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A doctor who cannot take a good history and a patient who cannot give one are
in danger of giving and receiving a bad treatment
Goals of History Taking :
1. Gaining the patients confidence
2. Assessing the personality and character of the patient
3. Arriving at a tentative diagnosis
4. Plotting the work-up
The greater the number of symptoms , the less significance of each
Psychosomatic reaction / PPSR ? or Neurocirculatory asthenia ?
Sign and Symptoms of Cardiac Diseases :
Shortness of breath ( dyspnea )
Orthopnea, easy fatigability, PNDs
Swelling of the feet and enlarging abdomen / ascites ( edema )
Pain in the chest ( angina ) : LPPQRST localization, precipitating,
palliative , quality, radiation, severity, timing/ temporal profile
Palpitations
Cyanosis ( central/ peripheral type ), clubbing
Hemoptysis ; nocturia , loss of appetite, nausea, vomiting ; abdominal
pain, dysphagia ; dizziness / syncope ; visual disturbances ; epistaxis ;
skin/ dry/ sweating/pale / flushed
PAST HISTORY : DM , thyroid disease or other metabolic disorders ? ;
rheumatic fever, occupation , exposure to cardiotoxic agents , has he taken any
cardiac meds, digitalis . What is the tobacco or alcohol history ? Cocaine /
methamphetamine / shabu use ? has she been taking the pill ?
FAMILY HISTORY : any close member with congenital heart dse, RF, DM, HPN,
or CAD ? anybody died at an earlier age from IHD or HPN
PHYSICAL EXAMINATION
directed history and a targeted physical examination
clinical performance does not improve predictably as a function of experience;
instead, the acquisition of new examination skills may become more difficult for a
busy individual practitioner
Educational techniques to improve bedside skills include repetition, patientcentered teaching conferences, and visual display feedback of auscultatory
events with Doppler echocardiographic imaging
Why do we need to do physical examination ?
history and physical examination to the presence, severity, and prognosis of
cardiovascular disease
heart rate, blood pressure, signs of pulmonary congestion, and the presence of
mitral regurgitation (MR) bedside risk assessment in patients with acute
coronary syndromes
can inform clinical decision making before the results of cardiac biomarkers
testing are known.
jugular venous pressure (JVP) and the presence or absence of a third heart
sound (S3) prognosis of patients with systolic heart failure
Accurate characterization of cardiac murmursvalvular and congenital heart
lesions
enhancing the clinician-patient relationship cannot be overestimated
GENERAL APEARANCE :
The examination does not wait until the removal of the shirt .
SKIN :
hemochromatosis : unusually tan or bronze discoloration ; cause of the
associated systolic heart failure
Jaundice : visible first in the sclerae, has a broad differential diagnosis but
in the appropriate setting can be consistent with advanced right heart
failure and congestive hepatomegaly or late-term "cardiac cirrhosis
Cutaneous ecchymosis : vitamin K antagonists or antiplatelet agents such
as aspirin and thienopyridines
Lipid disorders : subcutaneous xanthomas, particularly along the tendon
sheaths or over the extensor surfaces of the extremities
Severe hypertriglyceridemia can be associated with eruptive
xanthomatosis and lipemia retinalis.
Palmar crease xanthomas : specific for type III hyperlipoproteinemia
Pseudoxanthoma elasticum, a disease associated with premature
atherosclerosis, is manifested by a leathery, cobblestoned appearance of
the skin in the axilla and neck creases and by angioid streaks on
funduscopic examination.
Extensive lentiginoses : Carney syndrome, which includes multiple atrial
myxomas.
lupus pernio and erythema nodosum dilated cardiomyopathy, especially
with heart block, intraventricular conduction delay, or ventricular
tachycardia
HEAD :
De Musset sign : head bobbing in Aortic Regurgitation
Enlarged skull : Pagets disease ; increased pulse pressure ( SBP- DBP =
> 40 mm Hg ) ; high output failure due to arteriovenous fistulae in affected
bones?
