Professional Documents
Culture Documents
EXAMINATION
CARDIOVASCULAR SYSTEM
Importance of History
Taking
Obtaining an accurate history is the
critical first step in determining
the etiology of a patient's
problem.
A large percentage of the time )
70%), you will actually be able make
a diagnosis based on the history
alone.
How to take a history?
Listening
Chest pain
Shortness of breath
Ankle swelling
Palpitations
Syncope
Intermittent claudication
Chest Pain
Relieving factors
Character of pain
Worse on taking a
Severity
deep breath
Duration
(pleuritic)
Radiation
Worse on movement
At rest or on
Autonomic symptoms
exertion Sweating
Previous episodes Nausea
Causes of Chest Pain
Cardiovascular Chest wall
Angina Coughing
Stable
Intercostal muscle
Unstable
Myocardial infarction strain/myositis
Aortic dissection Herpes zoster
Myocarditis Viral pleurodynia
Pleuropericardial Thoracic radiculopathy
Pericarditis Rib fracture
Pleurisy Rib tumour
Pneumothorax Costochondritis
Gastrointestinal
Gastro-oesophageal
reflux
Oesophageal spasm
Acute Anteroseptal MI
Dyspnoea
Rheumatic fever
Previous cardiac investigations
Previous myocardial infarction
Coronary angioplasty + stent
insertion
Coronary artery bypass grafting
Pacemaker insertion
Medications
Anti-anginal agents
Use of sublingual nitrate spray
Antihypertensive agents
Anti-arrhythmics
Statins
Platelet inhibitors, e.g., Aspirin
Anticoagulants, e.g., Warfarin
Allergies
NB Document in front of chart and inform
nurses
Social History
Occupation
e.g., train driver, long distance truck
driver
Smoking
Number of pack years
Alcohol intake
Stairs at home
Family History
General Precordium
Hands Inspection
Pulse Palpation
Percussion
Blood pressure
Auscultation
Face
Back
Neck
Abdomen
Jugular venous
Lower limbs
pressure
Other
Examination - General
High arched
palate
Examination - Hands
Clubbing
Splinter haemorrhages (infective
endocarditis)
Oslers nodes (tender)
Janeway lesions (non-tender)
Xanthomata (Hyperlipidaemia)
Splinter
Haemorrhages
Clubbing
Examination - Pulse
Character and volume
Radial artery
assessed from carotid
Rate (normal = 60- artery
100)
Collapsing pulse (aortic
Bradycardia (<60)
regurgitation)
Tachycardia (>100)
Pulsus alternans (left
Rhythm
ventricular failure)
Regular
Irregular Pulse deficit (atrial
Radiofemoral delay
fibrillation)
(coarctation of the
aorta)
Examination - Blood
Pressure
Sphygmomanometer Deflate at 4 mmHg/s
Systolic/diastolic Difference between
pressure arms of <10 mmHg
Normal <140/90 Pulsus paradoxus =
mmHg (lower in exaggerated
diabetes) reduction in BP with
Korotkoff sounds inspiration (>10
Use larger cuff width mmHg)
for large arms Postural hypotension
Examination Face and
Neck
Jaundice Central cyanosis
Xanthelasmata Carotid pulse
Corneal arcus character
Malar flush (mitral
Slow rising (AS)
stenosis) Bisferiens (AS + AR)
High arched palate
Collapsing (AR)
Alternans (LVF)
(Marfans syndrome)
Jerky (HOCM)
Dental caries
Carotid bruit
(infective
endocarditis)
Eye signs in
Hyperlipidaemia
CORNEAL XANTHELASMATA
ARCUS
Jugular Venous Pressure
Patient at 45 degrees Fills from above
Good lighting Hepatojugular reflux
Internal jugular vein Abnormal if >3 cm above
Reflects right atrial zero point:
pressure RV failure
Zero point = sternal RV infarct
angle Tricuspid stenosis
Visible but not palpable Tricuspid regurgitation
Pericardial effusion
Complex wave form (a, c,
SVC obstruction
v waves)
Fluid overload
Decreases on inspiration
Precordium - Inspection
Scars
Median sternotomy
CABG
Valve replacement
Lateral thoracotomy
Sternotomy
Infraclavicular scar
(pacemaker)
Pectus excavatum Pectus
excavatum
Pacemaker box
Apex beat
Precordium - Palpation
Apex beat
Location
Character
Heaving
Thrusting
Double
Tapping
Paradoxical
Left parasternal heave
Thrills (palpable murmurs)
Systolic
Diastolic
Palpable P2 (pulmonary
hypertension)
Pacemaker box
Precordium Auscultation
Heart Sounds
Bell low pitched
sounds
Diaphragm high
pitched sounds
Mitral Tricuspid
Pulmonary Aortic
areas
S1 (first heart sound)
S2 Splitting (A2,
P2)
Abnormalities of Heart
Sounds
Loud S1 S3 (third heart sound)
Soft S1 S4 (fourth heart
Loud A2 sound)
Loud P2 Summation gallop
Soft A2 Opening snap
Splitting of S1 Systolic ejection click
Increased splitting of Mid-systolic click
S2 Tumour plop
Fixed splitting of S2
Pericardial knock
Reversed splitting of S2
Metallic click
Precordium Auscultation
Murmurs
Timing of murmur
Pitch
Systolic
Radiation
Diastolic
Continuous
Dynamic
Site of maximal
manoeuvres
Respiration
intensity Left-sided on exp.
Loudness Right-sided on insp.
Grades I-VI Valsalva
Thrill Squatting
Heart Murmurs
Systolic
Diastolic
Pansystolic
Early diastolic
Mitral regurgitation Aortic regurgitation
Tricuspid regurgitation Pulmonary regurgitation
Ventricular septal defect Mid-diastolic
Ejection systolic Mitral stenosis
Aortic stenosis Tricuspid stenosis
Pulmonary stenosis Atrial myxoma
HOCM Continuous
Atrial septal defect Patent ductus arteriosus
Late systolic Arteriovenous fistula
Mitral valve prolapse Pericardial friction
rub
Examination Back
Urinalysis
Haematuria (infective
endocarditis)
Fundi
Hypertensive
retinopathy
Roth spots (infective
endocarditis)
Temperature chart
Infective endocarditis