1.

2.

HISTORY & PHYSICALEXAMINATION OF CVS Presented by: Mandeep Duarah (CRI)

HISTORY TAKING IN CVSShould record the details of: PRESENTING SYMPTOMS
chest pain, fatigue & dyspnoea, palpitations, and presyncope or syncope. PREVIOUS
ILLNESS HABITS smoking, alcohol abuse FAMILY HISTORY DRUG HISTORY

3.

PRESENTING SYMPTOMSCHEST PAIN1. Myocardial ischaemia Ischaemia of the

heart results from an imbalance between myocardial oxygen supply & demand, producing pain
called angina. The patient describes retrosternal pain which may radiate into the arms, the
throat or the jaw. It has a constricting character, is provoked by exertion & relieved rapidly by
rest. View slide
4.
2. Pericarditis Also causes central chest pain, which is sharp in character & aggravated
by deep inspiration, cough or postural changes. Usually idiopathic or caused by coxsackie B
infection. View slide
5.
3. Aortic dissection Severe tearing pain in either the front or the back of the chest.
Onset is abrupt, unlike the crescendo quality of ischaemic cardiac pain.
6.

DYSPNOEA A major symptom of many cardiac disorders, particularly left heart

failure.1. Exertional Dyspnoea Most troublesome symptom in heart failure. Exercise causes
a sharp increase in left atrial pressure & this contributes to the pathogenesis of dyspnoea by
causing pulmonary congestion.

7.

2. Orthopnoea In patients with heart failure lying flat causes a steep rise in left atrial
pressure, resulting in pulmonary congestion & severe dyspnoea.3. Paroxysmal Nocturnal
Dyspnoea Caused by congestion (excessive or abnormal accumulation of blood) in the lungs,
along with accumulation of excess fluid in the lungs (pulmonary edema), which occurs as a result
of left sided heart failure.

8.

FATIGUE Important symptom of heart failure. Caused partly by deconditioning &

muscular atrophy but also by inadequate oxygen delivery to exercising muscle, reflecting
impaired cardiac output.

9.

PALPITATION Description of the rate & rhythm of the palpitation is essential. Rapid
irregular palpitation is typical of atrial fibrillation Rapid regular palpitation of abrupt onset occurs
in atrial, junctional & ventricular tachyarrhythmias.

10.

DIZZINESS & SYNCOPE Cardiovascular disorders produces dizziness & syncope by

transient hypotension, resulting in abrupt cerebral hypoperfusion. Recovery is usually rapid.

11.

PHYSICAL EXAMINATION OF CVS INSPECTION OF THE PATIENT

EXAMINATION OF THE RADIAL PULSE MEASUREMENT OF HEART RATE & BLOOD
PRESSURE JUGULAR VENOUS PULSE PALPATION OF THE ANTERIOR CHEST
WALL AUSCULTATION OF THE HEART

12.

INSPECTION OF THE PATIENT Chest wall deformities such as pectus excavatum

(hollowed chest) should be noticed. Most common congenital deformity of anterior chest wall
Sunken appearance of sternum, may compress the heart & displace the apex Hypothesized
that there is impairment of CVS function.

13.

Large ventricular or aortic aneurysms may cause visible pulsations. Superior vena
caval obstruction is associated with prominent venous collaterals on the chest wall. Prominent
venous collaterals around the shoulder occur in axillary or subclavian vein obstruction.

14.

ANAEMIA May exacerbate angina & heart failure. Pallor of the mucous membranes
is a useful physical sign but for confirmed diagnosis lab measurements of haemoglobin
concentration is required.CYANOSIS Bluish discoloration of the skin & mucous membranes
caused by increased concentration of reduced haemoglobin in the superficial blood vessels.

15.

a. Central cyanosis Caused by reduced arterial oxygen sauration caused by cardiac or

pulmonary disease. Affects not only the skin & lips but also the mucous membrane of the
mouth. Causes include pulmonary oedema (which prevents adequate oxygenation of the
blood) & congenital heart disease (tetralogy of fallot, eisenmengers syndrome).

