Slide 1: PRESENTAION
BIPIN CVS The Cardiac Exam: History Taking : The Cardiac Exam: History Taking Introduction
As with any part of the physical exam, a complete cardiac exam should begin with a detailed cardiac history. A good historian should be able to predict the physical exam findings before attempting the actual physical exam. A thorough cardiac history should include investigating for the following cardiac symptoms, as well as general cardiac heart:
Cyanosis (turning blue)
Dyspnea (shortness of breath)
Edema (dependent - i.e. gravity edema)
Hemoptysis (coughing up blood)
Irregular heart beat
Note: Cx2DEFx2GHI (Chest pain, Cyanosis, Dyspnea, Edema, Fainting, Fatigue, General, Hemoptysis, Irregular heart beat) Chest pain : Chest pain is one of the most frightening symptoms a person can have. It is sometimes difficult even for a doctor or other medical professional to tell what is causing chest pain and whether it is life-threatening. Potentially life-threatening causes of chest pain are as follows
Heart attack (acute myocardial infarction): A heart attack occurs when blood flow to the arteries that supply the heart (coronary arteries) becomes blocked. With decreased blood flow, the muscle of the heart does not receive enough oxygen. This can cause damage, deterioration, and death of the heart muscle. Chest pain Myocardial Ischaemia : is a disease of heart result from imbalance between myocardial oxygen supply and demand producing pain call angina .. Examples: coronary artery disease (atherosclerosis of the coronary arteries). Its risk increases with age, smoking, hypercholesterolaemia (high cholesterol levels), diabetes, hypertension (high blood pressure)
Classification of pain: retrosternal pain which may radiates in the arms, throat or jaws Myocardial Ischaemia Slide 6: Angina:
Angina is chest pain related to an imbalance between the oxygen demand of the heart and the amount of oxygen delivered via the blood. It is caused by blockage or narrowing of the blood vessels that supply blood to the heart. Angina is different from a heart attack in that the arteries are not completely blocked, and it causes little or no permanent damage to the heart. "Stable" angina occurs repetitively while exercising and goes away with rest. "Unstable" angina results in unusual and unpredictable pain not relieved totally by rest, or pain that actually occurs at rest.
CAUSES OF ANGINA
1.Impaired myocardial oxygen supply
Coronary artery disease(atherosclerosis ,diabetes mellitus)
Coronary artery spasm
2. Increased myocardial oxygen demand
Left ventricular hypertrophy
HIGH RISK GROUPS
Elderly aged man or woman with family history of coronary artery disease (smoking ,hypertension , hypercholesterolaemia) Slide 8: Aortic dissection:
The aorta is the main artery that supplies blood to the vital organs of the body, such as the brain, heart, kidneys, lungs, and intestines. Dissection means a tear in the inner lining of the aorta. This can cause massive internal bleeding and interrupt blood flow to the vital organs. Slide 9: This photo shows cross-sections of an iliac artery into which dissection had extended from the
aorta. Note blood filling the false lumen in the split media. The true lumen is compressed. Slide 10: Pulmonary embolism:
A pulmonary embolus is a blood clot in one of the major blood vessels that supplies the lungs. It is a potentially life-threatening cause of chest pain but is not associated with the heart. Slide 12: □Definition: acute inflammation of the pericardium
□Sign: the friction rub: no any special complaint of patient; in some cases there may be pain.
※causes: appear during the course of an acute illness, especially rheumatic fever, but also in pneumonia, tuberculosis and virus infections. It is a common feature of myocardial infarction and of uremia.
□The ECG characteristically shows convex ST elevation and sometimes T-wave inversion over the affected area. Pericarditis Slide 14: □Definition: increase in pericardial fluid occuring in most cases of acute pericarditis
□symptoms and signs: according to the amount of pericardial fluid, may be no symptoms.
