Cardiac Exam

Agus Santosa
Exterior Anatomy of the Heart
Anatomy of the Heart
 Valves of the Heart
• Tricuspid – Directs the flow of blood from the
right atrium to the left ventricle.
• Mitral Valve – Directs the flow of blood from
the left atrium to the left ventricle.
• Pulmonic (semilunar) – Lies between the right
ventricle and the pulmonary artery.
• Aortic Valve (semilunar) – Lies between the
left ventricle and the aortic artery.
 Circulation in the Heart
1. Oxygen-poor blood (shown
in blue) flows from the body
into the right atrium.
2..Blood flows through the right
atrium into the right ventricle.
3. The right ventricle pumps
the blood to the lungs, where
the blood releases waste gases
and picks up oxygen.
4. The newly oxygen-rich
blood (shown in red) returns
to the heart and enters the
left atrium.

5. Blood flows through the

left atrium into the left
ventricle.

6. The left ventricle pumps

the oxygen-rich blood to all
parts of the body.
 The cardiac exam includes:
•Inspection of jugular venous pressure
•Inspection, palpation, and auscultation of the 4 cardiac areas with the
diaphragm
•Auscultation over the tricuspid and mitral areas with the bell
•Some symthoms
 Specific areas for examination
 Aortic area: 2nd ICS, RSB
 Pulmonic area: 2nd ICS, LSB
 Tricuspid area: 5th ICS, LSB
 Mitral or Apical area: 5th ICS, MCL
 Erb’s point: 3rd ICS, LSB
 Epigastric : over xyphoid process
Landmarks
Inspection Jugular Vein

Inspection of jugular venous pressure should be done with the patient

lying with their head tilted to the left side. The patient should be
elevated to the point where jugular venous distention is seen in the mid-
neck. In a patient with a markedly elevated jugular venous distention,
they may actually need to be sitting upright , or in a patient with a low-
normal jugular venous pressure this may need to be at 0 o to see the
distention in the mid-neck.

Remember that the rest of the cardiac exam should be done with the pt
at 30o
106-110: Inspection and
Palpation
Inspection and Palpation

Inspection done correctly; right

side, head tilted left, patient
elevated. (Note in a female patient
they may have the gown on like in
the picture during inspection)
•Inspection, palpation and
auscultation for rest of cardiac
examination performed at 30
degrees
•Inspection of all 4 areas
•Palpation of aortic area (right
second intercostal space just
lateral to sternum)
Palpation of pulmonic area

Left second intercostal space just lateral to sternum

Palpation of right ventricular and tricuspid area

Left lower sternal border

Palpation of apical area

•If apical impulse not

palpable, patient in left
lateral decubitus
•Palpation done with
fingerpads in all 4
areas
•Palpation of apical
area (about fifth
intercostal space mid-
clavicular line)
Palpation: Apical Area

•If apical impulse not palpable, patient in left

lateral decubitus
 Cardiac Auscultation

•Auscultation with Diaphragm Aortic area

•Auscultation with Diaphragm Pulmonic area
•Auscultation with Diaphragm Tricuspid area (left lower sternal border)
•Auscultation with Diaphragm Mitral area (apical area)
•Auscultation with Diaphragm Sitting, left lower sternal border, patient fully exhaled
 Cardiac Auscultation

•Auscultation with bell. Mitral area

•Auscultation with bell. Mitral area in the left
lateral decubitus position
•Done correctly - Bell applied light pressure, not
heavy (remember newer stethoscopes diaphragm
lightly OK)
•Auscultation with bell. Tricuspid area
Auscultate with the diaphragm at the left
lower sternal border with the patient sitting
and fully exhaled. This is the optimal
position to listen for aortic insufficiency.
(Note: this is a different patient!)
Common signs and symptoms of
CV disease
- Chest pain (most common CV symptom)
• Angina
– often described as “pressure” rather than pain
– Usually brought by physical/emotional stress
– Last: 2-5 minutes ; rarely > 20
– Relieved with rest / NTG
• ACS (acute coronary syndrome)
– Pain similar to angina ; may be more intense
– Often occurs at rest
– Usually last >30 minutes; usually > 2 hours
– Not relieved by rest/NTG; requires analgesic
• Pericarditis
– May mimic ACS; often described as sharp, stabbing,
shooting
– Aggravated by movement
– Tend to be constant
– Relieved by sitting up, leaning forward, shallow breathing
– Dyspnea
• Subjective sensation of being unable to breath
• Usually cause by congestion from LVF
• Types:
– Dyspnea on exertion (DOE)
– Orthopnea : inability to breathe while lying flat
– Paroxysmal nocturnal dyspnea (PND): nightime episodes
of SOB due to lying flat which increases venous return
(preload)
– Fatigue / Weakness
• Symptom of decreased forward CO
• Usually seen as unusual fatigue at end of normal day
previously tolerated
• Exertional fatigue : sense of weakness or heaviness
of extremities
• Medications that can cause fatigue:
– Diuretics : orthostatic hypotension , hypokalemia
– Beta Blockers, Calcium Channel Blockers, Digoxin,
antihypertensive medications
– Fluid retention
• Fluid accumulation in tissues
• Common cardiac causes
– Heart failure
– Constrictive pericarditis
– Restrictive cardiomyopathies
– Weight gain of 2 lbs in 4 days or 3-5 pounds over a month
may be indicative of heart failure
– More severe in evening
• Anasarca
– Generalized edema
– Seen in severe heart failure, hepatic cirrhosis, and nephrotic
syndrome
• Edema scale : evaluated by pressing thumb for 5 seconds
– 0 = absent
– +1 = slight indentation : disappears rapidly
– +2 = indentation readily noticeable : disappears
within 10-15 seconds
– +3 = deep indentation ; disappears within 1-2
minutes
– +4 = marked, deep indentation ; may be visible in >5min
• Syncope/Presyncope
– Temporary loss of consciousness,
lightheadedness, dizziness
– Cardiac cause most commonly result of
inadequate cardiac output from arrythmias
• Palpitations
– Awareness of heart beat with sudden changes in
rate, rhythm, increased stroke volume
– Associated with : tachycardias, bradycardias,
atrial fibrillation, PVCs, aortic and mitral
regurgitation, signs of heart failure
• Other symptoms
– GI
• Nausea, anorexia, vomiting from RVF, digoxin toxicity,
inferior MI
• Indigestion or flu like symptoms may be sole s/s of MI,
especially in elderly or diabetic patient
– Extremity pain
• Intermittent claudication indicative of PVD due to decreased
blood flow to muscles during time of increased demand
• Ischemia from PVD
• Other symptoms
– Decreased urine output
• Indicative of heart failure and hypovolemia
• Look for concomitant weight gain due to CHF
– Nocturia
• Sign of heart failure
• Caused by increased preload to heart