00:01
Having now obtained a
history, both the family
history, a past history, a… a symptom history,
we already have an idea about what the diagnosis
is. So now, we move to the physical examination
in an attempt to confirm what we had from
the history. The physical exam really contributes
about 10% to the diagnosis. Again, I’d like
to repeat, 90% of the diagnosis is already
in your mind based upon the history. So, what
kinds of things on the physical exam standout?
Well, here are two very severe examples. On
the left, you see a patient whose leg has
a lot of peripheral edema, a lot of swelling.
00:40
You can see that a finger has been pushed
into the soft tissue, leaving a mark that stays
for quite a while. That's proof that there is
swelling in the tissues with fluid and that
is the cause of the edema. On the right hand
side, we see an example of what is called
“clubbing of the fingernails”. These rounded
specific finger-like changes are seen, sometimes
as a result of just a genetic factor with
no heart disease. But very often, it’s seen
in patients who have long standing cyanotic
heart disease - that is where the blood in their
arterial system is much bluer, the oxygen
level is much lower than it should be. And
I’ll show you some more examples of that.
But longstanding cyanotic - longstanding blue
blood in the arterial system results in this
kind of change in the fingernails. Now, here
is a sign that this patient has a very high
serum cholesterol. You see the little cholesterol
deposits on the eyelid. That’s known as a
xanthelasma. It’s actually a collection
of cholesterol crystals and this tells you
immediately, even before you obtain the blood
test, that this patient has a very high level
of cholesterol in their blood.
01:56
The other thing we will see, as we start the
physical exam, we are going to look at the
chest build. Some patients have what is known
as pigeon chest, with a large bulging breastbone
or sternum. Others have the exact opposite, it's
known as “pectus excavatum”, an excavated
breastbone which lies bent down deeper into
the chest. These can compress the heart in
certain ways and cause chest pain symptoms
that can mimic a heart attack or even angina,
which is the pain that comes when you… the
heart is exerted, but doesn’t get enough
blood flow, but is short of heart attack.
These need to be looked at when you think
about-- Oh well, really, maybe the patient’s
chest pain isn’t being caused by narrowing
in the blood vessels in the heart. Sometimes,
these skeletal changes can be so severe that
they impair the function of the heart and
patients may report fatigue or even shortness
of breath.
02:53
Here we see an example of a patient with cyanosis.
Notice that the skin is quite blue, this often
happens because there are shunts - that is openings
inside the heart, and blue blood from the right
side of the circulation is getting over on
to the arterial side. Remember the clubbed
fingernails I showed you? That goes with longstanding
cyanosis. Usually, these individuals have
had congenital heart disease from childhood.
So, there are a number of other clues you
are going to be looking at. Patients with
increased thyroid activity will have bulging
eyes. Patients with anemia may have bounding
pulses. Patients with a leak in the aortic
valve called aortic insufficiency or aortic
regurgitation may have bounding pulses and
so forth. There are many findings throughout
the body which will also point us in the direction
of one or the other heart disease. Of course,
we are going to be looking for any changes
in the skin, rashes or other findings. Bleeding
under the skin that might suggest some sort
of longstanding heart infection, so forth.
There are many, many findings. I’m not at
liberty to take you through all of them. There
are huge textbooks written on the various
findings. But just to tell you, that a number
of findings will point you in the direction
of a diagnosis that maybe you hadn’t thought
about when you were taking the history.
04:23
Although, again, let me reiterate, most of
the history… most of the time the history
will point you in the right direction. So,
having inspected the patient, we have sort
of felt the chest, see if we can feel the
heart racing or pounding, see if the pulse
is regular or irregular. Now, we are going
to take our stethoscope and we are going to
listen to the heart. And we are going to be
looking for a number of different findings.
04:49
Again, I’m just going to briefly describe
them. There are again, chapters, long chapters
in Cardiology textbooks that will describe
this in greater detail. Remember from our
first anatomy lecture, we talked about the
location of the heart, slightly to the left
of the midline and that there were different
areas on the chest where the different four
valve sounds could be heard. And here you
see again that diagram. You see the heart
showed faintly in the background on this chest
and you see the places where you can best
hear with the little black dots the sounds
from the various heart valves. You will notice
that the aortic area is up here on the upper
part of the right chest wall, the pulmonic
valve on the left, the mitral valve below
it and the tricuspid valve over again back
to the right. These are the places you will
listen for particularly extra sounds related
to those valves and also for murmurs. And
here we see it in diagram, so it’s a just
a little clearer, you see the four areas where
we will listen particularly for sounds from
the aortic valve, the pulmonic valve, the tricuspid
valve or the mitral valve.
