Please enable JavaScript.
Coggle requires JavaScript to display documents.
History and Examination Cardiology, Closed Questions to asks in addition…
History and Examination Cardiology
6 Cardinal Symptoms of Cardiac Disease
Chest discomfort (pain / tightness)
Dyspnoea
Leg swelling
Palpatations
Syncope
Fatigue (or intermittent claudication)
Chest Discomfort
Features
Quality
Location / size
Radiation
Tiggers
Mode of onset
Duration
Epidemiology
5-10% of referral to adult ED are chest pain
15-25% of chest pain presentations to ED have ACS
DDx
Central
Cardiac
Ischaemic hear disease (infaction or angina)
Coronary artery spasm
Pericarditis / myocarditis
Mitral valve prolapse
Aortic aneurysm / dissection
Non-cardiac
PE
Oesophageal disease
Mediastinitis
4, Costochondritis (Tietze disease)
Trauma (soft tissue, rib)
Lateral / Peripheral
Pulmonary
Infarction
Pneumonia
Pneumothorax
Lung cancer
Mesothelioma
Non-pulmonary
Bornholm disease (epidemic myalgia)
Herpes zoster
Trauma (ribs / msk)
Classical Presentations
Severe tearing chest pain radiation to the back
Aortic Dissection
RF
Marfans
Erles danlos
Bicuspid aortic valves
Sharp central chest pain, pleuritic and positional, but relieved by sitting forward
Pericarditis
ST elevationand PR depression on ECG
Angina
Typical & Atypical for Angina
Typical
Radiates to both rams and shoulders
Precipitated by exertion
Associated with diaphoresis
Associated with N/V
Worse than previous angina / similar to previous MI
Atypical
Pleuritic
Sharp
Positional
Reproducible with palpation
Inflramammary location
Other Symptoms
Indigestion
Bleching
Dyspnoea
More common in women, diabetics, elderly
Myocardial Infarction
Region of Infarction
Inferior MIs have more concurrent abdominal symptoms ( nausea/ abdo pain) than Anterior
Not associated with differences in pain location
Severity
Severity not statistically different between ischaemic and non ischaemic groups
Time onset
Typically cresendo over minutes
Pain > 30min usually MI or non ischaemic - troponin useful
Levine's sign
Angina Scale (Canadian Cardiovascular Society)
Classes
Other Tools
GTN use / anti-anginal use
Walking distance
Historic walking distance
Summary
Assess for pointers towards a specific diagnosis (incl non-cardiac, eg cough, dysphagia)
Assess for typicality of symptoms
Place in the contex of the pt risk factors and previous medical history
CVS Risk Factors
Modifiable
HTN
Dyslipidaemia
DM
Smoking
Obesity
Physical inactivity
Non-modifiable
Fhx of Premature CVD
Men 55
Women 65
2, Age
Sex
Dyspnoea
Questions
Dyspnoea on exertion
Baseline distance
Exercise limited by other symptoms eg arthritis
Orthopnoea
Pillows
Changes
Paroxysmal noctural dyspnnoea
Typical hx - opens window at night for "better Oxygen"
Assess resp symptoms
Wheeze
Cough
Haemoptysis
Associated leg swelling
Unilateral
Bilateral
Improved in morning
Compressible - pitting
Medication related
Grading Heart failure
NYHA - New York Heart Association
https://www.researchgate.net/publication/298420570/figure/tbl1/AS:732670015332355@1551693552550/NYHA-classification-of-heart-failure.png
Very strong predicter of mortality
ACC
Not used
Palpatations
Definition
Awareness of your own heartbeat
Causes
HF
ANxiety
Ectopics
Arrhythmia
Differentiation
Flutters / Skips / Pounds
Pounding - more likely to be sinus
Skips - more likely to be ectopics
FLutters - more likely to be SVT
Tap it out
Features of arrythmia
Last > 5 min
Hx known cardiac disease
No underlying panic disorder
Affected by sleeping - long QTs wake you up at night
Occuring at work
AVNRT (SVT)
Regular rapid pounding sensation in neck
Syncope / lightheadedness
Time course
Onset
Duration
Syncope
Definition
Transient rapid loss of conciousness with spontaneous recovery
DDx
Syncrope
2. Epileptic seizure
Psychogenic
Rare causes
Closed Questions to Distinguish Seizure / Syncopre
During
Seizure
Tonic-clonic movements prolonged
Hemilateral clonic movement
Clear automatisms - lip smacking / chewing / frothing at mouth (partial seizures)
Tongue biting
Blue face
Syncope
Tonic clonic movements short duration (<15s) start after loss of conciousness
Before
Seizure
Aura
Syncope
N/V
Abdominal discomfort
Feeling cold/ hot
Lightheadedness
Blurring vision
After
Seizure
Prolonged confusion
Aching muscles
Syncope
Short duration of symptoms
N/v
Pallor (neurally mediated)
Other
Fhx
Timing of event (night)
Pins and needles before event
Incontinence after event
Injury after the event
Headache after event
Sleepy after event
Nausea and abdominal discomfort
Examination
General Examination
Age
Posture
Demeanour
General Health Status
Syndromal
Down's
Marfan's
Turner's
Dyspnoea
Cyanosis
Cachexia
Pallor
Mental status
Lines / Drains
Catheter
Telemetry
Central Line
Distress? Resting quietly
BMI
Hands
Clubbing
Cyanotic congenital heart disease
Infective endocarditis
Arachnodactyly
Marfan's
Ehlers Danlos
Splinter haemorrhagesc
common endocarditis
Janeway lesions / osler nodes
Rare
Familial Hypercholesterolaemia Markings
Xanthelasma
Arcus senillis
Tendon xanthoma
4.
