HISTORY AND

EXAMINATION
CARDIOVASCULAR SYSTEM
Importance of History
Taking
Obtaining an accurate history is the
critical first step in determining
the etiology of a patient's
problem.
A large percentage of the time )
70%), you will actually be able make
a diagnosis based on the history
alone.
How to take a history?

The sense of what constitutes important

data will grow exponentially in future as
you learn about the pathophysiology of
disease
You are already in possession of the tools
that will enable you to obtain a good
history.
An ability to listen and ask common-sense
questions that help define the nature of a
particular problem.
A vast and sophisticated fund of
knowledge not needed to successfully
interview a patient.
General Approach
Introduce yourself.
Note never forget patient names
Creat patient appropriately in a friendly relaxed way.
Confidentiality and respect patient privacy.

Try to see things from patient point of view. Understand patient

underneath mental status, anxiety, irritation or depression.
Always exhibit neutral position.

Listening

Questioning: simple/clear/avoid medical terms/open, leading,

interrupting, direct questions and summarizing.
Taking the history
. &
Recording:
Always record personal details:
name,
age,
address,
sex,
ethnicity,
occupation,
religion,
marital status.
Record date of examination
Complete History Taking
Chief complaint
History of present illness
Past medical history
Systemic enquiry
Family history
Drug history
Social history
Presenting Complaint

Chest pain
Shortness of breath
Ankle swelling
Palpitations
Syncope
Intermittent claudication
Chest Pain
Relieving factors
Character of pain
Worse on taking a
Severity
deep breath
Duration
(pleuritic)
Radiation
Worse on movement
At rest or on
Autonomic symptoms
exertion Sweating
Previous episodes Nausea
Causes of Chest Pain
Cardiovascular Chest wall
Angina Coughing
Stable
Intercostal muscle
Unstable
Myocardial infarction strain/myositis
Aortic dissection Herpes zoster
Myocarditis Viral pleurodynia
Pleuropericardial Thoracic radiculopathy
Pericarditis Rib fracture
Pleurisy Rib tumour
Pneumothorax Costochondritis
Gastrointestinal
Gastro-oesophageal
reflux
Oesophageal spasm
Acute Anteroseptal MI
Dyspnoea

Unexpected awareness of breathing

At rest or on exertion
Quantify exercise tolerance (yards
walked, stairs climbed)
Orthopnoea = shortness of breath on
lying supine
Number of pillows
Paroxysmal nocturnal dyspnoea
Causes of Dyspnoea
Airways disease
COPD
Chest wall
Chronic bronchitis Pleural effusion
Emphysema Rib fracture
Asthma Kyphoscoliosis
Bronchiectasis Neuromuscular
Cystic fibrosis Cardiac
Parenchymal disease Left ventricular failure
Pneumonia Mitral valve disease
Pulmonary fibrosis Cardiomyopathy
Tumour Pericardial effusion
Pneumothorax Other
Pulmonary vasculature Anaemia
Pulmonary embolism Acidosis
Pulmonary hypertension Psychogenic
Pulmonary Oedema

Normal Chest Pulmonary

Radiograph Oedema
 Ankle Swelling
Unilateral or bilateral Drugs
Proximal extent of Calcium channel
blockers
oedema
Other
Pitting/non-pitting
Cirrhosis
Cardiac Nephrotic syndrome
Congestive cardiac Protein-losing
failure enteropathy
Right ventricular failure Deep vein thrombosis
Cor pulmonale Hypothyroidism
Constrictive pericarditis Lymphoedema
Palpitations
= Unexpected Sinus tachycardia
awareness of Ventricular
heartbeat extrasystoles
Ask patient to tap Atrial fibrillation
palpitations on chest
Atrial flutter
Slow or fast
Supraventricular
Regular or irregular
tachycardia
Duration
Ventricular
Speed of onset or
tachycardia
offset
Relieving manoeuvres
Syncope

= Transient loss of consciousness due to

cerebral hypoperfusion
What was the patient doing at the time?
Standing for prolonged period
Standing up suddenly (postural
hypotension)
Coughing
Prodromal symptoms
Abnormal movements (epilepsy)
Sensation of room spinning (vertigo)
Intermittent
Claudication
Pain in one or both calves, thighs or
buttocks
Brought on by walking a certain
distance (claudication distance)
Worse on walking uphill
Relieved by rest
Suggests peripheral vascular disease
Risk factors for Ischaemic
Heart Disease
1. Hyperlipidaemia
2. Diabetes mellitus
3. Smoking
4. Hypertension
5. Obesity
6. Family history
Past Medical History

Rheumatic fever
Previous cardiac investigations
Previous myocardial infarction
Coronary angioplasty + stent
insertion
Coronary artery bypass grafting
Pacemaker insertion
Medications

Anti-anginal agents
Use of sublingual nitrate spray
Antihypertensive agents
Anti-arrhythmics
Statins
Platelet inhibitors, e.g., Aspirin
Anticoagulants, e.g., Warfarin

Allergies
NB Document in front of chart and inform
nurses
Social History

Occupation
e.g., train driver, long distance truck
driver
Smoking
Number of pack years
Alcohol intake
Stairs at home
Family History

Ischaemic heart disease

Angina
MI
CABG
Hypertrophic obstructive
cardiomyopathy
Dilated cardiomyopathy
HOCM
Physical Examination

General Precordium
Hands Inspection

Pulse Palpation
Percussion
Blood pressure
Auscultation
Face
Back
Neck
Abdomen
Jugular venous
Lower limbs
pressure
Other
Examination - General

Position patient at 45 degrees

Respiratory rate
Cachexia
Marfans syndrome
Downs syndrome
Did Abraham Lincoln have
Marfans Syndrome?