※ signs of heart oneself:
① cardiac impulse: weakness ② Cardiac dullness enlarged towards two sides ③ heart sounds :faintness, S1,S2 lower/softan ④ early diastolic added sound(pericardial knock) ⑤ pulse paradoxes Pericardial effusion THE CARDIAC EXAMINATION : Before the examination,ensure THE CARDIAC EXAMINATION ※A quiet environment
※Light come from the left side of the bed
※Patient in supine position, the examiner stand on the right side of the bed
INSPECTION : Slide 18: ※ Inspect the general appearance
position,breath,skin,mouth, eyes, chest configuration, extremities and nails etc.
※ the position, range, rhythm and intensity of apical impulses
※ Check for other pulsation in the anterior chest: note location What are needed to be seen? AnaemiaCyanosisClubbing of fingers and toesColdness of extremitiesPyrexiaOedama : AnaemiaCyanosisClubbing of fingers and toesColdness of extremitiesPyrexiaOedama Slide 20: Palpation Slide 21: ※The act of feeling with a hand and hands.
※Further define things we see and reveal things we can not see.
※To confirm and amplify the findings observed on inspection.
※Inspection and palpation are inseparably interrelated.
※Functions of palpation
The palpation discriminates textures, dimensions, consistencies and temperature. Palpation Slide 22: Palpation in heart examination Slide 24: ※ Pulsation of the abdominal aorta and the impulse from the volume or pressure-loaded right ventricle ※placed under the xiphoid process while the patient gently inhales.
※To distinguish these two,place the palm of your hand on the epigastric area and move your fingers up under the rib cage.the examiner can feel the aorta pulsation
forward against the palmer surface of your fingers,
or the right ventricle beating downward against your finger tips. Slide 26: Percussion ※Purpose of percussion: ascertain borders of heart
※Contents: percussion of cardiac dullness border (relative cardiac dullness border,absolute cardiac dullness border)
Note: percussion sounds: resonance, hyperresonance,dullness,flatness ※Indirect percussion: The tip of the right middle finger strikes the tip of the left middle finger laid firmly against the skin, thus producing a sound. Slide 27: Method and procedure of percussion of cardiac dullness border Slide 28: □Percussion of left cardiac dullness:
※ Percussion starts to the left on the chest, from 2~3cm apart from the apical impulse towards cardiac dullness (relative cardiac dullness) which is normally medial to the left midclavicular line in the 5th intercostals space. [on pathological situation, according to the actual position of the apical impulse]
※Percussion is performed from left towards cardiac dullness in the 4th, 3rd and 2nd intercostals spaces. Slide 30: □Percussion of right cardiac dullness:
※ to the right of the chest, percussion is done in the midclavicular line down to a dull point (the upper margin of liver).
※percussion from right towards cardiac dullness in the 4th(above the liver dullness), 3rd, and 2nd intercostals spaces.
□Connect every point of the cardiac dullness to be the left and right borders of heart. Measure the vertical distances from each point of cardiac dullness to the mid-sternal line with a stiff ruler. Slide 31: □ cardiac dullness enlarged towards to left and downward : When the left border of cardiac dullness falls outside the midclavicular line (downward and outward enlargement of the left cardiac border to the 6th intercostals space, even farer), it usually indicates that the left ventricle is enlarged.
□ cardiac dullness enlarged towards to left : if the left border of cardiac dullness goes out of left midclavicular line(the left cardiac towards left in the 5th intercostals space), it suggests that the right ventricle enlarged. Clinical significance of enlargement of border of cardiac dullness Slide 32: Mitral valve stenosis:
right ventricle enlargement Slide 33: Note: In patient with pleural effusion, pneumothorax, or emphysema, the relative dullness of the entire heart border may be smaller or even disappear Auscultation : Auscultation Slide 36: □heart rate □rhythm
※changes of heart sounds(S1,S2)
※extra heart sound
□pericardial friction sound Contents of heart auscultation Slide 37: heart rate (HR) □The heart beats per minute
In normal adult, HR=60~100/minute
□Both tachycardia and bradycardia can be caused by physiological factors, pathological factors or drugs.
tachycardia :severe anemia, high fever, hyperthyroidism, heart failure and various types of arrhythmia
bradycardia :syncope, complete heart block, sick sinus syndrome Slide 38: □The rhythm of heart beat
□In the normal person, the rhythm of the heart beat is regular or slight irregular during respiration with no clinical importance, and any deviation from this regularity is termed arrhythmia.