Premature frontal baldness : CAD ?
Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasia):
Hereditary telangiectasias on the lips, tongue, and mucous membranes
Malar telangiectasia : mitral stenosis and scleroderma
High arched palate : Marfans syndrome and other connective tissue
disease
Bifid uvula : Loeys-Dietz syndrome
Orange tonsils :Tangier disease
Congenital heart diseases : associated hypertelorism, low-set ears, or
micrognathia.
FACE :
Myxedema : coarse , puffy face , dry sallow skin, sparse eyebrows
pericardial effusion, CHF , CAD and mild HPN
Thyrotoxicosis : exopthalmos, lid lag atrial fibrillation and high output
failure ; MVP
Hypothyroidism CHF
EYES :
Arcus senilis or coneal arcus : under the age of 50 y/o hyperlipidemia
or early atherosclerosis ? ; lacks specificity as an index of coronary heart
disease risk.
Xanthelasma / Xanthomas lipid deposits
Cataract : DM ? ; in the young : rubella syndrome PDA
Blue sclerae : osteogenesis imperfect
Fundoscopy : assess the microvasculature, especially among patients
with established atherosclerosis, hypertension, or diabetes mellitus ;
should be performed routinely in the assessment of patients with
suspected endocarditis and those with a history of acute visual change ;
Branch retinal artery occlusion or visualization of a Hollenhorst plaque
Relapsing polychondritis may manifest as an inflamed pinna or, in its later
stages, as a saddle-nose deformity because of destruction of nasal
cartilage
Wegener's granulomatosis can also lead to a saddle-nose deformity.
Examination of the Retina
Arteriovenous ratio ; Optic disc: edema ; blurred margins cupping with
sharp contours ; Keith Wageners classification ( See Barbara Bates
book )
Variations of caliber : beading ; hypercholesterolemia or spasm ;
Severe HPN : scattered flame- shaped hges , very constricted arterioles,
cotton wool spots;
Hollenhurst cholesterol plaques and calcium emboli : from the heart , aorta,
great vessels or carotid arteries
EARS :
Pulsatile ears TR
Diagonal crease : assoc. with CAD but does not apply to Native American
Indians
NECK :
Vigorous carotid arterial pulsations AR , coarctation of the aorta (COA),
thyrotoxicosis or anxiety
Distended veins : RV failure , tricuspid valve dse, SVC syndrome
Webbed neck : Turners syndrome ( infantilism) COA
Noonans syndrome : ( short stature , webbed neck , hypertelorism,
mental and sexual retardation) PS ; often with ASD
CHEST :
COPD: pink puffer / blue bloater ( emphysema/ chronic bronchitis ,
respectively ) cor pulmonale , RV failure
Barrel chest deformity , pursed lips , tachypnea and use of accessory
muscles COPD
Kyphoscoliosis cor pulmonale
Cheyne stoke respiration : ( wax and wane respiration separated with
apneic spells ) serious cardiovascular and cerebrovascular disease ;
LV failure
Midline sternotomy, left posterolateral thoracotomy, or infraclavicular scars
at the site of pacemaker/defibrillator generator implantation
subclavian or vena caval obstruction : prominent venous collateral pattern
: head and neck appear dusky and slightly cyanotic and the venous
pressure is grossly elevated without visible pulsations SVC syndrome
Connective tissue disease : pectus carinatum ("pigeon chest") and pectus
excavatum ("funnel chest")
severe kyphosis and compensatory lumbar, pelvic, and knee flexion of
ankylosing spondylitis Aortic regurgitation
Straight back syndrome refers to the loss of the normal kyphosis of the
thoracic spine and has been described in patients with mitral valve
prolapse (MVP) and its variants
cyanotic congenital heart disease, the chest wall appears to be
asymmetric, with anterior displacement of the left hemithorax
HANDS :
Hyperthyroidism : warm , sweaty palm tachycardia can cause
Cardiomyopathy
