31. DPR | History and Physical Exam of the Cardiovascular System Part 1

What mnemonic is used to guide the cardiac history HPI?

OPQRRSTAA: Onset, Place, Quality, Radiation/Region, Severity, Timing, Aggravating, Alleviating, Associated symptoms. Include: duration, frequency, baseline, progression, self-treatment, recent evaluation, pertinent negatives.

What is the recommended approach when taking a cardiac history?

Use open-ended questions, be systematic, curious, and establish urgency. Symptoms may overlap with other systems.

What questions should be asked to establish the onset of cardiac symptoms?

Ask 'When did this start?' and 'Is this symptom still occurring?' Assess progression, constant vs intermittent.

What should be asked to assess location and radiation of cardiac pain?

Ask 'Where is the pain located? Can you point to it?' and 'Does the pain go anywhere else?' Radiation may include jaw, arm, back, shoulder, or stomach.

How is quality of cardiac pain assessed?

Let patient describe in own words first. Examples: sharp, dull, throbbing, ache, 'elephant sitting on chest,' pressure, stabbing, burning.

How is severity of cardiac symptoms assessed?

Ask on a 1-10 scale. Assess how it affects ADLs (work, sleep, cooking, hobbies).

What questions are asked for aggravating and alleviating factors?

Ask what makes it better or worse. Examples: exertion, rest, OTC meds (Tylenol, ibuprofen, Tums, Gas-X). 'What have you tried for this?'

What are common associated symptoms in cardiac history?

Shortness of breath, nausea, diaphoresis, fatigue. Include pertinent negatives.

What should be documented in past medical history for cardiac evaluation?

Dyslipidemia, hypertension, diabetes, thyroid disease.

What family history is important in cardiac history?

Cardiovascular disease in relatives, and age of onset.

What social history factors are important in cardiac evaluation?

Smoking, alcohol, drug use, physical activity, and diet.

What are the vital signs included in the cardiac exam?

Temperature, BP in both arms, pulse, respiratory rate, SpO2, height, weight, BMI.

What is done during inspection of the cardiac exam?

Patient seated, gown lowered to expose chest. Look for deformities and visible impulses.

Where is the normal point of maximal impulse (PMI) located?

At the 5th intercostal space, left midclavicular line, diameter <2.5 cm, palpated with finger pads.

What abnormal PMI findings suggest right ventricular hypertrophy?

PMI shifted to the xiphoid/epigastrium.

What abnormal PMI findings suggest left ventricular hypertrophy?

PMI >2.5 cm in size or displaced more than 10 cm lateral from midclavicular line.

What sounds are best heard with the diaphragm of the stethoscope?

High-pitched sounds: S1, S2, murmurs of aortic and mitral regurgitation, pericardial friction rubs.

What sounds are best heard with the bell of the stethoscope?

Low-pitched sounds: S3, S4, and mitral stenosis.

Where is the aortic auscultation area located?

2nd intercostal space, right sternal border.

Where is the pulmonic auscultation area located?

2nd intercostal space, left sternal border.

Where is the tricuspid auscultation area located?

3rd/4th intercostal space, left sternal border.

Where is the mitral auscultation area located?

5th intercostal space, left midclavicular line.

What patient position accentuates S3, S4, and mitral murmurs?

Left lateral decubitus position.

What patient position accentuates aortic murmurs and pericardial rubs?

Leaning forward.

What event does the first heart sound (S1) represent?

Closure of mitral and tricuspid valves, start of systole. Heard best at apex. 'LUB'.

What event does the second heart sound (S2) represent?

Closure of aortic and pulmonic valves, start of diastole. Heard best at base. 'DUB'.

When is a physiologic split of S2 heard?

During inspiration, A2 and P2 split, best at 2nd ICS LSB.

What causes a split S1?

Delay in tricuspid valve closure.

What are the expected normal cardiac exam findings?

S1, S2 present; regular rate and rhythm; no murmurs, rubs, or gallops; PMI nondisplaced; pulses 2+ bilaterally; extremities warm without edema; no tissue texture changes.

What does an S3 sound indicate in adults?

Pathologic ventricular dysfunction. (Normal in children, physiologic in young).

What does an S4 sound indicate?

Pathologic finding due to atrial contraction against a stiff ventricle (LVH, hypertensive heart disease).

What does a pericardial rub sound like and what does it indicate?

Harsh, coarse, 'Velcro' or 'rubber on rubber' sound caused by inflamed pericardial layers.

What does a murmur represent?

Turbulent blood flow, often producing a 'whoosh' sound. Classified by timing, location, radiation, intensity.

What are key 'Do’s' in documenting a cardiac H&P?

Organize by SOAP, subjective is patient’s words, objective is exam/labs, document negatives, credit all maneuvers performed.

What are key 'Don’ts' in documenting a cardiac H&P?

Do not use the word 'normal'; do not put subjective data in objective section; do not omit steps (if not documented, it didn’t happen).

Give an example of normal cardiac documentation.

