Cardiovascular history and examination Flashcards
Cardiovascular history: chest pain
SOCRATES.
Site- central?
Onset- sudden? what was the patient doing?
Character- ask patient to describe pain, crushing? heavy?
Radiation- ask specifically if it moves to the arm, neck, or jaw.
Associations- ask specifically about SOB, nausea, sweating.
Timing? Duration?
Exacerbating and alleviating factors- worse with respiration or movement (less likely angina)? relieved by GTN? worse on inspiration and better leaning forwards (pericarditis)?
Severity- out of 10?
Is patient known to have angina or chest pain? better/worse/same as usual pain? more frequent? decreasing exercise tolerance?
‘Heartburn’ more likely if ‘burning’, onset after eating/drinking, worse lying flat, or associated with dysphagia.
Cardiovascular history: palpitations
‘Ever aware of your own heartbeat?
When and how did it start/stop?
Duration?
Onset sudden/gradual?
Associated with blackout (how long)?
Chest pain?
Dyspnoea?
Food related, e.g. caffeine?
Regular fast palpitations may reflect paroxysmal supra ventricular tachycardia (SVT) or ventricular tachycardia (VT).
Irregular fast palpitations are likely to be paroxysmal AF, or atrial flutter with variable block.
Dropped or missed beats related to rest, recumbency, or eating are likely to be atrial or ventricular ectopics.
Regular pounding may be due to anxiety.
Slow palpitations are likely to be due to drugs such as beta-blockers, or bigeminus.
Reassurance is vital and can be therapeutic.
Check a TSH and consider a 24hr ECG (Holter monitor).
Cardiovascular history: dyspnoea
Duration?
At rest?
On exertion?
Determine exercise tolerance (and any other reason for limitation, e.g. arthritis).
NYHA classification?
Worse when lying flat, how many pillows does the patient sleep with (orthopnoea)?
Does the patient ever wake up in the night gasping for breath (paroxysmal nocturnal dyspnoea), and how often?
Any ankle swelling?
Cardiovascular history: dizziness/blackouts
Did they lose consciousness? for how long? short duration suggests cardiac while long duration suggests neurological cause. Any warning (pre-syncope)? What was patient doing at the time? Sudden/gradual? Associated symptoms? Any residual symptoms, e.g. confusion? How long did it take for patient to return to 'normal'? Tongue biting, seizure, incontinence? Witnessed? Memory loss pre/post event?
Cardiovascular history: claudication
SOCRATES.
Foot/calf/thigh/buttock?
Claudication distance- how long can the patient walk before onset of pain?
Rest pain?
Cardiovascular history: past history
Angina? Any previous heart attack or stroke? Rheumatic fever? Diabetes? Hypertension? Hypercholesterolaemia? Previous tests/procedures (ECG, angiograms, angioplasty/stents, echocardiogram, cardiac scintigraphy, coronary artery bypass grafts)?
Cardiovascular history: drug history
Aspirin GTN Beta-blocker Diuretic ACE inhibitor Digoxin Statin Anticoagulant
Cardiovascular history: family history
First degree relatives having had cardiovascular events, especially if <60 years.
Cardiovascular history: social history
Smoking Impact of symptoms on daily life Alcohol (number of units) Hobbies Exercise
Cardiovascular history: ischaemic heart disease risk factors
Hypertension Smoking Diabetes mellitus Family history (1st degree relative <60yrs old with IHD) Hyperlipidaemia
Cardiovascular examination: introductions
Introduce yourself. Obtain consent to examine. Position the patient appropriately- lying on the bed at 45 degrees. Expose them to the waist. Explain what you are doing throughout.
Cardiovascular examination: general inspection
Assess general state (ill/well). Look for clues (oxygen, GTN spray). Colour (pale, cyanosed, flushed). Short of breath? Scars on chest wall?
Cardiovascular examination: hands
Temperature: capillary refill time.
Inspect skin: tobacco staining, peripheral cyanosis, tendon xanthomata (hyperlipidaemia), Janeway lesions, Osler’s nodes (signs of infective endocarditis).
Inspect nails: clubbing, splinter haemorrhages, nail bed pulsation (Quincke’s sign of aortic regurgitation), nail fold infarcts (vasculitis).
Clubbing = congenital cyanotic heart disease and endocarditis.
Splinter haemorrhages, Osler’s nodes (tender nodules, e.g. in finger pulps) and Janeway lesions (red macules on palms) are signs of infective endocarditis- if found, examine the fundi for Roth’s spots (retinal infarcts).
Cardiovascular examination: radial and brachial pulses
Radial: rate, rhythm, radio-radial delay (palpate pulse bilaterally simultaneously, e.g. from aortic arch aneurysm), radiofemoral delay (palpate ipsilateral pulses simultaneously- sign of coarctation of aorta), collapsing pulse (identify radial pulse, then wrap your fingers around wrist- check for pain in arm/shoulder before elevating arm from the elbow straight up).
Brachial: just medial to tendinous insertion of biceps; waveform character.
Cardiovascular examination: blood pressure
Hyper- or hypotensive? Pulse pressure (wide = aortic regurgitation, arteriosclerosis; narrow = aortic stenosis, dry).
Cardiovascular examination: neck
JVP: ask patient to turn head to the left and look at the supraclavicular fossa- comment on the height of the JVP and waveform, press on the abdomen to check the abdomino-jugular reflex.
