[05.01a] History and Physical Examination of the Cardiovascular System (Part 1) V2.1.pdf

General Data (Risk Factors)

What is the first aspect of the cardiovascular history mentioned?

General Data, History of Present Illness, Past Medical History, Family History, Personal and Social History

What are the five main components included in the Cardiovascular History section?

~75% of the diagnosis of a cardiac problem

What proportion of the diagnosis of a cardiac problem is comprised by the Cardiovascular History?

Age and Sex

What two specific items are listed under General Data (Risk Factors)?

55 years old and above

At what age does a male patient usually have a risk factor for coronary disease?

65 years old

At what age may women already be at risk for coronary artery disease after the start of menopause?

Male <55 years old or female <65 years old

What defines premature coronary disease?

Symptoms, Patient’s functional capacity, History of febrile illness, Pregnancy

What four specific items are listed under History of Present Illness (HPI)?

To capture the development and progression of a cardiovascular disease

Why should the history of present illness be chronological?

How well the patient can still do physical activity

What does functional capacity relate to in the HPI?

The patient is symptomatic at rest

What characteristic indicates the most severe functional capacity related to physical activity?

Rheumatic fever, endocarditis, TB

What are three common infections related to a cardiovascular problem that should be sought in the history of febrile illness?

Most cardiovascular medicines could not be given in pregnancy

Why is history of pregnancy sought in the HPI?

Hx of systemic illnesses, Medications and allergies

What two specific items are listed under Past Medical History (PMH)?

Hypertension (HPN), diabetes mellitus (DM), cardiovascular disease (CVD), peripheral vascular disease (PVD), thyroid disease, bronchial asthma/chronic obstructive pulmonary disease (COPD)

What specific systemic illnesses should be considered in the Past Medical History?

They might not be related but would give a clue to the current condition or symptomatology of the patient

Why are current medications sought, even if they aren't cardio-related?

Up to a first degree relative

For Family History, what is the extent of relatives that should be considered?

Siblings, parents, uncles, aunties, and first cousins

Who is included in a first-degree relative for purposes of Family History?

HPN, ischemic heart disease, DM, or dyslipidemia

What specific conditions should be considered in the family history?

Cigarette smoking, Alcohol intake, Illicit drug use, Obesity, Athletic history, Dietary intake, Type A personality

What seven specific items are listed under Personal and Social History (PSH)?

10 sticks/day

What quantity of cigarette smoking is considered a significant history?

Pack/years

Besides sticks/day, what other unit can cigarette smoking history be counted in?

10-pack/year history

If a patient smokes 10 sticks over a period of 20 years, what is their pack/year history?

Approximately 2 beers/day

What amount of alcohol intake is generally considered allowable?

Cocaine and shabu

What two illicit drugs are specifically mentioned as being capable of inducing cardiovascular illness?

Uncontrolled BP

In hypertensive patients, Type A personality can lead to what?

Workaholic and obsessive compulsive type

What are the two defining characteristics of a Type A personality, a risk factor?

High in fat or salt

What characteristic of dietary intake is considered a risk factor?

Stroke

Eating foods high in fat (e.g., chicharon, morcon, lechon) during holiday seasons increases the risk of what?

Chest pain/discomfort, Diaphoresis, Hypotension

What are the three main symptoms listed for Coronary Artery Disease (CAD) & Myocardial Infarction (MI)?

Chest pain on exertion that is relieved by rest

What type of chest pain is highly specific to CAD (typical angina)?

Diaphoresis and Hypotension

When atypical chest pain is present, what accompanying symptoms increase its specificity for CAD?

Not enough to simply mention chest pain as it can be typical, atypical, or non-anginal

Why must physicians be explicit about chest pain symptoms in CAD?

Left-sided CHF

Which type of Congestive Heart Failure (CHF) is more common?

Cor pulmonale (pulmonary heart disease)

In what specific condition is isolated right-sided CHF usually seen?

Progression of left-sided CHF

What is the most common cause of right-sided CHF?

Exertional dyspnea

What symptom typically begins the progression of heart failure symptoms for a typical patient?

Exertional Dyspnea → PND → Orthopnea

What sequence of symptoms indicates left-sided CHF?

Hepatomegaly → Ascites → Edema

What sequence of symptoms indicates right-sided CHF?

Shortness of breath after activity

What is Exertional Dyspnea?

Waking up at night with shortness of breath, often 2 hours after lying down

What is Paroxysmal Nocturnal Dyspnea (PND)?

Blood backs up from the heart to the lungs when lying flat

What is the physiological reason PND occurs?

Drowning sensation when lying flat

What specific sensation characterizes Orthopnea?

Orthopnea

Which symptom means the patient cannot lie flat without immediate discomfort?

Dyspnea at rest

Which dyspnea symptom is considered more distressing compared to exertional dyspnea?

Fluid filling the abdomen

What is Ascites?

Swelling of feet and legs due to fluid accumulation

What is Edema?

Pitting edema

What characteristic type of edema is seen in heart failure?

Non-pitting edema

What kind of edema is usually seen in hypothyroidism?

Anasarca

What term describes generalized swelling that may indicate severe heart failure but is commonly associated with renal or liver pathology?

