HISTORY TAKING AND CLINICAL EXAMINATION OF CARDIAC PATIENT

DR. MOHAMMED FAKHRY
Ass. Professor of Medicine Consultant Internist/Cardiologist Department of Internal Medicine King Fahd Hospital of the University

A) HISTORY
IMPORTANCE OF HISTORY: The richest source of information. It establishes a strong bond between the patient and his physician. It is the cornerstone of the diagnosis of some diseases.

CARDINAL SYMPTOMS IN HEART DISEASE:
Dyspnea Chest pain Cyanosis Syncope Palpitation Edema Cough Hemoptysis Fatigue Intermittent Claudication

DYSPNEA:
“Unpleasant Awareness of Breathing”.

CAUSES:
2) Pulmonary • COPD • Restrictive L. Disease • Br. Asthma • Ch. W. Dis. 3) Cardiac – CHF (MS, MR, AS, MI. CM) 4) Anemia 5) Obesity 6) Psychogenic.

FUNCTIONAL CLASSES OF DYSPNEA: (NYHA classification)
Class I Class II Class III Class IV D.O. extraordinary exertion (no Dyspnea on average exertion) D.O. moderate exertion D.O. mild exertion D. at rest (PND & Orthopnea)

II. CHEST PAIN OR DISCOMFORT:
Common Causes: CAD  Angina Pectoris, Unstable Angina and Acute Myocardial Infarction Mitral Valve Prolapse Pericarditis Esoph. Reflux and Esoph. Spasm Peptic Ulcer Disease Biliary Disease Cervical Disc Diseases

 TYPICAL ANGINAL PAIN “in chronic stable angina”:
Site Quality of pain Duration (few minutes) Radiation Provoking factor (Ex, exit, cold.weather.) Relieving factors (rest & TNG) Associated symptoms Risk Factors

 UNSTABLE ANGINA
New onset frequent angina. Crescendo or accelerated angina. Post MI Angina. Duration. Relation to rest. Response to TNG.

 ACUTE MYOCARDIAL INFARCTON PAIN: Site Quality Duration Associated Symptoms Response to S. L. TNG

III. CYANOSIS:
“Bluish Discolorationof Mucous Membranes.”

Peripheral. Central.

IV. DIZZINESS PRESYNCOPE AND SYNCOPE.
Definition: Causes:
Drugs: V. Dilators Vasovagal syncope Carotid S. Hypersensitivity. Cardiac Arrhythmia 5) Cardiac Lesions (AS, MS, PS)

PALPITATION:
“Unpleasant Awareness of Forceful or Rapid Beating of the Heart.”

Main Cause: Cardiac Arrhythmias Description:
– – – – – Fast or slow Regular or irregular Onset and offset Duration Associated symptoms

VI. EDEMA OF THE LOWER LIMBS. CAUSES: Cardiac. Renal. Hypoalbuminemia (Liver cirrhosis). Venous Insufficiency.

VII. COUGH DUE TO CHF:
It occurs when P.V. P. ↑ high like with exercise in cases of CHF.

VIII. HEMOPTYSIS:
Mild: P. Congestion (CHF)  Ruptured P. Capillaries. It occurs in the course of P. Infarcton. It occurs in the Eisenmenger Complex. Massive:  Ruptured A-V Fistula.  Ruptured Aortic Aneurysm.

IX. FATIGUE:
It is usually due to low C.O.

X. INTERMITTENT CLAUDICATION:
Peripheral Vascular Disease (PVD)

B) CLINICAL EXAMINATION
GENERAL CLINICAL EXAMINATION: Patient’s position : (45º inclination of the head of the bed) JVPº more convenient. Quiet & warm room with good lights.

