Cardiac Examination for Internal Medicine

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Introduction:

Cardiovascular examination follows the same sequence as any other systemic examination: inspection (seeing), palpation (feeling), and auscultation (listening) (NOTE: there is no percussion (tapping)). All examination steps are important and should be followed in this sequence. For example, inspection is very important when evaluating a herpetic rash. The classic dermatomal pain comes in before the rash in VZV, so the presenting symptom would be "chest pain" in a patient with VZV flare on the chest, but this pain has nothing to do with the chest. Palpation (ie., touching) confirms initial findings. The best idea is to ask the patient to "point to your chest pain with one finger." If the patient places one finger on the precordium, it is not cardiac pain 99% of the time. Cardiac pain is diffuse and not focused or localized. Furthermore, (and especially in young females) place your hand on the costochondral junction and gently press it. If pain is produced, it is costochondritis also known as Tietze's Syndrome. A patient with Tietze's Syndrome does not need a cardiac stress test but motrin. This is the reason why proper systemic examination is important.

Flow or innocent murmurs:

Not all murmurs are produced by valvular abnormalities. There are certain extra-cardiac murmurs can also be produced by skeletal or pulmonary abnormalities, and these are called flow or innocent murmur. The patient may have kyphosis or scoliosis and this causes blood flow to become turbulent as it flows through a normal valve. Thus, ECHO and the ECG are perfectly normal but there is a murmur is present.

Another concept to take note of is called the venous hum, which is basically heard in children when blood flow, due to an obstruction in the superficial fascia layers, causes turbulence in the big neck veins of a child. Applying pressure on the neck area and listening with a stethoscope will cause completely block the flow making the hum temporarily disappear. Additionally, if you change the head position of the child in such a way that there is no obstruction in blood flow, the venous hum will completely disappears. If it was a murmur, it would remain constant all the time.

Apex beat:

This is the point of maximal impulse. The apex beat is located in the left intercoastal space just medial to the midclavicular line, and always feel for the apex beat with the tip of your finger because it is a very localized area and you don't need your entire palm. Note if the apex beat is shifted anywhere. If the apex beat is shifted outward, you're talking left ventricular hypertrophy. If it's shifted inward, you're talking some type of skeletal abnormality like scoliosis or kyphosis. You also need to note the character of the apex beat. For example, if the apex beat is forceful and sustained, you're talking aortic stenosis. Furthermore, if the apex beat is forceful but not sustained ie., hyperdynamic/hyperkinetic, you're talking aortic regurgitation or thyrotoxicosis, pregnancy, and fever. If the apex beat is described as tapping, you're talking mitral stenosis.

Parasternal heave:

Parasternal heave is felt at the base of your palm on the precordium of the patient. If parasternal heave is present, the base of your palm will be lifted up. Parasternal heave on the left side signifies left atrial enlargement or right ventricular hypertrophy.

Precordial thrill

A cardiac thrill is basically a palpable murmur. A thrill is best felt on the AV fistula of a patient on dialysis.

Cardiac auscultation:

There are four areas where you listen to with your stethoscope. The first area you listen to is the mitral area; the second area to listen to is the tricuspid area; the third area to listen to is the aortic area; the fourth area to listen to is the pulmonary area. There are four heart sounds that you listen to - S1 (M1P1), S2 (A2P2), S3 (normal in pregnant women and athletes; indicative of left ventricular failure), and S4 (mostly abnormal and indicative of end stage left ventricular heart failure).

Summation gallop

All heart sounds - S1, S2, S3, and S4 are present in a patient and is not very uncommon.

