What are common symptoms of heart disease
- chest discomfort
- breathlessness
- palpitation
- syncope/dizziness
- oedema
What are the cardiovascular causes of chest pain?
- angina
- myocardial infarction
- pericarditis
- aortic pain
Describe the characteristics of angina
- precipitates by exertion
- eased by rest and/or GTN
Describe the characteristics of myocardial infarction
- similar distribution to angina
- more severe
- persists at rest
Describe the characteristics of pericarditic pain
- sharp
- raw or stabbing
- varies with breathing or movement
Describe the characteristics of aortic pain
- severe
- tearing
- sudden onset
- radiates to the back
What are the aggravating factors of angina?
- exertion
- emotional excitement
- cold weather
- exercise after meals
What are the relieving factors of angina?
- rest
- glyceryl trinitrate
- warm-up before exercise
Describe the site of angina or myocardial infarction
- retrosternal
- radiates to arm, epigastrum, neck
Describe the site of pericarditic pain
- retrosternal
- may radiate down left shoulder or back
Describe the site of aortic pain
Often felt between the shoulder blades and/or behind the sternum
What is dyspnoea?
- breathlessness
- awareness of increased drive to breathe
(non-specific)
What is orthopnoea?
Dyspnoea on lying flat
- sign of advanced heart failure
What is palpitation?
an unexpected awareness of the heart beating in the chest
In what ways can you distinguish palpitations?
- onset and termination (abrupt/gradual)
- precipitating factors (exercise/alcohol/caffeine)
- frequency and duration
- character and rhythm
What are the main causes of syncope?
- postural hypotension
- neurocardiogenic syncope (vasovagal)
- arrythmias
- mechanical obstruction of cardiac output
What are the causes of unilateral oedema of the leg?
- DVT
- soft tissue infarction
- trauma
- immobility
- lymphatic obstruction
What are the causes of bilateral oedema of the leg?
- Heart failure
- chronic venous insufficiency
- hypoproteinaemia
- lymphatic obstruction
- Drugs
- IVC obstruction
- Thiamine deficiency
- Milroy’s disease
- Immobility
What factors should you establish from the presenting complaint?
- frequency
- duration
- severity
- causative/relieving factors
- breathessness
- recent chest, or lower limb pain
How can you assess for functional impairment?
- impact of symptoms
- strenuous/gentle exercise provoking symptoms
- can you keep up with walking with others?
- domestic/occupational capacity
- how far can you walk before pain (uphill/flat)
What factors should be obtained from the past medical history?
- rheumatic fever
- heart murmurs
- hypertension
- DM
- kidney disease
- thyrotoxicosis
- marfan’s syndrome
What medications should you enquire about?
- thyroxine
- amphetamines/cocaine
- NSAIDs
- herbal medicines
- beta blockers
What family history factors are relevant?
- premature CAD in 1st degree
- sudden unexplained death in the family at a young age
What social factors are important
- smoking
- alcohol
- poor nutrition
What should be noted on general examination?
- looks unwell
- breathless/cyanosed
- fightened/distressed
- medical aids (oxygen)
- correctly position the patient at 45 degrees
What are you looking for on the hands?
- Temperature
- peripheral cyanosis
- CRT (<2s)
- finger clubbing
- splinter haemorrhages
- tar staining
How do you assess the radial pulse?
- rate
- rhythm
- volume
- character
assess simultaneously
What are you looking for on the face?
- conjuctival palor (anaemia)
- corneal arcus (hyperlipidaemia)
- xanthelasma (hyperlipidaemia)
- central cyanosis (lips and tongue)
How do you assess the jugular venous pressure
- patient @ 45 degrees
- head tilited up and to the left
- JVP is double pulsation
Hepatojugular reflex cab exaggerate a raised JVP = press on the right upper quadrant of the abdomen
How do you detect a collapsing pulse?
- raising patients hand above their head
What is the surface landmark for the radial pulse?
- at the wrist, lateral to the flexor carpi radialis tendon
What is a normal resting HR?
60-100
Bradycardia < 60
Tachycardia > 100
What are the steps of BP measurement?
- patient rested
- support arm at heart level
- apply cuff
- palpate brachial pulse
- inflate cuff until brachial pulse is impalpable
- inflate 30 above this with stethascope over brachial artery
- deflate slowly until you hear regular tapping (korotkoff sounds phase 1)
- Continue to deflate until sounds disappear
sound of tapping = systolic
sounds disappear = diastolic
What should you inspect the praecardium for?
- scars
- abnormal shape/contour
- visible pulsations
- devices in situ
What should you palpate on the praecardium?
- apex beat
- heaves
- thrills
Where can the apex beat be found?
- 5th intercostal space in the midclavicular line
- feel the borders of the clavicle and work out 1/2 way
- Palpate sternal angle where 2nd rib meets sternum and meet you mid point
- Count down five spaces
What is a heave?
left parasternal impulse and is resent where there is an abnormally strong cardiac impulse
How is a heave assessed?
place entire stretched out hand on the chest parallel to the sternum on the left side with with your fingers pointing towards the patient’s neck
If present, heel of your hand will move
What is a thrill?
palpable murmur caused by turbulent blood flow through a heart valve
Where should a thrill be assessed?
- apex
- upper praecardium
- sternal notch
Which areas of the chest should be auscultated?
- mitral area
- tricuspid area
- pulmonary area
- aortic area
Where is the mitral area?
- 5th intercostal space in the mid-clavicular line
Where is the tricuspid area?
4th intercostal space at the left sternal edge
Where is the pulmonary area?
2nd intercostal sace at the left sternal edge
Where is the aortic area?
2nd intercostal space at the right sternal edge
How should auscultation be performed?
M > T > P > A
- start with the diaphragm and then use the bell in the mitral area
- palpate the carotid/radial
What murmurs can be exaggerated?
- mitral stenosis
- aortic regurgitation
What manoeuvre can be performed on the mitral area?
- ask the patient to roll onto their left hand side and listen with the bell for mitral stenosis
What manoeuvre can be performed on the aortic area?
- ask the patient to sit forward and hold their breath in expiration
- listen at lower left sternal edge with diaphragm for aortic regurgitation
What other areas would you mention examining?
- blood pressure
- abdominal examination
- leg pulses
- oedema
- opthalmic examination
- urine dipstick
- observation charts
How do you finish a cardiovascular examination?
- summarize findings
- thank patient
- wash hands
How do you start a cardiovascular examination?
- wash hands
- introduce yourself
- confirm name & DOB
- explain procedure
- gain consent