HISTORY TAKING AND PE OF CARDIAC PATIENTS. Original.

HISTORY TAKING ANDHISTORY TAKING ANDCLINICAL EXAMINATIONCLINICAL EXAMINATIONOF CARDIAC PATIENTSOF CARDIAC PATIENTS

BASIC CLINICAL SKILLSBASIC CLINICAL SKILLSPARALLEL PROGRAMPARALLEL PROGRAM

DR. MOHAMMED FAKHRY, MD, FACCDR. MOHAMMED FAKHRY, MD, FACCAssociate Professor of Medicine,Associate Professor of Medicine,Consultant Internist/CardiologistConsultant Internist/Cardiologist

King Faisal UniversityKing Faisal UniversityKing Fahd Hospital of the UniversityKing Fahd Hospital of the University

DyspneaDyspnea

Chest painChest pain

CyanosisCyanosis

SyncopeSyncope

PalpitationPalpitation

EdemaEdema

CoughCough

HemoptysisHemoptysis

FatigueFatigue

Intermittent ClaudicationIntermittent Claudication

CARDINAL SYMPTOMS IN HEART DISEASE:

1)1) DYSPNEA:DYSPNEA: “Unpleasant Awareness of Breathing”.“Unpleasant Awareness of Breathing”.

CAUSES:CAUSES:1)1) PulmonaryPulmonary

• COPDCOPD • • Restrictive L. DiseaseRestrictive L. Disease• Br. AsthmaBr. Asthma • Cardiac – CHF (MS, MR, AS, MI. CM)Cardiac – CHF (MS, MR, AS, MI. CM)

2)2) AnemiaAnemia

3)3) ObesityObesity

FUNCTIONAL CLASSES OF FUNCTIONAL CLASSES OF DYSPNEA: DYSPNEA: (NYHA Classification)(NYHA Classification)

Class IClass I D.O. extraordinary exertion D.O. extraordinary exertion (No(No

Dyspnea on average exertion)Dyspnea on average exertion)

Class IIClass II D.O. moderate exertionD.O. moderate exertion

Class IIIClass III D.O. mild exertionD.O. mild exertion

Class IVClass IV D. at rest (PND & Orthopnea)D. at rest (PND & Orthopnea)

II. CHEST PAIN OR DISCOMFORT:II. CHEST PAIN OR DISCOMFORT:

Common Causes:Common Causes:1) CAD 1) CAD - Angina Pectoris- Angina Pectoris

- Unstable Angina. - Unstable Angina.

- Acute Myocardial Infarction- Acute Myocardial Infarction

2) Mitral Valve Prolapse 2) Mitral Valve Prolapse (MVP)(MVP)

3) Pericarditis3) Pericarditis

4) GERD.4) GERD.

5) Peptic Ulcer Disease ( PUD )5) Peptic Ulcer Disease ( PUD )

CHRONIC STABLE ANGINA:CHRONIC STABLE ANGINA: TYPICAL ANGINAL PAIN TYPICAL ANGINAL PAIN

SiteSiteQuality of painQuality of painDuration (few minutes)Duration (few minutes)RadiationRadiationProvoking factor (Exercise, Emotional Provoking factor (Exercise, Emotional excitement and Cold weather.)excitement and Cold weather.)Relieving factors (rest & TNG)Relieving factors (rest & TNG)Associated symptomsAssociated symptomsRisk FactorsRisk Factors

UNSTABLE ANGINAUNSTABLE ANGINA

New onset frequent anginaNew onset frequent angina

Crescendo or accelerated anginaCrescendo or accelerated angina

Duration Duration 10min -30min 10min -30min

Relation to restRelation to rest

Response to TNGResponse to TNG

ACUTE MYOCARDIAL INFARCTON PAIN:ACUTE MYOCARDIAL INFARCTON PAIN:

SiteSite

QualityQuality

Duration Duration > 30min. > 30min.

Associated SymptomsAssociated Symptoms

Response to S. L. TNGResponse to S. L. TNG

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

Peripheral.Peripheral.

Central.Central.