Hypothyroidism : rough , dry skin bradycardia can cause
Cardiomyopathy
Clubbing : congenital cardiac or pulmonary disease ; central right to left
shunts and also infective endocarditis ; cyanosis and softening of the root
of the nail bed, to the classic loss of the normal angle between the base of
the nail and the skin, to the skeletal and periosteal bony changes of
hypertrophic osteoarthropathy, which is seen rarely in patients with
advanced lung or liver disease
Splinter hemorrhages : linear petechiae under the nail ( midposition of the
nail beds ) may be the first clue in IE esp with a patient with FUO ; but
can also be seen in minor trauma ; high altitudes
Percussion wave
Incisura
AOP
CP
Tidal wave
Dicrotic wave
: aortic pressure
: internal carotid pulse
Inequality of pulses bet. carotid and radial arteries with right sided
pulses stronger supravalvular AS
Other causes of inequality : dissecting aneurysm, aortic arch
syndromes( atherosclerotic, syphilitic and arteritic), thoracic outlet
syndromes ( cervical rib, scaleneus anticus ) and local occlusive
disease of the peripheral artery
Other pulsations : right parasternal ( ascending aortic aneurysm) ;
Femoral and/or popliteal artery aneurysms should be sought in
patients with abdominal aortic aneurysm disease.
level of a claudication-producing arterial obstruction can often be
identified on physical examination
calf claudication, a decrease in pulse amplitude between the common
femoral and popliteal arteries will localize the obstruction to the level of
the superficial femoral artery, although inflow obstruction above the
level of the common femoral artery may coexist
However, the correlation between the presence of a bruit and the
degree of vascular obstruction is poor
BLOOD PRESSURE
Brachial artery or radial artery ( upper extremities) and popliteal and
dorsalis pedis ( lower extremities )
Materials : BP apparatus with rubber cuff ( with the length encompassing
at least 80 to 100 % and width of 40 to 50% of the arm/ leg
circumference )
Seated for at least 15 mins ; 1 hr free from caffeine/ smoking ; BP cuff at
the level of the heart ; inflated rapidly to at least 30 mm Hg above the
obliteration of the pulse ( palpation method ) ; deflated slowly to around 3
mm Hg / sec, deflated rapidly after the DBP is noted
Auscultatory Method
Korotkoff sounds
phase 1 : clear tapping sounds ( SBP )
phase 2 : soft murmur
phase 3 : loud murmur ; blood flows to the constricted arteries
phase 4 : muffling sound ; constriction of the brachial artery
diminishes ( used in Pedia pts. )
phase 5 : disappearance of the sound ( DBP )
Normal : Phase 4 and 5 has a 10 mm Hg difference ( DBP )
chronic, severe AR or a large arteriovenous fistula because of enhanced
diastolic "run-off." DBP may be low or 0 mm Hg or if the difference of
phase 4 and phase 5 is > 10 mm Hg , one should measure phase 4 ( e.g.
BP = 142/ 54/ 10 mm Hg )
Auscultatory gap : implications : one may report a normal SBP when in
fact HPN is present ; technique : keep your finger on the pulsing artery as
you inflate the cuff until the pulse disappears then you know you are
above the SBP ; a silence that sometime separate the separates the first
appearance of the Korotkoff sounds from their second appearance at a
lower pressure ; venous distention or reduced velocity of arterial flow into
the arm ; seen in HPN, aortic valve dse., marked bradycardia and heart
failure
best assessed at the brachial artery level, though it can be measured at
the radial, popliteal, or pedal pulse level
Blood pressure should be measured in both arms, and the difference
should be less than 10 mmHg
Unequal BP on arms : atherosclerotic or inflammatory subclavian artery
disease, supravalvular aortic stenosis, aortic coarctation, or aortic
dissection.
