2. HISTORY TAKING IN CVS
Should record the details of:
PRESENTING SYMPTOMS – chest pain, fatigue
& dyspnoea, palpitations, and presyncope or
syncope.
PREVIOUS ILLNESS
HABITS – smoking, alcohol abuse
FAMILY HISTORY
DRUG HISTORY
3. PRESENTING SYMPTOMS
CHEST PAIN
1. Myocardial ischaemia
Ischaemia of the heart results from an
imbalance between myocardial oxygen
supply & demand, producing pain called
angina.
The patient describes retrosternal pain
which may radiate into the arms, the throat
or the jaw.
It has a constricting character, is provoked
by exertion & relieved rapidly by rest.
4. 2. Pericarditis
Also causes central chest pain, which is sharp in
character & aggravated by deep inspiration,
cough or postural changes.
Usually idiopathic or caused by coxsackie B
infection.
5. 3. Aortic dissection
Severe tearing pain in either the front or the back
of the chest.
Onset is abrupt, unlike the crescendo quality of
ischaemic cardiac pain.
6. DYSPNOEA
A major symptom of many cardiac disorders,
particularly left heart failure.
1. Exertional Dyspnoea
Most troublesome symptom in heart failure.
Exercise causes a sharp increase in left atrial
pressure & this contributes to the pathogenesis of
dyspnoea by causing pulmonary congestion.
7. 2. Orthopnoea
In patients with heart failure lying flat causes a
steep rise in left atrial pressure, resulting in
pulmonary congestion & severe dyspnoea.
3. Paroxysmal Nocturnal Dyspnoea
Caused by congestion (excessive or abnormal
accumulation of blood) in the lungs, along with
accumulation of excess fluid in the lungs
(pulmonary edema), which occurs as a result of
left sided heart failure.
8. FATIGUE
Important symptom of heart failure.
Caused partly by deconditioning & muscular
atrophy but also by inadequate oxygen delivery to
exercising muscle, reflecting impaired cardiac
output.
9. PALPITATION
Description of the rate & rhythm of the palpitation
is essential.
Rapid irregular palpitation is typical of atrial
fibrillation
Rapid regular palpitation of abrupt onset occurs in
atrial, junctional & ventricular tachyarrhythmias.
10. DIZZINESS & SYNCOPE
Cardiovascular disorders produces dizziness &
syncope by transient hypotension, resulting in
abrupt cerebral hypoperfusion.
Recovery is usually rapid.
11. PHYSICAL EXAMINATION OF CVS
INSPECTION OF THE PATIENT
EXAMINATION OF THE RADIAL PULSE
MEASUREMENT OF HEART RATE & BLOOD
PRESSURE
JUGULAR VENOUS PULSE
PALPATION OF THE ANTERIOR CHEST WALL
AUSCULTATION OF THE HEART
12. INSPECTION OF THE PATIENT
Chest wall deformities such as pectus
excavatum (hollowed chest) should be
noticed.
Most common congenital deformity of
anterior chest wall
Sunken appearance of sternum, may
compress the heart & displace the apex
Hypothesized that there is impairment
of CVS function.
13. Large ventricular or aortic aneurysms
may cause visible pulsations.
Superior vena caval obstruction is
associated with prominent venous
collaterals on the chest wall.
Prominent venous collaterals around
the shoulder occur in axillary or
subclavian vein obstruction.
14. ANAEMIA
May exacerbate angina & heart failure.
Pallor of the mucous membranes is a useful
physical sign but for confirmed diagnosis lab
measurements of haemoglobin concentration is
required.
CYANOSIS
Bluish discoloration of the skin & mucous
membranes caused by increased concentration
of reduced haemoglobin in the superficial blood
vessels.
15. a. Central cyanosis
Caused by reduced arterial oxygen sauration
caused by cardiac or pulmonary disease.
Affects not only the skin & lips but also the
mucous membrane of the mouth.
Causes include pulmonary oedema (which
prevents adequate oxygenation of the blood) &
congenital heart disease (tetralogy of fallot,
eisenmenger’s syndrome).
16. b. Peripheral cyanosis
Cutaneous vasoconstriction slows the blood flow
& increases oxygen extraction in the skin & lips.
Can be seen in fingers, underneath fingernails,
other extremities.
Occurs in heart failure and mitral stenosis.
17. CLUBBING
Congenital cyanotic heart disease &
infective endocarditis.
OTHER CUTANEOUS AND OCULAR
SIGNS OF INFECTIVE
ENDOCARDITIS
Splinter haemorrhages in nail bed
Oslers nodes (tender erythematous
nodules in the pulp of the fingers)
Janeway lesions (painless
erythematous lesions on the palm)
18. COLDNESS OF THE EXTREMITIES
Important sign of reduced cardiac output in
severe heart failure.
Caused by reflex vasoconstriction of the
cutaneous bed.
PYREXIA
Infective endocarditis is associated with pyrexia
Can also occur for the first 3 days after
myocardial infarction.
19. OEDEMA
Subcutaneous oedema that pits on digital
pressure is a cardinal feature of congestive heart
failure.
