CARDIACASSESSMENT

HealthHistory
1.CurrentHealthStatus
chestpain
angina

myocardialinfarction

pericarditis

dissectingaorticaneurysm pulmonaryarteryhypertension

pneumothorax

pneumonia

esophagealreflux esophagealspasm

postmyocardialsyndrome

ribfracture

esophagealrupture

shortnessofbreath
syncope
swellingofanklesorfeetheartpalpitations
fatigue

2.PastHealthHistory
congenitalheartdisease
rheumaticfever
heartmurmur
highbloodpressure,highcholesterol,diabetesmellitusconfusion
fatigue
dentalwork

3.FamilyHistory
4.PersonalHabits

smoking
alcohol
sleep&restexercise
nutrition
stress&coping

TechniquesofExamination
Thepatientshouldbesupinewithupperbodyelevatedata1530Eangle.The
roommustbequiet,warm,andhavegoodlighting.Youshouldstandtotheright
ofthepatientbeingexamined.InspectionandPalpationoftheHeart
Inspectionandpalpationreinforceeachotherandaretimesavingwhendone
together.
Tangentiallightinghelpsyoudetectpulsations.
Theballofthehand(atthebaseofthefingers)isthemostsensitiveatdetecting
thrills.
Thefingerpadsaremoresensitiveindetectingpulsations.
InspectandPalpatefor:
Pulsationsthesearemorevisiblewhenpatientsarethin.Athickchestwallor
increasedAPdiametercanobscurethem.Pulsationsmayindicateincreasedblood
volumeorpressure.
Liftorheavestheseareforcefulcardiaccontractionsthatcauseaslightto
vigorousmovementofsternumandribs.
Thrillsthesearethevibrationsofloudcardiacmurmurs.Theyfeellikethethroat
ofapurringcat.Thrillsoccurwithturbulentbloodflow.
Youshouldinspectandpalpateatthefollowingareas:
1.AorticArea(secondinterspacetotherightofthesternum).

apulsationcouldindicateanaorticaneurysm.athrillcouldindicateaortic
stenosis.
2.PulmonicArea(secondinterspacetotheleftofthesternum).apulsationcould
indicatepulmonaryhypertension.
athrillcouldindicatepulmonicstenosis.
3.ERB'sPoint(thirdinterspacetotheleftofthesternum).
findingssimilartothatofaorticandpulmonicareas.
4.TricuspidArea(RightVentricularArea)(45thinterspace;lowerhalfofthe
sternum).
asustainedsystolicliftcouldindicaterightventricularenlargement.
asystolicthrillcouldindicateaventricularseptaldefect.
inpatientswithanemia,anxiety,hyperthyroidism,fever,pregnancy,orincreased
cardiacoutput,abriefpulsationmaybefelt.
5.MitralArea(LeftVentricularArea)(5thintercostalspaceatthemidclavicular
line).ThisiswhereyoucanfindtheApicalPulseandusuallycanfindthePointof
MaximumIntensity(PMI).
identifythePMIbylocation,diameter,amplitude,duration,andrate.Tohelp
identifyit,havepatientexhalecompletelyandholdbreathorhavethepatientlean
forward.Normalisalighttap,12cmindiameteratthe5thinterspaceattheleft
midclavicularline.PMIcouldbedisplaceddownandtotheleftwithventricular
hypertrophy,pregnancy,andCHF.
normallyseeninlessthanhalfthepopulation.
increasedpulsationcouldindicateincreasedcardiacoutput,anemia,anxiety,fever,
orpregnancy.
athrillcouldindicatemitralregurgitation,ormitralstenosis.6.EpigastricArea
(belowxyphoidprocess).
increasedaorticpulsationcouldindicateAAA,andaorticregurgitationorright
ventricularpulsationofrightventricularenlargement.

7.EctopicArea(23rdinterspaceattheLMCL)
increasedpulsationsinthisareaseeninpatientswithMI'sor
coronaryheartdisease.
8.SternoclavicularArea(topofsternumatjunctionofclavicles
pulsationofaorticarchmaybefeltinathinclient.