Unequal pulse : take the BP of both upper and lower extremities
Normal : SBP legs up to 20 mm Hg higher than the arms but the DBP
identical
Hills sign : in AR ; SBP : popliteal > brachial artery by 20 mm Hg
Greater leg to arm pressure differences are seen in patients with chronic
severe AR as well as patients with extensive and calcified lower extremity
peripheral arterial disease
Jugular venous pulse wave tracing (top) with heart sounds (bottom). The A wave represents
right atrial presystolic contraction and occurs just after the electrocardiographic P wave and just
before the first heart sound (I). In this example, the A wave is accentuated and larger than normal
due to decreased right ventricular compliance, as also suggested by the right-sided S4 (IV). The
C wave may reflect the carotid pulsation in the neck and/or an early systolic increase in right atrial
pressure as the right ventricle pushes the closed tricuspid valve into the right atrium. The x
descent follows the A wave just as atrial pressure continues to fall. The V wave represents atrial
filling during ventricular systole and peaks at the second heart sound (II). The y descent
corresponds to the fall in right atrial pressure after tricuspid valve opening. B. Jugular venous
wave forms in mild (middle) and severe (top) tricuspid regurgitation, compared with normal, with
phonocardiographic representation of the corresponding heart sounds below. With increasing
degrees of tricuspid regurgitation, the waveform becomes "ventricularized." C. ECG (top), jugular
venous waveform (middle), and heart sounds (bottom) in pericardial constriction. Note the
prominent and rapid y descent, corresponding in timing to the pericardial knock (K)
Rarely palpable
Soft, rapid, undulating quality,
Usually w/ 2 elevations & 2 throughs
per heart beat
Pulsations eliminated by light pressure
On the vein (s) just above the sternal
End of the clavicle
Level of the pulsations changes w/
Position, dropping as the pt. becomes
More upright
Level of pulsations descends with inspiration
CAROTID PULSATIONS
- palpable
- a more vigorous thrust w/ a single
outward component
- Pulsations not eliminated by pressure
PRECORDIAL PALPATION
Location, amplitude , duration and direction of the cardiac impulse
fingertips
LV apex impulse : at or medial to the 4- 5th LMCL ICS ; less than 2.5 cm
in diameter ; best appreciated at end expiration , with the heart closer to
the anterior chest wall; note for size, amplitude and rate of amplitude
thin, tall patients and patients with advanced obstructive lung disease and
flattened diaphragms, the cardiac impulse may be visible in the
epigastrium and should be distinguished from a pulsatile liver edge
Supine, sitting ( leaning forward ) and left lateral decubitus
Enlargement of the LV cavity leftward and downward displacement of
an enlarged apex beat
LVH: increase in amplitude, duration, size of the LV thrust ; impulse
displaced laterally and downward into the 6th to 7th ICS ( AR and dilated
CMP )
sustained apex beat is a sign of pressure overload, such as that which
may be present in patients with AS or chronic hypertension
CARDIAC AUSCULTATION:
Quiet room ; focus on the phase of the cardiac cycle ; timing of the
heart sound or murmur ( carotid arterial pulse, apical impulse or JVP),
cardiac sound or murmur (alterations, in its timing in physiologic and
pharmacologic interventions )
The eye and the ears often misses what is not in the observers mind ,
but sees and hears what it looks for . Didactic thinking
HEART SOUNDS :
vibrations assoc. with abrupt acceleration or deceleration of blood
FIRST HEART SOUND ( S1 ) : loudest at the apex ; closure of the
atrioventricular valves ( MV /TV )
influenced by the :
1. position of the mitral valve leaflet (MVL) at the onset of ventricular
systole
2. rate of rise of the LV pressure pulse
3. presence or absence of structural dse. of the MVL
4. amount of tissue , air or fluid between the heart and stethoscope
A. Normal. S1, first heart sound; S2, second heart sound; A2, aortic component of the second
heart sound; P2, pulmonic component of the second heart sound. B. Atrial septal defect with fixed
splitting of S2. C. Physiologic but wide splitting of S2 with right bundle branch block. D. Reversed
or paradoxical splitting of S2 with left bundle branch block. E. Narrow splitting of S2 with
pulmonary hypertension.