Heart sounds and murmurs:

Intensity of heart sounds refers to the loudness of heart sounds. Heart sounds may be distant or softly heard and this may be caused in a patient with a barrel-shaped chest, or a patient with pericardial effusion, or a patient with morbid obesity. Furthermore, heart sounds can be loud. For example, S1 is loud in mitral stenosis and S2 is loud in pulmonary or systemic hypertension. A variable intensity of the S1 is indicative of complete heart block. There are three different types of murmurs that we try to define: systolic, diastolic, and continuous. Systolic murmurs can be two types: ejection systolic (aortic stenosis) and pansystolic (mitral regurgitation). There are two diastolic murmurs: early diastolic murmur (valvular lesions and Austin Flint murmur due to aortic regurgitation) and mid-diastolic murmur (mitral stenosis). The third type of murmur is called continuous murmur because it continues in the systole and spills into the diastole (pulmonary embolism, PDA). You'll hear wide and fixed splitting of S2 in ASD specifically in the pulmonary area because there is no variation in expiration and inspiration. Paradoxical splitting means that the pulmonary valve closes before aortic valve because it is taking a long time for blood to flow through the aortic valve (P2A2). Another cause of paradoxical splitting is left bundle branch block. Note that splenomegaly and clubbing is seen in infective endocarditis, and clubbing and cyanosis is seen in congenital heart disease.

Pericardial friction rub and knock:

This is heard in pericarditis due to inflammation of the pericardium. How do you clinically differentiate between pleural rub and pericardial rub? First, pain might increase on deep inspiration in pleuritis. Second, with the patient holding his breath, the pleural rub goes away or changes in intensity, and pericardial rub doesn't. However, if the pleural rub goes away by the next day, it could be a decrease in inflammation or it could be an effusion (fluid accumulation between layers makes the rub goes away). The pericardial knock is an early diastolic heart sound produced by lost pericardial elasticity due to fibrosis which limits ventricular volume.

Aortic vs mitral stenosis:

Ejection systolic click always means aortic stenosis. Opening snap always means mitral stenosis. Note that mitral stenosis can also be caused by a tumor which lies very close to the mitral valve and blocks it. How do you differentiate between a mitral stenotic mid-diastolic murmur and a left atrial tumor or mass?

Patient positions and murmurs

The best position to hear an apical murmur is to turn the patient on the left side because the heart comes closer to the stethoscope. The best position to hear an aortic murmur is with the patient sitting up and bending forward.

Aortic stenosis

Chest pain, syncope, and shortness of breath are associated with aortic stenosis. Each of these symptoms has a prognosis attached to it and syncope carries the worst prognosis.

Syncope vs seizure:

How do you differentiate, on history taking, whether a patient had syncope or a seizure? Patients with seizures are more likely to have bowel and bladder incontinence, spasmodic muscles, and history of trauma.

Family history and chest pain:

What is a positive family history in a patient who presents with MI? You should know there are differences between males and females.

Additional Reading:

Random USMLE Facts

1. Random USMLE Facts volume 1-1
2. Random USMLE Facts volume 2-1
3. Random USMLE Facts volume 3-1
4. Random USMLE Facts volume 4-1
5. Random USMLE Facts volume 5-1
6. Random USMLE Facts volume 6-1
7. Random USMLE Facts volume 7-1
8. Random USMLE Facts volume 8-1
9. Random USMLE Facts volume 9-1
10. Random USMLE Facts volume 10-1
11. Random USMLE Facts volume 11-1
12. Random USMLE Facts volume 12-1

General and Systemic Examinations

1. General Examination for Internal Medicine
2. Jugular Venous Distention Workup
3. ER Chest Pain Workup
4. Format for Patient Presentation
5. Pulmonary Examination for Internal Medicine
6. Cardiac Examination for Internal Medicine
7. Abdominal Examination for Internal Medicine
8. Cranial Nerve Reflexes
9. Motor System Examination
10. Random Sensory System Facts
11. Random Stroke Facts

Medical Files & Presentations

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USMLE Step 2 CS Videos

1. Video of Cardiology Examination in a Clinical Setting
2. Video of Neurology Examination in a Clinical Setting
3. Video of Pulmonology Examination in a Clinical Setting
4. Video of Musculoskeletal Examination in a Clinical Setting
5. Video of Abdominal Examination in a Clinical Setting
6. Video of HEENT Examination in a Clinical Setting
7. Video and Description of Rinne Hearing Test
8. Video and Description of Weber Hearing Test

USMLE Laboratory (lab) Values

1. USMLE Blood Lab Values
2. USMLE Cerebrospinal Lab Values
3. USMLE Hematologic Lab Values
4. USMLE Sweat and Urine Lab Values

Medical Images

Useful Medical Images & Diagrams (link opens in a new window)

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