Patient interview techniques

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What are the preliminary requirements to
conduct the interview(cont.)
• Seating position of the patient : not opposite to the inter-
viewer, at the side of the desk, chair should not be lower than
the interviewer.
• Question techniques: no leading questions and do not be
judgmental
• Note taking and recording: Record some verbatim statements
only and if the patient is against it is better to stop and listen
actively.
• Time : individualized
• Be as empathetic and sympathetic as possible.
 Specific interviewing technique
• Open-ended question
• Closed-ended question
• Reflection
• Facilitation
• Confrontation
• Positive reinforcement
• Summation
• Explanation
 Open-ended questions
 Begin with broad open-ended questions to allow the patient
to speak as much as possible.

 At the beginning of the interview the examiner encourages

the patient to speak as spontaneously and openly as possible
 E.g. can you tell me please what troubles that bring you to-
day ? Then allow the patient to speak as much as possible.
 CLOSE-ENDED QUESTIONS
 CLOSED ENDED QUESTION IS USED to
• Ask specific information ( age ,address, name)
• In eliciting information about certain symptoms
• To assess such factor as frequency, severity, and duration of symp-
toms

• Do not use closed ended question at the beginning of the interview it

does not allow the patient to have the option.
 Reflection
• The interviewer repeats to the patient in supportive manner
something that the patient has said

• Purpose is to:
– assure the interviewer that, he has correctly understand what the
patient is trying to say
– to let the patient know that the interviewer is perceiving what is
being said
 Facilitation
• The interviewer helps the patient to continue the interview by providing
verbal and non-verbal cues that encourage the patient to talk.

-nodding ones head,leaning forward from ones seat and saying,

YES,THEN,UH-UHH,GO ON,I see,what else,any thing else
 Confrontation
• To point out to a patient something that the interviewer thinks the patient is
not paying attention to , missing, or some way denying

• Confrontation must be done skillful way so that the patient is not forced to
became hostile defensive
 Positive -reinforcement

• When patient has difficulty to express his problem.

• when the patient struggled with a particular topic and is unable to express
clearly, then the interviewer signals his approval by using positive rein-
forcement
e.g. good , that helps me a lot to understand you.
 Summation

• Periodically during the interviewer can take some moment and briefly
summarize what patient said

• It assures both understand each other

 Explanation

• The interviewer should explain about his

– diff.Dx. and the plan of treatment to the patient in easily understandable lan-
guage.
CARDIOVASCULAR EXAMINA-
Cardiovascular
TION History taking
and Examination
 THE HEART

For it is the heart by whose virtue and pulse the blood is

moved, perfected, made apt to nourish and is preserved
from corruption and coagulation…. It is indeed the foun-
tain of life, the source of all action.

William Harvey 1578-1657

04/15/2023 13
 Outline
• Introduction
• General examination
• Examination of vessels
– Arterial system
– Venous system
• Precordial examination
– Inspection
– Palpation
– Auscultation and
– Percussion??

04/15/2023 14
 O bjectives
Ω Able to take important cardiac history
Ω Able to do CVS physical examination
Ω Able to interpret physical finding
 Cardiovascular history

Major symptoms
 Chest pain or heaviness
 Dyspnea- exertional (note the degree of exercise
necessary to induce it) i.e. Grading Dyspnea,
 Orthopnea,
 Paroxysmal nocturnal dyspnea
 Ankle swelling
 Palpitations
 Syncope-
 Intermittent claudication-
 Fatigue
 Cardiovascular risk factor profiles.
 Previous ischemic heart disease
 Hypercholesterolemia
 Smoking
 Hypertension
 Family history of coronary artery disease
 Diabetes mellitus
 Renal failure
 Dental decay why???
 Edema
• Edema refers to the accumulation of excessive
fluid in the extravascular interstitial space.
• Interstitial tissue can absorb several liters of
fluid, accommodating up to a 10% weight gain
before pitting edema appears.
– Dependent edema appears in the lowest body
parts: the feet and lower legs when sitting, or the
sacrum when bedridden.
– Causes may be cardiac (congestive heart failure),
nutritional (hypoalbuminemia), or positional.
04/15/2023 18
• Grading of dyspnea
 Grade 1-Nobreathlessness
 Grade 2-Breathlessness on severe exertion
 Grade 3-Breathlessness on mild exertion
 Grade 4-Breathlessness at rest

