Cardiac history and examination Dr. Bakir M. Bakir Consultant Cardiac Surgery

The five finger approach to cardiac diagnosis  The cardiac history  The cardiac physical exam  Electrocardiogram  Chest X-ray  Cardiac diagnostic laboratory tests.

A good history should be both:  Concise.  Cover the important points.

Rules: 1. Patient should be allowed to tell his history in his own words. 2. Leading questions must be avoided unless the information can’t be obtained by other means

Questions: 1. Complete the inadequate description. 2. Elucidate the vague points. 3. Fill in the gaps in the history not mentioned by patient. 4. Emphasize the important points.

Types of questions: 1. Neutral questions. 2. Simple direct questions (yes/No). 3. Leading questions.

Personal data:  Name.  Age.  Sex.  Occupation.  Residence. The patients complaint: A simple statement in the patients own words and its duration.

Present History: This means detailed history of the patients present illness which must provide answer for the following questions: 1.Duration 2.Mode of onset (acute, sub acute, chronic). 3.Sequence of events: I.Course (progressive, regressive or recurrent). II.Appearance of new additional symptoms or disappearance of others. III.Treatment received during the course & response. 4.Analysis of each particular symptom.

Past History:  Childhood diseases.  Trauma.  Residences or travel abroad.  Drug therapy.  Operations.  Prior illness (cardiac, noncardiac).  Recent dental work  Prior cardiac procedure

Habits:  Smoking.  Physical efforts.  Addiction.

Family History:  Hereditary factor.  Exposure to same etiological circumstances.

Coronary artery disease risk factors  Cigarette smoking  Hypertension  Hyperlipidemia  Family history of CAD  Diabetes mellitus

Symptoms of Cardiac disorders:

1. Symptoms due to lung congestion:  Dyspnea.  Acute pulmonary edema.  Cough, hemoptysis.  Recurrent chest infections.

2. Symptoms due to systemic congestion:  Pain in the right hypochondrium.  Dyspepsia.  Swelling of lower limb.  Swelling of the abdomen.  Oliguria.

3. Symptoms due to low cardiac output: (tissue hypoxia →brain, muscles, kidneys)  Exertional fatigue.  Blurring of vision.  Dizziness / Syncope.  Oliguria, Angina.

4. Chest pain: 1. Of Cardiac Origin: Ischemia, pericarditis, Dissecting aorta, Aortic Aneurysm. 2. Other Causes:  Chest wall  Neurological  Mediastinum  Diaphragm  Abdominal. ( esophagus, stomach, gall bladder, pancreas).

Analysis: 1. Site & radiation. 2. Provocation & relief. 3. Duration. 4. Character. 5. Associated features.

Pearls regarding CAD  Many patients don’t have the classic text book symptoms  Angina doesn’t always mean coronary artery disease.  A high index of suspicion is necessary to avoid missing the diagnosis of acute aortic dissection.  Not all patients with acute MI develop ECG changes.

5. Symptoms due to changes in rate, Rhythm, or force → palpitation. ( time, mode of onset & offset, relation to exertion, duration, irregularity).

6. Symptoms due to pressure on surrounding structures. ( esophagus, bronchi, nerves, spine)

Cardiac physical examination Basic concepts: Basic concepts:  Try to secure, if possible, a well- lighted quiet room.  Perform examination from the patients right side.  Find recorded vital signs (or do them yourself-after all, they are vital.)

General Examination 1. General appearance. 2. Vital signs: pulse, temp. Blood pressure, respiration. 3. Hands: (cold, warm, clubbing, cyanosis, sweating) 4. Eyes 5. Neck: I.Neck veins. II.Pulsations (arterial vs. venous). III.Carotid arteries. IV.Trachea, thyroid gland.

6. Lower Limbs ( signs of PVD, edema, pulsations). 7. Abdomen: feel for palpable hepatomegaly and check if it is pulsatile (tricuspid regurge). Look for ascites,splenomegaly(IE), and an aortic aneurysm.

Local Examination

1. Combined Inspection and palpation: 1. Shape. 2. Cardiac impulses (apex beat, parasternal pulsations, epigastric, to the right of sternum, suprasternal notch, 2 nd left space) 3. Thrills. 4. Palpable heart sounds 5. Position of the mediastinum 6. Tactile vocal fremitus 7. Chest movements 8. Local tenderness,pulsations,wheezes.

2. Percussion  Types of percussion notes  Apices of the lungs  Anterior chest wall  Lateral chest wall  Posterior chest wall  Cardiac and hepatic dullness  Rules of percussion.

3. Auscultation: Apex, lower end of sternum (tricuspid area), aortic area and pulmonary area.  Murmurs: 1. Timing 2. Character 3. Point of maximum intensity and propagation 4. Relation to respiration 5. Intensity 6. ± Thrill.

Auscultation  The first and second heart sounds reflect valve closure.normally, valve opening is not heard.  S1 is the sound of closure of the mitral and tricuspid valves at the start of ventricular systole.  S2 is the sound of closure of the aortic and pulmonary valves at the start of ventricular diastole.

 Breath sounds.  Adventitious sounds.(rhonchi,crepitations,rub)  Vocal resonance.