SYSTOLIC SOUNDS :
Ejection sounds : sharp, high pitched; early systole, ffng the S1 ;
semilunar valve stenosis ( AS/ PS ), dilatation of the aorta or pulmo.
Artery ; heard at the LV apex area and 2 nd RICS
ejection sound that accompanies bicuspid aortic valve disease becomes
softer and then inaudible as the valve calcifies and becomes more rigid
Pulmonary Ejection sound : loudest ULSB ; heard better during expiration
ejection sound that accompanies pulmonic stenosis (PS) moves closer to
the first heart sound as the severity of the stenosis increases; the only
acoustic sound that decreases during inspiration
Non ejection clicks or midsystolic clicks with or without a late systolic
murmur : MVP or TVP ; result from chordae tendinae that are functionally
unequal in length or either or both AV valves ; heard at the LLSB and LV
apex
MVP : click-murmur complex will move away from the first heart sound
with maneuvers that increase ventricular preload, such as squatting. On
standing, the click and murmur move closer to S1.
Systolic clicks : later than the systolic ejection sound
DIASTOLIC SOUNDS
Opening snap ( OS ) : brief, high pitched , early diastolic sound, stenosis
of an AV valve ( MV/TV ) ;most often MV ;heard at LLSB and radiates to
the base of the heart ; decreases with progressive calcification and rigidity
of the anterior mitral leaflets
A2-OS interval ( 0.04 to 0.12 secs. ): inversely related to the height of the
mean left atrial pressure ; often confused with P2 at the 2 nd LICS
OS of TS occurs later in diastole than the mitral OS
Third heart sound ( S3 ) : low pitched ;produced in the ventricle ; 0.14 to
0. 16 s after A2 ; termination of the rapid filling ; rapid filling phase of
ventricular diastole; normal in children and pts with high cardiac output ;
over 40 y/o Ventricular failure / CHF ; disappears with tx of CHF
Left sided S3 : bell of stet; LV apex ; during expiration ; left lateral position
Right sided S3 : LSB or just beneath the xiphoid ; louder with inspiration ;
often accompanied with TR murmur
Early S3 (0.10 to 0. 12 s after A2 ) : constrictive pericarditis ; higher
pitched ( pericardial knock ) ; restrictive effect of the adherent pericardium
that abruptly halts the diastolic filling
Fourth Heart Sounds ( S4 ) : low pitched / bell of the stet ; presystolic
sound during ventricular filling ; effective atrial contraction; atrial filling
phase of ventricular diastole and indicates left ventricular presystolic
expansion ; absent in atrial fibrillation
S4 : diminished ventricular compliance
( diastolic dysfunction ) ;
resistance to ventricular filling ; seen in systemic hypertension, AS,
hypertrophic cardiomyopathy , IHD, acute MR, acute myocardial
infarction ; loud at LV apex, left lateral decubitus, increased in isotonic or
isometric exercise
Right sided S4 : RVH due to PS or pulmonary HPN ; frequently with
prominent systolic a wave in the JVP
S4 : delayed AV conduction ( AV blocks ) ; increases with age ; not
present with atrial fibrillation
pericardial knock (PK) is also high-pitched and occurs slightly later than
the opening snap, corresponding in timing to the abrupt cessation of
ventricular expansion after tricuspid valve opening and to an exaggerated
y descent seen in the jugular venous waveform in patients with
constrictive pericarditis
tumor plop is a lower-pitched sound that rarely can be heard in patients
with atrial myxoma. It may be appreciated only in certain positions and
arises from the diastolic prolapse of the tumor across the mitral valve
aorta
Pulmonary
Obstructive
Supravalvular pulmonary arterial stenosis
Valvular pulmonic valve stenosis
