History and Physical Examination of Cardiovascular System PDF

History and Physical Examination of Cardiovascular System Assoc. Prof. Oğuz Karaca Medipol University Faculty of Medicine Cardiology 1  Learning Goals Cardiac History Major Symptoms Ang...

History and Physical Examination of Cardiovascular System Assoc. Prof. Oğuz Karaca Medipol University Faculty of Medicine Cardiology 1  Learning Goals Cardiac History Major Symptoms Angina Pectoris / Dyspnea Past Medical History & Risk Factors Family History Cardiovascular Examination Cardiac Exam Vascular Exam Arteries Veins Auscultation Heart Sounds Pathological Sounds Murmurs 2  Cardiac History Start with personal details date of examination name age sex ethnicity occupation Major Complaints (Symptoms) History of Symptoms Past Medical History Family History 3  Major Cardiac Symptoms Chest Pain (Angina) Shortness of breath (Dyspnea) Palpitation Edema Syncope Claudication 4  Angina = Myocardial ischemia Myocardial O₂ imbalance Increased demand of O₂ or decreased supply of O₂ 5  Angina Pectoris Most common symptom Mechanism: myocardial ischemia CAD / other ischemic conditions Localization Retrosternal Character Squezzing, burning, pressure Radiation Left shoulder, left arm (or both), back, epigastric region. Provacation / Relief exercise, stress, cold / resting, nitrate) Duration (acute / subacute / chronic) 6  Typical Angina If all the 3 criteria are met: Typical Angina 1. Retrosternal pain / pressure / burning / squeezing 2. Increased pain with exercise / stress (physical / emotional) 3. Decreased pain with rest or nitrate 1-2/3 criteria → Atypical angina 0/3 → Non-cardiac chest pain 7  Causes of Chest Pain 1. Coronary Artery Disease / MI 4. Psychogenic Anxiety 2. Other Cardiovascular Causes Depression Cardiac psychosis a) Ischemic Aortic stenosis Severe Hypertension 5. Neurogenic / Locomotor System HOCM Torasic outlet syndrome Pulmonary Hypertension Severe anemia Cervical degenerative arthrosis Hypoxia Costachondritis b) Non-ischemic Herpes zoster Aortic dissection Trauma Pericarditis Mitral valve prolapse 6. Pulmonary Causes Pulmonary embolism 3. Gastrointestinal Causes Pulmonary infarct Eusophageal spasm Pneomothorax Reflux Peptic ulcer Pneumonia / Pleural effusion 8  History of a patient with chest pain Age / Gender Historyf of coronary artery disease (MI / PCI / CABG) CAD risk factors (HT / DM / HL / smoking / family history) Characteristics of chest pain (Typical / Atypical) Localization → Retrosternal Feature → Burning, pressure, squeezing Radiation → Left arm, shoulder, jaw, back, epigastrium Increased with → Physical (exercise-cold) / emotional stress Decreased with → Rest / nitrate Duration → New onset / chronic 9 Unstable Angina Pectoris Features New onset angina Rest pain / minimal effort Progressive angina Post-MI angına May be associated with Anxiety, fear, sweating, nausia, dyspnea 10  Shortness of Breath (Dyspnea) Dyspnea: a subjective feeling that one can not breath enough Cardiac mechanism: Pulmonary congestion 1. Exercise dyspnea 2. Orthopnea 3. Paroxysmal nocturnal dyspnea 4. Rest dyspnea 5. Acute pulmonary edema 11  Orthopnea Mechanism: Pulmonary congestion due to fluid redistrubiton in the pulmonary circulation while laying down. (While sitting / upright, fluid accumulates in the base of the lungs due to gravity. Mostly seen in Congestive Heart Failure The patient can not lay down because of dyspnea. The patient needs to sleep propped up in bed or sitting in a chair. Ask the patient how many pillows they need to sleep 12 Orthopnea 13 Paroxysmal Nocturnal Dyspnea Mechanism: Redistrubition of fluid into the pulmonary circulation (after laying down, excess volume returns to the heart and pulmonary congestion occurs) Dyspnea / orthopnea typically occurs 2-3 hours after falling asleep. Patient awakens with hunger of air. Attacks of severe shortness of breath and coughing that generally occur at night. 14 Paroxysmal Nocturnal Dyspnea 15  Cardiac Edema Mechanism: Increased total body fluid, increased hydrostatic pressure causes leakage from the vessels into the interstitial space. Excess volume mostly accumulates in the lower extremites (pretibial edema) At least 5 liters of excess fluid is needed to cause edema. Right heart failure: Edema seen in the legs, sacrum, abdomen (assites) Left heart failure: Pulmonary congestion / pulmonary edema 16 Cardiac Edema 17  Palpitation A subjective feeling that patient awares of heart beats. Heart beats may be felt as fast, slow, irregular, strong or paused. May (not) be associated with heart rhythm problems Tachycardias (sinüs tachycardia, atrial fibrillation, SVT) Bradycardias (AV blocks) Extra-systoles (VES / AES) Pauses 18 Palpitation 19  Syncope (Fainting) Cardiac syncope Cerebral hypoperfusion due to low cardiac output. Associated with sudden onset loss of body posture and loss of consciousness Spontaneous recovery Causes of Low Cardiac Output 1. Mechanical (aortic stenosis, HOCM) 2. Arrhythmic (ventricular tachycardia) 20  Past Medical History Risk factors for coronary artery disease Age (Male>45, Female>55) Male gender Diabetes mellitus Hypertension Dyslipidemia (High LDL, Low HDL, High Triglycerides) Smoking Family history of CAD (M