Palpation of the heart and cardiovascular assessment
Cardiovascular assessment
How cool would it be if we knew what to look for whilst palpating the heart? How about interpreting all those myriad heart sounds and murmurs? Not to mention the dreaded ECG.
Fear not, the Hands-on guide to Clinical Reasoning in Medicine helps simplify your approach to history taking and examination of cardiovascular system and other systems that does not require you to memorise facts. It is all laid out in a
- friendly
- visual and
- stimulating style
for medical students in their clinical years, junior doctors and nurse practitioners.
Plenty of clinical scenarios in a conversational style with two imaginary students will cement the ‘medicine’ whilst sub-consciously turning you into confident decision-makers!
Topics covered include:
1. History taking - Cardiac v/s non-cardiac chest pain
History taking can be fun if you know how to construct concept maps on the aetiology of each symptom based on an anatomical or pathophysiological model. Driving the history down to a diagnosis is what this book excels in and you will soon be doing this without tripping over.
For instance, did you know that you only need three P’s to discriminate between cardiac and non-cardiac chest pain? If the pain is pleuritic, positional or reproducible on palpation it makes it very unlikely to be cardiac in origin!
2. Cardiac physical examination
Wouldn’t it be easy, if you knew that cardiovascular signs are based on a mechanical model of cardiac function? Figure 1 shows this in action where all the signs seen in cor pulmonale are listed in the reverse direction of normal anatomical blood flow! This is in fact the order in which the signs appear.
Figure 1
Credit source: Irfan M, Hands-on Guide to clinical Reasoning in Medicine, Wiley-Blackwell; 1 edition (1 Feb. 2019)
Starting from the hands and working your way up to the face and down to the chest, I will show you how to pick up signs on the way that will make your life so much easier. For instance, did you know that xanthelasma, corneal arcus and plucked chicken skin appearance in axillae (pseudoxanthoma elasticum) all predispose to ischaemic heart disease?
Other pearls include, a cheat sheet for determining pulse volume by the pulse pressure. We will also learn that a raised jugular venous pulse (JVP) points to right heart failure (see below) but a positive hepato-jugular reflux tells you about left atrial stiffness and indirectly left heart failure!
JVP v/s carotid pulsation
Credit:
Park, J. Y., Eleid, M. F. and Michelena, H. I. (2016) ‘Abnormal Neck Veins’, JAMA Cardiology. American Medical Association, 1(4), p. 487. doi: 10.1001/jamacardio.2016.0540.
3. Palpation of the heart
Palpation of the heart can be described to death but did you know that it is the position of the apical impulse that gives you the most information? Therefore subjective terms describing the apical impulse like tapping, thrusting, etc are all better left in books.
- An apical impulse displaced down and out of the mid-clavicular line in the fifth intercostal space implies that the left ventricle is enlarged.
- Similarly, a left parasternal lift that stays up for the length of the systole suggests right ventricular hypertrophy (pressure overload). However, if the parasternal lift just rises and falls, it suggests right ventricular enlargement (volume overload).
p.s. a thrill is nothing but the palpatory counter-part of a murmur.
4. Percussion of the heart
Percussion does not give a lot of information except perhaps in the setting of pericardial effusion. Here, there is dullness in three areas, to the left, to the right and above (sub-sternally) of the area of cardiac dullness. This is especially appreciated in patients with emphysema.
5. Cardiac auscultation: Heart sounds and murmurs
Ever felt like you were the only one in the group who could not hear that murmur when everyone else could? So you just went along and pretended having heard it too. We have all been there!
Have you heard of the analogy of an orchestra on the earphones? I can tell you how to use this to concentrate on hearing all the heart sounds and murmurs.
Then I show you a wonderful way of predicting what sounds you will hear by just knowing what the examination has thrown up thus far. For example, if you find an apical impulse displaced down and out, it tells you that the left ventricle is enlarged – a sign of volume overload. Knowing that the third heart sound (S3) occurs in volume overload conditions and fourth heart sound (S4) occurs in pressure overload conditions, you can bet your bottom dollar that you would find a left-sided S3.
What are the valvular lesions that cause left-sided volume overload (more blood in the left ventricle)? Answer: regurgitant lesions like aortic and mitral regurgitation. This is because leaky valves do not shut properly, causing more blood to accumulate in the left ventricle when it is relaxing in diastole.
“What murmur will I hear?” you ask.
Surprisingly, I won’t give you a list of all the murmurs and the conditions you hear them in. Instead, I will turn this upside down and ask you to think of the possible lesions. In our case we have aortic and mitral regurgitation.
I will then show you an amazing method to predict what murmur you will hear based on simple physiology and the normal direction of blood flow!
And the list goes on…..
6. Chest x-ray and 12 lead ECG interpretation
Chest x-ray
Pulmonary edema on a chest x-ray and mediastinal widening in aortic dissection – we’ve got them all. How on earth can you say if there is upper lobe blood diversion? It’s not voodoo you know. There is a perfectly earthly explanation for this. It all lies at the hilar point and you can actually measure it, yes! I can even tell you the earliest sign of pulmonary edema and what comes last.
12 lead ECG interpretation
Did you know that the TP segment is the isoelectric baseline of an ECG? Ever wondered why those funny ST elevations occur and what ‘reciprocal changes’ mean, in myocardial infarction (MI)? By the way Q waves do not always mean an old MI and ST elevation does not always mean an MI. All of this has been covered and more!
Ready for a helping hand? You can find out all about the cardiovascular examination right now and buy the Hands-on Guide to Clinical Reasoning in Medicine here!
Not quite sure yet? Take a look at the contents inside:
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