Subvalvular infundibular stenosis
Increased flow, hyperkinetic states, left-to-right shunt (e.g., ASD,
VSD)
Dilatation of pulmonary artery
Holosystolic (regurgitant)
Atrioventricular valve regurgitation (MR, TR)
Left-to-right shunt at ventricular level (VSD)
EARLY DIASTOLIC MURMURS
Aortic regurgitation
Valvular; rheumatic deformity; perforation, postendocarditis,
posttraumatic, postvalvulotomy
Dilatation of valve ring: aorta dissection, annuloectasia, cystic
medial necrosis, hypertension
Widening of commissures: syphilis
Congenital: bicuspid valve, with VSD
Pulmonic regurgitation
Valvular: postvalvulotomy, endocarditis, rheumatic fever,
carcinoid
Dilatation of valve ring: pulmonary hypertension; Marfan
syndrome
Congenital: isolated or associated with tetralogy of Fallot, VSD,
pulmonic stenosis
MIDDIASTOLIC MURMURS
Mitral stenosis
Carey-Coombs murmur (middiastolic apical murmur in acute
rheumatic fever)
Increased flow across nonstenotic mitral valve (e.g., MR, VSD,
PDA, high-output states, and complete heart block)
Tricuspid stenosis
Increased flow across nonstenotic tricuspid valve (e.g., TR, ASD,
and anomalous pulmonary venous return)
Left and right atrial tumors
CONTINUOUS MURMURS
Patent ductus arteriosus
Coronary AV fistula
Ruptured aneurysm of sinus of Valsalva
Aortic septal defect
Cervical venous hum
Anomalous left coronary artery
Proximal coronary artery stenosis
Mammary souffle
bilateral cuff inflation to 20 mmHg over peak systolic pressure augments the
murmurs of MR, VSD, and AR, but not murmurs due to other causes.
NOTE: TR, tricuspid regurgitation; TS, tricuspid stenosis; PR, pulmonic
regurgitation; HCM, hypertrophic cardiomyopathy; MVP, mitral valve prolapse; PS,
pulmonic stenosis; MS, mitral stenosis; MR, mitral regurgitation; VSD, ventricular
septal defect; AR, aortic regurgitation; VPB, ventricular premature beat; and AF,
atrial fibrillation.
SYSTOLIC MURMURS
Holosystolic ( Pansystolic ) murmurs : flow bet. 2 chambers that have
widely different pressures throughout systole (e.g. LA and LV ) ; begin with
S1 and ends with S2 ; MR / TR , VSD , aortopulmonary shunts
MR / VSD : augmented by exercise ; high pitched
TR : increases with inspiration ; assoc. with pulmo. HPN
Trivial MR : 45% of normal people ; Trivial TR by Doppler : 70% of normal
people ; PR in 88 %
with MR
Behavior of the click (C) and murmur (M) of mitral valve prolapse with changes in loading
(volume, impedance) and contractility. S1, first heart sound; S2, second heart sound. With
standing (left side of figure), volume and impedance decrease, as a result of which the click and
murmur move closer to S1. With squatting (right), the click and murmur move away from S1 owing
to the increases in left ventricular volume and impedance (afterload)
DIASTOLIC MURMUR
Early diastolic murmur : begin with or shortly after S2 ; soon as the
corresponding ventricular pressure falls below that in the aorta and the
pulmonary artery
AR : decrescendo ; diastolic blow ; high pitched ; LPSB with the patient
leaning forward ; expiration ; increased with hand grip ( acute elevation of
the arterial pressure ; diminishes with amyl nitrate inhalation ( decreased
in arterial pressure )
Congenital PR without pulmo. HPN : low to medium pitched ; early
diastolic murmur
PRESYSTOLIC MURMUR
during ventricular filling that follows the atrial contraction ; in sinus rhythm
AV valve stenosis ( MS/ TS ); usually crescendo ; reaching peak intensity
at loud S1 ; at the moment of right and left atrial contraction
Right or left atrial myxoma : middiastolic or presystolic murmur
CONTINUOUS MURMUR
Begin in systole , peak near S2 and continue in all or part of diastole