CARDIOLOGY
Chest Hx Cardiovascular & Resp History Taking
SOCRATES
Chest Pain
• NB: Continuous prolonged pain = GORD, MSK, Resp.
• Pitting vs non-pitting oedema
Ankle/Leg
• Symmetrical oedema (RVF)
swelling
• Drug induced (e.g. Ca channel blocker – verapamil, -dipines)
• Exercise tolerance (what makes it stop? – be careful of fit individuals)
• MI = mitral regurg., pulmonary oedema, rupture of chordae tendinae, papillary muscle infarction
o Drug induced: cocaine, amphetamine
• LVF = Orthopnoea (breathing difficulty when lying down) ® # of pillows
Dyspnoea /SOB o redistribution of interstitial oedema to fill upper zones of lung decreasing overall blood oxygenation
(when sitting up ® oedema in lower lobes = less effect)
• LVF = Paroxysmal Nocturnal Dyspnoea (PND): Waking from sleep (exc. OSA)
• Diurnal or seasonal variation
• Wheezing?
• Vasovagal (sweaty/nausea/Dizzy) ® • Tussive (on cough)
Emotional stress (e.g. seeing blood, crowded
• Micturition (passing urine)
hot places)
• Hypoglyceamic episode
Syncope • Aortic stenosis (on exertion)
• Postural hypotension (CaBs)
[transient LOC due • Arrythmia (chest pain before syncope, anti-
to cerebral anoxia] arrhythmics, or heart block) è rapid recovery • Prolonged QT interval (antiarrhythmics, gastric
unlike seizures motility promotor, Antibiotics, antipsychotics)
• Stokes Adams attack = recurrent sudden • Bradycardia (BBs, CaBs, Digoxin)
syncope due to bradycardia • Seizures (post-ictal confusion)
1. HPS • Regularity/Rhythm ® Rate [Tap out for me!]
CADSPIF • When did it start? Triggers?
Type Onset Rhythm Feature
SVT Sudden Regular Pounding sensation in neck – CHECK CAFFIENE USAGE
(DDx: idiopathic premature v. ectopics)
Relived on Valsalva, carotid massage, cold ice cube
AF Sudden Irregular Lethargy, exertional dyspnoea, orthopnoea, postural
Palpitations
hypotension, light-headed
STEMI Sudden Pain or chest tightness
ST Gradual Regular Rapid pounding
Ectopics Sudden Irregular Pounding/fluttering/skipped beats followed by heavy
beat
VT ® VF Sudden Regular Syncope + rapid ® nausea, light-headed, exertional
dyspnoea, central chest tightness
• Max claudication distance ® Cramping pain?
Intermittent
• 6 P’s ® pain, pallor, paresthesia, perishingly cold, pulselessness, paralysed
claudication
o Lumbar spinal stenosis, popliteal artery entrapment in young men
• Lack of energy or lack of motivation?
Fatigue
• Sleeping issue (OSA) ® Daytime somnolescence, reduced CO (poor vascularization, aneamia)
Cough Productive vs non-productive ® Triggers (nocturnal, exercise, Risk factors, ACEi usage)
Sputum Volume ® Frequency ® Colour/Blood ® Consistency
Heamoptysis Volume ® Frequency ® Fresh red? Mixed in as streaks? coffee ground (vomit – upper GI bleed)
• Previous cardiac problems? Operations/stents ? ECGs/ • Birthplace + early life (childhood resp. dx)
angiograms? • Home Oxygen
• MDT? (e.g ED assoc. with ischemic heart disease) • Inhalers (freq + dosage)
Modifiable Risk Factors:
• Diabetes, HTN, IV drug use, HC (high LDL >5.2 mM), • Co-morbidities: Asthma | COPD | ILD
• CKD [highest risk for CAD], ED (linked to end-organ damage), o When diagnosed? How?
2. Past • chronic inflammatory disorder (e.g. RA, psoriasis, HIV), o Spacer and reliever usage (Freq. and technique)
MHx • obese/sedentary, smoking, gout, o Compliance + hospital Ax
Non-modifiable: • Other drugs causing lung toxicity
• Male, Age o COCP, MTX, NSAID, ACEi
• 1st degree relatives Hx of premature IHD, o Cocaine, thiazide, tryptophan, timolol (eye drops)
• past Hx of IHD or vascular HD
• Allergies: Ectopic Triad (food allergy + hayfever + eczema) ® epipen? Anaphylaxis or rash?
