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1. Project: Ghana Emergency Medicine Collaborative
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Document Title: Cardiac Evaluation
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Author(s): Joe Lex, MD (Temple University School of Medicine)
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2

3. Cardiac Evaluation
Joe Lex, MD, FACEP, FAAEM
Department of Emergency Medicine
Temple University School of Medicine
Philadelphia, PA 19140
3

4. Assessment of Cardiac Patient
• Chief complaint
• History of event and significant past
medical history
• Physical exam
4

5. Chief Complaint
• Cardiac disease chief complaints
➢Chest pain or discomfort
• Shoulder, arm, neck, or jaw pain or
discomfort
➢Dyspnea
➢Syncope
➢Abnormal heart beat or palpitations
➢May vary
C C
5

6. Chest Pain or Discomfort
• Common chief complaint in
myocardial infarction
• Noncardiac causes of chest pain
➢Pulmonary embolus
➢Pleurisy
➢Reflux esophagitis
• History of chest pain is important
➢OPQRST method
C C
6

7. Chest Pain or Discomfort
• Onset of the event
• Provocation or Palliation
• Quality of the pain
• Region and Radiation
• Severity
• Time (history)
C C
7

8. Chest Pain or Discomfort
C C
JHeuser (Wikipedia) 8

9. The Angina Monologue
C C
Chest tight…
Short of breath…
Sweaty…
9

10. Dyspnea
SOB
Who are
you calling
an SOB?!?!
10

11. Dyspnea
• May occur with ACS
• Symptom of heart failure
• Dyspnea unrelated to heart disease
➢Chronic obstructive pulmonary
disease
➢Respiratory infection
➢Pulmonary embolus
➢Asthma
SOB
11

12. Dyspnea
• Duration
• Circumstances of onset
• What aggravates or relieves,
including medications
• Previous episodes
• Associated symptoms
• Orthopnea
• Prior cardiac problems
SOB
12

13. Syncope
SYNCOPE
13

14. Syncope
• Sudden decrease in cerebral
perfusion
• Cardiac causes decrease cardiac
output
➢Dysrhythmias
SYNCOPE
14

15. Syncope
• Noncardiac causes of syncope
➢Stroke (note – I disagree)
➢Drug or alcohol intoxication
➢Aortic stenosis
➢Pulmonary embolism
➢Hypoglycemia (depends on how you
define syncope)
SYNCOPE
15

16. Syncope—History
• Aura: nausea, weak, lighthead
• Circumstances: position before
event, pain, stress
• Duration of syncopal episode
• Symptoms before syncope
• Other symptoms
• Previous episodes
SYNCOPE
16

17. Palpitations
• Sometimes normal
!
• May indicate serious dysrhythmia
PALPITATIONS
17
PublicDomainPictures (Pixabay)

18. Palpitations
• History and physical exam
➢Pulse rate (if obtained)
➢Regular versus irregular rhythm
➢Circumstances
➢Duration
➢Chest pain, diaphoresis, syncope,
confusion, dyspnea
➢Previous episodes
➢Medications
PALPITATIONS
18

19. Significant Past Medical History
• Is the patient taking prescription
meds, particularly cardiac meds?
➢Digoxin
➢Furosemide or other diuretic
➢Nitroglycerin
➢Beta blockers
• Is the patient being treated for any
other illness?
PMH
19

20. Significant Past Medical History
• ACS or angina
• CABG or PCI
• Implanted pacemaker or ICD
• Heart failure
• Hypertension
• Diabetes
• Chronic lung disease
PMH
20

21. Significant Past Medical History
• Allergies
• Other risk factors for cardiac event
PMH
21
bachmont (Wikimedia Commons)
Christian Razukas (Wikimedia Commons)
Kilom691 (Wikimedia Commons)

22. Physical Examination
22

23. Physical Examination
• Classic presentation of myocardial
infarction: pain or discomfort behind
sternum for more than 15 minutes
P E
geralt (Pixabay) 23

24. Physical Examination
• Other signs and symptoms
➢Apprehension
➢Diaphoresis
➢Dyspnea
➢Nausea and vomiting
➢Sense of impending doom
• Atypical presentations
P E
24

25. Nausea & Vomiting
25
tt2times (Flickr)

26. Sense of Impending Doom
26
dcosand (Flickr)

27. Initial Assessment
• Level of consciousness
• Respirations
• Pulse (rate, regularity)
• Blood pressure
• Skin
P E
27

28. Physical Examination
Look
Listen
Feel
P E
28

29. Look
• Skin color, capillary refill, skin
moisture
➢Oxygenation: pulse oximetry
➢Cardiac function: peripheral perfusion
• Jugular vein distention (JVD)
➢Evaluate with head elevated to 45o
➢Difficult to assess in obese patients
LOOK
29

30. Skin
LOOK
30
Dogbertio 14 (Wikipedia)

31. Skin
LOOK
31
Source Undetermined

32. Skin
LOOK
32
Source Undetermined

33. Jugular Vein Distention
LOOK
33
Source Undetermined

34. Jugular Vein Distention
LOOK
34
Source Undetermined

35. Look
• Peripheral and presacral edema
➢Back-pressure in venous circulation
➢Obvious in dependent areas
➢Nonpitting: minimal depression of
tissue after removal of finger pressure
➢Pitting: depression of tissue remains
after removal of finger pressure
LOOK
35

