Cardiac Evaluation and Medical History Quiz

Cardiac History and Physical Examination

• Chief Complaint and History of Present Illness:
  • Chest pain
  • Dyspnea
  • Edema of the feet and ankles
  • Palpitations
  • Syncope
  • Cough and hemoptysis
  • Nocturia
  • Cyanosis
  • Intermittent claudication

Past Medical History

• Any previous cardiac conditions
• Hypertension
• Diabetes
• Other relevant health conditions

Current Health Status and Risk Factors

• Current medications
• Lifestyle factors (e.g., smoking, alcohol consumption, exercise)

Family History

• History of heart disease in the family

Social and Personal History

• Occupation
• Hobbies
• Social support network

General Examination

• Vital signs:
  • Temperature
  • Pulse
  • Blood pressure
  • Respiratory rate
• General Appearance:
  • Body build (obese, cachectic)
  • Decubitus (orthopnea, prayers' position, squatting)
  • Color (pallor, cyanosis, jaundice)
    • Pallor: may indicate hypovolemia or anemia
    • Cyanosis: (bluish color)
      • Central cyanosis: observed in the lips, oral mucosa, and tongue (in congenital heart diseases, cor-pulmonale, and advanced heart failure)
      • Peripheral cyanosis: low cardiac output, low blood flow to peripheries like cardiogenic shock
    • Jaundice: may present in the sclera, lips, hard palate, under the tongue, and may be indicative of hepatic engorgement due to right ventricular failure
• Inspection:
  • Nails (finger clubbing): broadening of the distal phalanges of digits, giving them a drumstick or club-like appearance accompanied by abnormally curved and shiny nails. Indicates chronic poor oxygen perfusion to the distal tissues of the hand and feet (as in patients with chronic cardiac conditions, such as cyanotic congenital heart disease)
  • Subcutaneous nodules: subcutaneous firm swelling found in active rheumatic fever
  • Lower extremities: cardiac edema typically present in right-sided heart failure
  • Neck: vigorous pulsations
  • Fever: associated with rheumatic fever and infective endocarditis
  • Respiration: dyspnea may indicate left ventricular heart strain

Jugular Venous Distention

• Rationale: The internal jugular vein is in direct communication with the right atrium, serving as a manometer. Distention indicates elevated central venous pressure (CVP).
• Assessment: Measured as the vertical distance above the sternal angle (angle of Louis) with the patient supine and head elevated at 45 degrees.
• Normal: Jugular venous pulsation should not exceed 3 cm above the Angle of Louis.

Examination of Pulse

• Definition: Pressure wave in the arterial system produced by left ventricular ejection.
• Palpation: Carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis pulses should be palpated.
• Pulse Characteristics:
  • Rate (60-90 bpm)
  • Rhythm (regular or irregular)
  • Volume/Amplitude (strong or weak)
  • Equality (same on both sides)

Blood Pressure

• Definition: Lateral pressure exerted by blood on arterial walls.
• Measurement:
  • Systolic (highest pressure): occurs during ventricular systole.
  • Diastolic (lowest pressure): occurs during ventricular diastole.
• Methods:
  • Invasive (direct): using a catheter inserted into an artery
  • Non-invasive (indirect):
    • Palpatory step: used to determine systolic pressure
    • Auscultatory step: used to determine systolic and diastolic pressure

Auscultation

• Auscultation points:
  • Aortic area: second intercostal space close to the sternum on the right
  • Pulmonary area: second intercostal space to the left of the sternum
  • Tricuspid area: lower left sternal border, approximately the fourth to fifth intercostal space
  • Mitral area (apex of heart): fifth left intercostal space, medial to the midclavicular line
• Procedure: Auscultate each area using the diaphragm of the stethoscope for the four heart sounds.

Local Examination

• Palpation:
  • Skin: palpate for edema (pitting or non-pitting)
  • Precordium: locate the point of maximal impulse (PMI)
    • Normally located in the fifth intercostal space medial to the midclavicular line.
    • Assess location, diameter, and amplitude: A normal impulse is felt as a light tap extending over 1 cm. An area greater than 3 cm is usually pathological.
• Causes of Shifted Apex:
  • Factors outside the heart: chest and abdominal diseases, fibrosis, pleural effusion, pneumothorax, deformities of the chest, mediastinal lesions, abdominal distension.
  • Causes from the heart (cardiac enlargement): left ventricular hypertrophy, right ventricular hypertrophy.
• Carotid Artery Palpation: located by sliding the fingers along the side of the trachea at the level of the thyroid cartilage. Pulsations should be easily palpable.