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CLINICAL EXAMINATION
OF CARDIAC PATIENTS
BASIC CLINICAL SKILLS
PARALLEL PROGRAM
Dyspnea Edema
Chest pain Cough
Cyanosis Hemoptysis
Syncope Fatigue
Palpitation Intermittent Claudication
1) DYSPNEA:
“Unpleasant Awareness of Breathing”.
CAUSES:
1) Pulmonary
• COPD • Restrictive L. Disease
• Br. Asthma
• Cardiac – CHF (MS, MR, AS, MI. CM)
1) Anemia
2) Obesity
FUNCTIONAL CLASSES OF
DYSPNEA: (NYHA Classification)
Site
Quality of pain
Duration (few minutes)
Radiation
Provoking factor (Exercise, Emotional
excitement and Cold weather.)
Relieving factors (rest & TNG)
Associated symptoms
Risk Factors
UNSTABLE ANGINA
New onset frequent angina
Crescendo or accelerated angina
Duration → 10min -30min
Relation to rest
Response to TNG
ACUTE MYOCARDIAL INFARCTON PAIN:
Site
Quality
Duration → > 30min.
Associated Symptoms
Response to S. L. TNG
III. CYANOSIS:
“Bluish Discoloration of the Skin and
Mucous Membranes.”
Peripheral.
Central.
IV. DIZZINESS, PRESYNCOPE
AND SYNCOPE.
Definition:
Causes:
1) Drugs: V. Dilator Drugs
2) Vasovagal syncope
3) Cardiac Arrhythmia
4) Cardiac Lesions (AS, MS, PS)
V. PALPITATION:
“Unpleasant Awareness of Forceful or
Rapid Heart Beating.”
Mild:
P. Congestion (CHF) Ruptured P.
Capillaries.
It occurs in the course of P. Infarction
IX. FATIGUE:
It is usually due to low C.O.
X. INTERMITTENT CLAUDICATION:
Peripheral Vascular Disease
(PVD)
B) CLINICAL EXAMINATION
1)General Look
– Skin complexion (color)
– Pain or respiratory distress
– Level of consciousness ( Orientation to place,
time & persons)
– Body edema
2. HAND EXAMINATION:
1. Pallor
2. Cyanosis
3. Stigmata of Infective Endocarditis:
- Clubbing - Janeway lesion
- Splinter Hem. - Osler’s Nodules)
4. Signs of Hyperlipidemia:
Tendon Xanthomatosis
5. Signs of Thyrotoxicosis:
Fine Tremors
3. RADIAL PULSE:
1. Rhythm
2. Rate
3. Volume
4. Character:
Normal
Collapsing Pulse
Slow rising pulse
5. Vessel Walls
6. Equality and Synchronization
AA
)B (
B
Normal C-pulsus
Besferious
D-Pulsus
Besferious
Collapsing
E-Collapsing
Collapsing
pulse
4. BLOOD PRESSURE MEASUREMENT:
1. The Cuff
2. Position of the patient
Technique
– There are 5 KOROTKOFF’s Sounds:
Syst BP Korotkoff 1
Diast BP Korotkoff 5
5. RESPIRATORY RATE AND TEMPERATURE.
6. FACE EXAMINATION:
Abnormal Facies:
Down’s Syndrome
Marfan’s Syndrome
Malar Rash
Pallor:
Conjunctivae
Mucous Membranes of the Mouth
6. FACE EXAMINATION (cont’d)
Jaundice
Sclera
Mucous Membranes of the Mouth
Arcus Cornialis
Xanthelasma
Cyanosis
Signs of Hyperthyroidism
Exophthalmos
Lid Lag
Lid Retraction
Mouth Hygiene
7. JUGULAR VENOUS PRESSURE (JVP)
Auscultation:
Systolic Bruit
9. THYROID GLAND:
Inspection
Palpation
Percussion
Auscultation
10. EXAMINATION OF
THE PRECORDIUM:
A) Inspection:
Shape of the chest
– Pectus excavatum
– Pectus Craniatum
– Kyphosis & Scoliosis
Precordial Bulge
Scar of previous cardiac surgery
– Mid-sternotomy scar
A) Inspection (cont’d)
Apex Beat:
Epigastric pulsation:
Causes:
RV enlargement
Pulsatile hepatomegaly RS HF
Palpable Abd. Aorta
C) PALPABLE HEART SOUNDS AND CLICKS
STETHOSCOPE:
a) Bell Low frequency sounds → S3, S4
→ Mid-diastolic murmur → MS & TS.
Ausculatory Areas:
F) Gallop Rhythm:
Occurs due to presence of S3,S4 or a
summation of S3 & S4 in tachycardic patients.
Accentuated S1:
MS
TS
ST
Soft S1 →Long PR interval
Variable S1→ A. Fibrillation
Muffled S1 MR
Accentuated A2 → Systemic
Hypertension.
Accentuated P2 → P. Hypertension.
Soft A2 → AR.
Ejection Clicks:
PS.
AS.
Opening Clicks:
Prosthetic mitral and aortic valve
opening.
Closing Clicks:
Prosthetic Mitral and Aortic Valve closure
CARDIAC MURMURS:
Systolic Murmurs
ESM (crescendo decrescendo murmur)
A) Functional Hyperdynamic circulation.
Anemia.
Pregnancy.
Thyrotoxicosis.
A-V shunts.
Innocent in childhood and adolescence.
B) Organic:
AS
PS
Back
– Fine bilateral basal crepitation
LV Failure
– Sacral edema.
Liver Pulsatile & tender hepatomegaly
Sometimes Ascitis & splenomegaly
Examination of Other Parts of the Body:
Lower limbs:
A) Cardiac Edema:
– Bilateral & Pitting.
– Grades:
1+ Around ankle Joint..
2+ Below knee joint.
3+ Above knee joint.
4+ Scrotal edema, hydrocele, and edema of the
ant. abdominal wall.
B) Peripheral Circulation:
– Inspection & Palpation:
Pale and cold.
Hair loss.
Loss of sensation.
Signs of Gangrene PAD Total arterial occlusion
- Weak or absent pulsations:
– Dorsalis pedis
– Tibialis posterior
– Medial popliteal
– Femoral artery
– Poor capillary filling
C) Varicose Veins:
– Inspection
Dilated tortous superfacial veins
– Long saphenous vein
– Short saphenous vein
Ulceration
Pigmentation
Eczema
D) Deep Venous Thrombosis (DVT):