AuscultationoftheHeart
1.AorticArea2ndrightinterspaceclosetothesternum.
2.PulmonicArea
3.ERB'sPoint
4.TricuspidArea
5.MitralArea(Apical)5thleftinterspacemedialtotheMCL
2ndleftinterspace.
3rdleftinterspace.
5thleftinterspaceclosetothesternum.
1.Withyourstethoscope,identifythefirstandsecondheartsounds(S1andS2).
attheaorticandpulmonicareas(base).S2isnormallylouderthanS1.S2is
consideredthedubof'lubDUB.'S2iscausedbytheclosureoftheaorticand
pulmonicvalves.
atthetricuspidandmitralarea(apex)S1isoften,butnotalwayslouderthanS2.
S1isconsideredthelubof'LUBdub.'S1iscausedbytheclosureofthemitral
andtricuspidvalves.
S1issynchronouswiththeonsetoftheapicalimpulse.2.Identifytheheartrate.
tachycardia

bradycardia
3.Identifytherhythm.
ifitisirregular,trytoidentifythepattern.
Doearlybeatsappearonaregularrhythm?
Doestheirregularityvaryconsistentlywithrespiration?Isrhythmtotally
irregular?
4.ListentoS1first,thenS2atthepreviouslymentionedareasusingthe
diaphragmandthenthebell.
noteitsintensity.
arethereanysplittingsoundscheckduringinspirationwhereS2usuallysplitsat
pulmonicandERB'spoint.
athickchestwallorincreasedAPdiametermaymakeS2inaudible.
AlterationsinS1
a.S1isaccentuatedinexercise,anemia,
hyperthyroidism,andmitralstenosis.
b.S1isdiminishedinfirstdegreeheartblock.
c.S1splitismostaudibleintricuspidarea(Tlubdub).
AlterationsinS2
a.NormalphysiologicalsplittingofS2isbestheardatpulmonicarea.Itoccurson
inspiration(lubTdub,lubdub).
b.SplittingofS2canindicatepulmonicstenosis,atrialseptaldefect,right
ventricularfailure,andleftbundlebranchblock(lubTdub).
5.ListenforS3(ventriculargallop).
aphysiologicS3isfrequentlyheardinchildrenandinpregnantwomen.
itoccursearlyindiastoleduringrapidventricularfilling.Itisheardbestatthe
apexintheleftlateraldecubitusposition.
itisheardbestusingthebell.

apathologicS3occursinpeopleovertheageof40.Causeisusuallymyocardial
failure.
soundslikelubdubdee(or'Kentucky').6.ListenforanS4(atrialgallop).
itoccursbeforeS1
itislowpitchedandbestheardwiththebell.
oftennormalinolderadults.
itisheardbestattheapexintheleftlateraldecubitusposition.
itmaybecausedbycoronaryarterydisease,hypertension,myocardiopathy,or
aorticstenosis.
soundslikedeelubdub(or'Tennessee').7.Listenformurmurs.
CHECKTIMING.Aretheysystolicordiastolic?
(systolicmurmursmaybebenign.Diastolicmurmursareneverbenign).
LOCATIONOFMAXIMALINTENSITY.Whereisthemurmurbestheard?
FREQUENCY(pitch).
Thisvariesfromlowpitched,causedbyslowvelocityofbloodflow,tohigh
pitched,causedbyarapidvelocityofbloodflow.
INTENSITY.theloudnessofamurmurisdescribedonascaleof1to6:
Grade Intensity/Sounds

veryfaint,easilymissed

quiet,barelyaudible

moderatelyloudbuteasilyheard.SameintensityasS1orS2.

loudbutusuallynothrillpresent

veryloudthrillpresent

heardwithstethoscopeoffofchest.Thrillpresent.

RADIATION.somemurmursradiateinthedirectionofthebloodstreamby
whichtheyareproduced.Listenoverneck,back,shoulders,andleftaxilla.
QUALITY.
aorticmurmursareheardbestinfullexpirationwithpatientleaningforward.
mitralmurmursareheardbestafterexerciseinleftsidelyingposition.
AssessmentofExtraHeartSounds
musical
ejectionclick
openingsnap
midsystolicclick

blowing

harsh

rumbling