Pressure should be applied over a bony
prominence (tibia,lateral malleoli,sacrum)
In advanced heart failure oedema may involve
the legs, genitalia & trunk.
20. ARTERIAL PULSE
Should be palpated for evaluation of:
1. RATE & RHYTHM
Rate, expressed in beats per minute (bpm), is
measured by counting over a timed period of 15
seconds.
An irregular rhythm usually indicates atrial
fibrillation.
21. 2. CHARACTER
Defined by the volume & waveform and should be
evaluated at the right carotid artery (pulse
closest to the heart & least subject to damping &
distortion)
Pulse volume is small in heart failure & large in
aortic regurgitation.
Pulsus alternans – relatively high amplitude or
normal amplitude pulse followed by a pulse of
lower amplitude, occurs in severe left ventricular
disease.
22. Pulsus paradoxus – occurs when the pulse
prssure falls by >10mm hg with each inspiration,
found in constructive pericarditis & cardiac
tamponade.
Bisferiens pulse (biphasic pulse) – with 2 systolic
peaks is usually attributed to a combination of
aortic stenosis & aortic regurgitation.
23. 3. SYMMETRY
Symmetry of the radial, branchial, carotid,
femoral, popliteal & pedal pulses should be
confirmed.
Coarctation of the aorta causes symmetrical
reduction & delay of the femoral pulses compared
with the radial pulses.
24. MEASUREMENT OF BLOOD
PRESSURE
Measured using sphygmomanometer
Patient is placed at supine position
A cuff of atleast 40% the arm circumference in
width is attached to a mercury manometer &
inflated around the extended arm
Auscultation over the brachial artery reveals 5
phases of korotkoff sounds as the cuff is deflated:
25. Phase 1: the first appearance of the sounds
marking systolic pressure
Phase 2 & 3: increasingly loud sounds
Phase 4: abrupt muffling of the sounds
Phase 5: disappearance of the sounds.
Conditions where korotkoff sounds remain audible
despite complete deflation of the cuff (aortic
regurgitation, arteriovenous fistula) phase 4 must
be used for the diastolic measurement.
26. JUGULAR VENOUS PULSE
Best examined while the patient reclines at 45 degrees
with patients head partially rotated to one side.
Sternal angle is reference point for JVP
Differentiate from carotid
- multiple wave forms
- can be abolished by gental digital pressure
where as carotid pulsation is always palpable & cannot
be abolished by gentle digital pressure.
27. JUGULAR VENOUS PRESSURE
• Position the patient so that the upper level of JV pulse is
visible
• Place ruler at sternal angle which is 5cm above the RA
• Hold another ruler horizontally at the top of JV pulse
• Note how many cms this is above the sternal angle , add
5cms to this number & total is JV pressure
• Normal pressure is less than or equal to 9cm.
29. PALPATION OF CHEST WALL
Used for detection of parasternal heaves &
apex beat
Parasternal heave is discerned with the heel or
flat of the right hand against the left
parasternal region, right ventricular
hypertrophy causes a left parasternal heave.
Apex beat is defined as the lowest & most
lateral point at which the cardiac impulse can
be palpated.
The apex beat is normally located in the fifth
left intercostal space in the mid-clavicular line.
Apex beat is displaced in left ventricular
dilation.
30. AUSCULTATION OF THE HEART
Use the diaphragm for high pitched
sounds & murmers
Use the bell for low pitched sounds &
murmers
Sequence of auscultation
- Upper right sternal border (URSB) with
diaphragm(aortic area)
- Upper left sternal border (ULSB) with diaphragm
(pulmonary area)
- Lower left sternal border (LLSB) with diaphragm
(tricuspid)
- Apex ( mitral area)
31. After the age of 40 S3 is nearly always
pathological, usually indicating left ventricular
failure, mitral regurgitation
S4 is also pathological and heard in aortic
stenosis, hypertrophic cardiomyopathy.
32. systolic clicks & opening snaps
Valve opening is normally silent
In aortic stenosis valve opening produces a click,
the click is only audible if the valve cusps are
pliant & non-calcified, and is prominent in
bicuspid valve.
In mitral stenosis, elevated left atrial pressure
causes forceful opening of the thickened valve
leaflets, this generates a snap.
33. Heart murmurs
Caused by turbulent flow within the heart &
greater vessels.
Turbulence is caused by increased flow through a
normal valve usually aortic and pulmonary.
Murmurs may also indicate valve disease or
abnormal communications between the left &
right sides of the heart (septal defects).
34. According to the phase of systole or diastole during
which it is heard murmurs are classified as:
1. Systolic murmurs
Midsystolic murmur – caused by turbulence in the
left or right ventricular outflow
Pansystolic murmur – mitral regurgitation, tricuspid
regurgitation, ventricular septal defect
Late systolic murmur – mitral valve prolapse,
tricuspid valve prolapse.
35. 2. Diastolic murmurs
Early diastolic murmurs – caused by regurgitation
through aortic and pulmonary valves
Mid diastolic murmurs – caused by turbulent flow
through the atrioventricular valves (mitral stenosis)
Presystolic murmur – mitral & tricuspid stenosis.
3. Continuous murmurs
Heard during systole & diastole
Patent ductus arteriosus