Examination of the heart and the circulatory system

Complaints

• Chest pain– Angina pectoris– Pericarditis– Aortic aneurysm dissection– Extracardial causes

• Esophagus• Lung, pleura• Chest wall (muscle, neural, bone, joint)• Anxiety

Complaints• Angina pectoris

– Features• Constricting, pressing pain• Radiates to the left shoulder, arm

– But can be radiate to the neck, mandibule, back, epigastrium

• Reversible – few minutes• Provoked by

– Physical activity– Smoking, hypoxia– Cold– Big meal

• Relieving factor - nitrates

Complaints

• Angina pectoris subtypes– Effort angina– Status anginosus– Crescendo angina

Complaints• Pain from other arteries

– Intermittent claudication

– Abdominal angina

Complaints

• Pain in other localisation– Raynaud’s-phenomenon

Complaints

• Arrythmia– Palpitation– Tachycardia– Bradycardia– Syncope– Extrasystolia

Complaints

• Dyspnea– Inspiratory dyspnea– Subtypes

• Effort dyspnea• Dyspnea on rest

– Orthopnea dyspnea relieves in

vertical position– Paroxysmal nocturnal dyspnea

Complaints

• Edema according to the gravitaion

• In laying patients: sacral edema

Complaints

• Other complaints

– Nycturia v. nocturia

– Coughing– Weakness, decreased loadability

Complaints

• Important anamnestic data:– In the family history

• Hypertension• Early heart death, sudden death, ischemic heart

disease

– Factors• Smoking• Alcohol consumption

Inspection• Cyanosis

• Gärtner’s-sign - the blood filled vein can’t became empty during elevation of the hand

• Drumstic fingers

clubbed fingers

• Aortic valve insufficiency – Capillary pulsation

Palpation

• Pulse– Radial, ulnar artery– Dorsalis pedis artery– Tibial posterior artery behind the inner ankle

– Popliteal artery– Femoral artery– Carotis

Palpation• Pulse features

– 1. Frequency • Frequent or rare

– 2. Amplitudo• High or small

– 3. Compressibility• Hard or soft

– 4. Speed of increasing• Quick or slow

– 5. Palpability

Palpation– 6. Rythm

• Regular or irregular– Irregular – arrhythmia

» Phasic sinus arrhythmia – respiratory arrhythmia

» Extrasystole „premature beat”

Episodic or frequent

» Bigeminy, trigeminy

Palpation

Atrial fibrillation - absolute arrhythmia irregular and inequal pulse

Palpation• Apical impulse

– Normal: 1-2 cm medially to the left midclav. line in the V. intercostal space surface: 1 cm2

– Alterations• Goes to the left – dilatation, hypertrophy• Goes to the right – small heart• Goes up - pushed up

– Quality• Higher – hypertrophy• Wider - dilatation

Palpation

• Murmurs

Percussion• Rules

– Must to do it in the intercostal spaces

– The percussioned finger is always parallel to the checked border

• Order– Lower border right side, mc.line

VI. intercostal sp.

– Right border

– Upper border

– Left border

Auscultation

• Sound : short (0,2 sec), sharp bordered

• Murmur : longer, borders are blurred

Auscultation - Sounds

• Sounds– I. sound – systolic – longerit comes after the longer interval – II.sound – diastolic – shorter

• Development of sounds– Closure of valves

• Systolic: mitral and tricuspidal• Diastolic: aortic and pulmonal

– Opening of the other valves– Muscle contraction– Blood flow

Auscultation – I. sound – S1

• Alterations– Loud

• tachycardia • strong physical activity• extrasystole• stenotic mitral valve

– Soft• heart failure• emphysema• pericardial effusion• thick chest wall

Auscultation – II.sound – S2

• Normally the loudness of the S2 sounds of the aortic and pulmonal valve are equal (the aortic valve is more deeper)– Alterations

• S2 soft – hypotony• S2 is louder somewhere

– Above the aortic valve hypertension– Above the pulmonal valve pulmonar hypertension

• S2 is absent – aortic valve insufficency

Auscultation - Murmurs

Subgroups– Extracardial – pericardial friction rub

– Intracardial

Auscultation – Intracardial murmurs

• Development of murmurs – turbulent flow– Organic valvular diseases

irregular surface of the vessel– Functional - no organic alteration

papillar muscle insufficiency, heart dilatation– Accidental - no organic or functional alteration

increased blood flow,

decreased blood viscosity

Intracardial murmurs

• Place in the cardiac cycle–Systolic or diastolic

• Location of maximal intensity - punctum maximum

• Radiation of the murmur• Shape plateau, crescendo, descrescendo• Intensity• Pitch high, medium, low• Quality blowing, harsh, musical, rumbling

Auscultation - Murmurs• Cardiac cycle

– Systole• Pansystolic • Protosystole - early• Mesosystole - mid• Telesystole - late

– Diastole• Protodiastole• Mesodiastole• Praesystole

Auscultation - Murmurs

• Radiation of murmurs – always in the direction of the blood flow

Examples:– Mitral insufficiency – to the axilla

– Aortic stenosis – to the carotid artery

Auscultation – murmurs - shape

Plateau – mitral regurgitation

Crescendo-decrescendo –

aortic stenosis - ejection

Auscultation – murmurs - shape

• Decrescendo – aortic regurgitation

• Crescendo – mitral stenosis