IV. DIZZINESS, PRESYNCOPE IV. DIZZINESS, PRESYNCOPE AND SYNCOPE.AND SYNCOPE.

Definition:Definition:

Causes:Causes:1)1) Drugs: Drugs: V. Dilator DrugsV. Dilator Drugs2)2) Vasovagal syncopeVasovagal syncope

3)3) Cardiac ArrhythmiaCardiac Arrhythmia

4)4) Cardiac Lesions (AS, MS, PS) Cardiac Lesions (AS, MS, PS)

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

Main Cause:Main Cause: Cardiac Arrhythmias Cardiac Arrhythmias

Description:Description:– Fast or slowFast or slow– Regular or irregularRegular or irregular– DurationDuration– Associated symptomsAssociated symptoms

VI. EDEMA OF THE LOWER LIMBSVI. EDEMA OF THE LOWER LIMBS

CAUSES:CAUSES:CardiacCardiac

RenalRenal

Hypoalbuminemia (Liver cirrhosis)Hypoalbuminemia (Liver cirrhosis)

Venous InsufficiencyVenous Insufficiency

VII. COUGH DUE TO CHF:VII. COUGH DUE TO CHF:

It occurs when P.V. P. It occurs when P.V. P. withwith

exercize or even at rest in patients exercize or even at rest in patients

with CHF with CHF transudation of fluid into transudation of fluid into

alveolar spaces alveolar spaces CoughCough, and, and

sometimes sometimes HemoptysisHemoptysis

VIII. HEMOPTYSIS:VIII. HEMOPTYSIS:

Mild:Mild: P. Congestion P. Congestion (CHF)(CHF) Ruptured P. Ruptured P.

Capillaries.Capillaries. It occurs in the course of It occurs in the course of P. InfarctionP. Infarction

IX. FATIGUE:IX. FATIGUE:

It is usually due to low C.O.It is usually due to low C.O.

X. INTERMITTENT CLAUDICATION:X. INTERMITTENT CLAUDICATION:

Peripheral Vascular Disease Peripheral Vascular Disease (PVD)(PVD)

B) CLINICAL EXAMINATIONB) CLINICAL EXAMINATION

GENERAL CLINICAL EXAMINATION:GENERAL CLINICAL EXAMINATION:

Patient’s positionPatient’s position : (45º inclination of the : (45º inclination of the head of the bed)head of the bed)

JVPJVP

more convenientmore convenient

Quiet & warm room with good lightsQuiet & warm room with good lights

General Clinical Examination (cont’d)General Clinical Examination (cont’d)

1)General Look1)General Look– Skin complexion (color)Skin complexion (color)– Pain or respiratory distressPain or respiratory distress– Level of consciousness ( Orientation to place, Level of consciousness ( Orientation to place,

time & persons)time & persons)– Body edemaBody edema

2. HAND EXAMINATION:2. HAND EXAMINATION:

1.1. PallorPallor

2.2. CyanosisCyanosis

3.3. Stigmata of Infective Endocarditis:Stigmata of Infective Endocarditis:

- Clubbing - Janeway lesion - Clubbing - Janeway lesion

- Splinter Hem. - Osler’s Nodules)- Splinter Hem. - Osler’s Nodules)

4. Signs of Hyperlipidemia:4. Signs of Hyperlipidemia:Tendon XanthomatosisTendon Xanthomatosis

5. Signs of Thyrotoxicosis:5. Signs of Thyrotoxicosis:Fine TremorsFine Tremors

3. RADIAL PULSE:3. RADIAL PULSE:

1.1. RhythmRhythm

2.2. RateRate

3.3. VolumeVolume

4.4. Character:Character:

NormalNormal

Collapsing PulseCollapsing Pulse

Slow rising pulseSlow rising pulse

5. Vessel Walls5. Vessel Walls

6. Equality and Synchronization6. Equality and Synchronization

AA

B

)B(

CollapsingCollapsingE-Collapsing

pulse

D-Pulsus Besferious

C-pulsus Besferious

Normal

4. BLOOD PRESSURE MEASUREMENT:4. BLOOD PRESSURE MEASUREMENT:

11. The Cuff. The Cuff22. Position of the patient. Position of the patient

TechniqueTechnique– There are 5 KOROTKOFF’sThere are 5 KOROTKOFF’s Sounds: Sounds:

Syst BP Syst BP Korotkoff 1 Korotkoff 1Diast BP Diast BP Korotkoff 5 Korotkoff 5

Abnormal FaciesAbnormal Facies::

Down’s SyndromeDown’s SyndromeMarfan’s SyndromeMarfan’s SyndromeMalar RashMalar Rash

