Cardiac Exam 2023 Hull PDF

Cardiac Examination Claire E. Hull, MHS, PA‐C July 12, 2023 Cardiac Anatomy and Cardiac Cycle DIASTOLE Period of ventricular filling Mitral and Tricuspid (AV) valves are open Aortic and Pulmonic (semilunar) valves closed SYSTOLE Period of ventricular contraction Mitral and Tricuspid (AV) valves are...

Cardiac Examination Claire E. Hull, MHS, PA‐C July 12, 2023 Cardiac Anatomy and Cardiac Cycle DIASTOLE Period of ventricular filling Mitral and Tricuspid (AV) valves are open Aortic and Pulmonic (semilunar) valves closed SYSTOLE Period of ventricular contraction Mitral and Tricuspid (AV) valves are closed Aortic and Pulmonic (semilunar) valves open Basic Cardiac Anatomy for Clinical Exam LV on left lateral and anterior The RV anterior The RA right border LA mostly posterior Important Landmarks 1. Aortic focus 2nd right ICS 2. Pulmonic focus 2nd and 3rd left ICS 3. Tricuspid 4th left ICS/LLSB 4. Mitral 4th or 5th left ICS in MCL Prepare Establish a quiet environment Have adequate exposure (but maintain patient modesty and comfort) Have equipment available Stethoscope Measuring tape Inspection: General Appearance Look for signs of acute cardiac distress Skin: cyanosis, diaphoresis, pallor, cool temperature Resp: difficulty breathing Chest Pain – Levine’s sign Anxiety Look for signs of chronic heart conditions Skin: clubbing of the fingernails (chronic hypoxia), xanthelasma ( cholesterol), surgical scars Habitus: obesity; underdeveloped lower extremities (coarctation). Many other P.E. signs can suggest underlying heart failure (edema, cachexia, enlarged liver, cold extremities, etc) Genetic Syndromes associated with cardiac conditions Ehlers‐Danlos, Marfan’s syndrome (and others) tin toenails Clubbing Xanthelasma palpebra rum xp i Hypercholestra can see on elbows radiate up arm shoulder Apex pmi Inspection: Apical Impulse Represents beat of the left ventricle during systole Normally visible in the 4th or 5th left ICS in mid‐clavicular line May be difficult to visualize Using tangential light may help in o stingpterest Palpation of the Precordium Best performed from the right side with the patient supine and the upper trunk elevated 30 degrees. Point of Maximal Impulse (PMI)– usually generated by the apex but it may be produced by an enlarged or hypertrophied RV, a dilated aorta or pulmonary artery, or an LV wall motion abnormality. Abnormal cardiac impulses‐ Can be caused a number of cardiac abnormalities: aortic regurgitation, aortic stenosis, hypertrophy, aneurysms, dilation, etc. Parasternal Lift – often due to RV hypertrophy Heave – a more pronounced Thrill – a palpable murmur lift How to Palpate the Precordium Side of hand (over bone) – thrills, lifts, heaves Careful! Palpation of Apical Impulse Provides an estimate of the size of the heart Assess location, diameter ( 10 years, and adults: 60 ‐ 100 beats per minute Abnormal heart sounds Physiologic Splitting of S2 The second heart sound (S2) is produced by the closure of the aortic (A2) and pulmonic (P2) valves. The A2 sound is normally much louder than the P2 due to higher pressures in the left side of the heart; thus, the A2 sound is the main component of S2 heart sound. A physiologic split S2 occurs during inspiration when the A2 sound precedes P2 by a great enough distance to allow both sounds to be heard separately. During deep inspiration, the decrease in intrathoracic pressure causes an increase in venous return to the heart. This causes the right atrium and ventricle to fill slightly more than normal, and it takes the ventricle slightly longer during systole to eject this extra blood. This delay in ejection forces the pulmonary valve to stay open a bit longer than usual, and the normally small difference between aortic and pulmonary valve closure becomes noticeable as a split S2. Special Maneuvers Accentuate S2 and aortic murmurs Accentuate S1 and mitral murmurs Exhale fully while leaning forward and hold breath Lie on left side while listening over apex What are you listening for? Normal heart sounds Rate and Rhythm Abnormal/Extra Heart Sounds – stay tuned! Murmur Friction Rub Gallop Click Opening Snap Summary Always start with inspection & palpation Ensure proper exposure to precordium while maintaining patient’s modesty Be aware of hand placement Take the time to listen carefully Questions?