, or overactivity of the parasympathetic nervous system (PSNS) which results in a slow HR (heart rate). This is often called a vasovagal attack - remember…HR x SV = CO - so, ↓HR x SV = ↓CO - if the HR is slow, less blood is being ejected by the LV - the CO drops, so less oxygenated blood reaches the body, including the brain - so, cerebral symptoms occur, such as syncope - precipitating factors, associated phenomena, duration, medication history, and past history can help determine the cause for syncopal episodes PERIPHERAL EDEMA - this is an abnormal accumulation of fluid in interstitial tissues, in the periphery - can be a manifestation of right ventricular failure (explored further in Lesson 5) - fluid collects in dependent areas, so the fluid distribution is determined by gravity and ambulation - ambulatory patients experience edema in the legs and feet - bedridden patients develop edema over the sacrum - greater degrees of edema can extend to the abdomen (ascites), the torso and the face (anasarca) - edema of the arm is most likely due to superior vena cava syndrome or thrombophlebitis - edema that develops in one leg only is likely due to thrombophlebitis or venous insufficiency A good example of pitting edema can be viewed at… http://www.virtualmedstudent.com/links/physical_examination/pitting_edema.html Can’t ctrl+click on this underlined link? Just copy and paste the complete address into the location bar of your browser and click “enter”. OTHER SIGNS & SYMPTOMS - often, cardiac patients have other phenomena associated with chest pain - these can include a combination of several complaints, signs and symptoms - some common associated phenomena are: - dyspnea (with activity or at rest) - cough - decreased breath sounds - diaphoresis - changes in skin color (ie: pallor, cyanosis, ashen, grey, waxy tone) - weakness, fatigue - dizziness, headache - anxiety, sense of impending doom - nausea, vomiting …Proceed to Lesson 2, Part 2