16.

b. Peripheral cyanosis Cutaneous vasoconstriction slows the blood flow & increases
oxygen extraction in the skin & lips. Can be seen in fingers, underneath fingernails, other
extremities. Occurs in heart failure and mitral stenosis.

17.

CLUBBING Congenital cyanotic heart disease & infective endocarditis.OTHER

CUTANEOUS AND OCULARSIGNS OF INFECTIVEENDOCARDITIS Splinter haemorrhages
in nail bed Oslers nodes (tender erythematous nodules in the pulp of the fingers) Janeway
lesions (painless erythematous lesions on the palm)

18.

COLDNESS OF THE EXTREMITIES Important sign of reduced cardiac output in

severe heart failure. Caused by reflex vasoconstriction of the cutaneous bed.PYREXIA
Infective endocarditis is associated with pyrexia Can also occur for the first 3 days after
myocardial infarction.

19.

OEDEMA Subcutaneous oedema that pits on digital pressure is a cardinal feature of

congestive heart failure. Pressure should be applied over a bony prominence (tibia,lateral
malleoli,sacrum) In advanced heart failure oedema may involve the legs, genitalia & trunk.

20.

ARTERIAL PULSEShould be palpated for evaluation of:1. RATE & RHYTHM Rate,
expressed in beats per minute (bpm), is measured by counting over a timed period of 15
seconds. An irregular rhythm usually indicates atrial fibrillation.

21.

2. CHARACTER Defined by the volume & waveform and should be evaluated at the
right carotid artery (pulse closest to the heart & least subject to damping & distortion) Pulse
volume is small in heart failure & large in aortic regurgitation. Pulsus alternans relatively high
amplitude or normal amplitude pulse followed by a pulse of lower amplitude, occurs in severe left
ventricular disease.

22.

Pulsus paradoxus occurs when the pulse prssure falls by >10mm hg with each
inspiration, found in constructive pericarditis & cardiac tamponade. Bisferiens pulse (biphasic
pulse) with 2 systolic peaks is usually attributed to a combination of aortic stenosis & aortic
regurgitation.

23.

3. SYMMETRY Symmetry of the radial, branchial, carotid, femoral, popliteal & pedal
pulses should be confirmed. Coarctation of the aorta causes symmetrical reduction & delay of
the femoral pulses compared with the radial pulses.

24.

MEASUREMENT OF BLOODPRESSURE Measured using sphygmomanometer

Patient is placed at supine position A cuff of atleast 40% the arm circumference in width is
attached to a mercury manometer & inflated around the extended arm Auscultation over the
brachial artery reveals 5 phases of korotkoff sounds as the cuff is deflated:

25.

Phase 1: the first appearance of the sounds marking systolic pressure Phase 2 & 3:
increasingly loud sounds Phase 4: abrupt muffling of the sounds Phase 5: disappearance of
the sounds.Conditions where korotkoff sounds remain audibledespite complete deflation of the
cuff (aorticregurgitation, arteriovenous fistula) phase 4 mustbe used for the diastolic
measurement.

26.

JUGULAR VENOUS PULSE Best examined while the patient reclines at 45 degrees
with patients head partially rotated to one side. Sternal angle is reference point for JVP
Differentiate from carotid - multiple wave forms - can be abolished by gental digital
pressurewhere as carotid pulsation is always palpable & cannotbe abolished by gentle digital
pressure.

27.

JUGULAR VENOUS PRESSURE Position the patient so that the upper level of JV pulse
is visible Place ruler at sternal angle which is 5cm above the RA Hold another ruler horizontally
at the top of JV pulse Note how many cms this is above the sternal angle , add 5cms to this
number & total is JV pressure Normal pressure is less than or equal to 9cm.

28.

CAUSES OF ELEVATED JUGULARVENOUS PRESSURE Congestive heart failure

Cor pulmonale Pulmonary embolism Right ventricular infarction Tricuspid valve disease
Tamponade Constrictive pericarditis Superior vena cava obstruction

29.

