Cardiovascular System History and Examination

Cardiovascular System History and Physical Examination

• Learning Goals: Covers cardiac history (symptoms, medical history, family history), cardiovascular examination (cardiac exam, vascular exam - arteries, veins), and auscultation (heart sounds, pathological sounds, murmurs).

Cardiac History

• Personal Details: Includes date of exam, name, age, sex, ethnicity, and occupation.
• Major Complaints (Symptoms): Details of patient's chief complaints.
• History of Symptoms: Chronology of symptoms, onset, duration, and characteristics.
• Past Medical History: Previous illnesses, surgeries, and chronic conditions.
• Family History: Details of cardiovascular diseases in family members.

Major Cardiac Symptoms

• Chest Pain (Angina): A type of chest pain, pressure, or discomfort.
• Shortness of Breath (Dyspnea): Subjective feeling of not being able to breathe enough. Can be caused by cardiac or pulmonary issues.
• Palpitation: Subjective feeling that the heartbeat is abnormal (fast, slow, irregular).
• Edema: Swelling, usually in the extremities, caused by fluid retention.
• Syncope: Loss of consciousness due to insufficient blood supply to the brain.
• Claudication: Pain in the limbs due to reduced blood flow, often with exercise.

Angina = Myocardial Ischemia

• Mechanism: Myocardial oxygen imbalance, either increased demand or decreased supply (coronary artery narrowing).
• Angina described as chest pain, pressure, discomfort.

Angina Pectoris

• Most Common Symptom: Myocardial ischemia due to coronary artery disease or other ischemic conditions.
• Localization: Retrosternal (behind the breastbone), radiating to left arm, shoulder, back, epigastric region.
• Character: Squeezing, burning, pressure.
• Provacation/Relief: Exercise, stress, cold; resting, nitrate.
• Duration: Acute, subacute, or chronic.
• Typical Angina: Meets all 3 criteria: retrosternal pain, increased pain with exercise/stress, decreased pain with rest/nitrate.
• Atypical Angina: Meets 1-2/3 criteria.
• Non-cardiac chest pain: None of the 3 criteria met.

Causes of Chest Pain

• Coronary Artery Disease/MI: First possible cause.
• Other Cardiovascular Causes: Ischemic (e.g., aortic stenosis, hypertensive heart disease) or non-ischemic (e.g., aortic dissection).
• Gastrointestinal Causes: Esophageal spasm, reflux, peptic ulcer.
• Psychogenic: Anxiety, depression, cardiac psychosis.
• Neurogenic/Locomotor: Thoracic outlet syndrome, cervical degenerative arthropathy.
• Pulmonary Causes: Pulmonary embolism, pulmonary infarct, pneumothorax.

History of a Patient with Chest Pain

• Age and Gender: Risk factors.
• History of Coronary Artery Disease (CAD): Previous myocardial infarction (MI), percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG).
• CAD Risk Factors: Hypertension (HT), diabetes mellitus (DM), hyperlipidemia (high LDL, low HDL, high triglycerides), smoking, and family history.
• Characteristics of Chest Pain: Localization, features (burning, squeezing, pressure), radiation, provocation/relief, duration (acute, subacute, chronic).

Unstable Angina Pectoris

• Features: New onset angina, rest pain, progressive angina, or post-MI angina.
• Associated Symptoms: Anxiety, fear, sweating, nausea, dyspnea.

Shortness of Breath (Dyspnea)

• Definition: Subjective feeling of not being able to breathe enough.
• Cardiac Mechanism: Pulmonary congestion.
• Types: Exercise dyspnea, orthopnea, paroxysmal nocturnal dyspnea, rest dyspnea, acute pulmonary edema.

Orthopnea

• Mechanism: Pulmonary congestion due to fluid redistribution when lying down (gravity).
• Associated with: Congestive heart failure.
• Patient Presentation: Unable to lay flat due to shortness of breath. Needs pillows to sleep propped up.