Palpitation, Dizziness, Syncope

What are the three main symptoms of Arrhythmia?

Awareness of one’s heartbeat

What is Palpitation?

Fast rhythm or irregular rhythm

What does palpitation imply about the heart rhythm?

Total loss of consciousness

What is Syncope?

Ventricular tachycardia

In the context of arrhythmia, what condition leading to cardiac arrest means a patient who reclines will not regain consciousness after syncope?

Fever, Peripheral emboli (Janeway lesions or Splinter hemorrhages)

What are the two main symptoms listed for Infective Endocarditis (IE) & Rheumatic Fever?

Intermittent claudication, Phlebitis

What are the two main symptoms of Peripheral Vascular Disease (PVD)?

Leg pain with exertion and relieved by rest, often accompanied by cramps

What is Intermittent claudication?

Vein inflammation, swelling and redness of the lower extremities

What is Phlebitis?

Osler’s Nodes

Which skin lesion related to emboli is immunologic, painful, and situated towards the tip of the fingers?

Janeway Lesions

Which skin lesion related to IE is a form of septic emboli, not painful, and situated at the palms and soles?

Splinter hemorrhages

What specific finding can be seen in IE patients, related to emboli?

It starts while you are already talking with a patient; interviewing them and getting a history

When does the Cardiovascular Physical Examination start?

Tiredness, Apprehension, Tachypnea, Cyanosis, Peripheral edema

What five signs should be checked for in the General Appearance of the Patient during the PE?

Color of the lips and tongue

Where should cyanosis be checked?

Tap (Phase 1), Swish, Loud & crisp, Muffling (Phase 4), Sounds disappear (Phase 5)

What are the five phases of Korotkoff sounds?

Phase 1

What phase of Korotkoff sounds is the systolic BP?

Phase 5

What phase of Korotkoff sounds is the diastolic BP in adults?

Phase 4 sound (Muffling)

What marker is used for diastolic BP in the pediatric population?

Difference between the systolic and diastolic blood pressure

What is Pulse pressure?

50-60 mmHg

What is considered a normal pulse pressure?

60 mmHg

What defines a widened pulse pressure?

Severe anemia, Hyperthyroidism, Heart failure, Elderly

What four types of patients might exhibit a widened pulse pressure?

Coarctation of the aorta

What condition may cause differences in BP between the arms and legs, often seen in young hypertensives?

Subclavian artery stenosis

What might be the cause if a patient has a blood pressure of 120/80 on the left arm and 80/40 on the right arm?

Popliteal arterial pressure that was >20 mmHg higher than the brachial arterial pressure

According to Shiraishi et al. (2017), what is the definitive measurement for Hill's sign?

Pallor, pale conjunctiva, icteric sclerae, JVP, thyroid enlargement, carotid bruit and character of carotid pulses

What are the findings checked during the Examination of the Head and Neck?

When there is chronic passive congestion of the liver, patients with heart failure can get icteric sclerae

Besides hepatitis, why is icteric sclerae relevant in a cardiac exam?

Thyroid enlargement

What neck finding should always be part of the physical examination?

Fine rales, coarse rales, rhonchi or wheezing

What should be checked for when examining the lungs?

Parenchymal type and alveolar type of fluid accumulation

What do fine rales imply?

Bronchial problem

What do coarse rales and rhonchi or wheezing typically point to?

Severe or acute heart failure

What cardiac issue can cause wheezing, meaning it is not exclusive to a pulmonary problem?

Renal bruits, Ascites, Abnormal aortic pulsation, Hepatomegaly, Splenomegaly

What five signs should be checked for during the examination of the abdomen?

Renal artery stenosis

Why is listening for renal bruits important?

Dullness in the abdomen

What physical technique is involved in examining for ascites?

Cyanosis, clubbing of fingers, and arterial pulse wave abnormalities

What three signs should be checked for when examining the extremities?

Prolonged hypoxemia

What does clubbing imply?

Absence or delay in femoral pulse compared to brachial pulse

What finding may suggest coarctation of the aorta, obstruction to the abdominal aorta, or Takayasu's disease?

Sternal angle, internal jugular vein (IJV), external jugular vein (EJV)

What are the three main landmarks for evaluating the JVP?

Approximately 5 cm

What is the fixed distance from the center of the right atrium to the sternal angle of louis used in JVP calculation?

30 degrees

At what position should the patient usually be placed to look for the pulsations of the IJV?

JVP (Jugular Venous Pulse)

What is the venous flow returning to the heart called?

Central Venous Pressure (CVP)

The calculated JVP (in cm water) is equivalent to what other pressure?

6-8 cm, up to 10 cm

What is the normal range for JVP (or CVP)?

Abnormality that will affect the right side of the heart

What can JVP detect abnormalities in?

The JVP is 12 cm at an 80 degree angle

How would you report a very high JVP in a patient with severe heart failure who must be reclined at an almost upright position to see the pulsation?

Rarely palpable (thin walled blood vessel)

What describes the palpability and wall thickness of Jugular Venous Pulsations?

Pulsation is eliminated by light pressure on the veins just above the clavicle

How can JVP be eliminated, which helps differentiate it from carotid pulse?

Pulsation usually descends with inspiration

How is the JVP level affected by respiration?