Pallor:Pallor:ConjunctivaeConjunctivaeMucous Membranes of the MouthMucous Membranes of the Mouth

5. RESPIRATORY RATE AND TEMPERATURE.5. RESPIRATORY RATE AND TEMPERATURE.

6. FACE EXAMINATION:6. FACE EXAMINATION:

JaundiceJaundice ScleraSclera Mucous Membranes of the MouthMucous Membranes of the Mouth

Arcus CornialisArcus CornialisXanthelasmaXanthelasmaCyanosisCyanosisSigns of HyperthyroidismSigns of Hyperthyroidism ExophthalmosExophthalmos Lid LagLid Lag Lid RetractionLid Retraction

Mouth HygieneMouth Hygiene

6. FACE EXAMINATION (cont’d)6. FACE EXAMINATION (cont’d)

Position of the patient Position of the patient 45º 45º

Rt. Internal JVRt. Internal JV

Waves:Waves:

7. JUGULAR VENOUS PRESSURE (JVP7. JUGULAR VENOUS PRESSURE (JVP))

Normal JVP = Normal JVP = 8 cm water. 8 cm water.

Cause of absent Cause of absent A A wave wave A. Fib A. Fib Cause of prominent Cause of prominent AA wave wave → PAH → PAH

and TSand TSCause of Prominent Cause of Prominent VV wave wave TR TR

7. JUGULAR VENOUS PRESSURE (JVP) (cont’d)7. JUGULAR VENOUS PRESSURE (JVP) (cont’d)

Surface AnatomySurface Anatomy

InspectionInspection NormalNormal Corrigan’s SignCorrigan’s Sign

PalpationPalpation Location:Location:

Lt thumb for Rt carotid ALt thumb for Rt carotid A Rt thumb for Lt carotid ARt thumb for Lt carotid A

VolumeVolume CharacterCharacter ThrillThrill

Auscultation:Auscultation: Systolic BruitSystolic Bruit

8. CAROTID PULSE:8. CAROTID PULSE:

InspectionInspectionPalpationPalpationPercussionPercussionAuscultationAuscultation

9. THYROID GLAND:9. THYROID GLAND:

A) Inspection: A) Inspection: Shape of the chestShape of the chest

– Pectus excavatumPectus excavatum– Pectus CraniatumPectus Craniatum– Kyphosis & ScoliosisKyphosis & Scoliosis

Precordial BulgePrecordial BulgeScar of previous cardiac surgeryScar of previous cardiac surgery

– Mid-sternotomy scarMid-sternotomy scar

10. EXAMINATION OF10. EXAMINATION OF THE PRECORDIUM: THE PRECORDIUM:

A) Inspection (cont’d)A) Inspection (cont’d)

Apex Beat: Apex Beat:

Causes of absent apical impulse:Causes of absent apical impulse:EmphysemaEmphysemaObesityObesityDextrocardiaDextrocardiaLt. pleural effusion or pneumothoraxLt. pleural effusion or pneumothoraxSevere pericardial effusion Severe pericardial effusion

Other Cardiac pulsations:Other Cardiac pulsations: P. areaP. areaAortic areaAortic areaEpigastriumEpigastrium

B) PALPATIONB) PALPATION

1.1. Apical Impulse (PMI)Apical Impulse (PMI)SiteSite

CharacterCharacter• NormalNormal• HyperdynamicHyperdynamic• SustainedSustained• Tapping Tapping (palpable S1)(palpable S1)• Localized or diffuseLocalized or diffuse

ThrillThrill

2) Other Pulsation:2) Other Pulsation: Left Parasternal Heave.Left Parasternal Heave.

CausesCauses R.V. enlargementR.V. enlargement Severe LA dilatationSevere LA dilatation

Pulmonary areaPulmonary area Dilated Pulm. Artery.Dilated Pulm. Artery. PHPH

Aortic AreaAortic Area Aortic aneurysmAortic aneurysm

Epigastric pulsation:Epigastric pulsation: Causes:Causes:

RV enlargementRV enlargement Pulsatile hepatomegaly Pulsatile hepatomegaly RS HF RS HF Palpable Abd. AortaPalpable Abd. Aorta

C) PALPABLE HEART SOUNDS AND CLICKSC) PALPABLE HEART SOUNDS AND CLICKS

1.1. Palpable S1Palpable S1 Tapping apical impulse Tapping apical impulse

2.2. Palpable P2 Palpable P2 PH PH

D) THRILLS:D) THRILLS:

