2. Take a succinct and focused history of a patient
presenting with symptoms commonly associated with
cardiovascular diseases
Clinical symptoms and signs of cardiovascular diseases
Perform a cardiovascular examination competently and
professionally
Signs of specific disorders
Put together signs and symptoms to make a list of
differential diagnosis
9. PC: chest pain
HPC: central chest tightness radiating to jaw on walking
uphill only and relieved by GTN and rest.
OtherCV symptoms: SOB, ankle oedema, PND,
orthopnoea, palpitations and syncope, intermittent
claudication
Cardiovascular risk factors
PMH:
DH:
FH:
SH: smoking, alcohol, illicit drugs
Systems review:
10. Can have a normal CV examination
You should specifically look for
General:
▪ Nicotine stains, corneal arcus, xanthelsama, xanthoma
▪ Anaemia
High BP
Precordium:
▪ May or may not have heart murmur (AS)
May have signs of heart failure:
▪ raised JVP, displaced apex, peripheral oedema, bibasal
crackles
11. Investigations
12 lead ECG—look for evidence of
▪ ST elevation, ST depression,T wave inversions or biphasicT
wave
▪ LVH, LBBB, abnormal rhythm etc.
Chest x ray
▪ Cardiomegaly, pulmonary oedema
▪ Think about the differential diagnoses to exclude
Blood tests
▪ FBC—anaemia, platelet
▪ Biochemistry—troponins, lipid profile, Hba1c
12. Can be caused by cardiac or pulmonary
diseases
Cardiac diseases causing shortness of breath
Heart failure
Ischaemic heart disease –during episode of angina
Severe anaemia with ischaemic heart disease
13. Shortness of breath on exertion/ at rest
NewYork Heart Association classification of heart failure
I = no symptom at rest, dyspnoea on rigours exertion only
II = no symptom at rest, dyspnoea on exertion
III = mild symptoms at rest, symptoms with ordinary
activities
IV = significant dyspnoea at rest, severe dyspnoea on very
mild exertion (less than ordinary activities)
14. Shortness of breath
Acute/ chronic
Exertion/ rest
Orthopnoea
Paroxysmal nocturnal dyspnoea
Ankle oedema (right heart failure)
Has it increased recently?
Cough—white frothy sputum
Wheeze—differential diagnosis: obstructive airway
d
15. PMH:
DH: are they on HF treatment?
SH:
FH:
Systems r/v
What has caused the patient’s heart failure?
17. Rhythm problem
Muscle problem
Volume overload
(excessive preload)
Outflow obstruction
(Excessive afterload)
Arrhythmias
e.g.Atrial
fibrillation, severe
brady/
tachycarrthymias
LVF:
Hypertension
Aortic stenosis
RVF:
Pulmonary stenosis
Pul HTN (primary or
secondary), PE
(Mitral stenosisPulHTN)
Any regurgitation:
AR, MR (LVF)
Fluid overload, NSAIDS
TR (RVF)
Ischaemic heart disease
Cardiomyopathy
Decreased ventricular filling
(restrictive)
Restrictive cardiomyopathy,
constrictive pericarditis,
cardiac tamponade
18. High-output failure
Anaemia
Pregnancy
Hyperthyroidism
Pagets disease
AV malformation
Beri beri—wet beri beri secondary to thiamine deficiency
20. This is a good time to talk about
cardiovascular examination
We will return to history taking for
palpitations and syncope
We will talk about individual valve disorder
and conditions that are commonly examined
21. Systematic approach
Develop a (conventional) routine and stick
with it
Practice is the most important, you want to
look slick!
Really look for the sign when you say you are
looking for it
22. Easy points (to miss/ fail on)
Wash hands
Introduce self, ask for permission
Be grateful to patient
Position at 45 degrees
Expose upper body (+ legs for scars)
Ask about pain
Remember not to cause pain!
23. Spend time at foot of the bed and inspect!
External paraphenalia
Pt comfortable/ breathless at rest
Does pt look pale? Flushed (malar rash)?
Pacemaker?
Scars—mid sternotomy +/- leg scars, apical
If +: what operation?Valve? CABG?
24. Hands:
Clubbing (IE & congenital cyanotic heart d)
Splinter haemorrhages, Janeway lesions, Osler’s
nodes (IE)
Peripheral cyanosis, temperature of the hands and
capillary refill
xanthoma
Pallor
Radial pulse:
heart rate and rhythm (look for AF)
Collapsing pulse (AR): ask about pain in the arm
25. Brachial pulse
Comment on character: normal, slow-rising (AS)
BP
Say you would check the BP at this stage
Neck
(Palpate carotid pulse)
Inspect JVP
26. Normal JVP is at 4cm above sternal angle at 45
degrees
How to distinguish from carotid pulse?