36. Look
LOOK
36
Source Undetermined

37. Look
• Indicators of cardiac disease
➢Nitroglycerin patch
➢Midsternal scar from CABG
➢Implanted pacemaker or automatic
implantable cardioverter-defibrillator
(left upper chest; abdominal wall)
➢Medic alert information
LOOK
37

38. Look
LOOK
38
RegBarc (Wikipedia)

39. Look
LOOK
Robert the Noid (Flickr)
Source Undetermined 39

40. Listen
• Lung sounds
➢Equality
➢Adventitious sounds: may indicate
pulmonary congestion or edema
• Heart sounds
➢Gallops
LISTEN
40

41. Heart Sounds
• Auscultate for:
➢Frequency (pitch)
➢Intensity (loudness)
➢Duration
➢Timing in the cardiac cycle
LISTEN
41

42. Auscultating Heart Sounds
LISTEN
42
Pearson Scott Foresman (Wikimedia Commons)

43. Auscultating Heart Sounds
LISTEN
43
Gene Hobbs (Wikipedia)

44. Auscultating Heart Sounds
LISTEN
44
University of Cape Town (oerafrica)

45. Point of Maximal Impulse (PMI)
• Apical impulse
➢Visible and palpable
➢Produced by contraction of left
ventricle
• Pulse deficits noted by palpating or
auscultating apical impulse and
carotid pulse simultaneously
FEEL
45

46. S1
• “Lub” sound
➢Mitral and tricuspid valve closure
➢Beginning of ventricular systole
• Diaphragm of stethoscope at apex
of heart
➢5th intercostal space
S 1
46

47. S2
• “Dub” sound
➢Aortic and pulmonic valve closure
➢End of ventricular systole
• Use diaphragm of stethoscope at
2nd intercostal space to right and
left of the sternum
➢Aortic and pulmonic areas
S 2
47

48. S3
• Extra heart sound
➢Rapid ventricular filling
• Common in children, athletes, and
young adults
• Abnormal in persons >30 y/o
• Use bell of stethoscope at apex
S 3
48

49. S3
• Sounds like “Ken-Tuck-Y”
➢Emphasis on “Tuck”
➢“Ken” = S1, “Tuck” = S2, “Y” = S3
• Warning sign of congestive heart
failure
S 3
49

50. S4
• Last of ventricular filling
• Tensing of atrioventricular valves
• Atrial contraction
• Just before S1
• Heard at apex with stethoscope bell
• Sounds like “Ten-nes-see”
➢Emphasis on “Ten”
➢“Ten” = S4, “Nes” = S1, “See” = S2
S 4
50

51. Heart Sounds
• Aortic: 2nd ICS right of sternum
• Pulmonic: 2nd ICS left of sternum
• Tricuspid: 5th ICS left of sternal
border
• Mitral: 5th ICS medial to left
midclavicular line ➔ over left
ventricle
VALVES
52

52. Murmurs
• Murmurs classified by seven
different characteristics: timing,
shape, location, radiation, intensity,
pitch and quality
• TIMING: systolic or diastolic
• SHAPE: crescendo, decrescendo,
or crescendo-decrescendo
VALVES
53

53. VALVES
54
Madhero88 (Wikipedia)

54. Murmurs
• LOCATION: 6 places on anterior
chest to listen for heart murmurs
➢Five of six adjacent to sternum;
each roughly corresponds to
specific part of the heart
➢Four places usually more than
adequate
VALVES
55

55. VALVES
56
University of Cape Town (oerafrica)

56. Murmurs
• RADIATION: to where does the
sound of the murmur radiate?
➢Rule of thumb: sound radiates in
direction of blood flow
• INTENSITY: loudness of murmur,
➢Graded on scale from 0 – 6 / 6
VALVES
57

57. Grade Description
1 Very faint
2 Soft
3 Heard all over precordium
4 Loud, with palpable thrill
5 Very loud, with thrill. Heard when
stethoscope partly off chest.
6 Very loud, with thrill. Heard when
stethoscope completely off chest.
58

58. Murmurs
• PITCH: low, medium or high
➢Determined by whether it can be
auscultated best with bell or
diaphragm of stethoscope
• QUALITY: blowing, harsh, honking,
rumbling, musical
VALVES
59

59. Murmurs
Three important murmurs in EM
1. Mitral regurgitation ➔ may
indicate blown papillary muscle in
acute MI
2. Aortic stenosis in syncope ➔
may determine cause
3. Aortic insufficiency in syncope,
chest pain ➔ aortic dissection
VALVES
60

60. M R
61
University of Cape Town (oerafrica)

61. Mitral Regurgitation
M R
Wapcaplet (Wikipedia) 62

62. A I
63
University of Cape Town (oerafrica)

63. Aortic Insufficiency
A I
64
BruceBlaus (Wikipedia)

64. Aortic Stenosis
A S
BruceBlaus (Wikipedia) 65

65. Feel
• Peripheral or presacral edema
• Pulse
➢Rate
➢Regularity
➢Equality
➢Pulse deficit
➢Pulsus paradoxus
➢Pulsus alternans
FEEL
66

66. Feel
• Skin
➢Diaphoretic, pale skin
• Peripheral vasoconstriction
• Sympathetic stimulation
➢Cyanosis
• Poor oxygenation
➢Fever
• Infection
FEEL
67

67. Skin
FEEL
68
Source Undetermined

68. Putting It All Together
EXAM
69
Source Undetermined

69. Conclusions
• Chief complaint
• Brief history
• Physical exam: look, listen, feel
• Think binary: murmur, yes or no;
abnormal breath sounds, yes or no
70