1. History taking and physical examination in Cardiovascular system. Akintunde A.A Department of Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria.

2. History taking • Involves the obtainment of information from patients about their case • A narrative work! • A detective work! • Like Sherlock Holmes, Not like Eugenia Abu! • Logical interpretation of clinical history • Antecedent risk factor

3. Precipitants • Complications • Prognosis

4. Core Component of History taking • Biodata • Name • Age • Occupation • Gender • Religion • Residence • Tribe

5. History of presenting complaints • Which system does this refer to? • Highlight in order of occurrence

6. Main complaints • Common complaints • Pain • Fever • LOC

7. History of presenting illness • History of symptom • History of aetiology • History of treatment • History of complication

8. When was the patient last quite well? • Mode of onset of disease • Define disease progression • Desribe main presentation fully • Chronology of symptom • Pertinent negatives

9. Past medical history • Developmental and antenatal history • Drug history • O&G History • Family and Social history

10. Systemi review of systems • CVS • Chest • Abbdomen • Genito-urinary • Musculoskeletal • Neurological

11. Clinical Summary • Short • Straight to d point! • Important negatives • Enough to make a differential diagnosis.

12. Cardiovascular system Examination • Arterial pulse • Locomotorbrachialis • Blood pressure • Jugular venous pressure • Precordium

13. Leftventricular output- radial pulse • JVP- right atrial pressure • Position • Exposure • Be calm • Take permission! • Be articulate!

14. CVS examination • Inspect quickly • Position in bed • Dyspnoea • Orthopnoea • Cyanosis • Neck pulsation • Proptosis • Fluffy hair • Hyperpigmentation • Cahexia • gynaecomastia

15. Arterial Pulse • Rate • Rhythm • Volume • Characetristics • Vessel wall • Sychronicity

16. Radiofemoral delay • Peripheral pulse • Pulse deficit

17. Blood pressure check! • Standard ways to measure BP • Interpretation • Thigh BP popliteal systolic BP>brachial BP 60mmHg, Hill’s sign - Aortic regurgitation • JNC VII • WHO • ESC • AHA • Nigerian Hypertension Society • Forum for the prevention of Hypertension in Africa

18. Causes of • Tachycardia • Bradycarda • Irregularly irregular pulse • Pulsusalternans • Pulsustardus et parvus • Pulse deficit

19. Jugular venous pressure • Differentiate JVP from carotid pulsation • Hepatojugular reflux • Measure JVP in metres • Assess wave forms a,c and v waves • Canon a waves • Kussmauls sign –paradoxical inspiratory rise in JVP (Venous pulsusparadoxus) seen in EMF, pericardial effusion, cardiac tamponade

20. A controversy!! But important……. • Trachea shift!!

21. Precordium • Inspect • Palpate • Percussion( only when u suspect Pericardial effusion • Auscultation

22. Heart sounds • S1,2,3,4 • Loud S1- hyperdynamic circulation, mitral stenosis, • Soft S1-MR • Variable intensity in complete heart block • Any added sound? Click or murmur?

23. Murmur • Murmur- timing? • Area of maximum intensity • Grading • Configuration-diamond shaped, decrescendo, holosystolic, systolic click murmur • Respiratory variation • Right sided murmur increase on inspiration • Left sided murmur increase on expiration • conductivity

24. Aortic area- loud A2 HTN • Decrescendo diastolic murmur in aortic area – AR • Pulmonary area • Loud P2 • Splitting of P2, exagerated, reversed, fixed. • Neck- carotid bruits • Back basal lung crackles • Ewart sign-presence of bronchial signat posterior lung base due to compression of bronchi by large cardiomegaly or PE.

25. Liver palpation- hepatomegaly, pulsatile?, ascites, • Legs- pedal oedema

26. Further examination • Fundoscopy • Kidneys-APKD • Renal bruits

27. Functional classification of severity of heart disease • NYHA/CCS • I • II • III • IV