The History taking And Physical Examination
The complete history requires information pertaining to: Symptoms Traditional cardiovascular risk factors A general medical history Occupation Habits Family history Systems review
The major symptoms associated with cardiac disease include : • Chest discomfort • Dyspnea • Palpitations • Syncope
Chest Pain Due to: Angina pectoris and myocardial infarction, Other cardiovascular diseases, Gastrointestinal diseases, Psychogenic diseases, Neuromuscular diseases, Diseases of the pulmonary system
Angina pectoris Quality? chest discomfort is usually described as "tightness," "pressure," "burning," "heaviness," Precipitating factors? the discomfort is inducedbyexercise, emotion, eating, or cold weather. Location? Anginal pain is ordinarily retrosternal. Radiation? The chest pain of myocardial ischemia tends to radiate bilaterally across the chest into the arms (left more than right) and into the neck and lower jaw. Occasionally, radiation to the back or occiput is noted.
Relieving factors? Angina is usually relieved within 5 to 20 minutes by rest, with or without the use of vasodilator drugs such as nitroglycerin (TNG), although sublingual TNG or TNG spray characteristically hastens relief. Occasionally, angina will dissipate despite continued exercise (the walk-through phenomenon) or will not occur when a second exercise effort is undertaken that previously produced chest discomfort (warmup phenomenon). Both circumstances can be attributed to the opening of functioning coronary arterial collaterals during the initial myocardial ischemia.
Myocardial infarction Pain associated with acute coronary syndrome (ACS) is usually more severe and longer-lasting than anginal pain and is often associated with nausea, vomiting, and diaphoresis
Pericarditis Pain is sharpand penetrating in quality Relief by sitting up and bending forward,worsening by changes in body position, during deep inspiration Radiate to the shoulders, upper back, and neck because of irritation of the diaphragmatic pleura.
Aortic dissection The pain is usually of sudden onset Patients frequently characterize the pain as having a tearing quality, and commonly localized to the interscapular area. The discomfort can radiate widely into the neck, back, abdomen, flanks, and legs and can migrate, depending on the location and progression of the aortic dissection
Respiratory Symptoms 1.Dyspnea is defined as difficult respiration or the unpleasant awareness of one's breathing. Dyspnea on effort is usually caused by congestive heart failure, chronic pulmonary disease, or physical deconditioning
2.Orthopnea results from an increase in hydrostatic pressure in the lungs that occurs with assumption of the supine position. It consists of cough and dyspnea in some patients with LV failure or mitral valve (MV) disease and necessitates the use of two or more pillows on lying downlie flat comfortably.
3.Paroxysmal nocturnal dyspnea(PND) is the occurrence of dyspnea during sleep, commonly 2 to 3 hours after going to bed, which is relieved by assuming the upright position. The probable mechanism for this relatively specific symptom of left-sided heart failure is the increase in central blood volume in the supine position
Palpitation .Patients may use a variety of terms to describe their awareness of the heartbeat (palpitations), such as flutters, skips, or pounding. The likelihood of a cardiac arrhythmia is modestly increased with a known history of cardiac disease (LR, 2.03) and decreased when symptoms resolve within 5 minutes (LR, 0.38) or in the presence of panic disorder (LR, 0.26) .A report of a regular, rapid-pounding sensation in the neck (LR, 1.77) or visible neck pulsations associated with palpitations (LR, 2.68) increases the likelihood that atrioventricular nodal reentrant tachycardia (AVNRT) is the responsible arrhythmia Simple premature beats can be perceived as a "floating" or "flopping" sensation in the chest caused by the more forceful beat that occurs after the pause following the premature beat. Rapid heart action of a paroxysmal tachycardia usually begins and terminates abruptly
Syncope Defined as the transient loss of consciousness caused by inadequate cerebral blood flow secondary to an abrupt decrease in cardiac output . Return of consciousness to the alert state is prompt Stokes-Adams syncope is caused by intermittent complete heart block, sinus arrest, or ventricular tachyarrhythmias .
