Examination of the patients with cardiovascular diseases

Inquiry

Patients with heart diseases usually have following main complaints:

1. Dyspnea – usually in cardiac patients is a sign of the developing heart failure, the degree of
dyspnea being a measure of this insufficiency. When questioning the patient it is important
to find out the conditions under which dyspnea develops. For example, at the initial stages
of heart failure dyspnea develops only during exercise (climbing stairs, fast walk); at the
advanced stages it develops during normal walk or even at rest. Cardiac dyspnea is caused
by increased pressure in the lesser circulation (initially on pulmonary veins, than in
arteries), that leads to stimulating of the respiratory center.
2. --------- are known as cardiac asthma. They should be differentiated from dyspnea - cardiac
asthma arises suddenly, at rest, often during night rest or exercises, foamy sputum appears
with traces of blood.
3. Palpitations - are felt as accelerated and intensified heart contractions. Palpitation is
determined by the increased excitability of the patient's nerve apparatus that controls heart
activity. Palpitation is a sign of affection of the heart muscle in cardiac diseases such as
myocarditis, myocardial infarction, congenital heart diseases; it may arise as a reflex in
diseases of some other organs - hyperthyroidism, in fever, anemia, because of some drugs
(atropine). Patients with heart diseases may feel palpitation constantly or in attacks.
Palpitation may occur in healthy persons - under physical exercises, emotional stress, and
smoking.
4. due to disorders in the cardiac rhythm. Patients feel sinking or stoppage of the heart.
5. Pain in chest - is a very important and informative sign. The character of pain is different
in various diseases of the heart. The doctor should determine by interview:
- The location of the pain; its radiation and duration;
- Its character (acute, boring, feeling of heaviness, pressure, piercing)
- Cause or conditions under which it develops (exercise, emotions, walking, during nigh sleep);
- Conditions under which it decreases or disappears.
Pain develops in:
a) “angina pectoris" - acute insufficiency of the coronary circulation, which results in myocardial
ischemia. In this case pain is characterized in the following way:
- located retrosternal;
- it usually radiates under the left scapula, the left part of the neck, the left mandibula, the left part
of the chest;
- it lasts 2-20 minutes, not longer;
- it is like a felling of pressure, heaviness, boring;
- is caused by exercise, stress emotions,
.. is abated by rest and nitroglycerin under tongue.
b) dissecting aneurysm of the aorta. It usually:
- moves gradually along the aorta;
- radiates to the spinal column; it is permanent;
- it is piercing;
- it is not abated by anything.
c) myocarditis- inflammation of the myocardium. Pain is usually:
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- located in the region of the apex of the heart;
- it has a long duration - several hours,
- pressing acute pain; dull, mild;
- is intensified by exercise.
d) pericarditis – inflammation of pericardium. Pain is:
- located in the middle of the sternum
- may persist several days or arise in attacks; - it is shooting, stabbing;
- is intensified during exercise, cough under the pressure of stethoscope;
e) neurosis - neurological problems because of overstraining (overworking) or
emotional stresses. In this case pain is:
- located in the region of the apex of the heart;
- no irradiation; it has a long duration - hours~ days; - it is stabbing, acute; - caused by stress~ not
by exercise.
6. Cough - is due to congestion (increasing pressure) in the lesser circulation. The cough in heart
diseases is usually dry, sometimes with small amount of sputum.
7. Haemoptysis - is due to a pronounced congestion (increasing pressure) in the lesser circulation
and when a rupture of fine bronchial vessels occurs.
8. Edema - occurs because of venous congestion in the greater circulation in severe heart diseases.
It develops first of all in the malleolus region, dorsal part of the foot; in the initial stages it
develops in the evening and resolves after night sleep. Fluid accumulated in the abdomen is called
ascites, in the pleural cavity – hydrothorax. Congestion and enlargement of the liver as a
consequence of congestion in greater circulation appears as heaviness in the right hypochondria.
10. Weakness, fatigue, disturbance of the sleep.

INSPECTION
1. Posture
- Orthopnoea : patients with heart failure, in which is developed congestion in the lesser
circulation, usually have this kind of forced posture. It is characterized by half-sitting position,
with the legs on the floor. In this position greater portion of blood remains in the vessels of the
lower extremities and so, the volume of the circulating blood becomes decreased and the
congestion in the lesser circulation decreases also - the patient is feeling better.
- Sitting in bed slightly leaning forward - patients with pericarditis.
2. Skin - is often cyanotic (slightly blue). Usually is pronounced in parts of body that are
farther from the heart - fingers, tip of the nose, lips, ear lobes. It is called acrocyanosis. It
depends on the increased content of reduced haemoglobin in the venous blood because of
excessive absorption of oxygen by tissues in slow, congestive circulation of the blood.
Color of the skin may be: violet-red (mitral stenosis); pale (aortal heart diseases); jaundice (
in grave heart failure); coffee with milk (septic endocarditis).
3. Edema - If the patient is active, it develops first of all in the malleolus region, dorsal part of
the feet, the shins; it gradually develops upward. If the patient is lying in bed, edema is
placed in the lumbar region. It may extend onto the entire body, when the fluid accumulates
in the abdomen -is called ascites, in the pleural cavity - hydrothorax, in the pericardium -
hydropericardium. Generalized edema is called - anasarca. Skin in Edema is cyanotic or
pale, smooth, tense. Edema develops in the evening and resolves after night sleep.
Local edema sometimes develops in cardiovascular pathology, such as:
• compressed vena cava superior (in exudative pericarditis), in which we have edema
of the superior parts of the body - face, neck, shoulder;
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 • thrombophlebitis - will be edema of the affected extremity.

