cardiac assement.1
TRANSCRIPT
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Chest pain, tightness ordiscomfort.Shortness of breath
PalpitationSyncope or dizzinessRelated cardiovascular history -
-Transient ischemic attack,-stroke,-peripheral vascular disease
-peripheral edema
HISTORY.
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Chest pain
Chest pain is one of the important
symptoms of heart disease. Location: usually in the front of the chest
(retrosternal).
Radiation: spread to the neck, jaw, back,left or right arm.
Nature: chest pain due to cardiacischemia is typically tight and crushing inquality.
Patients may refer to angina pain as'indigestion'.
Other features include duration,
aggravating and relieving factors, andassociated s m toms e. . nausea and/or
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Chest pain
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BREATHLESSNESS
Cardiac causes include
severe pulmonary oedema
acute MI, cardiac arrhythmia
, pericarditis
pericardial effussion
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qCont.
qDyspnea on exertion may be the
evidence of heart failure.
qBreathlessness on lying flat
(orthopnea
qAny attacks waking the patient from
sleep (paroxysmal nocturnal
dyspnoea) or at rest?
qCheyne-Stokes or periodic breathing
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PALPITATIONSPalpitations- presentation of acardiac arrhythmia.Rhythm: tap out the rate andregularity; -a missed beat suggestsextra systoles.Duration:- sudden short episodessuggest paroxysmal tachycardia;-longer duration with irregularities
suggests Arial dysrhythmia.Associated symptoms: pain,dyspnoea, feeling faint or syncope.
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Drugs/medication:
Associated cough.
Limb ischemia, intermittent cloudication.
.Gastrointestinal symptoms:
Failure to thrive in children or weight loss
in in adults.
Urinary symptoms- oliguria..
Cerebral symptoms:-Dizziness, head ache
and mental changes
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EXAMINATION
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tBuild (obesity or wasting);
shortness of breath; difficulty intalking; do they look ill?
Look for pallor, jaundice,,
sweatiness and clamminess,
Look for any evidence of
syndromes or non-cardiovascularconditions associated withcardiovascular abnormalities.
ExaminationGeneral
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Malar flush - redness around thecheeks (mitral stenosis,).
Xanthalasma- yellowish depositsof lipid around the eyes, palms, or
tendons (hyperlipidaemia).Corneal arcus - a ring around the
cornea (normal aging orhyperlipidaemia).
Proptosis - forward projection ordisplacement of the eyeball(graves disease)
Face
http://www.patient.co.uk/DisplayConcepts.asp?WordId=GRAVES%20DISEASE&MaxResults=50 -
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Malar flush xanthalasma
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Corneal arcus proptosis
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Finger clubbing.
Capillary refill.
Splitncter haemorrhage (infective
endocarditis).
Oslers nodes- tender nodules in the
fingertips (infective endocarditis).
Sweaty palms, tremor (thyrotoxicosis)
Visible capillary pulsations in the nail
Hands
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FINGERSclubbing
ONTENT
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ONTENT
NORMAL CLUBBED
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Splinter haemorrhage
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- Assess Visible capillarypulsations in the nail bed(Quincke's sign
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8/9/12PULSES
-Palpate both radial pulses and assess rateand rhythm..- Palpate carotid pulse and assess volumeand character. Bruits
-Palpate the femoral,
- popolitial (located at the back of the kneewith a flexed knee)
-posterior tibia (located below the medialalveolus, lateral to the extensor hillocks longus)
- dorsalis pedis.
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RADIAL PULSE CAROTID PULSE SITE
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Dorsalis pedis poplitial.
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8/9/12Peripheral oedema
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8/9/12Degree of edema-
palpate the skin over the tibia for edema by-Squzeeing the skin for 30-60 sec.
Graded from --trace -4+.
Trace is slight indentation dissappear in ashort time.
