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Cardiac examination
- 1. Cardiac Examination Ahmed Elborae,MSc, MD, PhD, MRCP UK (London) Assistant Lecturer of Cardiology, Cairo University
- 2. 1-Hand 3-Neck 4-Leg 5-Abdomen 6-Lungs General examination Aim: Topick a cause or a result of cardiac problem 2-Head 0- General look Tall& Thin Marfan $ (Aortic disease) Morbid obese Metabolic $, HFPEF Position in bed Orthopnea (HF)
- 3. 1-Hand Dorsum Clubbing -Cyanotic heart disease -Toxic:endocarditis -Tumor: Myxoma Oscler nodule Painful Anemia Koilonychia Tremors Hyperthyroidism Endocarditis signs Splinter hge
- 4. Palm Endocarditis signs Janeway spot Painless Palmarerythema SLE Liver cirrhosis 1-Hand
- 5. Pulse -Rhythm (Regular Vs.irregular) -Rate per minute (30 sec. x 2) -Volume (Average, small, large) 1-Hand Equality: (Unequal) ? Iatrogenic Aortic dissection Atherosclerosis (Inside) Cervical rib (Outside)
- 6. Pulse character 1-Hand Water hammerpulse: -Anemia -Aortic regurge -Hyperthyroidism
- 7. Pulsus alternans: Advanced LV failure Pulsus paradoxus : Cardiac tamponade , Pulmonary embolism Pulsus tardus et parvus : severe AS Pulsus bisfiriens : Combined AS+AR, HCM
- 8. No smoking last30 minutes Empty bladder Standing BP after 3 minutes Esp. eldery to exclude orthostatic hypotension (Drop>20/10 mmHg)
- 9. 2-Head Eye Mouth Xanthelasma (↑Cholesterol) Pallor(Anemia) Jaundice Cyanosis Ulcers Painless e.g. SLE Painful e.g. Behcet Face Malar rash (MS,PHTN,SLE) Macroglossia (Amyloidosis,myxedema, acromegaly)
- 10. 3-Neck Pulsating Non pulsating Neck veins Normal:≤ 3 cm in 45° And not seen above clavicle in sitting position
- 11. Neck veins Ventricular diastoleVentricular systole Ventricular diastole Positive wave before pulse Normally > (Inspiratory collapse) Kussmaul sign : Inspiratory distension : (Constrictive pericarditis, Tamponade, Pulmonary embolism) Deep Y descent : Constrictive pericarditis
- 12. 3-Neck Carotid Thrill > (carotidstenosis, AS) AR signs (Corrigan, De Musset) Thyroid& LN Thyrotoxicosis
- 13. 4-Leg Pulsations Dosalis pedis& ATA Posteriortibial Popliteal Oedema SVG scar CABG
- 14. 5-Abdomen Palpation for Hepatomegally Cardiaccauses: (Right sided HF, tricuspid & pericardial diseases) Percussion for ascites
- 15. 6-chest -↓air entry (Effusion) -Finebasal crepitation (Congestion) -Bubbling crepitation (Pulm. Oedema) -Wheezes (Cardiac asthma) -Bronchial breathing (Pneumonia, abscess, infarction)
- 16. Local cardiac Examination Palpation(Whichchamber enlarged?) Auscultation (Which valve affected?)
- 17. Inspection Precordial bulge (Congenital heartdiseases) Scar (CABG, Valve) surgery Dilated Vein SVC obstruction Modern era Minimal invasive
- 18. 2-Apex character Heaving :AS Thrusting: AR, MR Tapping: MS Palpation of pulsations and thrill
- 19. 2-Lt parasternal heaving(RV + + +) Using the base of the hand RV LV Thrill (VSD) Using (Head of metacarpal bones) Palpation of pulsations and thrill
- 20. Palpation of pulsationsand thrill 4-Pulmonary 3-Aortic 5-Epigastric (RV) 2nd space Pulsations Using finger tips Thrill (AS –PS) Using palm (Head of metacarpal bones)
- 21. Auscultation • S1 (T,M), S2 (A,P) (↑,↓, splitting) • Murmurs (Character, time, site , radiation,↑ or↓) • Additional sounds (S3,S4,Snap,Click,rub) T P M A1 A2
- 22. Heart sounds ↑ ↑↑ S1 (MS, Tachycardia) ↓ ↓ ↓ S1: (MR, Bradycardia) T P M A S2 S1 ↑ ↑ ↑ A2 (systemic HTN) ↓ ↓ ↓ A2: (AS,AR) ↑ ↑ ↑ P2 (pulmonary HTN) ↓ ↓ ↓ P2: (PS,PR) Mitral& tricuspid closure (Systole) Aorta& pulmonary closure (Diastole)
- 23. Wide splitting (inspiration) “DelayP2 closure” (PS,RV failure, RBBB) Paradoxical splitting (Expiration) “Delayed A2 closure” (AS, LV failure, LBBB) Wide fixed splitting (Inspiration& Expiration) (ASD) Normal Inspiration > ↑ Rt systemic venous return > Delay P2 closure Expiration > ↑ Lt pulmonary venous return > Delay A2 closure
- 24. Timing with carotidpulsation Increase with inspiration Increase with inspiration Continuous infra-clavicular VSD: Harsh pansystolic
- 25. S3 (↑Volume) Anemia, thyrotoxicosis, MR (Dilatedventricle) Cardiomyopathy HF S4 (↓Compliance > ↑ atrial contraction) (Stiff ventricle) LV hypertrophy- Ischemia S3 gallop S4 gallop S3+Tachycardia S4+Tachycardia
- 26. Opening snap Mitral stenosis Ejectionclick Congenital aortic/pulmonary stenosis Abrupt systolic doming P A M Pericardial rub (Pericarditis) Continue after breath holding
- 27. Prosthetic valve Mechanical valve Tissuevalve TAVI valve Usual S1, S2 Mitral metallic click S1 Aortic metallic click S2 Best heard over sternum while sitting Any regurge murmur is pathological If click not heard, stuck valve???
- 28. 1-Hand 3-Neck 4-Leg 5-Abdomen 6-Lungs General examination Aim: Topick a cause or a result of cardiac problem 2-Head Local examination Palpation(Which chamber enlarged?) Auscultation (Which valve affected?)
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