1.1. Diastolic ThrillsDiastolic Thrills MS & TSMS & TS

2.2. Systolic ThrillSystolic Thrill MR at the M. areaMR at the M. area

AS AS A. areaA. area

PS PS P. area P. area

VSD VSD 3 3rdrd & 4 & 4thth Lt. ICS Lt. ICS

33. . Continuous ThrillContinuous Thrill PDA PDA

C)CARDIAC AUSCULTATIONC)CARDIAC AUSCULTATION

STETHOSCOPE:STETHOSCOPE:a)a) BellBell Low frequency sounds Low frequency sounds S3, S4 S3, S4

Mid-diastolic murmur Mid-diastolic murmur MS & TS. MS & TS.

b) Diaphragm b) Diaphragm High frequency sounds High frequency sounds S1, S2, S1, S2, E. clicks, and clicks due to prosthetic valves. E. clicks, and clicks due to prosthetic valves.

Systolic murmursSystolic murmurs

Early diastolic murmur Early diastolic murmur ARAR

Continuous murmur Continuous murmur PDAPDA

C) CARDIAC AUSCULTATION:C) CARDIAC AUSCULTATION:

CircumstancesCircumstancesQuiet and warm room.Quiet and warm room.

Systematic approach:Systematic approach: S1 at mitral area S1 at mitral area (diaphragm)(diaphragm) S2S2 at pulmonary area at pulmonary area (diaphragm)(diaphragm)

S3 & S4 at M. area & T. area S3 & S4 at M. area & T. area (Bell)(Bell) Inching auscultationInching auscultation

C) CARDIAC AUSCULTATION:C) CARDIAC AUSCULTATION:

Ausculatory Areas:Ausculatory Areas:

Mitral AreaMitral Area Apex beat area (5Apex beat area (5thth LICS) LICS)

Tricuspid AreaTricuspid Area 4 4thth LICS at sternal edge LICS at sternal edge

22ndnd Aortic Area Aortic Area 3 3rdrd LICS at sternal LICS at sternal edge edge Pulmonary AreaPulmonary Area 2 2ndnd LICS at sternal LICS at sternal edge edge 11stst Aortic Area Aortic Area 2 2ndnd RICS at sternal edge RICS at sternal edge

C) CARDIAC AUSCULTATION:C) CARDIAC AUSCULTATION:

E) Heart Sounds Pattern on Cardiac E) Heart Sounds Pattern on Cardiac Auscultation:Auscultation:

Lub ---- Dub ---- Lub ---- DubLub ---- Dub ---- Lub ---- Dub

F) Gallop Rhythm:F) Gallop Rhythm:

Occurs due to presence of Occurs due to presence of S3S3,,S4S4 or a or a summation of summation of S3S3 & & S4S4 in tachycardic patients. in tachycardic patients.

Accentuated S1:Accentuated S1:MSMS

TSTS

STST

Soft S1 Soft S1 Long PR intervalLong PR interval

Variable S1Variable S1 A. FibrillationA. Fibrillation

Muffled S1 Muffled S1 MRMR

Accentuated A2Accentuated A2 Systemic Systemic HypertensionHypertension..

Accentuated P2Accentuated P2 P. Hypertension.P. Hypertension.

Soft A2Soft A2 AR.AR.

Paradoxical Splitting of S2Paradoxical Splitting of S2 -- ASAS

Opening SnapOpening Snap MS MS

Ejection Clicks:Ejection Clicks:PS.PS.AS.AS.

Opening Clicks: Opening Clicks: Prosthetic mitral and aortic valve Prosthetic mitral and aortic valve

opening.opening.

Closing Clicks:Closing Clicks:Prosthetic Mitral and Aortic Valve closure Prosthetic Mitral and Aortic Valve closure

CARDIAC MURMURS:CARDIAC MURMURS:Systolic MurmursSystolic Murmurs

ESMESM (crescendo decrescendo murmur)(crescendo decrescendo murmur)

A)A) FunctionalFunctional Hyperdynamic circulation.Hyperdynamic circulation. Anemia.Anemia. Pregnancy.Pregnancy. Thyrotoxicosis.Thyrotoxicosis. A-V shunts.A-V shunts. Innocent in childhood and adolescence.Innocent in childhood and adolescence.