04/15/2023 19
• Orthopnea is dyspnea that occurs on lying supine or
on recumbent position due to increase venous return.
• Paroxysmal nocturnal dyspnea (PND) is dyspnea
that occurs abruptly about 30 minutes to 2 hours after
going to bed and is relieved by standing up or sitting
up.
• Intermittent claudication -

04/15/2023 20
• Palpitation is unpleasant awareness of forceful or
rapid beating of the heart.
– Patients describe it as pounding, jumping, racing or irregu-
larity of the heart.
• Syncope is a transient loss of consciousness resulting
from insufficient blood supply to the brain.
• A patient feeling light headed but no loss of con-
sciousness is considered to be pre-syncope.
E.g. vasovagal syncope, postural syncope and cardiac
syncope
04/15/2023 21
Past history
 History of ischemic heart disease:
 Myocardial infarction,
 Coronary artery bypass grafting
 Rheumatic fever, Rheumatic Heart Disease, chorea,
 Sexually transmitted disease like syphilis,
 Recent dental manipulation,
 Thyroid disease like graves disease
 Prior medical examination revealing heart disease
 Drugs intake
Social history
• Tobacco and alcohol use
• Occupation
Family history
 Myocardial infarction, cardiomyopathy, congenital heart dis-
ease, Marfan's syndrome

 Coronary artery disease risk factors in the family.

– Hypertension
– Hyperlipidemia
– Family history of coronary artery disease
– Diabetes mellitus
 Functional status in established heart disease

• New York Heart Association /NYHA/ classification –

– Class I-disease present but no symptoms, or angina or dyspnea during unusually intense
activity
– Class II-angina or dyspnea during ordinary activity

– Class III-angina or dyspnea during less than ordinary activity

– Class IV-angina or dyspnea at rest
• Used for adults and adolescents
 Modified Ross Heart failure classification for chil-
dren

Class I
Asymptomatic
Class II
Mild tachypnea or diaphoresis with feeding in infants
Dyspnea on exertion in older children
Class III
Marked tachypnea or diaphoresis with feeding in infants
Prolonged feeding times with growth failure
Marked dyspnea on exertion in older children
Class IV
Symptoms such as tachypnea, retractions, grunting, or diaphoresis at rest

04/15/2023 25
 Causes of chest pain 

 Myocardial ischemia or infarction

 Vascular pain
 Aortic dissection 
 Aortic aneurysm
 Pleura-pericardial pain
 Pericarditis
 Infective pleurisy 
 Pneumothorax
 Pneumonia 
 Autoimmune disease
 Mesothelioma 
 Metastatic tumor
• Chest wall pain
 Persistent cough 
 Muscular strains, trauma 
 Intercostal myositis 
 Thoracic herpes zoster 
 Coxsackie B infection 
 Thoracic nerve compression or infiltration 
 Rib fracture
 Rib tumor, primary or metastatic 
 Slipping rib syndrome
Gastrointestinal pain
 Gastroesophageal reflux (common) 
 Esophageal spasm (rare)
 Tracheitis 
 Intubation 
 Central bronchial carcinoma 
 Inhaled foreign body
 Mediastinal pain
 Esophageal spasm 
 Esophagitis
 Mediastinitis 
 Sarcoid adenopathy 
 Lymphoma
 Causes of orthopnoea

 Cardiac failure
 Uncommon causes
 Massive ascites
 Pregnancy
 Bilateral diaphragmatic paralysis
 Large pleural effusion
 Severe pneumonia
NB: 2 major or 1 major
and two minor criterion
needed for diagnosis.
 Clubbing
• Clubbing is the swelling of the distal parts of
the fingers or toes due to an increase in the
soft tissues.
• Exact mechanism is not known.
• However, it is believed that prolonged hypoxemia →
causes the release of unknown humoral substance →
causes the dilatation of the vessels of the fingertips and toes
→ leading to interstitial edema and swelling of the subcu-
taneous tissues.
04/15/2023 31
 Causes of clubbing

