Cardiac history and examination

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Cardiac history and examination

• Dr. Bakir M. Bakir
• Consultant Cardiac Surgery

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The five finger approach to cardiac diagnosis

• The cardiac history
• The cardiac physical exam
• Electrocardiogram
• Chest X-ray
• Cardiac diagnostic laboratory tests.

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• A good history should be both
• Concise.
• Cover the important points.

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Rules

1. Patient should be allowed to tell his history in
   his own words.
2. Leading questions must be avoided unless the
   information cant be obtained by other means

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Questions

1. Complete the inadequate description.
2. Elucidate the vague points.
3. Fill in the gaps in the history not mentioned by
   patient.
4. Emphasize the important points.

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Types of questions

1. Neutral questions.
2. Simple direct questions (yes/No).
3. Leading questions.

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Personal data

• Name.
• Age.
• Sex.
• Occupation.
• Residence.
• The patients complaint
• A simple statement in the patients own words and
  its duration.

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Present History

• This means detailed history of the patients
  present illness which must provide answer for the
  following questions
• Duration
• Mode of onset (acute, sub acute, chronic).
• Sequence of events
• Course (progressive, regressive or recurrent).
• Appearance of new additional symptoms or
  disappearance of others.
• Treatment received during the course response.
• Analysis of each particular symptom.

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Past History

• Childhood diseases.
• Trauma.
• Residences or travel abroad.
• Drug therapy.
• Operations.
• Prior illness (cardiac, noncardiac).
• Recent dental work
• Prior cardiac procedure

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Habits

• Smoking.
• Physical efforts.
• Addiction.

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Family History

• Hereditary factor.
• Exposure to same etiological circumstances.

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Coronary artery disease risk factors

• Cigarette smoking
• Hypertension
• Hyperlipidemia
• Family history of CAD
• Diabetes mellitus

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Symptoms of Cardiac disorders
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1. Symptoms due to lung congestion

• Dyspnea.
• Acute pulmonary edema.
• Cough, hemoptysis.
• Recurrent chest infections.

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2. Symptoms due to systemic congestion

• Pain in the right hypochondrium.
• Dyspepsia.
• Swelling of lower limb.
• Swelling of the abdomen.
• Oliguria.

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3. Symptoms due to low cardiac output(tissue
hypoxia ?brain, muscles, kidneys)

• Exertional fatigue.
• Blurring of vision.
• Dizziness / Syncope.
• Oliguria, Angina.

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4. Chest pain

• Of Cardiac Origin
• Ischemia, pericarditis, Dissecting aorta, Aortic
  Aneurysm.
• Other Causes
• Chest wall
• Neurological
• Mediastinum
• Diaphragm
• Abdominal. ( esophagus, stomach, gall bladder,
  pancreas).

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• Analysis
• Site radiation.
• Provocation relief.
• Duration.
• Character.
• Associated features.

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Pearls regarding CAD

• Many patients dont have the classic text book
  symptoms
• Angina doesnt always mean coronary artery
  disease.
• A high index of suspicion is necessary to avoid
  missing the diagnosis of acute aortic dissection.
• Not all patients with acute MI develop ECG
  changes.

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5. Symptoms due to changes in rate, Rhythm, or
force ? palpitation.

• ( time, mode of onset offset, relation to
  exertion, duration, irregularity).

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6. Symptoms due to pressure on surrounding
structures.

• ( esophagus, bronchi , nerves, spine)

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Cardiac physical examination

• Basic concepts
• Try to secure, if possible, a well-lighted quiet
  room.
• Perform examination from the patients right side.
• Find recorded vital signs (or do them
  yourself-after all, they are vital.)

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General Examination

• General appearance.
• Vital signs pulse, temp. Blood pressure,
  respiration.
• Hands (cold, warm, clubbing, cyanosis,
  sweating)
• Eyes
• Neck
• Neck veins.
• Pulsations (arterial vs. venous).
• Carotid arteries.
• Trachea, thyroid gland.

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1. Lower Limbs ( signs of PVD, edema, pulsations).
2. Abdomen feel for palpable hepatomegaly and check
   if it is pulsatile (tricuspid regurge). Look for
   ascites ,splenomegaly(IE), and an aortic aneurysm.

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Local Examination
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1. Combined Inspection and palpation

1. Shape.
2. Cardiac impulses (apex beat, parasternal
   pulsations, epigastric, to the right of sternum,
   suprasternal notch, 2nd left space)
3. Thrills.
4. Palpable heart sounds
5. Position of the mediastinum
6. Tactile vocal fremitus
7. Chest movements
8. Local tenderness,pulsations,wheezes.

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2. Percussion

• Types of percussion notes
• Apices of the lungs
• Anterior chest wall
• Lateral chest wall
• Posterior chest wall
• Cardiac and hepatic dullness
• Rules of percussion.

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3. Auscultation

• Apex, lower end of sternum (tricuspid area),
  aortic area and pulmonary area .
• Murmurs
• Timing
• Character
• Point of maximum intensity and propagation
• Relation to respiration
• Intensity
• Thrill.

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Auscultation

• The first and second heart sounds reflect valve
  closure.normally, valve opening is not heard.
• S1 is the sound of closure of the mitral and
  tricuspid valves at the start of ventricular
  systole.
• S2 is the sound of closure of the aortic and
  pulmonary valves at the start of ventricular
  diastole.

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• Breath sounds.
• Adventitious sounds.(rhonchi,crepitations,rub)
• Vocal resonance .