Methods of examination of a heart • Inquiry • Inspection • Palpation • Percussion • Auscultation • Laboratory and instrumental studies
Patient’s complaints typical for heart diseases • Dyspnea • Pain in the heart area • Oedema • Cough • Palpitation • Heart intermissions
Dyspnea • the subjective feeling of air hunger or shortness of breath or digressing feeling of air deficit. • At the initial stages of heart failure, dyspnoea develops only during exercise, such as ascending the- stairs or a hill, or during fast walk. Further, it arises at mildly increased physical activity. During talkind, after meals or during normal walk. .In advanced heart failure, dyspnoea is observed even at rest.
Cardiac asthma • Exaggerated dyspnea. • Patient complaints on acute air hunger. • Other findings - rising of gurgling rales during breathing, expectoration of foamy sputum with impurity of blood. • An attack of cardiac asthma usually arises suddenly, at rest, or soon after a physical or emotional stress, sometimes during night sleep.
Pain • It is necessary to find out its exact localization, reasons and conditions of its occurrence (physical or emotional overload, its occurrence at rest, during motion or in dream), character (acute, dull pain, feeling of weight or compression behind sternum, slight dull pain in the top of the heart), duration, irradiation.
Pain often develops due to acute insufficiency of the coronary circulation, which results in myocardial ischaemia. This pain syndrome is called stenocardia or angina pectoris. • In angina pectoris pain is retrosternal or slightly to the left of the sternum; it most commonly radiates to the region under the left scapula, the neck, and the left arm. The pain is usually associated with exercise, emotional stress, and is abated by nitroglycerin.
Cough • is due to congestion in the lesser circulation. The caugh is usually dry; sometimes a small amount of sputum is coughed up. Dry cough is also observed in aortal aneurism because of the stimulation of the vagus nerve. • Haemoptysis in grave heart diseases is mostly due to congestion in the lesser circulation and rupture of fine bronchial vessels (e.g. during coughing)/ Haemoptysis mostly occurs in patients with mitral heart disease. It may occur in embolism of the pulmonary artery.
Oedema • Sign of venous congestion in the greater circulation occurs in severe heart diseases • first develops only in the evening and resolves during the nigit sleep. Oedema occurs mostly in the malleolus region and on the dorsal side of the foot; shins are then affected. In graver cases when fluid is accumulated at the abdominal cavity (ascites) he patient would complain of heaviness in the abdomen and its enlargement.
palpitationis felt like accelerated and intensified heart contractions • Palpitation is a sign of affection of the heart muscle in cardiac diseases such as myocarditis, myocardial infarction, congenital heart diseases, etc. it may arise as a reflex in diseases of some other organs, in fever, anaemia, neurosis, hyperthyroidism, and after administration of some medicinal preparations (atropin sulphate, etc.).
Intermissions • (escaped beats) which are due to disorders in the cardiac rrhythm. Intermissions are described by the patients as a feeling of sinking, stoppage of the heart.
Temperature • Cool hands occur most commonly as a result of exposure to a cold environment. However, this can also reflect vascular insufficiency, vasospasm, or hypovolemia.
General complaints. • weakness, rapid fatigue, decreased work capacity, increased excitability, deranged sleep. • headache, nausea, noise in the ears or the head are not infrequent n essential hypertension patients. • Some heart disease's (myocarditis, endocarditis, etc.) are attended by fevered (usually Subfebrile) temperature; sometimes high fever may occur.
Anamnesis • - Poor weight gain, poor feeding habits, and fatigue during feeding • - Frequent respiratory infections and difficulties • - Cyanosis with or without clubbing of fingers • - Evidence of exercise intolerance in addition, • - a history of previous defects in a sibling, • - -In rheumatic fever a history of a previous streptococcal infection is of primary importance.
