History taking and physical examination in Cardiovascular system.

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