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 Edema
Chest pain Cough
Cyanosis Hemoptysis
Syncope Fatigue
Palpitation 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 D.O. extraordinary exertion (no

Dyspnea on average exertion)
Class II D.O. moderate exertion
Class III D.O. mild exertion
Class IV 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. The Cuff
2. Position of the patient
3. Home measurement
4. 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)
Cause of absent A wave  A. Fib
Cause of Prominent V wave  TR
Causes of Cannon A wave
Kussmaul’s Sign
↑ JVP during Inspiration > Expiration
Causes:
3. Constrictive Pericarditis
4. Cardiac tamponade
5. Severe RV failure
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
Precordial Bulge
Scar of previous cardiac surgery
– Mid-sternotomy scar
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
Diastolic Murmurs:
– Early Diastolic murmur:
AR
PR
– Mid-diastolic murmur:
MS
TS
VSD & ASD→M.area
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.
- MDM  TS
 Best heard over T. areas.
 ↑ by deep inspiration.
Mid-Late Apical Systolic Murmur → MVP
 Best heard at M. area.
 ↑ by hand grip & sitting position.
 ↑ by valsalva maneuver.
 ↑ by Amyle Nitrite Inhalation.
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.