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Home , Auscultation, Heart sounds

9/6/2016

CARDIAC EXAM WORKSHOP

Will Baker MMS PA-C DFAAPA Clinical Assistant Professor University of Texas Rio Grande Valley

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OBJECTIVES

After taking this workshop the attendee will be able to:  Determine the “normal” of the chest in the approach to the assessment.  Understand the “normal” position of the heart within the chest/mediastinum  Understand that there are variants to the anatomical positioning of the heart

OBJECTIVES

 Determine the areas of examination for inspection, and  Be able to utilize this information as a platform in the assessment of the heart  Be completely familiar with the base information in order to contrast normal verses abnormal findings

OBJECTIVES

 Utilize this information in the correlation of hands-on learning in the clinical application  Properly evaluate and analyze abnormal findings in conjunction with the history of the patient.

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HEART FUNCTION TRIVIA

 At a rate of 72 bpm the adult heart beats 104,000 times a day and 38million beats per year.  At every stroke approx. 5 cu.in. (82ml) of blood is forced out into the body or 8,193 liters (2,164gal.) a day.  In terms of work, this is the equivalent of raising one ton (2,240lbs.) to a height of 41ft. every 24hrs.

HEART TRIVIA

 Blood Vessels (60,000mi)  If you are 25lbs. over weight, you have nearly 5,000 extra miles of vessels to go through

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You are seeing a Guyanese male who is approximately 59 years-old and accompanied by his son. The son tells you that his father “has been falling a lot”. His hx. Is significant for recurrent bouts of malaria, no injuries from his falls and no hx. of surgeries. He is not on any and has no known .

The Guyanese man walks into the exam area without help and did not appear to be in distress. His chest was of normal size and configuration. There were no observed abnormalities but there was a palpable lifts & his PMI was lateral to the MCL His rate & rhythm was normal but you hear the following on auscultation.

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“When I first gave my mind to vivisection, as a means of discovering the motions of the heart… I found the task so truly arduous, so full of difficulty, that I was almost tempted to ask with Francastorius, that the motion of the heart was only to be comprehended by God.” William Harvey 1578 - 1657

ANATOMY REVIEW

 What are the chest landmarks for the heart position?  Why do we need to know them?  What is normal?

LANDMARKS OF THE CHEST NECESSARY FOR HEART EXAM

 Sternum (Body)  Manubrium  Suprasternal Notch  Sternoclavicular Joint

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LANDMARKS OF THE CHEST

 Manubriosternal Junction (Angle of Louis)  Ribs (2nd)  Intercostal Spaces (2nd,3rd,4th & 5th)  Xiphoid Process  Sternal Border (Rt. & Lt.)

ADDITIONAL ANATOMY

 Neck  Carotid  Jugular (internal/external)  Abdomen   common iliac  femoral

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PERICARDIUM

 Surrounds the heart  Double Layered (parietal/visceral)  Fluid Between Layers (REDUCES FRICTION)

CHAMBERS OF THE HEART

 Right  Left Atrium  Right  Left Ventricle

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VALVES OF THE HEART

 Tricuspid (Rt. atrium – Rt. ventricle)  Mitral (Lt. atrium – Lt. ventricle)  Pulmonic (Rt. ventricle – pulmonary )  Aortic (Lt. ventricle - aorta)

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PHYSIOLOGY ELECTICAL CONDUCTION

 Autonomic Nervous System  Sinoatrial Node initiates electrical impulse (natural pacemaker)  Atrioventricular Node  Bundle of HIS  Bundle Branches (left & right)  Purkinje Fibers

Depolarization

Depolarization Repolarization

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VESSELS OF THE HEART

 Arteries originate in the aorta  Epicardial - Subendocardial  Left Coronary  Left Anterior Descending (widow maker)  Circumflex  Diagonal  Obtuse Marginal  Right Coronary  Posterior Descending Artery

DUCTUS ARTERIOSUS CLOSES

FORAMEN OVALE CLOSES

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H + FOUR PRINCIPLES OF EXAM

 History FIRST!  Inspection  Palpation  ?  Auscultation

HISTORY –

 Pain – with exertion or without exertion  Dyspnea – with exertion or without exertion  Palpitation – an awareness of a sensation  rate – tachycardic

INSPECT THE PATIENT

 Do they appear ill or in distress?  Diaphoretic?  ?  Finger clubbing?  ?

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INSPECTION OF THE CHEST

 You have to see skin!  THE POWER OF OBSERVATION!  WHAT DO YOU SEE OTHER THAN NORMAL ?  Abnormal movement: lift or heave?  Abnormal superficial vessels: coarctation?

