Cardiovascular system Chest pain Characteristics of the pain Where exactly Does it radiate Nature of pain....burning, stabbing, crushing, gripping? Precipitating factors Time course and relieving factors Associated features....nausea, vomiting, sweating, SOB.... Breathlessness Lying flat (orthopnoea)...how many pillows do they use...LVF Paroxysmal nocturnal dyspnoea......Do they ever wake at night fighting for breath....LVF On minimal exertion....how far can they walk...and what stops them....pain, breathlessness Ankle swelling...RVF Duration Degree Ascites Nausea and poor appetite due to bowel oedema Right upper quadrant discomfort due to hepatic congestion. Fatigue
Lighting Seated and comfortable Stripped to the waist General Inspection General features Age, sex, general health Obese or skinny Breathless Position in bed....do they seem to need to sit up? Eyes Jaundiced Xanthalasma...hyperlipidemia Face Cyanosis Teeth....poor dental hygiene? Praecordium Any obvious deformity Visible collateral veins Presence of scars. Ankles. Swelling/oedema.
Pulse Presence and symmetry Check both radial pulses together for asynchrony (aortic dissection, vasculitis) Rate Rhythm Irregularly irregular? Volume Bounding pulse CO2 retention/LVF Small volume shock. Pulsus paradoxus Detectable increase in pulse volume is felt during expiration (cardiac tamponade or severe asthma) Pulsus alternans Alternate pulses are felt as strong or weak due to presence of bigeminy Character Requires considerable practice to feel waveforms!!
Position patient so that he is reclining comfortably until the waveform is clearly visible. Rest the patients head on a pillow to ensure that the neck muscles are relaxed Look across the neck from the right side of the patient. (due to anatomy of innominate veins) Identify the jugular vein pulsation Abdomino-jugular reflux- gently press over the abdomen for ten seconds. This increases venous return to the right side of the heart and the JVP normally rises Occlusion: the JVP waveform is obliterated by gently occluding the vein at the base of the neck with your fingers Can be raised in: Fluid overload- characteristically in heart failure Primarily a sign of right sided heart failure. Acute pulmonary embolism COPD
Systole starts at the point of closure of the mitral valve (FIRST HEART SOUND) as the pressure in the left ventricle exceeds that in the left atrium. Contraction occurs before the pressure in the left ventricle exceeds that in the aorta.... At which point the aortic valve opens and blood starts to flow into the aorta. Left ventricle relaxes.... Aortic pressure exceeds that in the left ventricle and the aortic valve closes (SECOND HEART SOUND) The ventricle continues to relax until the pressure falls below that in the filled left atrium.. The mitral valve opens to allow blood to flow into the left ventricle.
S1- ‘lub’ caused by closure of the mitral and tricuspid valves at the onset of ventricular systole and is best heard at the apex. S2- ‘dup’ caused by closure of the pulmonary and aortic valves at the end of ventricular systole and is best heard at the left sternal edge. Physiological splitting may occur at inspiration S3- ‘dum’ best heard with the bell. Normal in children, young adults and during pregnancy.
Locate the apex beat Normally in the 5 th left intercostal space, at or medial to the mid-clavicular line Normally briefly lifts the palpating fingers Palpate for thrills at the apex and both sides of the sternum Maybe absent in overweight or muscular people Maybe absent due to hyper-inflated chest as in asthma or emphysema. If you cannot feel it ask the patient to lay on his left side.
LISTEN TO ALL WITH DIAPHRAGM AND BELL. Aortic – second right intercostal space Pulmonary- Second left intercostal space Aortic regurgitation may be louder here Tricuspid- fourth left intercostal space Especially for tricuspid regurgitation Mitral regurgitation and aortic stenosis are often louder here Mitral- fifth intercostal space mid calvicular line Mitral stenosis with bell. To elicit mitral stenosis roll patient into left lateral and listen with bell. Ask patient to sit up and lean forward. Listen over 2 nd intercostal space and over left sternal edge with diaphragm for the murmur of aortic regurgitation.
Breathlessness Common with some degree of heart failure Accumulation of fluid in the alveoli occurs with left heart failure because increased left atrial end diastolic pressure leads to elevated pressure in the pulmonary veins and capillaries. Orthopnoea Dyspnoea when lying flat Sign of advanced heart failure Lying flat increases venous return to the heart and in patients with a failing left ventricle may precipitate pulmonary venous congestion and pulmonary oedema Paroxysmal nocturnal dyspnoea Sudden breathless which wakes the patient from sleep choking or gasping for air. Gradual accumulation of fluid during sleep Patients may sit on edge of bed and open windows to get some air.