General Clinical Examination (cont’d) 1)General Look
– Skin complexion (color) – Pain or respiratory distress – Level of consciousness (place, time & persons) – Body edema – Abnormal Facies
Marfan’s Syndrome Down’s Syndrome

– Involuntary Movements  Rheumatic chorea

2. HAND EXAMINATION:
Pallor Cyanosis Stigmata of Infective Endocarditis: - Clubbing - Janeway lesion - Splinter He. - Osler’s Nodules) Signs of Hyperlipidemia:
Xanthoma Palmaris Tendon Xanthomatosis

 Signs of severe AR: Quincke’s Signs  Signs of Thyrotoxicosis: Fine Tremors

3. RADIAL PULSE:
Rhythm Rate Volume – Normal – High Low  Character: – Collapsing Pulse – Slow rising pulse (pulsus parvus et tardus or Anacrotic Pulse) – Pulsus alterans – Pulsus paradoxicus – Pulsus bigeminus – Pulsus bisferious Vessel Walls Radio-radial and Radio-femoral Equality and Synchronization

4. BLOOD PRESSURE MEASUREMENT:
1. 2. 3. 4. The Cuff Position of the patient Home measurement Ambulatory 24 Hours BP Monitoring.

Technique – KOROTKOFF Sounds Syst BP  Korotkoff 1 Diast BP  Korotkoff 5

Blood Pressure Measurement (cont’d)
Optimal BP <120 Systolic <80 Diastolic Prehypertensive Stage  120-139 systolic  80-89 diastolic Stage 1 HPT  140-159 systolic  90-99 diastolic Stage 2 HPT  ≥160 systolic  ≥100 diastolic

5. RESPIRATORY RATE AND TEMPERATURE. 6. FACE EXAMINATION:

Abnormal Facies:
Down’s Syndrome Marfan’s Syndrome Molar Rash Plethoric Face

Pallor:
 Conjunctiva  Mucous Membranes of the Mouth

6. FACE EXAMINATION (cont’d)

Jaundice
Sclera Mucous Membranes of the Mouth

Arcus Cornialis Xanthelasma Cyanosis Signs of Hyperthyroidis
Exophthalmos Lid Lag Lid Retraction

Mouth Hygiene

7. JUGULAR VENOUS PRESSURE (JVP)

Position of the patient  45º Rt. Internal JV Anatomical Course Waves Normal JVP = ≤ 8 cm water. Causes of Prominent A wave
PH PS TS T. Atresia (Giant A wave)

7. JUGULAR VENOUS PRESSURE (JVP) (cont’d)

↑ JVP during Inspiration > Expiration Causes: 3. Constrictive Pericarditis 4. Cardiac tamponade 5. Severe RV failure

Cause of absent A wave  A. Fib Cause of Prominent V wave  TR Causes of Cannon A wave Kussmaul’s Sign

8. CAROTID PULSE:
Surface Anatomy Inspection
 Normal  Corrigan’s Sign

Palpation
Location:  Lt thumb for Rt carotid A  Rt thumb for Lt carotid A
    Volume Character Thrill  Carotid shadder Vessel walls

Auscultation:
Systolic Murmur Systolic Bruit

9. THYROID GLAND:
Inspection Palpation Percussion Auscultation

10. EXAMINATION OF THE PRECORDIUM:
A) Inspection:
Shape of the chest
– – – Pectus excavatum Rectus Craniatum Kyphosis & Scoliosis

– Mid-sternotomy scar

Precordial Bulge Scar of previous cardiac surgery

A) Inspection (cont’d)
Apex Beat:
Causes of absent apical impulse: Emphysema Obesity Dextrocardia Lt. pleural effusion or pneumothorax Severe pericardial effusion.

Other cardiac Impulses: Lt. parasternal P. area Aortic area Epigastrium

B) PALPATION
 Apical Impulse Site Character
 Normal  Hyperdynamic  Sustained

Tapping  Localized or diffuse

Thrill

2) Other Pulsation:
Left Parasternal Heave

Causes
 

R.V. enlargement Severe LA dilatation

Pulmonary area Dilated Pulm. Artery

Causes:
  

PH Idiopathic Post-stenotic

Aortic Area  Aortic aneurysm Epigastric pulsation:

