Cardiac Examination Dr Will Ricketts - PowerPoint Presentation

Slide1

Cardiac Examination

Dr Will Ricketts

Clinical Teaching Fellow, Bart’s Health

Honorary Lecturer,

QMUL

Slide2

Getting StartedPatient’s Road Map

Order

of the ExaminationTying it All Together

Standard Order

Slide3

Getting StartedPatient’s Road Map

Order

of the ExaminationTying it All Together

Standard Order

Slide4

Wash Hands

I

ntroduce (& Consent)Position (on couch, sat at 45°)

E

xpose (from waist up)

R

etreat to Observe

Getting Started -

WIPER

Slide5

Retreat to Observe

End of Bed

Age/General Appearance (Well/Unwell)Paraphernalia (Oxygen, Drugs

etc

)

Pacemaker

Obvious OedemaSyndromesClose Up

Scars (Chest/Legs)

Hands

Order of the Examination

Slide6

Getting StartedPatient’s Road Map

Order

of the ExaminationTying it All Together

Standard Order

Slide7

HandsWrists (+ Groin)

Arm

NeckEyesMouthChest

Patient’s Road Map

1

2

3

Slide8

Hands

Clubbing

Tar StainingStigmata of Endocarditis

Peripheral Cyanosis

Wrists (+ Groin)

Arm

NeckEyesMouth

Chest

Hands

1

Slide9

Hands

Wrist

(+ Groin)

Radial Pulse

Rate (6s x 10 or 15s x 4)

Rhythm

RegularIrregularly Irregular (AF)

Regularly Irregular (Heart Blocks)

Collapsing Pulse

Arm

Neck

Eyes

Mouth

Chest

Wrist

1

Slide10

Hands

Wrists

(+ Groin)Radial-Radial DelayArm

Neck

Eyes

Mouth

Chest

Radial-Radial Delay

1

Slide11

Hands

Wrist (+ Groin)

Radio-Femoral DelayIn Exam just state “I would like to assess for Radio-Femoral Delay”

Arm

Neck

Eyes

MouthChest

Radio-Femoral Delay

1

Slide12

HandsWrists (+ Groin)

Arm

Brachial Pulse

Character

NeckEyes

Mouth

Chest

Brachial Pulse

1

Slide13

HandsWrists (+ Groin)

Arm

Brachial Pulse

Character

Blood Pressure

Just ask

Absolute

+ Pulse

Pressure = Systolic – Diastolic

Neck

Eyes

Mouth

Chest

Blood Pressure

1

Slide14

HandsWrists (+ Groin)

Arm

Neck

Carotid Pulse

Character

JVP

HeightWave Form!

Trachea

EyesMouth

Chest

Neck

1

2

Slide15

HandsWrists (+ Groin)

Arm

NeckCarotid Pulse

Character

JVP

Height

Wave

Form

Trachea

Eyes

Mouth

Chest

Jugular Venous Pulsation/Pressure

1

2

Slide16

HandsWrists (+ Groin)

Arm

NeckEyesPallor – Anaemia

Arcus

Xanthalasma

Mouth

Chest

Eyes

1

2

Slide17

HandsWrists (+ Groin)

Arm

NeckEyesMouth

Central Cyanosis

Chest

Mouth

1

2

Slide18

HandsWrists (+ Groin)

Elbows

NeckEyesMouthChest

Chest

1

2

3

Slide19

Hands

Wrists (+ Groin)

ElbowsNeckEyesMouth

Chest – Standard Order

Observe

Palpate

(

Percuss

)

Auscultate

Chest – Standard Order

1

2

3

Slide20

Hands

Wrists (+ Groin)

ElbowsNeckEyesMouth

Chest

Observe

Should have already done this!

Palpate

Auscultate

Chest – Observation

1

2

3

Slide21

HandsWrists (+ Groin)

Elbows

NeckEyesMouth

Chest

Observe

Palpate

ApexHeaves

Thrills

Auscultate

Chest – Palpation

1

2

3

Slide22

Palpation – Apex

Beat

Apex =

Most Inferior-Lateral point cardiac impulse can be palpated

Palpate with radial border of index finger

Mark out location

Start at

M

anubriosternal

angle = 2

nd

Costal Space

Normal =

5

th

ICS

MCL

Slide23

Hands

Wrists (+ Groin)

Elbows

Neck

Eyes

Mouth

Chest

Observe

Palpate

Apex

Heaves

Ulnar Border of Hand

Left Sternal Edge

Parasternal Heave = RVH

Thrills

Auscultate

Palpation – Heaves

Slide24

Hands

Wrists (+ Groin)

Elbows

Neck

Eyes

Mouth

Chest

Observe

Palpate

Apex

Heaves

Thrills = Palpable Murmurs

Ulnar Border 2

nd

ICS

Auscultate

Palpation – Thrills

Slide25

Hands

Wrists (+ Groin)

ElbowsNeckEyesMouth

Chest

Observe

Palpate

Auscultate

Four Areas

Usually start at Mitral

Chest – Auscultation

1

2

3

Slide26

Heat Sounds = Valves Snapping ShutS1(with pulse) = Mitral + Tricuspid Closing

S2 (between pulses) = Aortic + Pulmonary Closing

Are the heart sounds normal?Additional Sounds?