PALPATION (WARM YOU HANDS)

 There is palpation & then there is palpation!  Lay your hand on the chest  What do your sensory receptors tell you?  Where is the point of maximum impulse (PMI) (5th ICS MCL)  Thrill  Lift or heave

PERCUSSION

 Change in tone  How big is the heart?

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ASCULTATION WHAT DO YOU HEAR & WHAT DO YOU NEED TO HEAR?

 RATE (Normally 60-100 bpm Adult)  RHYTHM (Regular/Irregular)  PITCH (High-diaphragm, Low-bell)  TIMING (Systolic/Diastolic)  S1(Tricuspid/Mitral)  S2(Aortic/Pulmonic)

KNOW HOW TO USE YOUR

 Ear pieces forward  Ear pieces clean  Ear pieces not missing (ouch!)  Diaphragm or bell in correct position

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HEART SOUNDS

 Music Background is helpful  Tones  Pitches  Rhythms  Timing

HEART SOUNDS (WARM YOUR STETHOSCOPE!)

 S1 “LUB” (Start of )  Atrioventricular Valves close  Tricuspid & Mitral  Heard Best at the Apex (4 ICS LT SB-5 ICS LT MCL)  Coordinate timing with the Carotid pulse

HEART SOUNDS

 S2 “DUB” (End of Systole)  Semilunar valves close  Pulmonic/Aortic  Heard best at the Base (2nd ICS LT/RT SB)

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HEART SOUNDS

 How do you know that it is the S1?

 PAUSE ()

In an average life span our heart if normal pauses 20yrs. 

ASCULTATION – DIASTOLE

 S3 (Early Diastole – Vibratory Filling of the Ventricles) Sometimes Normal: (HEARD BEST WITH BELL IN LT. LAT. DECUB.)  CHILDREN  YOUNG ADULTS  3RD TRIMESTER OF PREGNANCY

ASCULTATION – DIASTOLE

 S4 (Late Diastole – Vibration of Valves & Ventricle Walls)  Sometimes Normal: (HEARD BEST WITH BELL IN LT. LAT. DECUB.)  TRAINED ATHLETES  HEALTHY OLDER PERSON

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ASCULTATION

 Patient Positions  Sitting Up, 30degree Supine, and Prone  Position Yourself on the Patient’s right side  Female Patient – Bra on or off? & chaperone  Start at the 2nd ICS RT Sternal Border (Aortic) with Diaphragm of the Stethoscope  Next go to the 2nd ICS LT Sternal Border (Pulmonic)

ASCULATION

 Go to the 3rd ICS LT Sternal Border (Second Pulmonic)  Next 4th ICS LT Sternal Border (Tricuspid)  Finally the 5th ICS MCL (Apex/Mitral)  Have the Patient lean forward & recheck the 4th & 5th areas.

ASCULTATION

 Lay the Patient down and recheck all heart areas with the Diaphragm & Bell  Have the Patient lay in the left lateral decubitus position and listen with the Bell for S3/S4

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ABNORMALITIES

 Rate (conduction, endocrine)  Rhythm (conduction, endocrine)  Valvular disease (rheumatic heart)  Infection or (SLE)  Muscular (HCM/HOCM – myocardiopathy)  Congenital (patent ductus arteriosus)

ABNORMAL APPEARANCE OF CHEST (INSPECTION)

 SHAPE OF THE CHEST  BARREL SHAPED   PECTUS CARANATUM

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CONTUSION OF THE HEART

FLAIL CHEST

ABNORMAL FEEL (PALPATION)

 Lift or Heave ACCENTUATED PMI HYPERTROPHY OF RT. VENTRICLE  Thrill PALPABLE VIBRATION ASSOCIATED WITH 4/6 – 6/6 MURMURS

ABNORMAL FEEL (PALPATION)

 PMI on the Wrong Side DETROROTATION OF THE HEART TRANSPOSITION

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ABNORMAL DULLNESS (PERCUSSION)

 CARDIOMEGALY  Mass?  Hematoma?  ? DULLNESS BEYOND THE MCL OR RT STERNAL BORDER

ABNORMAL SOUNDS (KISA!)

 RESONANCE  RATE  RHYTHM  RUB  RUMBLE

ABNORMAL SOUNDS (RESONANCE) CAN YOU HEAR THE HEART? 1. NO SOUND! (CPR?) 2. SOUND IS DISTANT (FLUID AROUND IT?) 3. LOUD (HYPERDYNAMIC?) 4. STETHOSCOPE – EAR PIECES?