PALPATION OF CHEST WALL Used for detection of parasternal heaves & apex beat
Parasternal heave is discerned with the heel or flat of the right hand against the left parasternal
region, right ventricular hypertrophy causes a left parasternal heave. Apex beat is defined as
the lowest & most lateral point at which the cardiac impulse can be palpated. The apex beat is
normally located in the fifth left intercostal space in the mid-clavicular line. Apex beat is
displaced in left ventricular dilation.

30.

AUSCULTATION OF THE HEART Use the diaphragm for high pitched sounds &
murmers Use the bell for low pitched sounds & murmers Sequence of auscultation- Upper
right sternal border (URSB) withdiaphragm(aortic area)- Upper left sternal border (ULSB) with
diaphragm(pulmonary area)- Lower left sternal border (LLSB) with diaphragm(tricuspid)- Apex
( mitral area)

31.

After the age of 40 S3 is nearly always pathological, usually indicating left ventricular
failure, mitral regurgitation S4 is also pathological and heard in aortic stenosis, hypertrophic
cardiomyopathy.

32.

systolic clicks & opening snaps Valve opening is normally silent In aortic stenosis
valve opening produces a click, the click is only audible if the valve cusps are pliant & noncalcified, and is prominent in bicuspid valve. In mitral stenosis, elevated left atrial pressure
causes forceful opening of the thickened valve leaflets, this generates a snap.

33.

Heart murmurs Caused by turbulent flow within the heart & greater vessels.
Turbulence is caused by increased flow through a normal valve usually aortic and pulmonary.
Murmurs may also indicate valve disease or abnormal communications between the left & right
sides of the heart (septal defects).

34.

According to the phase of systole or diastole duringwhich it is heard murmurs are

classified as:1. Systolic murmurs Midsystolic murmur caused by turbulence in the left or right
ventricular outflow Pansystolic murmur mitral regurgitation, tricuspid regurgitation, ventricular
septal defect Late systolic murmur mitral valve prolapse, tricuspid valve prolapse.

35.

2. Diastolic murmurs Early diastolic murmurs caused by regurgitation through aortic

and pulmonary valves Mid diastolic murmurs caused by turbulent flow through the
atrioventricular valves (mitral stenosis) Presystolic murmur mitral & tricuspid stenosis.3.
Continuous murmurs Heard during systole & diastole Patent ductus arteriosus

The Cardiac Exam: History Taking

Introduction

As with any part of the physical exam, a complete cardiac exam

should begin with a detailed cardiac history. A good historian
should be able to predict the physical exam findings before
attempting the actual physical exam. A thorough cardiac history
should include investigating for the following cardiac (8)
symptoms, as well as general cardiac heart:

Chest pain

Cyanosis (turning blue)

Dyspnea (shortness of breath)

Edema (dependent - i.e. gravity edema)

Fainting (syncope)

Fatigue

General

Hemoptysis (coughing up blood)

Irregular heart beat

Tip: Think Cx2DEFx2GHI (Chest pain, Cyanosis, Dyspnea,

Edema, Fainting, Fatigue, General, Hemoptysis, Irregular
heart beat)
Questions for each symptom should cover the 7 classic dimensions of directed
history taking:
1.

quality (q1)

2.

quantity (q2)

3.

aggravating (alleviating) factors (af)

4.

time course (t)

5.

location (l)

6.

associated symptoms (as)

7.

setting (s)

Tip: Think Qx2ATLAS (Quality, Quantity,

Aggravating/Alleviating factors, Time course, Location,
Associated symptoms, Setting)
A sample list of relative questions pertaining to each symptom (including question
category) is shown below.
Chest Pain

Where is the pain (l)?

When did the pain first start (t)?
How long does it last (t)?
Does the pain radiate, if so where (q2/am)?

 How often do you have the pain (q2)?

