Cardiac Assessment

Patients History:

Important points to note are the following;

1. Medical problems,

2. Past medical history,

3. Physician's Examination,

4. History of medications including doses,

5. Laboratory tests,

1. Blood tests for the specific cardiac enzymes, such as CK-MB or troponin level (indicate Myocardial infarction).

2. Electrolytes such as potassium, magnesium, calcium levels (decreases in ventricular arrhythmias).

3. Complete blood count (CBC), which indicates the presence of anemia by the level of hemoglobin and hematocrit values.

4. blood urea nitrogen (BUN) test,

5. Liver function test,

6. complete cholesterol test also called a lipid panel or lipid profile: is a blood test that can measure the number of Lipids includes cholesterol, triglycerides, high-density lipoprotein (HDL), and low-density lipoprotein (LDL),

7. Atrial blood gases (ABGs) test.

6. Diagnostic Tests:

1. Chest x-ray,

2. ECGs,

3. Exercise Tolerance (ETT) Tests,

4. Cardiac catheterization,

5. Other tests.

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Physical Examination

Heart Rate and Rhythm:

• When we take the initial heart rate, either by palpation or auscultation, it is important to count it for a full minute three times.

• Always note the rhythm is regular or irregular.

•  it is impossible to identify a specific rhythm by palpation or auscultation alone.

• There is a normal respiratory variation in heart rate; inspiration results in an increase in heart rate and expiration result in a slowing down the heart rate.

• Heart rate can be identified by ECG.

Respiratory Rate and Rhythm:

• both rate and rhythm of respiration should be noted. 

• Breathing pattern and use of accessory muscles are also noted.

Dyspnea:

• Patients with left ventricular dysfunction from coronary artery disease, congestive heart failure, cardiomyopathies, valvular dysfunction, hypertensive heart disease, pericarditis with cardiac tamponade, and arrhythmias may all present with Dyspnoea.

• When Dyspnoea begins with activity e then is called Dyspnea on exertion DOE and progress to occurring at rest.

• Dyspnoea scale (Box 1).

Box 1: Dyspnoea Scale

0 = No dyspnoea 1 = Mild, noticeable 2 = Mild, some difficulty 3 = Moderate difficulty 4 = Severe difficulty

Blood pressure:

• Atrial blood pressure is a product of cardiac output and total peripheral resistance an increase in either of these factors will increase blood pressure and a decrease in others may decrease blood pressure.

Angina:

• Angina presents as pain or heaviness in the shoulder, jaw, elbow, or upper back between the scapula.

• Angina may radiate from the chest to the left arm, or right arm, or both arm, neck, Jow, epigastrium.

• The patient is asked to rank his or her discomfort on agina scale.

Box-2: Angina Scale

0 = No angina 1 = Light, noticeable 2 = Moderate, bothersome 3 = Severe, very uncomfortable; preinfarction pain 4 = Most pain; Infarction pain

Observation and palpation

1. Cyanosis: a bluish color of skin, nail beds, lips, and tongue may be present when atrial oxygen saturation is 85% or less than 85%.

2. Pallor: the absence of pink, Rosy color may indicate a decrease in cardiac output.

3. Edema: bilateral peripheral edema is a result of congestive heart failure. Edema of one leg is usually associated with local factors within the same leg such as a varicose vein, lymphedema, or thrombophlebitis.

4. Corneal arcus: it is the lipid deposits that appear as a ring on the outer region of the cornea. they are usually white or grey.

5. Xanthelasma: yellowish deposit of cholesterol underneath the skin. it usually occurs on or around the eyelids.

6. Dentition: Infective endocarditis (IE) often is caused by bacteria that colonize teeth.

7. Apex beat: 

1. The location of Apex and the point of maximum impulse is noted.

2. The point of maximum impulse is usually present at the 5th intercostal space along the midclavicular line.

3. Apex beat is not seen in the obese, muscular person and in a lady with the pendular breast.

4. If the left ventricle has increased in size as frequently occurs with the patients in left ventricular failure the apex beat or point of maximum impulse will be displaced laterally to the axilla.