B) Organic:B) Organic: ASAS PSPS

PSM PSM (Pansystolic murmur)(Pansystolic murmur) MRMR TRTR VSDVSD

Diastolic Murmurs:Diastolic Murmurs:– Early Diastolic murmur:Early Diastolic murmur:

ARAR

PRPR– Mid-diastolic murmur:Mid-diastolic murmur:

MSMS

TSTS

Continuous MurmurContinuous Murmur– PDA.PDA.

Description of a murmur:Description of a murmur:QualityQualityIntensity – Scale of 6 gradesIntensity – Scale of 6 gradesSite of maximum intensitySite of maximum intensityRadiationRadiationManeuvers which increases or decreases Maneuvers which increases or decreases its intensityits intensity

e.g. e.g. - PSM due to MR- PSM due to MR Best heard over the mitral area.Best heard over the mitral area. handgriphandgrip Radiates to axillaRadiates to axilla

- PSM due to TRPSM due to TR Beast Heard at TR area.Beast Heard at TR area. deep inspirationdeep inspiration

- PSM due to VSDPSM due to VSD Best heard at 3Best heard at 3rdrd & 4 & 4thth LICS LICS Radiates to Rt. Side of the chestRadiates to Rt. Side of the chest hand griphand grip

- ESM due to Valvular AS:ESM due to Valvular AS: Best heard at aortic areas.Best heard at aortic areas. By expirationBy expiration Hand gripHand grip Radiates mainly to the neck (carotid arteries).Radiates mainly to the neck (carotid arteries).

- EDM EDM AR AR Best heard over aortic areas.Best heard over aortic areas. by hand grip and expiration.by hand grip and expiration. sitting up and leaning forward.sitting up and leaning forward.

- MDM MDM MS MS Best heard over the M. Area.Best heard over the M. Area. Little exercise (Little exercise (HR).HR). Left decubitus position.Left decubitus position.

Examination of Other Parts of the Body:Examination of Other Parts of the Body:

BackBack– Fine bilateral basal crepitationFine bilateral basal crepitation

LV FailureLV Failure

– Sacral edema.Sacral edema.

LiverLiver Pulsatile & tender hepatomegaly Pulsatile & tender hepatomegaly

Sometimes Sometimes Ascitis & splenomegaly Ascitis & splenomegaly

Examination of Other Parts of the Body:Examination of Other Parts of the Body:

Lower limbsLower limbs::

A) Cardiac Edema:A) Cardiac Edema:– Bilateral & Pitting.Bilateral & Pitting.– Grades:Grades:

1+1+ Around ankle Joint..Around ankle Joint..

2+2+ Below knee joint. Below knee joint.

3+3+ Above knee joint. Above knee joint.

4+4+ Scrotal edema, hydrocele, and edema of the Scrotal edema, hydrocele, and edema of the ant. abdominal wall.ant. abdominal wall.

B) Peripheral Circulation:B) Peripheral Circulation:– Inspection & Palpation:Inspection & Palpation:

Pale and cold.Pale and cold. Hair loss.Hair loss. Loss of sensation.Loss of sensation.Signs of Gangrene Signs of Gangrene PAD PAD Total arterial occlusion Total arterial occlusion

- - Weak or absent pulsations:Weak or absent pulsations:– Dorsalis pedisDorsalis pedis– Tibialis posteriorTibialis posterior– Medial poplitealMedial popliteal– Femoral arteryFemoral artery– Poor capillary fillingPoor capillary filling

C) Varicose Veins:C) Varicose Veins:– InspectionInspection

Dilated tortous superfacial veinsDilated tortous superfacial veins– Long saphenous veinLong saphenous vein– Short saphenous veinShort saphenous vein

UlcerationUlceration

PigmentationPigmentation

EczemaEczema

D) Deep Venous Thrombosis (DVT)D) Deep Venous Thrombosis (DVT)::

– Unilateral Pitting edema.Unilateral Pitting edema.– Darker skin than the other limbs.Darker skin than the other limbs. surface temperature.surface temperature.– Tense and painful calf.Tense and painful calf.– Superfacial varicosity.Superfacial varicosity.

- Leg circumference is usually - Leg circumference is usually 2.5cm than the other 2.5cm than the other leg (anatomical reference leg (anatomical reference tibial tuberosity tibial tuberosity