The common faint (vasovagal syncope) results from bradycardia and hypotension caused by excessive vagal discharge. It has brief premonitory signs and symptoms such as nausea, yawning, diaphoresis, and sometimes the feeling of decreased hearing or vision. Following a fainting episode, the patient can be pale and diaphoretic and have a slow heart rate Hypersensitive carotid sinus syncope A history of episodes during an activity such as shaving, wearing of a tight collar, or extreme turning of the head can occur LV outflow obstruction(aortic stenosis or hypertrophic cardiomyopathy), loss of consciousness with effort can occur
Edema Edemais a common symptom or finding in patients with right- or left-sided heart failure. A patient can detect edema of the ankles and lower legs during the day and note that it diminishes during the night. Persistent edema in the legs from which veins were harvested at the time of bypass surgery is common. The calcium antagonists can produce bilateral edema of the lower legs . .
Cyanosis Cyanosis is a bluish color of the skin or mucous membranes caused by excess amounts of reduced hemoglobin. A distribution of cyanosis involving the mucous membranes as well as the periphery (central cyanosis) is caused by the admixture of venous blood at the level of the heart or great vessels. A patient or a family member can detect that the cyanosis is more intense in the feet than in the hands. This differential cyanosis suggests a right-to-left shunt through a patent ductus arteriosus in a patient with Eisenmenger physiology. Peripheral cyanosis does not involve the mucous membranes but is the result of slow peripheral flow with in the setting of circulatory failure, shock, or peripheral vasospasm
Functional disability. • How strenuous is the physical activity required to elicit symptoms? • Assignment of symptom severity contributes importantly to Risk assessment Clinical decision-making Patient outcome
New York Heart Association Functional Classification Class I No limitation of physical activity.No symptoms with ordinary exertion Class II Slight limitation of physical activity.Ordinary activity causes symptoms Class III Marked limitation of physical activity. Less than ordinary activity causes symptoms.Asymptomatic at rest. Class IV Inability to carry out any physical activity without discomfort. Symptoms at rest
Jugular Venous Pressure and Wave Form
Examination of the Jugular Venous Pulse The two main objectives : estimation of the CVP and inspection of the waveform. Usually, the right internal jugular vein (IJV) is superior for both purposes Simultaneous palpation of the left carotid artery aids the examiner in deciding which pulsations are venous. In patients in sinus rhythm, the venous waveform is typically biphasic, whereas the carotid upstroke is monophasic.
Venous pressure traditionally has been measured as the vertical distance between the top of the jugular venous pulsation and the sternal inflection point (angle of Louis). A distance >4.5 cm at 30° elevation is considered abnormal
The use of the clavicle may provide an easier reference for standardization. Venous pulsations above this level in the sitting position are clearly abnormal, as the distance between the clavicle and the right atrium is at least 10 cm. • It should also be noted that bedside estimates of CVP are made in centimeters of water but must be converted to millimeters of mercury to provide correlation with accepted hemodynamic norms (1.36 cmH2O = 1.0 mmHg). • Right atrial pressure >10 mm Hg (as predicted on bedside examination) had a positive value of 88% for the prediction of a pulmonary artery wedge pressure of >22 mmHg.
In patients suspected of RV failure but with a normal resting venous pressure, the abdominojugular test is useful. The abdominojugular reflex is performed using pressure over the right upper quadrant, for at least 10 seconds. A sustained rise of >3 cm in the venous pressure for at least 15 seconds is a positive response.
The normal venous pressure should fall by at least 3 mm Hg with inspiration. • A rise in venous pressure (or its failure to decrease) with inspiration is known as the Kussmaul sign,and is classically associated with: • Constrictive pericarditis, • Restrictive cardiomyopathy, • Pulmonary embolism, • RV infarction • Advanced systolic heart failure.