06:07
So, what kinds… what kinds of things are
we are looking for when we look at the patient?
First of all, we are looking to see if there
is heaving or bouncing of the chest - an overactive
heart. Then we are going to put our stethoscope
on the chest listening in each of the four
areas, and we are going to listen first to
the first heart sound, then we are going to
listen to the second heart sound and we are
going to hear if they… one of them is particularly
loud or if they are split. Remember, that
the first heart sound is made by the closure
of the mitral and tricuspid valve. The second
heart sound is made by closure of the aortic
and pulmonic valve, and sometimes you can actually
hear them slightly different in timing. Most
commonly, you hear the second heart sound split.
You hear the separate pulmonic and aortic
components. So, of course, we always joke
the heart makes two sounds - lub and dub so
that a normal heartbeat goes “lub-dub, lub-dub,
lub-dub”. But, in fact, the second heart
sound is often split. So, it’s often “lub-dudub,
lub-dudub, lub-dudub”. Let me slow that
down for you, “lub-dudub, lub-dudub”.
You hear there were two components to the
second heart sound. Sometimes, you can even
hear two components to the first heart sound
when the mitral and tricuspid valve close
slightly differently. So, then you would hear
“tudda tudda, tudda tudda, tudda tudda”.
You heard there were two components to each
of those. That can be totally normal, but
it’s important to distinguish them from
other heart sounds that are not normal. For
example, you can have a third heart sound
or a fourth heart sound. These sounds are
not normal. The fourth heart sound is a sign
that the ventricle is a little stiff. That’s
often seen in older folks, it doesn’t necessarily
mean serious disease. But the third heart
sound is a much more serious thing. When you
hear a third heart sound, it means the heart
has been severely damaged. Let me give you
some examples. So, let’s go back to “lub-dub”,
I won’t give you the splitting of the second
heart sound “lub-dub, lub-dub”. When there
is fourth heart sound, it occurs just before
the first heart sound. So, “vadda-bub, vadda-bub,
vadda...” Let me slow it down “vadda-bub,
vadda-bub”. There is a little soft VEH that
comes before the first heart sound. That’s
not so serious. The third heart sound means
the ventricle has been severely injured and
that is a third sound that comes after the
second one. So, it’s “lub dub-dub, lub
dub-dub or lub-dudub, lub-dudub, lub-dudub”
and it’s very clear when you hear that.
08:52
Occasionally, you will hear in a young teenager
who has very high cardiac output because of
puberty, but when you see it in an older person,
it usually means serious injury to the heart.
09:04
Then we listen for murmurs. What are murmurs?
Murmurs are sounds made by the turbulent blood
flow coming across a valve or going back through
a valve when the valve leaks. You see an example
- when you take a garden hose, you turn it
on and you bend the hose. You hear this “cheee”
sound as turbulance is created by the narrowing
in the… in the hose. That’s exactly what’s
happening with a heart murmur. Let’s take
some example. Suppose we have narrowing of
the aortic valve so that during systole when
the heart squeezes, it is pushing blood through
a narrowed aortic valve so there is a lot
of turbulence on the other side of the aortic
valve. So, when do you hear that? You hear
it during systole that is during the time
when the heart squeezing. So, here is the
normal heart, “lub-dub, lub-dub, lub-dub”.
09:54
Here is the heart with aortic stenosis “lub
chee-dub, lub chee-dub, lub chee-dub”. The
“chee” sound is the turbulent flow across
the aortic valve. Now, what happens if the
aortic valve is not narrowed or stenotic,
as we call it, but in fact, leaks? That means
that there is going to be blood flowing back
into the left ventricle during diastole. So,
what does that sound like? Well, let’s start
with the normal heart “lub-dub, lub-dub,
lub-dub”. Now, let’s have the murmur of
aortic regurgitation or insufficiency “lub-dub
cheww, lub-dub cheww, lub-dub cheww, lub-dub
chew”. The “cheww” sound is the blood
rushing back into the left ventricle during
diastole. Those are just two examples. We
have examples of murmurs of mitral stenosis,
mitral regurgitation, tricuspid regurgitation
so forth and so on. And all of these are,
of course, learned during Cardiology training
and they tell the Cardiologist or the internist,
“Hey, we have to usually obtain an echocardiogram.”
We need to look at that valve and see how
badly damaged it is and whether it needs a
possible repair or replacement.