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ABNORMAL SOUNDS (RATE) WHAT IS THE RATE? 1. NORMAL (60 – 100) 2. BRADYCARDIC (<60) 3. TACHYCARDIC (>100)

RATES

with heart block – 25 to 45bpm  with Paroxysmal Atrial Tach - >200bpm  Normal newborn – 120 to 170  Normal 1yr old – 80 to 160

ABNORMAL SOUNDS (RHYTHM)

 Normal  Premature Arial Beat (PAC)  Skipped Beat (2 DEGREE BLOCK)  Premature Beat (PVC)  Transient Pause (SSS)  Regularly Regular (BIGEMINY)  Irregularly Irregular (AF)

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*****

ABNORMAL HEART SOUNDS

RUB RUB - RUB RUB RUB A squeaking type of sound

*****

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EXTRA HEART SOUNDS

 S1/S2 SPLITS  S3/S4  Opening Snap  Ejection Clicks  Murmurs

HOW TO DIFFERENTIATE?

 Tone  Timing  S1/S2 – somewhat similar – diaphram/bell  S3/S4 – different tone & timing – bell - early diastole or late diastole

SPLIT S2

 Physiological – at the base of the heart on inspiration  Fixed Splitting – unaffected by breathing  Paradoxical – occurs during expiration associates with BBB

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ABNORMAL HEART SOUNDS MURMURS - DISCRIPTION

 TIMING (DIASTOLIC/SYSTOLIC) (early, mid, late)  AFFECTED BY BREATHING (YES/NO)  LOCATION – heard best(2ND ICS LT., 4TH ICS LT, etc.) [Aortic, Pulmonic, Mitral, Tricuspid]  INTENSITY (1/6,2/6,3/6,4/6-thrill,5/6, 6/6)

ABNORMAL HEART SOUNDS MURMURS - DISCRIPTION

 RADIATES (LT. AXILLA, NECK, BACK, LEAN)  QUALITY (HARSH,BLOWING,MUSICAL)  PATTERN (CRESENDO,DECRESENDO)  PITCH (HIGH-DIAPH./LOW-BELL)

ABNORMAL HEART SOUNDS MURMURS - DISCRIPTION

 Hand Grip – increase or decrease murmur?  – increase or decrease murmur?

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MURMURS ASSOCIATED WITH /REGURGITATION

 MITRAL  TRICUPID  AORTIC  PULMONIC

AORTIC STENOSIS

 SYSTOLIC  NOT AFFECTED BY BREATHING  AORTIC AREA – RT 2ND ICS  VARIOUS INTENSITY  RADIATES INTO RT CAROTID AREA  COARSE  DIAMOND SHAPE  MEDIUM PITCH  DECREASED CAROTID PULSE

MITRAL STENOSIS

 DIASTOLIC (ALL Diastolic Murmurs are Pathological)  NOT AFFECTED BY BREATHING  APEX – LEFT LATERAL DECUBITUS  INTENSITY VARIOUS – THRILL POSS.  DOES NOT RADIATE  LOW PITCH - BELL

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PULMONARY STENOSIS

 SYSTOLIC  IS AFFECTED BY BREATHING  PULMONIC AREA – LT 2ND ICS  VARIOUS  RADIATES INTO NECK  COARSE  DIAMOND SHAPE  MEDIUM

TRICUSPID STENOSIS

 DIASTOLIC  AFFECTED BY BREATHING  TRICUSPID AREA – LT 3RD OR 4TH ICS LSB  VARIOUS  TYPICALLY DOES NOT RADIATE  RUMBLE  LOW PITCH – BELL  Has JVD

AORTIC REGURGITATION

 DIASTOLIC (LEAN FORWARD)  NOT AFFECTED BY BREATHING  APEX  USUALLY 3/6 OR GREATER  TYPICALY DOES NOT RADIATE  BLOWING  DIAMOND SHAPED  HIGH PITCH - DIAPHRAM

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MITRAL REGURGITATION

 SYSTOLIC (HOLOSYSTOLIC)  NOT AFFECTED BY BREATHING  APEX – LT 5TH ICS MIDCLAVICULAR  VARIOUS  RADIATES - AXILLA  HARSH  PLATEAU  HIGH PITCH - DIAPHRAM

PULMONIC REGURGITATION

 DIASTOLIC  AFFECTED BY BREATHING

HARD TO DIFFENTIATE BETWEEN AR

TRICUSPID REGURGITATION

 SYSTOLIC (HOLOSYSTOLIC)  AFFECTED BY BREATHING  LEFT LOWER STERNUM  VARIES IN INTENSITY  MAY RADIATE A LITTLE LATERALLY  BLOWING  MEDIUM PITCH (WILL HAVE JV DISTENSION)