Common
 Cardiovascular
 Cyanotic congenital heart disease
 Infective endocarditis
 Respiratory
 Lung carcinoma
 Chronic pulmonary suppuration:
 Bronchiectasis
 Lung abscess
 Empyema
 Idiopathic pulmonary fibrosis….
 CONT..
 Uncommon Respiratory
 Cystic fibrosis
 Asbestosis
 Pleural mesothelioma or pleural fibroma
 Gastrointestinal
 Cirrhosis
 Inflammatory bowel disease
 Coeliac disease
 Thyrotoxicosis
 Neurogenic diaphragmatic tumors
 Unilateral clubbing
 Bronchial arteriovenous aneurysm
 Axillary artery aneurysm
• Grading of Clubbing
– Grade 1: Obliteration of the angle of nail bed
– Grade 2: Fluctuation of the nail bed
– Grade 3: Increased curvature of the nail esp. In its
long axis
– Grade 4: Drumstick appearance: swelling of the
pulp of the finger in all its dimensions

04/15/2023 34
Detection of clubbing

Normal Clubbing
 Investigations
• ECG is useful for assessment of
– Arrhythmias
– Conduction defects
– Myocardial ischemia or infarction
– Myocardial hypertrophy
– Electrolyte disturbance
– Toxicity of certain drugs like digitalis
• Holter monitor or ambulatory ECG is battery powered cassette
tape recorder used for continuous recording for 24 hours and is im-
portant for detection of transient arrhythmias.

• Chest x-ray….
04/15/2023 36
• Chest x-ray
– Heart size
– Calcification
– Lung fields
• For pulmonary hypertension by enlargement of hilar
vessels
• Kerly B-Lines for pulmonary edema and
• Pleural effusion

• Echocardiography ..…

04/15/2023 37
• Echocardiography for assess-
ing
– Size of all chambers
– Left ventricular function-ejection fraction
– Regional wall motion abnormalities due to MI
– Complications of MI like MR, LV aneurysm, pap-
illary mm dysfn.
– Structural VHD like stenosis and regurgitation
– Pericardial effusion

04/15/2023 38
Introduction of Normal Anatomy

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Valves of the Heart and Circulation

04/15/2023 43
 General examination
• Examination of the hands
• Cyanosis (central and peripheral)
• Look for any malformation
• Examination of eye for paleness
• Examination of lower extremities for edema

04/15/2023 44
 Pre-requisites
• Supine position with the upper body raised by ele-
vating the head of the bed or table to about 30°.
• Two other positions are also needed:
– Turning to the left side- bring the ventricular apex closer
to the chest wall enhancing detection of the PMI and
– Sitting and leaning forward exhale completely, and stop
breathing in expiration - bring left ventricular outflow
tract closer to the chest wall, enhancing detection of aor-
tic insufficiency.
• The examiner should stand at the patient's right side.

04/15/2023 45
 Examination - Hands
• Clubbing
• Splinter hemorrhages (infective endocarditis)
• Osler’s nodes (tender)…OUCH !!!!
• Janeway lesions (non-tender)
• Xanthomata (Hyperlipidemia)

04/15/2023 46
 CLUBBING

04/15/2023 47
 Osler’s node

Janeway
lesions

Splinter Hemorrhages

04/15/2023 48
 General examination cont
• Cyanosis (central) Peripheral cyanosis

04/15/2023 49
• Cyanosis, a bluish purple discoloration of the tissues
due to an increased concentration of deoxygenated
hemoglobin in the capillary bed.
• It is most easily appreciated in the lips, nail beds,
earlobes, mucous membranes, and locations where
the skin is thin.
• Two mechanisms result in cyanosis:
– systemic arterial oxygen desaturation and
– increased oxygen extraction by the tissues.

04/15/2023 50
• Based upon these mechanisms, two types of cyanosis are de-
scribed: central and peripheral.
– Central cyanosis  — Central cyanosis is evident
when systemic arterial concentration of deoxygenated he-
moglobin (Hb) in the blood exceeds 5 gm/dL (3.1 mmol/
L) (oxygen saturation ≤85 percent).
– Of note, cyanosis cannot be detected by obser-
vation in patients with severe anemia (Hb
<5 gm/dL [3.1 mmol/L]).
– Best seen by inspecting the tongue, lips and
nailbeds.
04/15/2023 51
 Peripheral cyanosis   
• Patients with peripheral cyanosis have a normal systemic ar-
terial oxygen saturation.
• However, increased oxygen extraction → from sluggish
movement of blood through the capillary circulation → results
in a wide systemic arteriovenous oxygen difference and in-
creased deoxygenated blood on the venous side of the capil-
lary beds.
• Seen only in the nailbeds and finger tips and never on the
lips.