• Vaccinations: fluvax, pneumococcal?
3. Social • Living situation ® carers, apartment/stairs, mobility aids
• Occupation (esp. for resp.) ® birds or pets / miners / asbestos / IT office
Hx • Smoking + alcohol
[LOST] • Travel | Mood | Hobbies (spas/jacuzzi = non-TB bacterial infection) |
• Family CV diseases (Esp. Hx of CAD < 60 in 1st deg relative) ® IHD, HTN, HC
4. Family • Marfan’s syndrome or Ehler Danlos
Hx • FHx of lung cancer, CF
• A1-anti-trypsin deficiency (↑emphysema, liver disease)
, CV exam
• (45° with chest/neck fully exposed)
General • Syndromes: Marfan’s (AR,/MR/Mitral Prolapse), Turner’s (AS), Down syndromes (congenital heart disease)
inspection • General: Pallor, cyanosis, comfort, SOB
• Praecordium Scars: pacemakers/ metallic valve sounds
• Vital Signs
• Capillary refill, , peripheral cyanosis
Perfusion
• Temperature
• Clubbing (cyanotic CHD, IE), splinter haemorrhages (IE or mechanic occupation)
Nails
• Nicotine staining,
Dorsum • Extensor tendon Xanthomata (irregular nodules overlying tendon – HC)
• Janeway Lesions | Osler’s nodes (Painful purple palpules) (IE)
• Sweaty palms
Hands
Palms
Pulse -Rate & • Irregularly irregular = AF
Rhythm • Regularly irregular = 2nd deg heart block
• Weak or low volume = aortic stenosis + shock/hypovolaemia
• Bounding = sepsis, AR, T2 respiratory failure
• Collapsing: (sudden drop in PP when blood returns into
ventricle)® CHECK THERE is NO shoulder pain ® feel radial pulse
with right hand ® quickly lift arm with left hand ® feel for any
stronger tapping when arm is elevated
o AR, patent ductus arteriosus, high-output states e.g.
anaemia, thyrotoxicosis, fever, pregnancy)
Arms Pulse - character • Pulsus paradoxus = asthma, PE, pericarditis, MI
• Pulsus alterans (sig. beat-beat variation) = severe L) ventricular
failure
• Jerky = HOCM
• Radio-radio delay (aortic dissection/aneurysm or proximal
coarctation)
*Only ask ® Radio-femoral delay = aortic coarctation (i.e. narrowing of aorta) ® signs include
• Pre-repair: Severe HTN, weal left radial pulse, systolic vascular murmur
• Post-repair: left lateral thoracotomy scar
BP • Wide pulse pressure (AR), narrow pulse pressure (AS)
Face • Malar flush (MS, pulmonary stenosis)
• Conjunctival pallor (aneamia) | heamorrhages (IE) |
• Corneal arcus = HTN, HC, atherosclerosis
• Roth spots = IE, but also HTN, diabetes, Hypoxia
• Xanthelasma (HC)
Eyes
• Central cyanosis
Mouth • Petechiae on mucosa & Poor dentition (IE)
• Palate (high arched—Marfan’s syndrome) ® “LIFT tongue to roof of mouth”
• PQRST = Elevated JVP ( >3cm above sternal
angle –double pulsation of internal jugular vein)
o Pulmonary HTN/PE/PS/Pericardial TAS
TVR
effusion
RBBB TVR
o Qty of fluid (e.g. overload)
Face & § RVF
Neck §
§
SVC obstruction
Tamponade/TR
• Hepatojugular Reflux test
(apply pressure in RUQ ® observe JVP ®
sustained rise = RVF) HAB
• Carotid pulse (char + vol.)