Data of general inspection • forced posture • preference for sitting up in the left-sided heart failure(orthopnea) – cardiac asthma • Stiffness at one position – angina pectoris • Declining forward in sitting poistion – accumulation of fluid in pericardial cavity
facial expressions • Corvisar’s face – opened mouth, sticky eyes, general appearance of suffer and tideness (heart failure) • Mitral face – red-violet flash on the cheeks (mitral stenosis)
Skin colour • Acrocyanosis – in heart failure • Reddness – hypertonic crisis, fever • Pallor – hypertonic crisis • Coffee with milk – septic endocarditis
Inspection of heart region (precordium) • Cardiac hump-back • Pulsations: • Apex beat • Heart beat • Pulsation in projection of aorta or pulmonary trunk • Pulsation in jugular fossa
Apical and heart beat, their peculiarities • Location • Square • Height • Force • Resistance
Percussion • Borders of relative cardiac dullness (right, left, upper) • Borders of relative cardiac dullness (right, left, upper)
Auscultation was inculcated by French physitian Rene Laennec Рис. 10. Стетоскопи тверд!.
The heart is usually auscultated by a stethoscope or a phonendoscope, but direct (immediate) auscultation isalso used. The condition of the patient permitting, the heart sounds should be heard in various postures of the patient: erect, recumbent, after exersice (e.g. after repeated squatting). Sounds associated with the mitral valve’s pathology are well heard when the patient lies on his left side, since the heart apex is at its nearest position to the chest wall; aortic valve defects are best heard when the patient is in the upright posture or when he lies on his right side. The heart sounds are better heard if the patient is asked to inhale deeply and then exhale deeply and keep breath for short periods of time so that the respiratory sounds should not interfere with auscultation of the heart. The valve sounds should be heard in the order of decreasing frequency of their affection.
Sounds heard by stetoscope is called heart sounds. They are created due to vibrations of heart structures during their functioning
Examination sequence • -> Explain that you wish to examine the chest and ask the patient to remove his clothing above the waist. • ■> With the patient lying at approximately 45° to the • horizontal, listen over the precordium at the base of the heart, apex, and upper left and right sternal edges with both bell and diaphragm. Also listen over the carotid arteries and the axilla. • ■> At each site identify the first and second heart sounds and assess their character and intensity; note any splitting of the second heart sound. • ■> Concentrate in turn on systole (the interval between S, and S2) and diastole (the interval between the S2 and S,). Listen for added sounds and then for murmurs. • •♦ Roll the patient on to the left side. Listen at the apex using light pressure with the bell, to detect the mid-diastolic and presystolic murmur of mitral stenosis.
Formation of heart soundsa—atrial component (heard sometimes as an independent fourth sound); b—valvular component of the first sound; c—muscular component of the first sound; d—vascular component of the first sound; e—formation of the second sound; /—formation of the third sound
Auscultation involves listening for heart sounds with the stethoscope, similar to the procedure used in assessing breath sounds • The sounds produced by a working heart are called heart sounds. Two sounds can be well heard in a healthy subject; the first sound, which is produced during systole and the second sound, which occurs during diastole.
Сomponents of heart sounds • I heart sound: • the valve component, i.e. vibrations of the cusps of the atrioventricular valves during the isometric contraction phase • the muscular one due to the myocardial isometric contraction • the vascular one. This is due to vibrations of the nearest portions of the aorta and the pulmonary trunk caused by their distention with the blood during the ejection phase • Atrial one is generated by vibrations caused by atrial contractions • II heart sound: • The second sound is generated by vibrations arising at the early diastole when the semilunar cusps of the aortic valve and the pulmonary trunk are shut (the valve component) and by vibration of the walls at the point of origination of these vessels (the vascular component). • The intensity of myocardial and valvular vibrations depends on the rate of ventricular contractions: the higher the rate of their contractions and the faster the intraventricular pressure grows, the greater is the intensity of these vibrations.
Sequence of auscultation • The mitral valve - at the heart apex; • the aortic valve - in the second intercostal space to the right of the sternum), • the pulmonary valve - in the second intercostal space, to the left of the sternum, • tricuspid valve - at the base of the xyphoid process, • the aortic valve again at the Botkin-Erb point.