HISTORY AND PHYSICAL EXAM

History of present illness

inquire about symptoms of cardiac disease i.e. chest pain, dyspnea, fatigue, hemoptysis,
syncope, palpitations, peripheral edema, cyanosis
determine the degree of physical disability caused by cardiac symptoms(angina,
shortness of breath (SOB), undue fatigue, palpitations) using the New York Heart Association
(NYHA) functional classification
determine severity of angina pectoris using the Canadian Cardiovascular Society
classification (see Table 1 Cardiology Chapter) past medical history
cardiac risk factors: smoking, family history, elevated cholesterol, diabetes mellitus (DM),
hypertension (HTN), +/ elevated homocysteine levels
Previous operations: thoracotomy, saphenous vein stripping/ligation, peripheral
vascular surgery, carotid endarterectomy
Allergies, medications i.e. anticoagulants, antiarrhythmic, antiplatelet agents, ACE
inhibitors, diuretics, etc. family and social history
family history of coronary artery disease (CAD), congenital heart disease, Marfan
syndrome, malignant hyperthermia and other hereditary disorders should be noted
consider marital status and living conditions in discharge planning


Review of symptoms
cardiovascular: past cardiac procedures, and investigations
CNS: previous transient ischemic attack (TIA) or stroke (requires full neurologic work-up)
respiratory: if chronic obstructive pulmonary disease (COPD) is suspected, obtain
spirometry, pulse oximetry and ABG pre-op
Endocrine: DM and its complications should be noted
Hematologic: bleeding disorders, sickle cell screening if African heritage
Renal: impaired renal function and renal dialysis increase the risk of perioperative
complications; renal transplant patients should be followed by renal transplant service
preoperatively to manage medications
Gastrointestinal (GI): active peptic ulcer disease, active hepatitis, cirrhosis, and other GI
problems can seriously affect the outcome of cardiac surgery
Peripheral vascular: venous and arterial disease should be noted; intra-aortic balloon
pump insertion through a femoral artery may be difficult with aorta-iliac occlusive disease
Genitourinary (GU): prostate problems may impair Foley catheter insertion
Musculoskeletal (MSK): major skeletal deformities or active arthritic conditions may
interfere with airway management, ambulating, and recovery
Physical examination
height, weight, and vital signs
examine mouth, airway, neck, chest and abdomen
assess all peripheral pulses and auscultate the carotid and subclavian arteries for bruits
examine saphenous veins
Perform Allen's test on both hands in case a radial artery is used as a bypass conduit for coronary
artery bypass
infection following cardiac surgery can be disastrous, therefore rule out skin infections and dental
caries (especially prior to valve surgery)
CONSENT

Risks and benefits of surgery should be clearly outlined to the patient and his/her family (with patient's
permission) serious complications should be explained, such as death, stroke, myocardial infarction (MI),
infection, etc.