Ask about Onset and termination- abrupt or gradual Precipitating factors- exercise, alcohol, exercise, recreational or other drugs Frequency and duration of episodes- Character of the rhythm- ask them to tap it out.
Syncope and dizziness Postural hypotension Commonly caused by hypovoleamia, antihypertensive drugs, especially diuretics and vasodilators Neurocardiogenic syncope Occurs in healthy people who have been forced to stand for a long time or subject to painful or emotional stimuli. Results from abnormal autonomic reflexes and bradycardia and/or vasodilatation Arrhythmias SVT’s rarely cause syncope Most common cause is bradyarrythmia due to sick sinus syndrome, or atrioventricular block Drugs including digoxin, beta blockers and rate limiting calcium channel blockers may aggravate attacks. Mechanical obstruction to cardiac output. Severe aortic stenosis and cardiomyopathy can obstruct left ventricular outflow.
Angina Precipitated by exertion Eased by rest and/or GTN Myocardial infarction More severe Persists at rest Pericarditic pain Sharp, raw or stabbing Varies with movement or breathing Aortic Severe tearing Sudden onset radiates to the back
Site Angina/Myocardial Infarction Felt in centre of chest, radiates out Oesophageal Retrosternal or epigastric. Can radiate out. Aortic Between shoulder blades and behind sternum Onset Sudden or gradual Character Crushing, gripping, like a band across my chest, dull ache Radiation Associated symptoms Nausea (very common in MI) Sweating SOB Syncope Timing Angina pain tends to be short lived MI pain lasts fro 20 mins or more Exacerbating or relieving factors Rest may relive angina Will not relieve MI Severity
Cardiovascular Examination• Systematic– Time what you hear with the patients pulse.– First heart sound (precedes peripheral pulse)– Second heart sound (after pulse is felt)– Murmers during systole– The absence of silence during diastole– Any extra sounds.Jonathan Downham 2010
Cardiovascular Examination• Normal Heart SoundsJonathan Downham 2010
Cardiovascular Examination• The PrecordiumThis is the area on the front of the chest that relatesto the surface anatomy of the heart.Inspect the precordium with thepatient sitting at 45 degree anglewith shoulders horizontal.Jonathan Downham 2010
Cardiovascular ExaminationLocate the apex beatJonathan Downham 2010
Cardiovascular Examination• Heave– A palpable impulse that lifts your hand noticeably• Right ventricular hypertrophy• Thrills– Feel like a ringing phone or a fly trapped in oneshand• Aortic stenosis• Palpable first heart sounds– Mitral stenosis.Jonathan Downham 2010
Cardiovascular Examination• Abnormal heart sounds– Aortic Regurgitation•Timing- early diastolic•Location- left or right 2-4thintercostal space•Character- quiet, blowing•Use diaphragm with patientleaning forward.Jonathan Downham 2010
Cardiovascular Examination• Abnormal heart sounds– Mitral stenosis•Timing- mid diastolic. Maybe preceded by openingsnap.•Location- apex•Character- low pitchedrumbling•Listen for mitral stenosiswith lightly applied belland patient in left lateralpositionJonathan Downham 2010
Cardiovascular Examination• Abnormal heart sounds– Mitral regurgitation•Timing- pansystolic•Location- loudest at the apexJonathan Downham 2010
Cardiovascular Examination• Common Cardiovascular problems– Breathlessness• Common with some degree of heart failure• Orthopnoea– Dyspnoea when lying flat– Sign of advanced heart failure• Paroxysmal nocturnal dyspnoea– Sudden breathless which wakes the patient from sleepchoking or gasping for air.Jonathan Downham 2010
Cardiovascular Examination• Common Cardiovascular problems– Palpitations• An unexpected awareness of the heart beating• Most patients do not have a sustained arrhythmia• Those that do often do not experience palpitations.• Ask about– Onset and termination– Precipitating factors– Frequency and duration of episodes– Character of the rhythmJonathan Downham 2010
Cardiovascular Examination• Common Cardiovascular problems– Syncope and dizziness• Postural hypotension• Neurocardiogenic syncope• Arrhythmias• Mechanical obstruction to cardiac output.Jonathan Downham 2010
Cardiovascular ExaminationChest Pain•SOCRATES•Site•Onset•Character•Radiation•Associated symptoms•Timing•Exacerbating or relieving factors•SeverityJonathan Downham 2010
Cardiovascular ExaminationChest PainWatching the patient describing the characterof the pain is helpful•A clenched fist on the chest is worrying•A single pointed finger is less worryingTake time to tease out the history•Chest pain causes anxiety in patients and this maycloud genuine/significant pathology•Do not increase anxiety by performing unnecessaryinvestigations.If in doubt:MONA.Jonathan Downham 2010