The venous waveform is divided into several distinct peaks. • The a wave reflects right atrial presystolic contraction and occurs just after the electrocardiographic P wave, preceding the first heart sound (S1). • The x descent defines the fall in right atrial pressure after the a wave. • The c wave interrupts this x descent and is followed by a further descent. • The v wave represents atrial filling (atrial diastole) and occurs during ventricular systole.
For the noninvasive evaluation of arterial BP, a pneumatic cuff with a mercury or aneroid manometer is the most frequently used technique . • The mercury manometer is the gold standard; the aneroid manometer should be calibrated against the mercury manometer at least every 6 months.
METHOD OF BP MEASUREMENT Blood pressure should be measured in the seated position with the arm at the level of the heart The patient should be relaxed for 5 to 10 minutes. In the supine position, the arm should be raised to bring it to the level of the mid-RA (i.e., elevated on a pillow). The length and width of the cuff's bladder should be 80 and 40 percent of the arm's circumference, respectively The cuff should be placed 1 to 2 cm above the antecubitalfossa to allow for placement of the stethoscope over the brachial artery. The cuff should be inflated to 30 mm Hg above the systolic pressure and the pressure should be released at 2 to 3 mm Hg per second
The systolic pressure be recorded as the point at which the first tapping sounds occur (phase I) The diastolic pressure in adults be recorded as the point at which sounds become inaudible. In children and in adults with a hyperkinetic circulation, the diastolic pressure should be recorded as the point at which muffling of the sounds occurs (onset of phase IV).
Blood pressure should be measured in both arms either in rapid succession or simultaneously; normally the measurements should differ by <10 mm Hg, independent of handedness. Systolic leg pressures may be as much as 20 mm Hg higher than arm pressures; Leg blood pressure should be measured using a standard large arm cuff on the calf with simultaneous auscultation at the posterior tibial artery
The Ankle-Brachial Index The ankle-brachial index (ABI) is the ratio of the systolic blood pressure at the ankle divided by the higher of the two arm systolic blood pressures. It reflects the degree of lower-extremity arterial occlusive disease A resting ABI <0.9 is considered abnormal.
The arterial pulse occurs at the same frequency as the heartbeat. Ejection of blood with every cardiac contraction is converted to pulsations in arteries throughout the body.
Examination of the Arterial Pulse All pulses should be examined for symmetry, timing, and strength. Concomitant palpation of the brachial or radial pulse with the femoral pulse should routinely be performed; The carotid pulses should not be examined simultaneously or before auscultation for a bruit; light pressure should be used A pulse in the foot should not be considered absent unless examined with the foot in a dependent position. Otherwise, the arterial pulses usually are examined with the patient supine Although one of the two pedal pulses may not be palpable in up to 10% of normal subjects, the pair should be symmetric.
The carotid artery pulse the head rotated slightly toward the examiner. The carotid pulse should be palpated in the lower half of the patient's neck to avoid carotid sinus compression.
Brachial pulse Cup your hand under the patient’s elbow and feel for the pulse just medial to the biceps tendon. .
Palpate the radial pulse with the pads of your fingers on the flexor surface of the wrist laterally. Partially flexing the patient’s wrist may help you feel this pulse.
The femoral pulse. Press deeply, below the inguinal ligament and about midway between the anterior superior iliac spine and the symphysis pubis.
The popliteal pulse. The patient’s knee should be somewhat flexed, the leg relaxed. Place the fingertips of both hands so that they just meet in the midline behind the knee and press them deeply into the popliteal fossa.
The dorsalis pedis pulse. Feel the dorsum of the foot just lateral to the extensor tendon of the great toe.
The posterior tibial pulse. Curve your fingers behind the medial malleolus of the ankle.
Allen test The integrity of the arcuate system of the hand can be assessed using the Allen test.
1. Ask the patient to make a tight fist with one hand; 2. Compress both radial and ulnar arteries firmly between your thumbs and fingers. 3. Ask the patient to open the hand into a relaxed, slightly flexed position. The palm is pale.
4. Release your pressure over the ulnar artery. 5. If the ulnar artery is patent, the palm flushes within about 3 to 5 seconds.