1+ Mild pitting, slight indentation, noperceptable swelling of the leg
2+ Moderate pitting, indentation subsidesrapidly3+ Deep pitting, indentation remains for ashort time, leg looks swollen4+ Very deep pitting, indentation lasts a longtime, leg is very swollen
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ASSESSMENT OF PITTING EDEMA
2mm or less= 1+ Edema
2-4mm = 2+ Edema
4-6mm = 3+ Edema
6-8mm = 4+ Edema
Slight pitting
No visibledistortion
Disappearsrapidly
Somewhat
deeper pit No
readablydetectable
distortion Disappears
Pit is
noticeablydeep
May lastmore than 1
minute Dependent
Pit is very
deep Lasts as
long as 2-5minutes
Dependentextremity is
Pitted edema is tested by pressing & holding fingerinto the swollen tissue over a bony area for 5seconds. If there is an indentation left behind whenyou remove finger it is pitted edema
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ASSESSMENT OFPRECORDIUM
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INSPECTION
PALPATION
PERCUSSIONAUSCULTATIO
N
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INSPCTION
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Shape of the chest
Barrel chest
Pectrus excavatm (funnel shaped )chest
Pectus Carinatum(pigeon shapedchest
Kyphosis & Scoliosis.
chest scars and deformity
Note the respiratory rate.
Expansion of the chest
INSPECTION:
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Shape of the chest
Normal: bilaterally symmetrical /Elliptical
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Abnormal :
Barrel Shaped Chest
NT
PECTUS EXCAVATM (FUNNEL SHAPED
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PECTUS EXCAVATM (FUNNEL SHAPEDCHEST)
ONTENT
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PECTUS CARINATUM (PIGEONSHAPED CHEST)
CONTENT
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SHAPE OF SPINE
Kyphosis
ScoliosisTENT
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Chest expansion
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Method of examine jugular venous pressure
Use the right internal jugular vein (IJV).
The patient should be at a 45 angle.The patient's head should be turned slightly to
the left.
If possible, have a tangential light source that
shines obliquely from the left.
Locate the JVP - look for the double waveformpulsation
Measure the level of the JVP by measuring thevertical distance between the sternal angleand the top of the JVP. Measure the height -usually less than 4 cm)
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Apex Beat
Ape Beat
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Locate and palpate the apex beat .
usually the 5th/6th intercostal spacemid-clavicular line.
. Decide if the apex beat is normal ordisplaced Lateral displacement
suggests an enlarged heart. . A normalapex beat is short and sharp.
Causes of absent apical impulse:Emphysema
ObesityDextrocardiaLt. pleural effusion or pneumothoraxSevere pericardial effusion.
Apex Beat
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PERCUSSION
Percussion of cardiac borders.
Right upper cardiac border(between
the 2nd and 3rd intercostal spaces- Aortic
region -)
left upper cardiac border. (between
the 2nd and 3rd intercostal spaces at theleft sternal border- Pulmonic region )
LLSB left lower sternal border-
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AUSCULTATION.
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AUSCULTATION.
four classical auscultation areas: -
mitral/apex area, (5th intercostalspace, ICS, mid clavicular line)S1
tricuspid area, (left of lower part of
sternum 4th and 5th left ICSs, )S1
pulmonary area-left to the sternum(2nd left ICS) S2
Aortic area right of the sternum (2ndright ICS lateral to sternum)S2
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Additional areas of auscultation.
Auscultate in left axilla for radiation of a
murmur, and auscultate carotids forradiation and bruits.
Interscapular area for pansystolicmurmur of MR.
Anterior chest-3rd intercostals space onthe left side for murmur of AR)
Left intraclavicular areafor MRmumur,PDA murmur.
Left 3rd and 4th intercostals space formumur of VSD.
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first heart sound (S1) . Normal
second heart sound (S2
Extra heart sounds
S3and S4
Murmurs
Other abnormal sounds-clicks and
rubs.
HEART SOUNDS
f di l i
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sequence of cardiac auscultation.
Start from apex..
Proceed along the left sternal border below(tricuspid area) and pulmonary(above).
Then auscultate the right 2nd space(aortic area).
Auscultate additional areas whenever necessary.
. move stethoscope in an S-shape, starting at theapex beat.
Listen systematically to the auscultatory events in
the cardiac cycle i.e. (S1 and s2) and for addedsounds and murmurs..
Use both the bell and diaphragm appropriately inthe 4 areas the bell should only be placed lightly
on the skin
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Roll your patient slightly onto his left side andlisten in the 5th ICS with the bell for the lowfrequency mid diastolic murmur of mitral
stenosis..)
Auscultate in the axilla with the diaphragmfor radiation and comparative loudness of asystolic murmur.
auscultate with the diaphragm over bothcarotids for bruits and radiation of murmurs,.)
Next sit your patient forwards and listen withthe diaphragm at the lower left sternal edge,in expiration, for the high frequency diastolicmurmur of aortic regurgitation.
Finally, with the diaphragm, auscultate at thelung bases for the crackles of left ventricularfailure.
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