Examination of Radial Pulse

• The normal rate is 60-100 beats per minute.

• Irregularly irregular seen in atrial fibrillation.

• Regularly irregular seen in second-degree heart block.

• Radio-radial delay and Radio-femoral delay seen in the Coarctation of the aorta.

• Collapsing pulse is seen in aortic regurgitation and patent ductus arteriosus.

  

  Fig. 1: Radial pulse and carotid pulse
  

  
  

Examination of the Brachial Artery

• >15/20mmHg difference in blood pressure during standing and sitting is a sign of postural hypotension.

• >10mmHg difference in blood pressure in Right and Left arm is a sign of aortic dissection or Coarctation of the aorta.

Examination of the Carotid Artery

• Corrigan's sign is seen in patients with aortic regurgitation.

• Bruits are an abnormal sound generated by the turbulent flow of blood.

• Auscultate for bruits in the following region:

• Angle of Jaw

• Mid cervical

• Base of Neck

• Bruits are seen in patients with atherosclerosis, aortic stenosis.

Examination of Jugular Venous Pressure

• Patients with congestive heart failure with a backup of fluid into the venous musculature should be examined for the presence of jugular venous distention.

• To examine this sign the patient is placed at a 45-degree semirecumbent position (Fig. 2).

  

  Fig. 2: Position of patient

  
  

• The patient's head turns away from the side to be evaluated and the clinician observed for destination or pulsation of the jugular vein 3 to 5 cm above the sternum.

• The highest point of visible pulsation is determined and the vertical distance between this level and the level of the sternal angle of Louis is recorded.

• If difficulty in finding JVP, then apply abdominal pressure for 10-14 secs (Hepatojugular reflux) to amplify its presence.

• Elevated JVP has seen in:

• Right Heart failure

• Pericardial effusion

• Superior Vena cava obstruction

• Altered wave pulsation is seen in:

• Atrial fibrillation

• Tricuspid stenosis

• Tricuspid regurgitation

• Complete Heart Block.

Cardiac Percussion: Normal cardiac Percussion shows Dullness to percussion from sternum to 6 cm lateral to the left of the sternum.

Heart Auscultation

• Status of the heart is obtained from auscultation of the heart and lungs.

• Normal heart sound is identified as (Fig. 3):

• S1 (lub); which occurs at the time of closure of mitral and tricuspid valve and marks the beginning of systole and 

• S2 (dub); which occurs at the time of aortic and pulmonary valve closer and marks the end of systole.

  

  Fig. 3: Heart auscultation

  
  

• The aortic valve is best auscultated at the second intercostal space, right sternal border 

• the pulmonary valve is heard or auscultated at the second intercostal space, left sternal border 

• the tricuspid valve is auscultated at the 4th intercostal space, left sternal border and 

• the mitral valve is auscultated at the 5th intercostal space along the midclavicular line.

• Murmurs: 

• are abnormal heart sound results of valvular disorder due to changes in blood flow around and through the altered valve.

• a systolic murmur will present as audible turbulence between S1 and S2 and a diastolic murmur will present as turbulence between S2 and S1.

• Other abnormal sounds are S3 and S4. 

• S3 also known as ventricular gallop occur after as S2 and is associated with left ventricular failure.

• S4 is known as atrial gallop occurs before S1 and associated with myocardial infarction or chronic hypertension.

Lung Auscultation

• Normal lung tissue produces a vesicular sound which is a soft, & low-pitched sound in the peripheral aspect of the lung. 

• The bronchial breath sound which is a loud, & high pitched sound, centrally along the manubrium of the sternum.

• Vesicular sound is longer and louder with inspiration whereas the bronchial breath sounds are longer and harder with expiration 

• Patients with left ventricular failure have the adventitious sound of crackles. But crackles may also appear as the result of atelectasis.

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Related Topics:

• Cardiac Rehabilitation
• Physical therapy in CAD