Split Sounds?

Is there silence between the sounds?

If

not = Murmur

Auscultation

Slide27

Getting StartedPatient’s Road Map

Order

of the ExaminationTying

it All Together

Standard Order

Slide28

Where is it loudest?

Does it radiate?

Aortic to NeckMitral to AxillaIs it:

With the Pulse?

= Systolic

Between Pulses?

= Diastolic

Louder on:

Expiration? = LeftInspiration? = Right

Sitting Forward = A/P

Rolled Left = Mitral

Murmurs

Slide29

Aortic

Pulmonary

Mitral

Tricuspid

Systolic

Aortic Stenosis

Pulmonary Stenosis

Mitral Regurgitation

Tricuspid Regurgitation

Diastolic

Aortic Regurgitation

Pulmonary Regurgitation

Mitral Stenosis

Tricuspid Stenosis

Murmurs

Slide30

Murmur = Turbulent Blood Flow through a Faulty

Valve

Stenosis = Stiff/Slow to Open ≈ Creaky DoorRegurgitation = Failure to CloseWhere is it

Loudest/Radiate to?

= Valve Involved

Is it With

Pulse? = Systolic Between

Pulses? =

DiastolicShould that valve be Open/Closed in Systole/Diastole?

Aortic + Pulmonary – Open Systole/Closed Diastole

Mitral + Tricuspid – Closed Systole/Open Diastole

Murmurs from First Principles

Slide31

Circulation Schematic

LA

LV

RA

RV

Slide32

Cardiac Schematic

RA

LA

RV

LV

Slide33

Cardiac Schematic

RA

LA

RV

LV

Aorta

Pulmonary Artery

Slide34

Cardiac Schematic

RA

LA

RV

LV

Aorta

Pulmonary Artery

TV

MV

AV

PV

Slide35

Cardiac Schematic

– Normal Systole

TV Closed

MV Closed

AV Open

PV Open

Slide36

Cardiac Schematic

– Normal Diastole

AV Closed

PV Closed

TV Open

MV Open

Slide37

Systolic Murmurs

– Aortic

Stenosis

TV Closed

MV Closed

AV Partially Open

PV Open

Slide38

Systolic Murmurs

– Mitral Regurgitation

TV Closed

MV Partially Closed

AV Open

PV Open

Slide39

Diastolic Murmurs

- Aortic Regurgitation

AV Partially Closed

PV Closed

TV Open

MV Open

Slide40

Diastolic Murmurs

- Mitral

Stenosis

AV Closed

PV Closed

TV Open

MV

Partially

Open

Slide41

These can be extrapolated from their left sided equivalentsE.g.

PS ≈ AS

PR ≈ ARTS ≈ MSTR ≈ MR

They are quieter

And (with the exception of TR) Rarer

As is MS

Right Sided Murmurs

Slide42

Aortic

Pulmonary

Mitral

Tricuspid

Systolic

Aortic Stenosis

Pulmonary Stenosis

Mitral Regurgitation

Tricuspid Regurgitation

Diastolic

Aortic Regurgitation

Pulmonary Regurgitation

Mitral Stenosis

Tricuspid Stenosis

Murmurs – Improve the Odds

!

Common things are Common!

Slide43

Getting StartedPatient’s Road Map

Order

of the ExaminationTying

it All Together

Remember the Systems

Slide44

Getting StartedPatient’s Road Map

Order

of the ExaminationTying

it All Together

Does your murmur fit with the rest of your findings?

Remember the Systems

Slide45

Getting Started

Patient’s Road Map

Order of the ExaminationTying

it All Together

Does your murmur fit with the rest of your findings?

Completing your examination

Peripheral Oedema

Pulmonary Oedema

Remember the Systems

Slide46

Hands - Normal

Wrists (+ Groin) - Normal

ArmLow Volume, Slow Rising PulseNarrow Pulse Pressure

Neck - ?

JVP

Eyes – Normal

Mouth - NormalChest

?Aortic Thrill

Ejection Systolic MurmurLoudest – Aortic area on Expiration

Radiates to Carotids

Worked Example – Aortic Stenosis

1

2

3

Slide47

Getting StartedWIPER

Patient’s Road Map

Standard OrderObserve

Palpate

(

Percuss

)Auscultate

Tying it All Together

Summary

1

2

3

Slide48

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