04/15/2023 52
 Causes of cyanosis
Central cyanosis
• Acute
– Severe Pneumonia , Severe
asthma, pulmonary edema,
pulmonary embolism
• Chronic
– COPD, pulmonary fibrosis,
polycythemia, hemoglobin
abnormalities
04/15/2023
Peripheral cyanosis
All causes of central
cyanosis
Exposure to cold
Shock
Arterial or venous obstruc-
tion
Vasoconstriction as in Ray-
naud’s phenomenon
53
Examination of the eyes Subconjuctival petechiae
Xanthelasma

04/15/2023 54
 High arched palate

04/15/2023 55
 BP Measurement
• Patient rest for at least 5 minutes in a quiet setting,
• Choose a correctly sized cuff and position the patient's arm at
heart level, either resting on a table if seated or supported at
mid-chest level if standing.
• Make sure the bladder of the cuff is centered over the brachial
artery.
• Inflate the cuff approximately 30 mm Hg above the pressure at
which the brachial or radial pulse disappears.
• As you deflate the cuff, listen first for the sounds of at least
two consecutive heartbeats—these mark the systolic pres-
sure. Then listen for the disappearance point of the heart-
beats, which marks the diastolic pressure.
04/15/2023 56
04/15/2023 57
 Definition of hypertension
• Is arbitrary.
• HTN is taken as the level associated
– with doubling of long-term CV risks
– Level at which there is benefit of intervention
• Based on evidences of risk and benefit of interven-
tions definition of hypertension has been evolving.
• After an initial screen
• Average of two or more properly measured readings of
two or more visits
 Classification OF HTN - adults
JNC – 7 2017 ACC/AHA
• Normal Blood Pressure Elevated BP: systolic 120-129 or
• Systolic <120 - >90 mmHg and diastolic diastolic < 80 mmHg
<80 - >60 mmHg
Stage I: systolic 130-139 or dias-
• Prehypertension tolic 80-89mmHg
• Systolic 120-139 or diastolic 80-89 NO pre-hypertension.
mmHg
• Hypertension
 Stage 1 Hypertension:
 Systolic 140-159 or diastolic 90-
99mmHg
 Stage 2 Hypertension:
 Systolic 160 or diastolic 100mmHg
 Sever HTN Defined as BP > 180/120
• Paradoxical Pulse: greater than normal (10
mmhg) drop in systolic pressure during inspi-
ration.
eg. pericardial tamponade, constrictive pericardi-
tis .

04/15/2023 60
Examination of the Arterial System
• Rate (normal = 60-100)
– Bradycardia (<60)
– Tachycardia (>100)
• Rhythm
– Regular
– Irregular
• Rate and rhythm are checked in the radial artery using the pads of
your index and middle fingers, or assess the apical pulse using your
stethoscope.
• Character and volume assessed from carotid artery.
• Radio-femoral delay for assessing for coarctation of the aorta-com-
paring radial and femoral pulse
• Peripherally accessible arterial pulses

04/15/2023 61
Con’t
Peripherally accessible
Radial Artery for counting pulse
artery rate

04/15/2023 62
Technique for brachial artery palpation

Technique for palpation of the femoral

arteries

04/15/2023 63
 Technique for timing the femoral and radial pulses.

04/15/2023 64
 Technique for palpation of the popliteal artery

04/15/2023 65
Peripheral Pulses Posterior tibial pulse

Dorsalis pedis pulse

04/15/2023 66
 Venous System Examination

• Jugular venous pressure measurement

• Lower extremity venous system examina-

tion-advanced ( reading assignment)
 Jugular Venous Pressure (JVP)
• JVP reflects pressure in the right atrium
• Assessed from pulsations in the right internal
jugular vein that lies deep to SCM muscle.
• It shouldn’t be done in children < 12 yrs.
• Estimate Central Venous Pressure maximum is
3-4cm from sternal angle + 5cm from
atrium = (Right atrial pressure)
• JVP > 9 cm – IS ELEVATED.