Carotid pulse: inspect (visible carotid = Corrigan’s sign of aortic regurgitation), and palpate volume and character on one side then the other.
Cardiovascular examination: face
Colour: pale, flushed, central cyanosis.
Features: corneal/senile arcus, xanthelasma (signs of dyslipidaemia).
Pallor of the conjunctiva (anaemia).
Malar flush (mitral stenosis, low cardiac output).
Dental hygiene.
Exophthalmos or goitre (signs of Graves’ disease).
Dysmorphic face? e.g. Down’s syndrome, Marfan’s syndrome, etc.
Cardiovascular examination: praecordium, inspection
Scars: midline sternotomy, lateral thoracotomy (mitral stenosis valvotomy).
Cardiovascular examination: praecordium, palpation
Apex beat (lowermost lateral pulsation): usually 5th intercostal space in mid-clavicular line; measure position by counting intercostal spaces (sternal notch = 2nd intercostal space)- undisplaced/displaced? character: impalpable (?dextrocardia/COPD), tapping (palpable S1), double impulse, sustained/strong; count rate if pulse irregular.
Heaves and thrills: place the heel of the hand flat on chest to left then right of sternum; left parasternal heave = sustained thrusting usually felt at left sternal edge (right ventricular enlargement, e.g. in pulmonary stenosis, cor pulmonate, ASD); thrill = palpable murmur felt as a vibration beneath your hand.
Heaving: caused by outflow obstruction, e.g. aortic stenosis or systemic hypertension.
Thrusting: caused by volume overload, e.g. mitral or aortic incompetence.
Tapping: mitral stenosis, essentially a palpable 1st heart sound.
Diffuse: LV failure, dilated cardiomyopathy.
Double impulse: hypertrophic cardiomyopathy.
Cardiovascular examination: praecordium, auscultation
Apex (mitral area): listen with bell and diaphragm, identify 1st and 2nd heart sounds- are they normal? listen for added sounds and murmurs; with the diaphragm listen for a pan systolic murmur radiating to the axilla- mitral regurgitation.
At apex with bell, ask the patient to ‘roll over onto your left side, breathe out, and hold it there’ (a rumbling mid-diastolic murmur = mitral stenosis).
Lower left sternal edge (tricuspid area) and pulmonary area (left of manubrium in the 2nd intercostal space)- if suspect right-sided murmur, listen with patient’s breath held in inspiration.
Right of manubrium in 2nd intercostal space (aortic area)- ejection systolic murmur radiating to the carotids = aortic stenosis.
Sit the patient up and listen at the lower left sternal edge with patient held in expiration (early diastolic murmur = aortic regurgitation).
Also listen for bruits over the carotids if there is inequality between pulses or absence of a pulse: atherosclerosis, vasculitis.
Cardiovascular examination: to complete the examination
Palpate for sacral and ankle oedema.
Auscultate the lung bases for inspiratory crackles.
Examine the abdomen for a pulsatile liver and aortic aneurysm.
Check peripheral pulses, observation chart for temperature and oxygen sats, dip urine, perform fundoscopy.
Cardiovascular examination: lungs
Examine the bases for creps and pleural effusions, indicative of heart failure.
Cardiovascular examination: oedema
Examine the ankles, legs, sacrum, and torso for pitting oedema.
Cardiovascular examination: abdomen
Hepatomegaly and ascites in right-sided heart failure.
Pulsatile hepatomegaly with tricuspid regurgitation.
Splenomegaly with infective endocarditis.
Cardiovascular examination: fundoscopy
Roth spots: infective endocarditis.
Cardiovascular examination: urine dipstick
Haematuria.
Cardiovascular examination: presenting your findings
Signs of heart failure?
Clinical evidence of infective endocarditis?
Sinus/abnormal rhythm?
Heart sounds normal, abnormal, or additional?
Murmurs?
What is postural hypotension?
This is an important cause of falls and faints in the elderly.
It is defined as a drop in systolic BP of >20mmHg or diastolic >10mmHg after standing for 3 minutes vs lying.
What are the causes of postural hypotension?
Hypovolaemia (early sign).
Drugs, e.g. nitrates, diuretics, antihypertensives, antipsychotics.
Addison’s.
Hypopituitarism (low ACTH).
Autonomic neuropathy (DM, multisystem atrophy).
After a marathon run (peripheral resistance is low for some hours).
Idiopathic.
What is the treatment of postural hypotension?
Lie down if feeling faint.
Stand slowly (with escape route- don’t move away from the chair too soon).
Consider referral to ‘falls clinic’.
Manage autonomic neuropathy.
Increase water and salt ingestion.
Physical measures: leg crossing, squatting, elastic compression stockings, careful exercise.
If post-prandial dizziness, eat little and often, reduce carbohydrate and alcohol intake.
Head-up tilt of the bed at night increases renin release, so decreases fluid loss and increases standing BP.
1st-line drug = fludrocortisone, 2nd line = sympathomimetics e.g. midodrine or ephedrine, pyridostigmine.
What are the signs on physical examination of hyperlipidaemia?
Xanthomata are localised deposits of fat under the skin, occurring over joints, tendons, hands and feet.
Xanthelasma = xanthoma on the eyelid.
Corneal arcus = crescentic-shaped opacity at the periphery of the cornea.
Cardiovascular examination: pulses, rate
Is the pulse fast ≥100bpm or slow ≤60bpm?