Causes:
RV enlargement Pulsatile hepatomegalyRS HF Palpable Abd. Aorta

C) PALPABLE HEART SOUNDS AND CLICKS
 Palpable S1 Tapping apical impulse  Palpable P2  PH  Palpable S3  CHF  Palpable S4  HOCM  Palpable Clicks Metalic clicks  prosthetic valves

D) THRILLS:
 Diastolic Thrills  MS & TS  Rarely AR

Systolic Thrill
    MR at the M. area AS  aortic area PS  p. area VSD  3rd & 4th Lt. ICS

3. Continuous Thrill  PDA 4. Carotid Shadder  AS

C)CARDIAC AUSCULTATION
STETHOSCOPE:
 Bell  Low frequency sounds → S3, S4
→ Mid-diastolic murmur → MS b) Diaphragm  High frequency sounds → S1, S2, E. click, non-ejection click, clicks due to prosthetic valves. Systolic murmurs. Early diastolic murmur  AR Continuous murmur  PDA

C) CARDIAC AUSCULTATION:
Circumstances
Quiet and warm room. The physician should be well trained and with clear mind. Good stethoscope. Systematic approach:
S1 at mitral area (diaphragm) S2 at pulmonary area (diaphragm) S2 at aortic area for comparison S3 & S4 at M. area & T. area (Bell) Clicks  Diaphragm Inching auscultation

C) CARDIAC AUSCULTATION: Ausculatory Areas:
 Mitral Area  Apex beat area (5th LICS).  Tricuspid Area  4th LICS at sternal edge.  2nd Aortic Area  3rd LICS at sternal edge.  Pulmonary Area  2nd LICS at sternal edge.  1st Aortic Area  2nd RICS at sternal edge.

C) CARDIAC AUSCULTATION:
Ausculatory Areas (cont’d)
The HR should be counted from the M. area if it was totally irregular on radial pulse examination  pulsus deficit.

S1  M. area (mitral & tricuspid components) S2  P. area (aortic & pulm. components) → physiological splitting of S2

C) CARDIAC AUSCULTATION:
Ausculatory Areas (cont’d) Mitral & T. Areas for S3 and S4. S3  usually physiological in children and adolescents due to rapid filling of the LV. S3  CHF & volume overload. S4  HOCM, ACS, HPT. All ausculatory areas should be screened for systolic and diastolic murmurs (inching method).

C) CARDIAC AUSCULTATION
Timing in Cardiac Auscultation:
Carotid Impulse  systolic event. Apical Impulse  systolic event. The heart sound which correlates with the beginning of Carotid Impulse or Apical Impulse  S1. The heart sounds which correlates with the end of carotid or apical impulse  S2.

C) CARDIAC AUSCULTATION:
E) Heart Sounds Pattern on Cardiac Auscultation: Lub ---- Dub ---- Lub ---- Dub F) Gallop Rhythm:
Occurs due to presence of S3 or a summation of S3 & S4 in tachycardic patients.

Accentuated S1:
MS TS ST Short PR interval Hyperdynamic circulation (anemia, thyrotoxicosis & pregnancy) Prosthetic MV

Soft S1:
Long PR interval MR CHF LBBB Hypothyroidism

Variable S1:
Non-rheumatic A. Fibrillation 3º AVB Muffled S1  MR

Accentuated A2:
Systemic Hypertension. Congenital AS.

Accentuated P2:
P. Hypertension.

Soft A2:
AR. Aortic Valve Calcification.

Wide Splitting of S2 during inspiration: RBBB PS Fixed and Wide Splitting of S2: ASD RV Failure Paradoxical Splitting of S2: AS LBBB Severe LV Failure

Opening Snap  MS Ejection Clicks:
PS. AS. Prosthetic AVR (Opening Click of Prosth.AV)

Closing Click
Prosthetic Mitral valve closure (as a replacement of S1) Prosthetic AV closure (as a replacement of A2).

CARDIAC MURMURS:
Systolic Murmurs ESM (crescendo decrescendo murmur) A) Functional  Hyperdynamic circulation. Anemia. Pregnancy. Thyrotoxicosis. A-V shunts. Innocent in childhood and adolescence.

