HISTORY TAKING AND

CLINICAL EXAMINATION
OF CARDIAC PATIENTS
BASIC CLINICAL SKILLS
PARALLEL PROGRAM

DR. MOHAMMED FAKHRY, MD, FACC

,Associate Professor of Medicine
Consultant Internist/Cardiologist
King Faisal University
King Fahd Hospital of the University
CARDINAL SYMPTOMS IN HEART
DISEASE:

Dyspnea Edema
Chest pain Cough
Cyanosis Hemoptysis
Syncope Fatigue
Palpitation Intermittent Claudication
1) DYSPNEA:
“Unpleasant Awareness of Breathing”.

CAUSES:
1) Pulmonary
• COPD • Restrictive L. Disease
• Br. Asthma
• Cardiac – CHF (MS, MR, AS, MI. CM)
1) Anemia
2) Obesity
FUNCTIONAL CLASSES OF
DYSPNEA: (NYHA Classification)

Class I D.O. extraordinary exertion (No

Dyspnea on average exertion)
Class II D.O. moderate exertion
Class III D.O. mild exertion
Class IV D. at rest (PND & Orthopnea)
II. CHEST PAIN OR DISCOMFORT:
Common Causes:
1) CAD  - Angina Pectoris
- Unstable Angina.
- Acute Myocardial Infarction
2) Mitral Valve Prolapse (MVP)
3) Pericarditis
4) GERD.
5) Peptic Ulcer Disease ( PUD )
CHRONIC STABLE ANGINA:
TYPICAL ANGINAL PAIN

Site
Quality of pain
Duration (few minutes)
Radiation
Provoking factor (Exercise, Emotional
excitement and Cold weather.)
Relieving factors (rest & TNG)
Associated symptoms
Risk Factors
UNSTABLE ANGINA
New onset frequent angina
Crescendo or accelerated angina
Duration → 10min -30min
Relation to rest
Response to TNG
 ACUTE MYOCARDIAL INFARCTON PAIN:

Site
Quality
Duration → > 30min.
Associated Symptoms
Response to S. L. TNG
III. CYANOSIS:
“Bluish Discoloration of the Skin and
Mucous Membranes.”

Peripheral.
Central.
IV. DIZZINESS, PRESYNCOPE
AND SYNCOPE.
Definition:
Causes:
1) Drugs: V. Dilator Drugs
2) Vasovagal syncope
3) Cardiac Arrhythmia
4) Cardiac Lesions (AS, MS, PS)
V. PALPITATION:
“Unpleasant Awareness of Forceful or
Rapid Heart Beating.”

Main Cause: Cardiac Arrhythmias

Description:
– Fast or slow
– Regular or irregular
– Duration
– Associated symptoms
VI. EDEMA OF THE LOWER LIMBS
CAUSES:
Cardiac
Renal
Hypoalbuminemia (Liver cirrhosis)
Venous Insufficiency
 VII. COUGH DUE TO CHF:

It occurs when P.V. P. ↑↑with

exercize or even at rest in patients
with CHF → transudation of fluid into
alveolar spaces → Cough, and
sometimes Hemoptysis
VIII. HEMOPTYSIS:

Mild:
 P. Congestion (CHF)  Ruptured P.
Capillaries.
 It occurs in the course of P. Infarction
IX. FATIGUE:
It is usually due to low C.O.

X. INTERMITTENT CLAUDICATION:
Peripheral Vascular Disease
(PVD)
B) CLINICAL EXAMINATION

GENERAL CLINICAL EXAMINATION:

Patient’s position : (45º inclination of the

head of the bed)
JVP
more convenient
Quiet & warm room with good lights
General Clinical Examination (cont’d)

1)General Look
– Skin complexion (color)
– Pain or respiratory distress
– Level of consciousness ( Orientation to place,
time & persons)
– Body edema
2. HAND EXAMINATION:

1. Pallor
2. Cyanosis
3. Stigmata of Infective Endocarditis:
- Clubbing - Janeway lesion
- Splinter Hem. - Osler’s Nodules)
4. Signs of Hyperlipidemia:
Tendon Xanthomatosis
5. Signs of Thyrotoxicosis:
Fine Tremors
3. RADIAL PULSE:

1. Rhythm
2. Rate
3. Volume
4. Character:
Normal
Collapsing Pulse
Slow rising pulse
5. Vessel Walls
6. Equality and Synchronization
AA
)B (

B
 Normal C-pulsus
Besferious

D-Pulsus
Besferious

Collapsing
E-Collapsing
Collapsing
pulse
4. BLOOD PRESSURE MEASUREMENT:

1. The Cuff
2. Position of the patient

Technique
– There are 5 KOROTKOFF’s Sounds:
Syst BP  Korotkoff 1
Diast BP  Korotkoff 5
5. RESPIRATORY RATE AND TEMPERATURE.

6. FACE EXAMINATION:
Abnormal Facies:
Down’s Syndrome
Marfan’s Syndrome
Malar Rash

Pallor:
Conjunctivae
Mucous Membranes of the Mouth
6. FACE EXAMINATION (cont’d)
Jaundice
 Sclera
 Mucous Membranes of the Mouth
Arcus Cornialis
Xanthelasma
Cyanosis
Signs of Hyperthyroidism
 Exophthalmos
 Lid Lag
 Lid Retraction
Mouth Hygiene
7. JUGULAR VENOUS PRESSURE (JVP)

Position of the patient  45º

Rt. Internal JV
Waves:
7. JUGULAR VENOUS PRESSURE (JVP) (cont’d)

Normal JVP = ≤ 8 cm water.

 Cause of absent A wave  A. Fib
 Cause of prominent A wave → PAH
and TS
Cause of Prominent V wave  TR
8. CAROTID PULSE:
Surface Anatomy
Inspection
 Normal
 Corrigan’s Sign
Palpation
 Location:
 Lt thumb for Rt carotid A
 Rt thumb for Lt carotid A
 Volume
 Character
 Thrill

Auscultation:
 Systolic Bruit
9. THYROID GLAND:
Inspection
Palpation
Percussion
Auscultation
10. EXAMINATION OF
THE PRECORDIUM:
A) Inspection:
Shape of the chest
– Pectus excavatum
– Pectus Craniatum
– Kyphosis & Scoliosis
Precordial Bulge
Scar of previous cardiac surgery
– Mid-sternotomy scar
A) Inspection (cont’d)

 Apex Beat:

Causes of absent apical impulse:

Emphysema
Obesity
Dextrocardia
Lt. pleural effusion or pneumothorax
Severe pericardial effusion

 Other Cardiac pulsations:

P. area
Aortic area
Epigastrium
B) PALPATION
1. Apical Impulse (PMI)
Site
Character
• Normal
• Hyperdynamic
• Sustained
• Tapping (palpable S1)
• Localized or diffuse
Thrill
2) Other Pulsation:
Left Parasternal Heave.
Causes
 R.V. enlargement
 Severe LA dilatation

Pulmonary area Dilated Pulm. Artery.→ PH

Aortic Area  Aortic aneurysm

Epigastric pulsation:
Causes:
 RV enlargement
 Pulsatile hepatomegaly  RS HF
 Palpable Abd. Aorta
C) PALPABLE HEART SOUNDS AND CLICKS

1. Palpable S1 Tapping apical impulse

2. Palpable P2  PH
D) THRILLS:
1. Diastolic Thrills
 MS & TS
1. Systolic Thrill
 MR at the M. area
 AS  A. area
 PS  P. area
 VSD  3rd & 4th Lt. ICS
3. Continuous Thrill  PDA
C)CARDIAC AUSCULTATION

STETHOSCOPE:
a) Bell  Low frequency sounds → S3, S4
→ Mid-diastolic murmur → MS & TS.

b) Diaphragm  High frequency sounds → S1,

S2, E. clicks, and clicks due to prosthetic
valves.
Systolic murmurs
Early diastolic murmur  AR
Continuous murmur  PDA
C) CARDIAC AUSCULTATION:
Circumstances
Quiet and warm room.
Systematic approach:
 S1 at mitral area (diaphragm)
 S2 at pulmonary area (diaphragm)
 S3 & S4 at M. area & T. area (Bell)
 Inching auscultation
C) CARDIAC AUSCULTATION:

Ausculatory Areas:

 Mitral Area  Apex beat area (5th LICS)

 Tricuspid Area  4th LICS at sternal edge
 2nd Aortic Area  3rd LICS at sternal edge
 Pulmonary Area  2nd LICS at sternal edge
 1st Aortic Area  2nd RICS at sternal edge
 C) CARDIAC AUSCULTATION:
E) Heart Sounds Pattern on Cardiac
Auscultation:
Lub ---- Dub ---- Lub ---- Dub

F) Gallop Rhythm:
Occurs due to presence of S3,S4 or a
summation of S3 & S4 in tachycardic patients.
Accentuated S1:
MS
TS
ST
Soft S1 →Long PR interval
Variable S1→ A. Fibrillation
Muffled S1  MR
Accentuated A2 → Systemic
Hypertension.

Accentuated P2 → P. Hypertension.
Soft A2 → AR.

Paradoxical Splitting of S2→ - AS

Opening Snap  MS

Ejection Clicks:
PS.
AS.
Opening Clicks:
Prosthetic mitral and aortic valve
opening.
Closing Clicks:
Prosthetic Mitral and Aortic Valve closure
CARDIAC MURMURS:
Systolic Murmurs
ESM (crescendo decrescendo murmur)
A) Functional  Hyperdynamic circulation.
Anemia.
Pregnancy.
Thyrotoxicosis.
A-V shunts.
Innocent in childhood and adolescence.
B) Organic:
AS
PS

PSM (Pansystolic murmur)

MR
TR
VSD
Diastolic Murmurs:
– Early Diastolic murmur:
AR
PR
– Mid-diastolic murmur:
MS
TS
Continuous Murmur
– PDA.
Description of a murmur:
Quality
Intensity – Scale of 6 grades
Site of maximum intensity
Radiation
Maneuvers which increases or decreases
its intensity
e.g. - PSM due to MR
 Best heard over the mitral area.
 ↑ handgrip
 Radiates to axilla
- PSM due to TR
 Beast Heard at TR area.
 ↑ deep inspiration
- PSM due to VSD
 Best heard at 3rd & 4th LICS
 Radiates to Rt. Side of the chest
 ↑ hand grip
- ESM due to Valvular AS:
 Best heard at aortic areas.
 ↑ By expiration
 ↓ Hand grip
 Radiates mainly to the neck (carotid arteries).
- EDM  AR
Best heard over aortic areas.
↑ by hand grip and expiration.
↑ sitting up and leaning forward.
- MDM  MS
 Best heard over the M. Area.
 ↑ Little exercise (↑HR).
 ↑ Left decubitus position.
Examination of Other Parts of the Body:

Back
– Fine bilateral basal crepitation
LV Failure
– Sacral edema.
Liver  Pulsatile & tender hepatomegaly
Sometimes  Ascitis & splenomegaly
Examination of Other Parts of the Body:

Lower limbs:
A) Cardiac Edema:
– Bilateral & Pitting.
– Grades:
1+ Around ankle Joint..
2+ Below knee joint.
3+ Above knee joint.
4+ Scrotal edema, hydrocele, and edema of the
ant. abdominal wall.
B) Peripheral Circulation:
– Inspection & Palpation:
Pale and cold.
Hair loss.
Loss of sensation.
Signs of Gangrene  PAD  Total arterial occlusion
- Weak or absent pulsations:
– Dorsalis pedis
– Tibialis posterior
– Medial popliteal
– Femoral artery
– Poor capillary filling
C) Varicose Veins:
– Inspection
Dilated tortous superfacial veins
– Long saphenous vein
– Short saphenous vein
Ulceration
Pigmentation
Eczema
D) Deep Venous Thrombosis (DVT):

– Unilateral Pitting edema.

– Darker skin than the other limbs.
↑ surface temperature.
– Tense and painful calf.
– Superfacial varicosity.
- Leg circumference is usually ≥ 2.5cm than the other
leg (anatomical reference  tibial tuberosity