Paroxysmal Nocturnal Dyspnea

• Mechanism: Fluid redistribution to the lungs during sleep, causing excess volume to return to the heart and leading to congestion.
• Symptoms: Dyspnea/orthopnea occurring 2-3 hours after falling asleep, patient awakens with air hunger, severe shortness of breath and coughing episode, generally occurring at night.

Cardiac Edema

• Mechanism: Increased total body fluid and increased hydrostatic pressure causing leakage from vessels into interstitial space.
• Locations: Lower extremities (pretibial edema).
• Amounts: At least 5 liters of excess fluid needed to cause edema.
• Etiology (Causes): Right heart failure (edema in legs, sacrum, abdomen), left heart failure (pulmonary congestion/edema).

Palpitation

• Definition: Subjective awareness of the heartbeats: fast, slow, irregular, strong or paused.
• Possible Associated Clinical Problems: Associated with various heart rhythm problems (tachycardia, bradycardia, extrasystoles, pauses).

Syncope (Fainting)

• Cardiac Syncope: Cerebral hypoperfusion due to low cardiac output.
• Associated Symptoms: Sudden loss of body posture and consciousness followed by recovery.
• Causes: Mechanical (aortic stenosis, hypertrophic cardiomyopathy), arrhythmic (ventricular tachycardia).

Past Medical History

• Risk Factors for Coronary Artery Disease (CAD): Age (>45 Male, >55 Female), male gender, diabetes mellitus, hypertension, dyslipidemia (high LDL, low HDL, high triglycerides), smoking, family history (males <55, females <65), habits (smoking, alcohol, drugs), history of Rheumatic fever.
• Medication: List of chronic illnesses, previous operations, trauma, or allergies.

Family History

• Coronary Artery Disease (CAD): Family history of CAD. Age criteria for determining significant family history.
• Congenital Heart Disease: Atrial septal defect (ASD), ventricular septal defect (VSD), patent ductus arteriosus (PDA).
• Genetic Disorders: Hypertrophic cardiomyopathy, mitral valve prolapse, dilated cardiomyopathy, Marfan syndrome, Long QT syndrome.

Physical Examination

• Inspection: General appearance (e.g. tachypnea, anxiety, confusion), body type (e.g. Down, Turner, Marfan), sweating, cyanosis, anemia, obesity.
• Palpation: Cardiac size and position, apical beat (localization, strength), ventricular beat, thrill. Arterial pulses: palpation of peripheral pulses (temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial).
• Percussion: Size and position of organs, identify fluid collections (e.g., pleural or pericardial).
• Auscultation: Using stethoscope (diaphragm and bell), Silent environment. auscultation position and points (intercostal spaces).

Cardiovascular Examination

• Cardiac Examination: Inspection, palpation, and percussion. Auscultation (heart sounds, murmurs).
• Vascular Examination: Blood pressure measurement, palpation of arterial pulses (temporal, carotid, brachial, radial, femoral, popliteal, tibial), and jugular venous pressure (JVP) measurement.

Cardiac Exam

• Inspection: General appearance, body type (e.g. Down, Turner, Marfan), sweating, cyanosis, anemia, obesity. Venous distention, and Central venous pressure.
• Palpation: Apical beat (localization, strength), right ventricular beat, thrills (pulsations of increased blood flow).

Arterial Pulse

• Mechanism: The elastic expansion of arteries during the systolic phase of the heartbeat in the contraction of the cardiovascular system. As the heart relaxes, blood is drawn into the elastic arteries. As the heart contracts, blood rushes into the arteries; this produces a pulse.

Peripheral Pulses

• Location: The locations of various pulse points on the body.

Intercostal Spaces

• Louis Angle: Attachment point of corpus sterni, and manubrium sterni (2nd intercostal space).
• 2nd, 3rd, and 4th Intercostal Spaces: The locations of the intercostal spaces used during physical examinations.