+S1/S2; regular rate and rhythm; no murmurs, rubs, or gallops. PMI nondisplaced at 5th ICS MCL. No carotid bruits. Pulses 2+, equal bilaterally. Extremities warm, no edema.

Give an example of abnormal cardiac documentation.

Tachycardic with regular rhythm; grade 4 systolic murmur at LUSB. PMI displaced laterally 5 cm. Left carotid bruit present. 2+ pitting edema shins bilaterally.

What life-threatening conditions should always be considered in chest pain?

Angina, myocardial infarction, aortic dissection, pulmonary embolism.

What are common non-cardiac causes of chest pain?

Gastrointestinal (reflux, ulcers), pulmonary (pneumonia, bronchitis), musculoskeletal (trauma, strain).

What populations are more likely to present with atypical chest pain?

Women, elderly, and diabetics. Common symptoms: fatigue, back/jaw pain, SOB, nausea/vomiting.

What are common patient descriptions of palpitations?

Skipping, racing, fluttering, pounding, pauses. May be due to arrhythmia, forceful contraction, anxiety, thyroid disease.

How is orthopnea identified in cardiac history?

Dyspnea that occurs when lying down, relieved by sitting up. Ask how many pillows patient sleeps on.

What is paroxysmal nocturnal dyspnea (PND)?

Episodes of sudden dyspnea and orthopnea that awaken the patient from sleep.

Where does edema most commonly occur in cardiac disease?

Dependent areas such as legs, hands, and eyes. May worsen AM/PM. Example: trouble putting rings on.

What PMI changes indicate right ventricular hypertrophy vs left ventricular hypertrophy?

RVH: PMI shifted to epigastrium/xiphoid. LVH: PMI >2.5 cm or >10 cm lateral displacement.

Where is the normal Point of Maximal Impulse (PMI) located?

At the 5th intercostal space, left midclavicular line.

What is the normal diameter of the Point of Maximal Impulse (PMI)?

Less than 2.5 cm (about the size of a quarter).

What patient position best allows palpation of the Point of Maximal Impulse (PMI)?

Seated or in the left lateral decubitus position.

What does a Point of Maximal Impulse (PMI) shifted to the xiphoid/epigastric region suggest?

Right ventricular hypertrophy.

What does a Point of Maximal Impulse (PMI) displaced more than 10 cm lateral suggest?

Left ventricular hypertrophy.

Where is the aortic valve auscultation area located?

At the 2nd intercostal space, right sternal border.

Where is the pulmonic valve auscultation area located?

At the 2nd intercostal space, left sternal border.

Where is the tricuspid valve auscultation area located?

At the 3rd or 4th intercostal space, left sternal border.

Where is the mitral valve auscultation area located?

At the 5th intercostal space, left midclavicular line.

Which heart sound is louder at the apex, the first or second heart sound?

The first heart sound (S1) is louder at the apex.

Which heart sound is louder at the base, the first or second heart sound?

The second heart sound (S2) is louder at the base.

When is a physiologic split of the second heart sound (S2) best heard?

During inspiration at the 2nd intercostal space, left sternal border.

What physical exam finding is used to evaluate jugular venous pressure (JVP)?

Inspection of the jugular veins with the patient at 30 degrees.

What is the clinical significance of carotid bruits on auscultation?

They suggest turbulent flow, often due to carotid artery stenosis.

What pulses are routinely palpated in the cardiac exam?

Radial, dorsalis pedis, and posterior tibial pulses.

What are normal extremity findings in the cardiac exam?

Extremities warm, without edema, tenderness, or skin changes.

What does 2+ pitting edema in the lower extremities indicate?

It may indicate congestive heart failure or volume overload.

What is the normal finding for the Point of Maximal Impulse (PMI)?

Located at the 5th intercostal space, left midclavicular line, diameter <2.5 cm, nondisplaced.

What abnormal findings of the Point of Maximal Impulse (PMI) suggest pathology?

Shift to xiphoid/epigastric ‚Üí right ventricular hypertrophy; >2.5 cm or >10 cm lateral displacement ‚Üí left ventricular hypertrophy.

What are the normal heart sounds on auscultation?

S1 and S2 present. S1 louder at apex, S2 louder at base. Regular rate and rhythm.

What abnormal heart sounds may be heard?

S3 (ventricular dysfunction in adults), S4 (atrial contraction against stiff ventricle), murmurs (turbulent flow), pericardial rub (inflamed pericardium).

When is splitting of the second heart sound (S2) normal?

Physiologic splitting during inspiration, best heard at 2nd ICS left sternal border.

When is splitting of the second heart sound (S2) abnormal?

Persistent or fixed split may indicate atrial septal defect or pulmonary hypertension.

What are normal vital signs in the cardiac exam?

HR 60-100 bpm, BP ~110/70, Temp 98.6ºF, SpO2 ‚≥95%, BMI 18.5-24.9.

What abnormal vital sign findings suggest pathology?

Hypertension, tachycardia, tachypnea, hypoxemia, fever.

What are normal neck findings in the cardiac exam?

No jugular venous distention, no carotid bruits.