▪ Bisferiens—double pulse for every arterial pulse
▪ Decreases on inspiration and and sitting up
▪ Rises with expiration and lying down
▪ Not usually palpable
▪ Can be obliterated by finger
▪ Rises with pressure on the abdomen (hepatojugular reflux)
Raised JVP is a sign of right ventricular failure
LargeV waves = tricuspid regurgitation
CCF
30. Develop a routine for manouvres
1)Apex
Identify S1 and S2 or any murmur
▪ Do they sound normal? Mechanical?
▪ any added sounds or murmurs? Can you time murmur to carotid
pulse?—systolic/ diastolic?
Pansystolic murmur radiating to axilla best heard on max.
expiration (MR)
Mid-diastolic rumbling murmur best heard in left lateral
position over apex on max. expiration with bell (MS)
31. 2) Lower left sternal edge
Pansystolic murmur best heard here and on inspiration (+ raised JVP +
giant ‘v’ wave) =Tricuspid regurgitation
Pansystolic murmur best heard here can also beVSD
3) Right sternal border second intercostal space
Ejection systolic murmur radiating to carotids best heard on
expiration = AS
Is there any diastolic murmur? Move pt forward and listen at
lower left sternal edge
▪ Early diastolic murmur best heard sitting forward on expiration
(+collapsing pulse) = aortic regurgitation
32. So far you have listened for all the left-sided murmurs (MR,
MS,AS, AR) andTR
(VSD as a differential for MR,TR)
4) Left sternal border 2nd intercostal space
Pulm stenosis:
ejection systolic murmur radiating to left clavicle best heard on
inspiration
(Pulm regurg:early-diastolic murmur best heard here on inspiration)
(Tricuspid stenosis: mid-diastolic murmur best heard on inspiration)
33. Left-sided murmurs best heard on maximal
expiration
Right-sided murmurs best heard on max. inspiration
Diastolic murmurs are difficult to hear and require
special manouvres
MS—apex, left lateral position with bell on
expiration
AR—sit forward, lower left sternal edge on
expiration
34. Sit patient forward and listen to the lung
bases
Bibasal crackles—pul oedema (or other lung d)
Check for peripheral oedema
Sacral oedema
ankle/ leg oedema
Peripheral pulses—DP, PT, Femoral
(young pt with HTN—Radio-fem delay)
36. To palpate the peripheral pulses
Check observation charts for fever, BP, urine
dip (IE)
‘I would also like to do an ECG, CXR’
Hb to look for anaemia
WC, CRP, ESR—evidence of infection
ECHO
IfAF, mechanical valve
Think warfarin and check INR
37. Aortic Stenosis:
Slow-rising pulse, narrow pulse
pressure
Apex not displaced by
hyperdynamic
Palpable thrill
S1 + quiet S2, ESM best heard
right sternal edge 2nd ICS on
expiration radiating to carotids
+/- signs of LVF or CCF
+/- signs of IE
Aetiology:
• Congenital bicuspid
• Age-related degeneration
and calcification
• Rheumatic fever
38. AR
Collapsing pulse
Corrigan’s sign
Apex is displaced and
hyperdynamic
Soft S2, ESD best heard
over lower left sternal
edge on max expiration
and leaning forward
+/- LVF, RVF
+/- IE
Aetiology
• Marfan’s
• Ankylosing spondylitis
• Rheumatoid arthritis
• SLE
• HTN
• Rheumatic fever
• Syphilis
• Endocarditis
39. Malar flush
AF
(+/- scar for valvotomy)
Tapping apex, parasternal heave (RVH) and loud
P2 (pul HTN)
Loud S1, mid diastolic rumbling murmur best
heard over the apex in left lateral position on
expiration with the bell
48. Transient loss of consciousness usually leading
to falling. Rapid onset, subsequent recovery
usually spontaneous, complete and usually
prompt
Temporary cessation of cerebral function
(reticular activating system)
Results from transient and sudden reduction of
blood flow to the brain
49. PC: ‘collapse with loss of consciousness’
HPC:
Witnessed account
Preceding symptoms:
▪ None (!)
▪ Dizzy, dizzy on standing
▪ Chest pain, palpitations
▪ Micturition, defecation
▪ Hot stuffy environment, standing for prolonged period
50. Any injury to head/ face
Any features of seizures
Recovery—immediate, quick, prolonged with
confusion
History of similar episodes?
Postural dizziness?
PMH
DH: antihypertensives
FHx: sudden cardiac death