Cardiac Physical Exam – The Patient's History (Diagnostics)

by Joseph Alpert, MD

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    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.

    About the Lecture

    The lecture Cardiac Physical Exam – The Patient's History (Diagnostics) by Joseph Alpert, MD is from the course Introduction to the Cardiac System.

    Included Quiz Questions

    1. That the patient is unable to deliver oxygen to his extremities
    2. That the patient’s blood has increased oxygen content
    3. That the patient has appendicitis
    4. That the patient has insomnia
    1. Xanthelasma
    2. Lipoma
    3. Xanthogranuloma
    4. Chloroma
    5. Atheroma
    1. Pectus excavatum
    2. Pectus carinatum
    3. Kyphosis
    4. Scoliosis
    5. Lordosis
    1. 2nd intercostal space on the right side of the sternum
    2. 4th intercostal space on the left side of the sternum in the mid-axillary line
    3. 5th intercostal space on the right side of the sternum in the mid-clavicular line
    4. 5th intercostal space on the left side on the sternum in the mid-axillary line
    5. None of these
    1. Closure of the mitral and tricuspid valves
    2. Closure of the mitral and aortic valves
    3. Closure of the mitral and pulmonic valves
    4. Opening of the pulmonic and tricuspid valves
    5. Opening of the mitral and aortic valves
    1. Third heart sound
    2. First heart sound and second heart sound
    3. A first heart sound and splitting of the second heart sound
    4. A split first heart sound and a normal second heart sound
    5. None of these
    1. Fourth heart sound
    2. Second heart sound
    3. Third heart sound
    4. Splitting of the second heart sound
    5. Splitting of the first heart sound
    1. Echocardiogram
    2. Electrocardiogram
    3. Cardiac catheterization
    4. Valve replacement
    5. CT scan
    1. Systolic murmur
    2. Diastolic murmur
    3. Parasternal heave
    4. S3 and S4 heart sounds
    5. Fluttering heart rhythm

    Author of lecture Cardiac Physical Exam – The Patient's History (Diagnostics)

     Joseph Alpert, MD

    Joseph Alpert, MD

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