Premature beat (extrasystole)
Atrial fibrillation(Af) rhythm Heart disease - diagnostic tests : What tests are there for heart disease?
Electrocardiogram (ECG) This is the most common test for heart conditions. It is a simple, painless test that takes about 10 minutes.
The purpose of Holter monitoring is to look for heart rhythm problems over a 24 to 48-hour period. The Holter monitor is a small, portable, battery powered ECG machine worn when at home. It will record your heart rate and rhythm over a period of time Heart disease - diagnostic tests Slide 40: EchocardiogramThis test uses sound waves to study the movement of the heart's chambers and valves. This is particularly useful as you can assess different areas of the heart while it is beating. The echo sound waves create an image on the monitor as an ultrasound transducer probe is passed over the chest and heart.
Tilt table testA tilt table test is used to help explain why you have recurrent fainting spells or syncope. The test assesses whether the fainting spells are caused by a sudden drop in your blood pressure.
You may have an IV cannula inserted in your arm to give you special medications. Slide 41: Invasive tests
Echocardiogram stress test This is similar to a resting echo test. It is performed on people who need to have a exercise ECG but are unable to walk any great distance due to mobility problems. Medication is given via an IV cannula to simulate exercise. Heart function and rhythm are monitored.
Transoesphageal echocardiogram (TOE)
This test uses the same special sound wave technology that a regular echocardiogram uses, but the pictures are taken by inserting a special probe into the oesophagus (the food tube that connects the mouth with the stomach) rather than placing it on the patient's chest wall. A local anaesthetic spray is administered to the back of the mouth Slide 42: Cardiac catheterisation (angiogram) Coronary angiography is an x-ray procedure used to examine the arteries of the heart. An introducing sheath is inserted into an artery, usually in your groin or sometimes an arm. A catheter is threaded through this to the part of the aorta near the heart, where the coronary arteries start. A special dye is injected through the catheter, into your bloodstream
Electrophysiological studies (EPS) Your cardiologist might refer you for electrophysiology studies if you have an abnormal heart rhythm or palpitations. This type of investigation assists the doctor to make a definitive diagnosis and plan treatment for arrhythmia management. Slide 43: Blood tests Various blood test may be performed depending on your type of heart disease. These all help to build a picture of the nature of your disease.
full blood count
blood clotting times
In recent years the most commonly used blood test to measure the level of cardiac muscle damage are proteins called troponins. The level of troponins in the blood helps to give a quick and accurate idea of the amount of muscle damage after a heart attack. Cardiac troponins Cardiac troponin measurements help either confirm or exclude a heart attack in a person who may be having, or recently had, a cardiac event. They also help decide what treatments a person with unstable angina may need. Nuclear imaging tests : MUGA scan: A MUGA scan (Multi Gated Acquisition Scan) is a time proven nuclear medicine test designed to evaluate the function of the right and left Ventricles of the Heart. It is also called Radionuclide Angiography, as well as Gated Blood Pool Imaging.
Thallium stress test:This is a type of nuclear scanning test or myocardial perfusion imaging test. It shows how well blood flows to the heart muscle.
PET test:Positron emission tomography, also called PET imaging or a PET scan, is a type of nuclear medicine imaging. Nuclear imaging tests Treatment : Statins : help to reduce cholesterol and prevent heart disease in people at high risk and those who have already had a heart attacks or stroke. Find out more about these protective drugs.
Angioplasty :Coronary heart disease can reduce the blood flow to the heart. Angioplasty is a technique that improves the blood flow.
Cardioversion :This procedure helps your heart to return to a normal rhythm
Ablation: is a treatment that aims to try and control or correct an abnormal heart rhythm. It is sometimes called catheter ablation. Treatment Slide 46: Pacemakers :Your heart’s sinus node sends an electrical impulse to make your heart beat
ICD:Also known as implantable cardioverter defibrillators. It is a device which is able to give the heart electrical shocks. Slide 47: Thanks for your patience