What abnormal neck findings suggest pathology?

Jugular venous distention (heart failure), carotid bruits (carotid stenosis).

What are normal extremity findings in the cardiac exam?

Warm, without edema, tenderness, varicosities, or skin changes.

What abnormal extremity findings suggest pathology?

Pitting edema, skin changes, varicosities, or tenderness.

What are normal pulse findings in the cardiac exam?

Radial, dorsalis pedis, posterior tibial pulses 2+, equal bilaterally.

What abnormal pulse findings suggest pathology?

Weak, diminished, or unequal pulses may suggest vascular disease or obstruction.

A 62-year-old male with a history of hypertension presents with shortness of breath when lying down at night. He reports needing to sleep with three pillows to breathe comfortably. Which of the following best describes this finding?

A. Dyspnea on exertion
B. Orthopnea
C. Paroxysmal nocturnal dyspnea
D. Trepopnea
E. Platypnea

B

• A. Dyspnea on exertion – Shortness of breath with physical activity, not just lying flat.

• B. Orthopnea – Dyspnea when lying down, relieved by sitting up; often measured by # of pillows.

• C. Paroxysmal nocturnal dyspnea – Sudden nighttime episodes of shortness of breath that awaken the patient from sleep (not immediate on lying flat).

• D. Trepopnea – Dyspnea worse when lying on one side.

• E. Platypnea – Dyspnea when sitting upright, relieved by lying down.

A 55-year-old male undergoes cardiac auscultation. The physician hears a low-pitched sound best at the apex with the bell of the stethoscope, immediately after S2. This sound is considered normal in children but pathologic in adults. What is the most likely finding?

A. S1 split
B. S2 split
C. S3
D. S4
E. Pericardial friction rub

C

• A. S1 split – Represents mitral and tricuspid valve closure; not described here.

• B. S2 split – Aortic and pulmonic valve closure; physiologic with inspiration, not low-pitched gallop.

• C. S3 – Correct. Low-pitched, heard after S2 with bell at apex; normal in children but pathologic in adults (ventricular dysfunction).

• D. S4 – Heard before S1, associated with atrial contraction and stiff ventricle.

• E. Pericardial friction rub – Harsh, scratchy, “sandpaper” sound, not gallop-like.

A 68-year-old male with long-standing hypertension presents with exertional dyspnea. On exam, you note a laterally displaced PMI (>10 cm from midclavicular line) and an S4 gallop at the apex. Which structural change best explains these findings?

A. Right ventricular hypertrophy due to pulmonary hypertension
B. Left ventricular hypertrophy due to pressure overload
C. Dilated cardiomyopathy with volume overload
D. Atrial septal defect with fixed split S2
E. Aortic regurgitation with early diastolic murmur

B

• A. Right ventricular hypertrophy – Shifts PMI toward xiphoid/epigastrium, not lateral.

• B. Left ventricular hypertrophy – ✅ Causes laterally displaced PMI and S4 (atrial contraction against stiff LV, often from HTN).

• C. Dilated cardiomyopathy – Would cause an S3 (volume overload), not S4.

• D. Atrial septal defect – Produces fixed split S2, not lateral PMI.

• E. Aortic regurgitation – Early diastolic decrescendo murmur, not S4.

A 72-year-old diabetic woman presents with fatigue, nausea, and upper back pain. Her EKG shows ST-segment elevations consistent with acute myocardial infarction. On cardiac exam, you detect a new holosystolic murmur at the apex radiating to the axilla. Which complication is most likely?

A. Mitral regurgitation due to papillary muscle dysfunction
B. Aortic regurgitation due to valve rupture
C. Ventricular septal defect
D. Mitral stenosis due to rheumatic fever
E. Pericarditis with friction rub

A

• A. Mitral regurgitation – ✅ MI can cause papillary muscle ischemia/rupture → acute MR → holosystolic murmur radiating to axilla.

• B. Aortic regurgitation – Diastolic murmur at LSB, not apex holosystolic.

• C. Ventricular septal defect – Harsh holosystolic murmur at LSB, not apex/axilla.

• D. Mitral stenosis – Diastolic rumble with opening snap, not post-MI complication.

• E. Pericarditis – Produces friction rub, not holosystolic murmur.

A 45-year-old male presents with pleuritic chest pain that improves when leaning forward. On exam, you hear a scratchy, coarse sound throughout systole and diastole. Which additional finding would best confirm the suspected diagnosis?

A. Physiologic split S2 with inspiration
B. ST-segment elevations in multiple leads on EKG
C. Crescendo-decrescendo systolic murmur radiating to carotids
D. Holosystolic murmur radiating to axilla
E. Displaced PMI and S3 gallop

B

• A. Physiologic split S2 – Normal finding, not diagnostic.

• B. Diffuse ST elevations – ✅ Classic for pericarditis, along with rub and positional chest pain.

• C. Aortic stenosis – Crescendo-decrescendo systolic murmur.

• D. Mitral regurgitation – Holosystolic murmur radiating to axilla.

• E. S3 gallop – Suggests CHF, not pericarditis.