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Cardiac history and examination

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.

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Cardiac history and examination

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

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

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

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

  5. Questions: • Complete the inadequate description. • Elucidate the vague points. • Fill in the gaps in the history not mentioned by patient. • Emphasize the important points.

  6. Types of questions: • Neutral questions. • Simple direct questions (yes/No). • Leading questions.

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

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

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

  10. Habits: • Smoking. • Physical efforts. • Addiction.

  11. Family History: • Hereditary factor. • Exposure to same etiological circumstances.

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

  13. Symptoms of Cardiac disorders:

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

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

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

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

  18. Analysis: • Site & radiation. • Provocation & relief. • Duration. • Character. • Associated features.

  19. 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.

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

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

  22. Cardiac physical examination 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.)

  23. General Examination • General appearance. • Vital signs: pulse, temp. Blood pressure, respiration. • Hands: (cold, warm, clubbing, cyanosis, sweating) • Eyes • Neck: • Neck veins. • Pulsations (arterial vs. venous). • Carotid arteries. • Trachea, thyroid gland.

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

  25. Local Examination

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

  27. 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.

  28. 3. Auscultation: Apex, lower end of sternum (tricuspid area), aortic area and pulmonary area . • Murmurs: • Timing • Character • Point of maximum intensity and propagation • Relation to respiration • Intensity • ± Thrill.

  29. 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.

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

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