Auscultation Positions

• Sitting Position
• Supine
• Left Lateral
• Leaning Forward

Auscultation Points

• Aortic Focus: 2nd intercostal space, right sternal border.
• Pulmonary Focus: 2nd intercostal space, left sternal border.
• Tricuspid Focus: 4th intercostal space, left sternal border.
• Mitral Focus: 5th intercostal space, mid-clavicular line (cardiac apex).
• Mesocardiac Focus (Erb Point): 3rd intercostal space, left sternal border. (for VSD/AR)

What do we listen to?

• Heart rate: Bradycardia, normocardic (normal), and tachycardia.
• Rhythm: Regular or irregular.
• Heart sounds: Physiologic (S1, S2, rarely S3 and S4), and pathologic sounds can (S3 and S4).
• Additional Sounds: Systolic clicks, opening snap, pericardial knock, pericardial friction rub, and prosthetic heart valve clicks.
• Murmurs: Presence, classification, and characteristics (systolic, diastolic, and continuous).

Heart Sounds

• S1: Closure of AV valves (mitral and tricuspid).
• S2: Closure of semilunar valves (aortic and pulmonary).
• Systole: Time between S1 and S2 (ventricular contraction).
• Diastole: Time between S2 and S1 (ventricular relaxation).

First Heart Sound (S1)

• Mechanism: Closure of AV valves.
• Components: Mitral (M1) and Tricuspid (T1) components.
• Location: Best heard at mitral and tricuspid auscultation points.

Second Heart Sound (S2)

• Mechanism: Closure of semilunar valves (aortic and pulmonary).
• Components: A2 (aortic) and P2 (pulmonary) components.
• Location: Best heard at aortic and pulmonic auscultation areas.

Third Heart Sound (S3)

• Characteristics: Early diastolic heart sound, may be physiologic or pathologic, heard in 25-50% healthy young individuals.
• Mechanism: Ventricular filling after opening of the AV valves.

Fourth Heart Sound (S4)

• Characteristics: Late diastolic heart sound, usually pathologic.
• Mechanism: Ventricular filling by atrial contration

Pathological S3 and S4

• S3: Volume overload, systolic dysfunction, congestive heart failure.
• S4: Pressure overload, diastolic dysfunction, systemic hypertension.

Additional Sounds

• Systolic clicks: Mid-systolic click (mitral valve prolapse), ejection click (aortic/pulmonary valve stenosis/aneurysm)
• Opening Snap: Heard in mitral/tricuspid stenosis, shortly after S2.
• Pericardial Knock: Heard in constrictive pericarditis; hitting of ventricle on calcified pericardium during early diastolic ventricular filling.
• Pericardial friction rub: Heard in acute pericarditis, friction sound in parietal and visceral pericardial layers during heart cycle.
• Prosthetic heart valve clicks: Associated with prosthetic heart valves (caused by the mechanical function of the prosthetic valve).

Systolic Murmurs

• Mid-systolic: Aortic stenosis, pulmonary stenosis
• Late Systolic: Mitral valve prolapse
• Pansystolic: Mitral regurgitation, tricuspid regurgitation, ventricular septal defect(VSD)

Diastolic Murmurs

• Early Diastolic: Aortic regurgitation, pulmonary regurgitation
• Mid/Late Diastolic: Mitral stenosis, tricuspid stenosis, atrial myxoma

Continuous Murmurs

• Mechanism: Continuous pressure gradient between two chambers
• Examples: Patent ductus arteriosus (PDA), sinus valsalva aneurysm rupture, pregnancy/lactation, AV fistulas.

Intensity of Murmurs

• 1/6: Need training to hear
• 2/6: Any trained person could hear it.
• 3/6: Moderate intensity
• 4/6: Loud and palpable
• 5/6: Harsh heard by stethoscope only.
• 6/6: Loud enough to hear without the stethoscope.

This quiz covers the essential aspects of cardiac history taking and physical examination. It focuses on crucial components such as symptoms, medical and family history, as well as the cardiovascular examination techniques, including auscultation. Assess your understanding of the major cardiac symptoms and their implications.