o Slow-rising low volume (i.e. anacrotic
Neck plateau pulse)= AS Pathology
(at 45o) o Bounding/collapsing = AR or patent
• Dominant = TS, RVH ® PS,
ductus arteriosus
A waves Pulmonary HTN
[atrial contraction] • Cannon = Complete Heart Block, VT
Jugular pulsation Carotid pulsation
2 peaks /double 1 peak V wave Dominant = TR (very common)
waveform [passive atrial filling]
Impalpable Palpable • Absent = AF
Obliterated by Hard to obliterate X descent
• Exaggerated = constrictive
pressure @ base of [atrial relaxation]
pericarditis, cardiac tamponade
neck Y descent • Sharp = severe TR
Moves with respiration Little movement with [tricuspid valve • Slow = TS,
to increase VR respiration opens]
, • Chest Deformity (e.g. pectus excavatum/carinatum)
• Visible apex beat, distended veins (SVC obstruction)
Inspect • Scars (pacemaker, ICD)
o Sternotomy (midline) ® ?CABG, thoracic aortic aneurysm open repair
o valvotomy (mitral), lateral thoracotomy, under L clavicle, saphenous vein graft
• Palpate with whole hand ® 5th IC space (1cm medial to midclavicular line)
Apex beat
• Impalpable (DOPE): Dextrocardia, Obese, Pericardial effusion, Emphysema
position
• Displaced: LV dilation (MR, AR), cardiomegaly, RV enlargement
• Heaving: High pressure pulsation in LVH ® AS, systemic HTN
Apex beat • Thrusting: Large area/vol. pulsation in volume overload ® (MR, AR)
character • Tapping beat: palpable S1 in MS
Palpate
*Cannot feel ® patient roll to left and expire
Parasternal Heel of right hand over left lower parasternal edge with straight elbow
heave • Heave = RVH due to pulmonary HTN or PS
Palpate over valve areas with pads of fingers
Thrills • AS = Most common
• Pulmonary HTN = Palpable S2 over pulmonary area
Procedure
• Lying at 45o ® Feel apex then auscultate ® listen left axilla for radiation (MR)
Praecordium Mitral valve • Roll to LEFT side ® listen using BELL over apex on expiration ® accentuates MS
low tones
Tricuspid valve
Pulmonary valve • Loud pulmonary S2 (pulmonary HTN)
• Lying at 45o ® listen over right carotid artery while holding breath for RADIATION
(AS)
Aortic valve
• Sit patient forward and listen at Erb’s point (3rd IC space, left sternal edge) on
Auscultate expiration ® accentuates AR
[all heart • Right valves = heard better on full inspiration
valves with
diaphragm] • Left valves = heart better on full Expiration
• Systolic murmurs = radiate (AS, MR, PS, TR)
o S1 = regurgitation [leakage across ‘closed’ valve]
o S2 =stenosis [obstruction to flow]
Murmurs: o Innocent murmurs = systolic ejection murmur (minor turbulence in blood
flow in children)
o *Always perform dynamic auscultation (i.e. Valsalva manoevre) if
systolic murmur present (emphasises HCM and LVF)
• Diastolic murmurs= need dynamic manoeuvre to accentuate (AR, MS, PR, TS)
o S1 = stenosis
o S2 = regurgitation
Peripheral • Percuss back to exclude pleural effusion (stony dull percussion)
• Lungs • Auscultate lung bases for:
(signs of o coarse crackles while patient sitting (pulmonary oedema secondary to LVF)
fluid • Palpate sacrum, tibia and medial malleolus for 10s ® feel for any indent (RVF,
overload) • Abdo + Lower LImb hypoalbuminemia, AR assoc. with ankylosing spondylitis)
• Palpate for pulsatile hepatomegaly (?AR, RVF)
In Summary “Today I performed a CV exam on___________
“On general inspection, there was ____ peripheral stigmata of CV disease? With a regular/irregular pulse?
“On palpation, there were yes/no displaced apex / heaves/ thrills”
“On auscultation, 1st and 2nd heart sounds were present/absent with added sounds present/absent”
To complete • Check peripheral pulses, perform an ECG, • Urinalysis: dipstick the urine (heamaturia in IE)
• Palpate for hepatomegaly (RVF) • Bloods = FBC, EUC, LFT, CRP, BNP, TROPONIN
• Review observation charts [fever in IE] • SPECIFIC BLOODS = TFT, Fe, B12, folate
• 24 hr holter monitor = “flutter”, AF • Fundoscopy: Roth spots (IE) & Hypertensive changes (e.g. papilloedema)
paroxysmal
TAMPONADE CONSTRICTIVE PERICARDITIS
DEFINE Fluid in pericardiac sac Thick right inflamed pericardium
ONSET Chronic Acute
SX HypoTN (best to differentiate) Kussmaul breathing
Muffled HS
Raised JVP
RX Pericardiocentesis Meds – NSAID, aspirin +/- pred