04/15/2023 68
04/15/2023 69
Cont

• Steps
– Position patient 30°/45°
– Tangential light
– Identify internal jugular venous pulsation on the
right side of the patient;
– Extend a long rectangular object or card horizon-
tally from this point and a centimeter ruler verti-
cally from the sternal angle, making an exact right
angle.
– Measure the vertical distance in centimeters

04/15/2023 70
04/15/2023 71
 • Note that the height of the venous pressure as measured from the sternal angle is the same in all three positions, but your abil-
ity to measure the height of the column of venous blood, or JVP, differs according to how you position the patient. Jugular
venous pressure measured at more than 4 cm above the sternal angle, or more than 9 cm above the right atrium, is considered
elevated or abnormal.

04/15/2023 72
04/15/2023 73
04/15/2023 74
 Causes for rise in JVP are
• Congestive heart failure • Cardiac tamponade
• Cor-pulmonale • Constrictive pericarditis
• Pulmonary embolism • Superior vena cava ob-
• Right ventricular infarction struction
• Tricuspid valve disease • Hypertrophic or Restric-
tive cardiomyopathy
• Fluid overload
 Examination of Heart/ Precordium

• Inspection

• Palpation

• Auscultation
• Percussion ???

04/15/2023 76
PRECORDIUM - INSPECTION
• Scars
• Chest deformity
– Pectus excavatum
– Pectus carinatum
– Bulged precordium
• Apex beat: lowest and most lateral beat;
– Lt. 5th ICS
– MCL

04/15/2023 77
 Precordium - Palpation
• Point of maximal impulse (PMI)
– Location
– Character
• Heaving
• Thrusting
• Tapping
• localized/diffuse
• Left parasternal heave
• Thrills (palpable murmurs)
– Systolic
– Diastolic
• Palpable P2 (pulmonary hyper-
tension)
• Pacemaker box

04/15/2023 78
 PMI
• It locates the left border of the heart.
• Usu. At the 5th Intercostal space 7 to 9 cm lateral to the mid-
sternal line, typically at or just medial to the left MCL
• The width is from 1cm to 2.5cm and if greater than 2.5 indi-
cates LVH or enlargement.
• Displacement of the PMI lateral to the MCL or greater than 10
cm from the mid-sternal line also suggests LVH or enlarge-
ment.
• PMI in the xiphoid or epigastric area -RVH

04/15/2023 79
Auscultation

• Proper auscultation requires

– Quiet area,
– Avoid extraneous noise from
radios, televisions,
– The earpieces of the stetho-
scope are directed anteriorly
or parallel to the direction of
the external auditory canal.

04/15/2023 80
• Diaphragm - high-pitched sounds e.g. S1 and
S2, the murmurs of aortic and mitral regurgita-
tion, and pericardial friction rubs.
– Listen throughout the precordium with the di-
aphragm, pressing it firmly against the chest.
• Bell - low-pitched sounds of S3 and S4 and the
murmur of mitral stenosis.
• Apply the bell lightly, with just enough pressure to produce
an air seal with its full rim. Use the bell at the apex, then move
medially along the lower sternal border.
04/15/2023 81
 Precordium – Auscultation
Heart Sounds
Bell is used for low pitched sounds.
Diaphragm is used fro high pitched sounds.
Mitral  Tricuspid  Pulmonary  Aortic
areas
S1 - (first heart sound- Closure of the mi-
tral valve produces the first heart sound)
S2 - (second heart sound- Aortic valve clo-
sure produces the second heart sound)
Lub-dub-lub-dub

04/15/2023 82
• Systole is period of ventricular contraction and diastole is period of ventricular re-
laxation.
• Systole
– Aortic valve – open allowing ejection of blood from the left ventricle into the
aorta.
– Mitral valve - closed, preventing blood from regurgitating back into the left
atrium.
• Diastole
– Aortic valve - closed, preventing regurgitation of blood from the aorta back
into the LV.
– Mitral valve is open, allowing blood to flow from the left atrium into the re-
laxed LV.
• Note that during auscultation the first and second heart sounds define the duration
of systole and diastole.
– Arise from vibrations emanating from the leaflets, the adjacent cardiac struc-
tures, and the flow of blood.
04/15/2023 83
• Rapid ventricular filling as blood flows early
in diastole from left atrium to left ventricle
normally seen in children and young adults.
• In older adults, an S3, sometimes termed “an S3
gallop,” usually indicates a pathologic change
in ventricular compliance.