High arched
palate
Examination - Hands

Clubbing
Splinter haemorrhages (infective
endocarditis)
Oslers nodes (tender)
Janeway lesions (non-tender)
Xanthomata (Hyperlipidaemia)
 Splinter
Haemorrhages

Clubbing
Examination - Pulse
Character and volume
Radial artery
assessed from carotid
Rate (normal = 60- artery
100)
Collapsing pulse (aortic
Bradycardia (<60)
regurgitation)
Tachycardia (>100)
Pulsus alternans (left
Rhythm
ventricular failure)
Regular
Irregular Pulse deficit (atrial
Radiofemoral delay
fibrillation)
(coarctation of the
aorta)
 Examination - Blood
Pressure
Sphygmomanometer Deflate at 4 mmHg/s
Systolic/diastolic Difference between
pressure arms of <10 mmHg
Normal <140/90 Pulsus paradoxus =
mmHg (lower in exaggerated
diabetes) reduction in BP with
Korotkoff sounds inspiration (>10
Use larger cuff width mmHg)
for large arms Postural hypotension
 Examination Face and
Neck
Jaundice Central cyanosis
Xanthelasmata Carotid pulse
Corneal arcus character
Malar flush (mitral
Slow rising (AS)
stenosis) Bisferiens (AS + AR)
High arched palate
Collapsing (AR)
Alternans (LVF)
(Marfans syndrome)
Jerky (HOCM)
Dental caries
Carotid bruit
(infective
endocarditis)
Eye signs in
Hyperlipidaemia

CORNEAL XANTHELASMATA
ARCUS
 Jugular Venous Pressure
Patient at 45 degrees Fills from above
Good lighting Hepatojugular reflux
Internal jugular vein Abnormal if >3 cm above
Reflects right atrial zero point:
pressure RV failure
Zero point = sternal RV infarct
angle Tricuspid stenosis
Visible but not palpable Tricuspid regurgitation
Pericardial effusion
Complex wave form (a, c,
SVC obstruction
v waves)
Fluid overload
Decreases on inspiration
Precordium - Inspection

Scars
Median sternotomy
CABG
Valve replacement
Lateral thoracotomy
Sternotomy
Infraclavicular scar
(pacemaker)
Pectus excavatum Pectus
excavatum
Pacemaker box
Apex beat
Precordium - Palpation

Apex beat
Location
Character
Heaving
Thrusting
Double
Tapping
Paradoxical
Left parasternal heave
Thrills (palpable murmurs)
Systolic
Diastolic
Palpable P2 (pulmonary
hypertension)
Pacemaker box
Precordium Auscultation
Heart Sounds
Bell low pitched
sounds
Diaphragm high
pitched sounds
Mitral Tricuspid
Pulmonary Aortic
areas
S1 (first heart sound)
S2 Splitting (A2,
P2)
Abnormalities of Heart
Sounds
Loud S1 S3 (third heart sound)
Soft S1 S4 (fourth heart
Loud A2 sound)
Loud P2 Summation gallop
Soft A2 Opening snap
Splitting of S1 Systolic ejection click
Increased splitting of Mid-systolic click
S2 Tumour plop
Fixed splitting of S2
Pericardial knock
Reversed splitting of S2
Metallic click
 Precordium Auscultation
Murmurs
Timing of murmur
Pitch
Systolic
Radiation
Diastolic
Continuous
Dynamic
Site of maximal
manoeuvres
Respiration
intensity Left-sided on exp.
Loudness Right-sided on insp.
Grades I-VI Valsalva
Thrill Squatting
Heart Murmurs
Systolic
Diastolic
Pansystolic
Early diastolic
Mitral regurgitation Aortic regurgitation
Tricuspid regurgitation Pulmonary regurgitation
Ventricular septal defect Mid-diastolic
Ejection systolic Mitral stenosis
Aortic stenosis Tricuspid stenosis
Pulmonary stenosis Atrial myxoma
HOCM Continuous
Atrial septal defect Patent ductus arteriosus
Late systolic Arteriovenous fistula
Mitral valve prolapse Pericardial friction
rub
Examination Back

Percuss and auscultate lung bases

Left ventricular failure
Pleural effusion
Sacral pitting oedema
Right heart failure
Examination - Abdomen

Patient lying with one pillow (if

tolerated)
Tender hepatomegaly
Pulsatile liver (tricuspid
regurgitation)
Ascites
Splenomegaly
Abdominal aortic aneurysm
 Examination Lower Limbs
Peripheral oedema
Palpate arteries
Pitting/non-pitting
Femoral
Upper level
Popliteal
Achilles tendon Posterior tibial
xanthomata Dorsalis pedis
Capillary return Buergers test
Trophic skin changes (peripheral vascular
disease)
Peripheral Pulses

Dorsalis pedis Posterior tibial

pulse pulse
Examination - Other

Urinalysis
Haematuria (infective
endocarditis)
Fundi
Hypertensive
retinopathy
Roth spots (infective
endocarditis)
Temperature chart
Infective endocarditis