INSPECTION OF THE HEART REGION

We can observe normal phenomenon:
1. Pulsation in the fifth interspace medially of the left midclavicular line - the apex beat
(apical impulse); it is caused by the beat of the heart apex against the chest wall.
2. Pathological phenomenon:
• Can be seen – protrusion of the area over the heart, due to enlargement of the heart,
when the defects develop in childhood, when the chest is liable to changes.
• Pulsation to the left of the sternal line over a vast area, extending to the epigastria
region - so-called right ventricle impulse (RV impulse), due to contractions of the
enlarged right ventricle.
• Pulsation in the second right interspace, due to enlargement of ascending part of
aorta.

INSPECTION OF THE PERIPHERAL VESSELS

In healthy patients we'll see only:
1. Carotid pulse, synchronous to the heart beats
2. Jugular pulsation, hardly noticeable. During systolic dilation of the arteries the veins are
collapsed, because of acceleration of the venous blood flow, and during the diastolic
slowing of the blood flow, the neck veins swell. This is so-called "negative venous pulse".
Pathological phenomenon:
1. Swollen arteries, especially temporal ones, are found in patients with arterial hypertension
and atherosclerosis.
2. Pronounced pulsations of the carotid arteries (carotid shudder, dancing) we'll have in aortic
valve incompetence; in the same disease are specific pulsations of all the arteries –
subclavia, radial, brachial, arterioles.
3. Turgescent jugular veins, when veins are overfilled and dilated, due to general venous
congestion.
4. Local congestion with dilated veins is caused by compression of a vein by tumor, scars,
thrombosis.
5. In conditions of difficult blood outflow through the superior vena cava - are dilated the
veins of the head, neck, upper extremities, anterior surface of the trunk;
- in conditions of difficult blood outflow through the inferior vena cava - are dilated the veins
of the lower extremities and lateral surfaces of the abdominal wall;
- in conditions of difficult blood outflow through the portal vein - the collaterals become
dilated round the umbilicus, forming the caput Medusae.
6.) "Negative venous pulse" is pronounced in congestion.
7.) "Positive venous pulse" appears in the tricuspid valve insufficiency: in systole the veins are
swollen, and during the diastole the jugular veins are collapsed.

PALP ATION OF THE HEART

We must reveal:
• the apex beat and its characteristics;
• the presence of pathological phenomenon- the RV impulse,
• visible pulsations,
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 • thrills (“cat's purr" symptom, due to turbulent movements of the blood)
1. Apical impulse (apex beat) – is the beat of the heart apex against the chest wall. Its normal
characteristics are:

• Localization: in the fifth costal interspace, 1- 1,5 cm toward the sternum from the left
midclavicular line. It s position can be changed when the position of diaphragm is moved or
when the heart cavities are enlarged. Example: In patients with left-sided pleurisy with
effusion or hydropericardium the apex beat disappears;
• Area = 1,5 - 2cm (its surface);
• Height - is the amplitude of vibration of the chest wall at the apex beat area.
According to this character, apical impulse may be : (1) high (in the increased contractions of the
heart, in exercise, fever, hypertrophy of the heart; (2) moderate- in healthy persons.
• Power - it is estimated by the pressure that the heart apex thrusts against the palpating
fingers. It depends on the thickness of the chest wall and also, mostly on the strength of
contractions of the left ventricle. It can be: (1) moderate - in healthy persons; (2) forced - in
hypertrophy of the left ventricle.

So, in the hypertrophy of the left ventricle we'll have a diffuse, high and forced apical impulse.

Extra - apical, pathological pulsations:

1. RV impulse - is a pulsation to the left of the sternal line, over a vast area, extending to the
epigastria region; it appears in the hypertrophy and enlargement of the right ventricle.
2. Epigastria pulsation - may be due to :
• hypertrophy and enlargement of the right ventricle;
• pulsation of the abdominal aorta;
• liver pulsation
3. Thrills - are low vibrating murmurs, resembles purring of a cat. It is due to vibrations
caused by blood flow disturbances in heart valve disease.
4. Jugular pulsation – in aortic insufficiency
5. Hepato – jugular reflux

PERCUSSION of the heart

Is used to determine the size, position and the shape of the heart and the vascular bundle.
The right configuration of the heart is formed (from top to bottom) by the superior vena
cava (1st interspace), aorta ascendens (2nd interspace), and right atrium (3,4th intercostal space).
The left configuration of the heat is formed by the left part of the aortic arch (1st
interspace), pulmonary trunk (2nd interspace), auricle of the left atrium (3rd interspace), a narrow
strip of left ventricle (3,4,5th interspaces).
The anterior surface is formed by the right ventricle.
During percussion the heart gives a dull sound. The heart's part, covered by lungs, gives
slight (relative) dullness. So, we have:
1. Relative dullness of the heart, that corresponds to its true borders.
2. Absolute dullness of the heart – corresponds to the anterior surface of the heart that is not
covered by the lungs.
Normal borders of the relative dullness are:
1. Right border – 4th right costal interspace, 1 cm laterally from the right edge of the sternum.

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 2. Left border - 5th right costal interspace, 1-1,5 cm toward the sternum from the left
midclavicular line; it coincides with the apical impulse.
3. Upper border - 1 cm to the left of the sternal line, in the 3rd 1interspace.
Normal borders of the absolute dullness are:
1. Right border - 4th interspace, on the left edge of the sternum.
2. Left border - 1-2 cm medially from the left border of the Relative heart dullness.
3. Upper border - 1 cm to the left of the sternal line, on the 4th rib.
The transverse length of heart dullness is 5-6 cm.

Heart configurations:
1. Aortal configuration - in the dilation of left ventricle;
2. Mitral configuration - in the dilation of the left atrium.