History Taking And Pe Of Cardiac Patients. Original.

HISTORY TAKING AND CLINICAL EXAMINATION OF CARDIAC PATIENTS BASIC CLINICAL SKILLS PARALLEL PROGRAM

DR. MOHAMMED FAKHRY, MD, FACC ,Associate Professor of Medicine Consultant Internist/Cardiologist King Faisal University King Fahd Hospital of the University

CARDINAL SYMPTOMS IN HEART DISEASE: Dyspnea Chest pain Cyanosis Syncope Palpitation

Edema Cough Hemoptysis Fatigue Intermittent Claudication

1)

DYSPNEA: “Unpleasant Awareness of Breathing”.

CAUSES: 1) Pulmonary • COPD • Restrictive L. Disease • Br. Asthma • Cardiac – CHF (MS, MR, AS, MI. CM) 1) Anemia 2) Obesity

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: 1) CAD  - Angina Pectoris - Unstable Angina. - Acute Myocardial Infarction 2) Mitral Valve Prolapse (MVP) 3) Pericarditis 4) GERD. 5) Peptic Ulcer Disease ( PUD )

CHRONIC STABLE ANGINA: TYPICAL ANGINAL PAIN Site Quality of pain Duration (few minutes) Radiation Provoking factor (Exercise, Emotional excitement and Cold weather.) Relieving factors (rest & TNG) Associated symptoms Risk Factors

UNSTABLE ANGINA New onset frequent angina Crescendo or accelerated angina Duration → 10min -30min Relation to rest Response to TNG

 ACUTE MYOCARDIAL INFARCTON PAIN: Site Quality Duration → > 30min. Associated Symptoms Response to S. L. TNG

III. CYANOSIS: “Bluish Discoloration of the Skin and Mucous Membranes.”

Peripheral. Central.

IV. DIZZINESS, PRESYNCOPE AND SYNCOPE. Definition: Causes: 1) Drugs: V. Dilator Drugs 2) Vasovagal syncope 3) Cardiac Arrhythmia

4) Cardiac Lesions (AS, MS, PS)

V.

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

Main Cause: Cardiac Arrhythmias Description: – – – –

Fast or slow Regular or irregular 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. ↑↑with exercize or even at rest in patients with CHF → transudation of fluid into alveolar spaces → Cough, and sometimes Hemoptysis

VIII. HEMOPTYSIS: Mild:  

P. Congestion (CHF)  Ruptured P. Capillaries. It occurs in the course of P. Infarction

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) JVP 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 ( Orientation to place, time & persons) – Body edema

2. HAND EXAMINATION: 1. Pallor 2. Cyanosis 3. Stigmata of Infective Endocarditis:

- Clubbing - Janeway lesion - Splinter Hem. - Osler’s Nodules) 4. Signs of Hyperlipidemia: Tendon Xanthomatosis

5. Signs of Thyrotoxicosis: Fine Tremors

3. RADIAL PULSE: 1. 2. 3. 4.

5. 6.

Rhythm Rate Volume Character: Normal Collapsing Pulse Slow rising pulse Vessel Walls Equality and Synchronization

AA )B (

B

Normal

C-pulsus Besferious

D-Pulsus Besferious

E-Collapsing Collapsing Collapsing pulse

4. BLOOD PRESSURE MEASUREMENT: 1. The Cuff 2. Position of the patient Technique – There are 5 KOROTKOFF’s Sounds: Syst BP  Korotkoff 1 Diast BP  Korotkoff 5

5. RESPIRATORY RATE AND TEMPERATURE. 6. FACE EXAMINATION: Abnormal Facies: Down’s Syndrome Marfan’s Syndrome Malar Rash

Pallor: Conjunctivae Mucous Membranes of the Mouth

6. FACE EXAMINATION (cont’d) Jaundice

 Sclera  Mucous Membranes of the Mouth

Arcus Cornialis Xanthelasma Cyanosis Signs of Hyperthyroidism

  

Exophthalmos Lid Lag Lid Retraction

Mouth Hygiene

7. JUGULAR VENOUS PRESSURE (JVP)

Position of the patient  45º Rt. Internal JV Waves:

7. JUGULAR VENOUS PRESSURE (JVP) (cont’d) Normal JVP = ≤ 8 cm water.

 Cause of absent A wave  A. Fib  Cause of prominent A wave → PAH

and TS Cause of Prominent V wave  TR

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

Auscultation: 

Systolic Bruit

9. THYROID GLAND: Inspection Palpation Percussion Auscultation

10. EXAMINATION OF THE PRECORDIUM: A) Inspection: Shape of the chest – – –

Pectus excavatum Pectus 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 pulsations: P. area Aortic area Epigastrium

B) PALPATION 1. Apical Impulse (PMI) Site Character • • • • •

Normal Hyperdynamic Sustained Tapping (palpable S1) Localized or diffuse

Thrill

2) Other Pulsation: Left Parasternal Heave.

Causes  

R.V. enlargement Severe LA dilatation

Pulmonary area

Dilated Pulm. Artery.→ PH

Aortic Area  Aortic aneurysm Epigastric pulsation: Causes:   

RV enlargement Pulsatile hepatomegaly  RS HF Palpable Abd. Aorta

C) PALPABLE HEART SOUNDS AND CLICKS 1. Palpable S1 Tapping apical impulse 2. Palpable P2  PH

D) THRILLS: 1.

Diastolic Thrills  MS & TS

1.

Systolic Thrill    

MR at the M. area AS  A. area PS  P. area VSD  3rd & 4th Lt. ICS

3. Continuous Thrill  PDA

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

C) CARDIAC AUSCULTATION: Circumstances Quiet and warm room. Systematic approach:  S1 at mitral area (diaphragm)  S2 at pulmonary area (diaphragm)  S3 & S4 at M. area & T. area (Bell)  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: E) Heart Sounds Pattern on Cardiac Auscultation: Lub ---- Dub ---- Lub ---- Dub F) Gallop Rhythm: Occurs due to presence of S3,S4 or a summation of S3 & S4 in tachycardic patients.

Accentuated S1: MS TS ST Soft S1 →Long PR interval Variable S1→ A. Fibrillation Muffled S1  MR

Accentuated A2 → Systemic Hypertension.

Accentuated P2 → P. Hypertension. Soft A2 → AR. Paradoxical Splitting of S2→ - AS

Opening Snap  MS Ejection Clicks: PS. AS. Opening Clicks: Prosthetic mitral and aortic valve opening.

Closing Clicks: Prosthetic Mitral and Aortic Valve closure

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

B) Organic: AS PS

PSM (Pansystolic murmur) MR TR VSD

Diastolic Murmurs: – Early Diastolic murmur: AR PR – Mid-diastolic murmur: MS TS

Continuous Murmur – PDA.

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

-

PSM due to 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 at aortic areas. ↑ By expiration ↓ Hand grip Radiates mainly to the neck (carotid arteries).

-

EDM  AR Best heard over aortic areas. ↑ by hand grip and expiration. ↑ sitting up and leaning forward. MDM  MS

   -

  

Best heard over the M. Area. ↑ Little exercise (↑HR). ↑ Left decubitus position.

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 & Palpation: Pale and cold. Hair loss. Loss of sensation. Signs of Gangrene  PAD  Total arterial occlusion

- Weak or absent pulsations: – – – – –

Dorsalis pedis Tibialis posterior Medial popliteal Femoral artery Poor capillary filling

C) Varicose Veins: – Inspection Dilated tortous superfacial 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. - Leg circumference is usually ≥ 2.5cm than the other leg (anatomical reference  tibial tuberosity