1. Examination of the heart and the circulatory system

2. Complaints Chest pain –Angina pectoris –Pericarditis –Aortic aneurysm dissection –Extracardial causes Esophagus Lung, pleura Chest wall (muscle, neural, bone, joint) Anxiety

3. Complaints Angina pectoris –Features Constricting, pressing pain Radiates to the left shoulder, arm –But can be radiate to the neck, mandibule, back, epigastrium Reversible – few minutes Provoked by –Physical activity –Smoking, hypoxia –Cold –Big meal Relieving factor - nitrates

5. Complaints Angina pectoris subtypes –Effort angina –Status anginosus –Crescendo angina

6. Complaints Pain from other arteries –Intermittent claudication –Abdominal angina

7. Complaints Pain in other localisation –Raynaud’s-phenomenon

8. Complaints Arrythmia –Palpitation –Tachycardia –Bradycardia – Syncope –Extrasystolia

9. Complaints Dyspnea –Inspiratory dyspnea –Subtypes Effort dyspnea Dyspnea on rest –Orthopnea dyspnea relieves in vertical position –Paroxysmal nocturnal dyspnea

10. Complaints Edema according to the gravitaion In laying patients: sacral edema

11. Complaints Other complaints –Nycturia v. nocturia –Coughing –Weakness, decreased loadability

12. Complaints Important anamnestic data: –In the family history Hypertension Early heart death, sudden death, ischemic heart disease –Factors Smoking Alcohol consumption

13. Inspection Cyanosis Gärtner’s-sign - the blood filled vein can’t became empty during elevation of the hand Drumstic fingers clubbed fingers Aortic valve insufficiency –Capillary pulsation

14. Palpation Pulse –Radial, ulnar artery –Dorsalis pedis artery –Tibial posterior artery behind the inner ankle –Popliteal artery –Femoral artery –Carotis

15. Palpation Pulse features –1. Frequency Frequent or rare –2. Amplitudo High or small –3. Compressibility Hard or soft –4. Speed of increasing Quick or slow –5. Palpability

16. Palpation –6. Rythm Regular or irregular –Irregular – arrhythmia »Phasic sinus arrhythmia – respiratory arrhythmia »Extrasystole „premature beat” Episodic or frequent »Bigeminy, trigeminy

17. Palpation Atrial fibrillation - absolute arrhythmia irregular and inequal pulse

18. Palpation Apical impulse –Normal: 1-2 cm medially to the left midclav. line in the V. intercostal space surface: 1 cm 2 –Alterations Goes to the left – dilatation, hypertrophy Goes to the right – small heart Goes up - pushed up –Quality Higher – hypertrophy Wider - dilatation

19. Palpation Murmurs

20. Percussion Rules –Must to do it in the intercostal spaces –The percussioned finger is always parallel to the checked border Order –Lower border right side, mc.line VI. intercostal sp. –Right border –Upper border –Left border

21. Auscultation Sound : short (0,2 sec), sharp bordered Murmur : longer, borders are blurred

22. Auscultation - Sounds Sounds –I. sound – systolic – longer it comes after the longer interval –II.sound – diastolic – shorter Development of sounds –Closure of valves Systolic: mitral and tricuspidal Diastolic: aortic and pulmonal –Opening of the other valves –Muscle contraction –Blood flow

23. Auscultation – I. sound – S1 Alterations – Loud tachycardia strong physical activity extrasystole stenotic mitral valve –Soft heart failure emphysema pericardial effusion thick chest wall

24. Auscultation – II.sound – S2 Normally the loudness of the S2 sounds of the aortic and pulmonal valve are equal (the aortic valve is more deeper) –Alterations S2 soft – hypotony S2 is louder somewhere –Above the aortic valve hypertension –Above the pulmonal valve pulmonar hypertension S2 is absent – aortic valve insufficency

25. Auscultation - Murmurs Subgroups –Extracardial – pericardial friction rub –Intracardial

26. Auscultation – Intracardial murmurs Development of murmurs – turbulent flow –Organic valvular diseases irregular surface of the vessel –Functional - no organic alteration papillar muscle insufficiency, heart dilatation –Accidental - no organic or functional alteration increased blood flow, decreased blood viscosity

27. Intracardial murmurs Place in the cardiac cycle –Systolic or diastolic Location of maximal intensity - punctum maximum Radiation of the murmur Shape plateau, crescendo, descrescendo Intensity Pitch high, medium, low Quality blowing, harsh, musical, rumbling

28. Auscultation - Murmurs Cardiac cycle –Systole Pansystolic Protosystole - early Mesosystole - mid Telesystole - late – Diastole Protodiastole Mesodiastole Praesystole

31. Auscultation - Murmurs Radiation of murmurs – always in the direction of the blood flow Examples: –Mitral insufficiency – to the axilla –Aortic stenosis – to the carotid artery

32. Auscultation – murmurs - shape Plateau – mitral regurgitation Crescendo-decrescendo – aortic stenosis - ejection

33. Auscultation – murmurs - shape Decrescendo – aortic regurgitation Crescendo – mitral stenosis