04/15/2023 84
• Finally, although not often heard in normal
adults, a fourth heart sound, S4, marks atrial
contraction.
• It immediately precedes S1 of the next beat and
also reflects a pathologic change in ventricular
compliance.

04/15/2023 85
04/15/2023 86
 Sounds to be heard in auscultation
• First and second heart sound
• S and S sounds
3 4

• Murmur
• Splitting of the heart sounds
• Opening snap
• Pericardial knock/friction rub
• Heart murmurs are attributed to turbulent blood flow and are
distinguishable from heart sounds by their longer duration.
• May be “innocent,” as with flow murmurs of young adults.
• Two types of murmur
– A stenotic valve - an abnormally narrowed valvular orifice that obstructs blood
flow, e.g. Aortic stenosis,.
– Regurgitant murmur - is when a valve fails to fully close allowing blood to
leak backward in a retrograde direction, e.g. Aortic regurgitation or insuffi-
ciency.

04/15/2023 88
Precordium – Auscultation Murmurs
• Timing of murmur • Pitch
– Systolic • Radiation
– Diastolic • Dynamic maneuvers
– Continuous – Respiration
• Site of maximal intensity • Left-sided  on exp.
• Right-sided  on insp.
• Loudness
– Grades I-VI
– Thrill

04/15/2023 89
• Palpating the carotid pulse as you listen can
help you with timing. Murmurs that coincide
with the carotid upstroke are systolic.
• Diastolic murmurs usually indicate valvular
heart disease but systolic murmurs often oc-
cur when the heart valves are normal but may
indicate valvular disease.

04/15/2023 90
Heart Murmurs
• Systolic
– Pan systolic
• Mitral regurgitation
• Tricuspid regurgitation
• Ventricular septal defect
– Ejection systolic
• Aortic stenosis
• Pulmonary stenosis
• HOCM
• Atrial septal defect
– Late systolic
• Mitral valve prolapse
04/15/2023
• Diastolic
– Early diastolic
• Aortic regurgitation
• Pulmonary regurgitation
– Mid-diastolic
• Mitral stenosis
• Tricuspid stenosis
• Atrial myxoma
• Continuous
– Patent ductus arteriosus
– Arteriovenous fistula
91
 Cont
 Grading of Murmurs
1. Very faint, heard only with special effort
2. Quiet, but readily detected
3. Moderately loud
4. Loud, usually accompanied by a thrill
5. Very loud, with thrill, heard when the stetho-
scope is partly off the chest
6. Very loud, with thrill, heard when the stetho-
scope is entirely off the chest
04/15/2023 92
• Bruit-a murmur-like sound of vascular rather
than cardiac origin e.g. carotid stenosis.
• Radiation
– MR- to the axilla.
– AS – to the neck.

04/15/2023 93
 RELATION OF AUSCULTATORY FINDINGS
TO THE CHEST WALL
• The locations on the chest wall where you hear heart sounds
and murmurs help to identify the valve or chamber where they
originate.
– Mitral valve - heard best at and around the cardiac apex.
– Tricuspid valve - heard best at or near the lower left sternal border.
– Pulmonic valve - heard best in the 2nd and 3rd left interspaces close to the
sternum but at times may also be heard at higher or lower levels.
– Aortic valve - heard anywhere from the right 2nd interspace to the apex.
• These areas overlap, and you will need to correlate ausculta-
tory findings with other cardiac examination findings to iden-
tify sounds and murmurs accurately.

04/15/2023 94
 Recording the Physical Examina-
tion
• “The jugular venous pulse (JVP) is 3 cm
above the sternal angle with the head of bed
elevated to 30°. Carotid upstrokes are brisk,
without bruits. The point of maximal impulse
(PMI) is tapping, 7 cm lateral to the mid-ster-
nal line in the 5th intercostal space. S1 and S2
are well heard. No murmurs or extra sounds.”

04/15/2023 95
THANKS…