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HYPERTROPHIC CARDIOMYOPATHY

 Grip or Squat – will decrease the intensity  Valsalva – will increase the intensity

VENTRICULAR SEPTAL DEFECT

 SYSTOLIC (HOLOSYSTOLIC)  NOT AFFECTED BY BREATHLING  3RD – 5TH ICS LT  3/6  DOES NOT RADIATE  COARSE  PLATEAU  HIGH PITCHED - DIAPHRAM

PATENT DUCTUS ARTERIOSUS

 DUCTUS ARTERIOSUS HAS NOT CLOSED AFTER BIRTH  HARSH – MACHINE LIKE  CONTINUOUS  HEARD BEST IN THE 1ST – 3RD ICS’S

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VENOUS HUM

 A CONTINUOUS “SH” SOUND  ANTERIOR – UPPER CHEST AREA  BENIGN  POSTURAL CHANGES WILL SOMETIMES DEMINISH SOUND

INNOCENT/FUNCTIONAL MURMURS

 Anemia  Fever  Change of position will change the sound or it will not be heard

QUESTIONS?

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CASE STUDIES

A 24yr. old presents with a hx. of intermittent episodes of , and a sensation she is about to die. She has no major significant hx. other than the presenting complaint. No use of alcohol, tobacco or street drugs. She is not on OCM’s.

On exam of the heart there is no observed or palp. lifts or thrills. On auscultation she has the following sounds while auscultating over the apex area while the patient is in the supine and sitting position. What you heard is noted when she is upright. Also noted that her sternum is slightly depressed

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A 24-year-old male presents to your clinic with an awareness over 50+hours of an irregular . He is generally well but has a history of hypertension (too many super-jumbo burgers … with bacon … he's been “supersized”), which he has been trying to control with exercise and diet (he switched to tofu burgers yesterday).

There is no prior history of cardiac disease or palpitations. No family hx. of heart disease. He smokes socialy. He did “have a bit to drink” celebrating … well, whatever, just celebrating … who needs a reason! He was embarrassed about his drinking and thus waited 2 days to seek care.

Vital signs reveal an irregular radial pulse of ~130 bpm and a of 146/92 mm Hg. The patient seems somewhat anxious, but is afebrile and has normal respirations. He has no . But on auscultation you hear this.

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A 40yr. old homeless male is seen in your urgent care facility. He states that he has not been feeling well for almost a week. He says that he has felt like he had a fever and has had chills. Further hx. reveals that on several occasions he has used IV drugs. .

He appears chronically ill. His indicate his temp. being 102degrees F. His pulse is 110bpm His skin is pale and there are old injection sites of his arms without noted erythema or pus. He has bilateral bibasilar rales, and he has JVD. This is what you hear on auscultation

A 28-year-old male presents to your clinic with a gradual onset of dyspnea as well as . His hx. essentially has been benign except for recurrent sore throats that eventually lead to a T&A at age 12yrs. He is moderately active but has noted that his endurance is significantly decrease over the last several months. He does smoke but not use of alcohol or drugs.

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His vital signs at the time of exam T- 99 degrees F, P- 98, R- 12 On exam he is WD, WN and does not appear acutely ill. His chest appears normal but on palpation there is a suggestion of a lift. He has normal R/R but there is a murmur noted at the PMI area.

A 18-year-old female presents to your office with her parents. She runs track for her high school but seems to get “winded quickly”. There is no hx. of palpitations, or chest discomfort. She has noticed for a long time that her legs seem colder than her hands. She is taking no , and there is no family history of heart disease.

On exam she appears to not be in any distress at this time. The in her feet are diminished compared to her radial pulses. She is of slender build. Her chest does not reveal any lifts by observation or by palpation. Cardiac exam appears normal but auscultation of her back gives you this information.

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An 18-year-old high school student has just returned from a basketball game where he began experiencing chest pain that has been getting progressively worse over the last several hours. His father brings him into your night clinic and gives you a hx. that overall the patient has been health but has just gotten over “a nasty cold”.

On exam he appears ill. His temp. is 101degrees F. He does have some cervical adenopathy that is nontender. Auscultation reveals the following sounds.

A 6th month-old baby is brought in for its well baby check where you are practicing. The mother states that her pregnancy, L&D, and postpartum periods were without complication. The mother gave birth at home while on mission work in Central America

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On examination the child appears fearful but cooperative. Vital signs are normal. Exam is normal except for a systolic murmur that is heard.

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