How would you describe the pain - burning, pressing,
stabbing, crushing, dull, aching, throbbing, sharp,
constricting (q1)?
Does the pain occur at rest, with exertion, with stress, after
eating, when moving your arms, or during intercourse (af/s)?
Do you have any other symptoms with the pain such as
shortness of breath, palpitations, nausea, vomiting,
coughing, fever, leg pain (as)?
Cyanosis (bluish color skin)

Where is the bluish color skin?

How long have you noticed it?
Did is seem to happen suddenly or gradually?
What type of work do you do?
Does anyone else in your family has this condition?
What makes the bluish skin color better or worse?
Have you had any chest pain, cough, or bleeding associated
with the bluish color skin?
Dyspnea (shortness of breath)

How long have you been short of breath?

Did the shortness of breath occur suddenly or gradually?
Do you ever wake up at night feeling short of breath
(paroxysmal nocturnal dyspnea)?
How many pillows do you sleep on at night?
How far can you walk before you become short of breath?

 Have you notice swelling in your legs associated with your

shortness of breath?
Have you had any chest pain associated with your shortness
of breath?
Edema (dependent)

Do you have swelling in your legs?

When did you first notice the swelling?
Did it appear suddenly or gradually?
Is the swelling worse in the morning or evening?
Does the swelling decrease after a night's sleep?
Do you shortness of breath associated with the swelling?
Have you noticed any change in your weight?
Does elevating your feel make the swelling go down?
Do you have pain in your legs associated with the swelling?
Do both legs swell equally?
Are you taking any medications, if so, which ones?
Fainting (syncope)

How often do you faint (or feel like you are going to faint)?
What are you doing when you faint (or feel like you are
going to faint)?
Have you ever lost consciousness?
Does the fainting (of feeling like you are going to faint)
occur suddenly?
In what position were you when you fainted (or felt like you
were going to faint)?

 Have you noticed anything that seem to be associated with

the fainting (feeling like you are going to faint), for example,
chest pain, irregular heart beat, nausea, confusion, hunger,
tingling, or numbness?
Do you have any black, tarry bowl movements after the
fainting episode?
Do you have heavy periods?
Fatigue

How long have you felt fatigued?

Did the fatigue come on suddenly or gradually?
Do you feel tired all day or only in the morning and/or
evening?
Do you feel more tired at home or at work?
Is your fatigue relieved by rest?
When do you feel least tired?
General

Have you ever had any problems with your heart?

Have you ever had angina or a heart attack?
Have you ever had a cardiac catheterization or heart
surgery?
Do you have high blood pressure?
Have you ever been told you had a heart murmur or had
rheumatic fever?
Have you ever had phlebitis (pain) or swelling in your legs?
Hemoptysis (coughing up blood)

How long have you been coughing up blood?

 How often do you cough up blood?

Do you have chest pain when you cough up blood?
How much blood do you cough up?
Irregular Heart Beat

Do you have any problems with irregular heart beat or

palpitations (when you can feel your heart beating fast or
irregular)?
How long have you had the irregular heart beats?
When did you first notice the irregular heart beats?
How long did the irregular heart beats last?
What did the irregular heart beats feel like?
Did anything you do stop the irregular heart beats?
Did the irregular heart beats stop abruptly?
Could you count your pulse during the episode?
Can you tap on the table what the rhythm felt like?
Have you noticed the irregular heart beats during exercise?
Did you experience any sweating, flushing, or headaches
with your irregular heart beats?
Any you taking any medications, if so, which ones?
Has anyone ever told you that you had problems with your
thyroid gland?
Do you smoke or use any other recreational or street drugs,
if so, how much and how often?
How much caffeine do you drink a day (coffee, tea, soft
drinks)?

 After the irregular heart beats, do you need to urinate?

Please feel free to make suggestions of additional questions you typically ask
during your history through the comments page.
(17 March 2013)

david.kaelber@case.edu-- Copyright 1999-2013-- Unauthorized use prohibited