Systolic Murmurs (cont’d)
B) Organic:
AS - Supravalvular - Valvular - Subvalvular (HOCM-Subaortic descrete membrane) Coarctation of the aorta PS – Valvular – Infundibular – P. Artery stenosis

 Pansystolic Murmur
MR TR VSD

– Early Diastolic murmur: AR PR – Mid-diastolic murmur: MS TS VSD & ASD→M.area – – –

Diastolic Murmurs:

Continuous Murmur
PDA. Arteriovenous shunt. Arteriovenous malformation.

Description of a murmur: Quality and timing. Intensity – Scale of 6 grades. Site of maximum intensity. Radiation. Maneuvers which increases or decreases its intensity. e.g. - PSM due to MR
Best heart over the mitral area. ↑ handgrip Radiates to axilla

PSM  TR
 Beast Heard at TR area.  ↑ deep inspiration

-

PSM due to VSD
   Best heard at 3rd & 4th LICS Radiates to Rt. Side of the chest. ↑ hand grip

ESM due to valvular AS:
    Best heard on aortic areas. ↑ By expiration ↓ Hand grip Radiates mainly to the neck (carotid arteries).

ESM HOCM:
- Best heard at lower LSB and Mitral Area.

- ↑ Valsalva Maneuver (straining phases).
- ↓ Hand grip

ESM due to PS
 Best heard over the P. Area.  ↑ By deep inspiration.

-

EDM  AR
    Best heard over aortic areas. ↑ by hand grip and expiration. ↑ sitting up and leaning forward. Radiates to the lower LSB and C. Apex.

MDM  MS
   Best heard over the M. Area. ↑ Little exercise (↑ HR). ↑ Left decubitus position. Best heard over T. areas. ↑ by deep inspiration. Best heard at M. area. ↑ by hand grip & sitting position. ↑ by valsalva maneuver. ↑ by Amyle Nitrite Inhalation.

-

MDM  TS
     

Mid-Late Apical Systolic Murmur → MVP

Examination of Other Parts of the Body: Back
– Fine bilateral basal crepitation
LV Failure

– Sacral edema.

Liver  Pulsatile & tender hepatomegaly. Sometimes  Ascitis & splenomegaly.

Examination of Other Parts of the Body:

Lower limbs:
A) Cardiac Edema:
– – Bilateral & Pitting. Grades:
1+ Around ankle Joint.. 2+ Below knee joint. 3+ Above knee joint. 4+ Scrotal edema, hydrocele, and edema of the ant. abdominal wall.

B) Peripheral Circulation:
– Inspection:
Pallor. Hair loss. → PVD (Arterial stenosis) Signs of Gangrene  PVD  Total arterial occlusion.

– Palpation:
Cold limb. Sensation loss. Dry skin.

B) Peripheral Circulation (cont’d):
– Weak or absent pulsations: Dorsalis pedis. Tibialis posterior. Medial popliteal. Femoral artery. – Poor capillary filling.

C) Varicose Veins:

– Inspection Dilated superfacial tortous veins. – Long saphenous vein. – Short saphenous vein. Ulceration. Pigmentation. Eczema.

D) Deep Venous Thrombosis (DVT):
– Unilateral Pitting edema. – Darker skin than the other limbs. ↑ surface temperature. – Tense and painful calf. – Superfacial varicosity. Level: – below knee joint medial popliteal vein – above knee joint long saphenous vein or femoriliac venous thrombosis.

:D) Deep Venous Thrombosis
Leg circumference is usually ≥ 2.5cm than the other leg (anatomical reference  tibial tuberosity Thigh circumference ≥ 5cm than the other thigh. (Anatomical land mark medical or lateral epicondyle of the femor bone)

E) Peripheral signs of Severe AR:
– Pistol shot (Traub’s sign). – Durozie’s sign. – Quinck’s sign.

F) Signs of Hyperlipidemia:
– Arcus cornealis. – Xanthelasm. – Tendon Xanthomatosis. – Xanthoma Palmaris.

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