Assessing the Pulse
Assessing characteristics
Rate
Rhythm
Character
Volume
Character and volume best assessed at
Carotid
artery
Delay
Radial-radial delay
Right subclavian stenosis
Diffuse atherosclerosis
Radio-femporal delay
Coarctation
Less prominent radial pulse
Check for symmetry - central or isolated problem
Check ulnar pulse
Blood Pressure
Wide pulse pressure
. >50mmHg
Atherosclerosis
Aortic regurgitation
Shock
Normal pulse pressures
Less than 10mmg difference between arms
20mmHg higher in legs than arms
In differences - use the highest BP
Pulsus Paradoxus
There is a noramal physiological deacrese in systolic blood pressure during inspiration
Pulus paradoxus is the exaggeration of this decrease by more than 10mmHg
Associated increase in HR to compensate - hence name but main finding is in the BP
Causes
Constrictive pericarditis
Cardiac tamponade
Severe asthma
Sign of intraventicular depence
Head and Neck
Dentition
High arched palate
MArfans
Mitral facies
Mitral valve disease - stenosis
Eyes
Scleral icterus - haemolysis
Xanthelasma - familial hypercholesterolaemia
Neck
JVP
Pressure
Waveform
Observed in both EJV and IJV
IJV preffered - no valve between IJV and Right Atium and is in more direct vertical alignment
⭐ Jugular Vs Carotid Pulse
IJV
Appearance of pulse: Undulating two troughs and two peaks for every cardiac cycle (biphasic)
Response to inspiration: Height of column falls and troughs become more prominent
Palpability: Generally not palpable except in severe TR (tricuspod regurgitation)
Effect of pressure: Can be obliterated with gentle pressure at base of vein / clavicle
Carotid artery pulse
Appearance of pulse: Single brisk upstroke (monophasic)
Response to inspirtation: No change
Palpability: Palpable
Effect of pressure: Cannot be obliterated
Hepatojugular reflex
30 seconds but usually you see within 1-2 seconds
Measuring Volume
Height of the volume (peak of the V wave)
Measure distance above the sternum and add on 5cm
Measure from the Angle of Louis (where sternum meets manubrium)
Vertical distance from AoL to the Height of the venous pulsation
Less than 3cm from the AoL is normal
Aol is 5cm above right artrium so add 5cm onto measured JVP = cm H20 of water above right atrium
Divide by 1.36 (1.36cm H2O pressure = 1mmHg) to correspond with cath lab measurements
45 degree angle
Volume Status
Representation of central venous pressue (right atrial pressure)
Can be elevated in SVC compression regardless of central venous pressure - pembertens sign
JVP Pathologies
Cannon A Waves
Right atrium contracting against a closed Tricuspid
Occurs in AV dissociation (i.e Complete heart block / 3rd degreee heart block)
Giant A Waves
Right atrium forceful contraction against tricuspid stenosis / non compliant RV
Giant V Waves
Tricuspid regurgitation
Kussmaul's sign
Failure of JVP to fall with inspiration
Normal JVP should fall by 3mmHg with inspiration
Can be a sign of contrictive pericarditis / RV diastolic dysfunction
Chest
Inspection
Central sternotomy scar
By pass (CABG)
Scar on leg for vein harvesting
Valve replacement
Both
Pacemaker scar
Palpate box
Almost always on left
ICDs are bigger than pacemaker
Number of scars
If device on the right - check the left for previous site
Use right if infx on left
Palpation
Apex beat
5th intercostal midclavicular line - fingertips
Displaced apex beat
Heart failure
Dilated heart
Auscultation
Murmurs
Mitral regurgitation
Aortic regurgitation
Patent ductus arteriosus
https://upload.wikimedia.org/wikipedia/commons/thumb/e/e4/Phonocardiograms_from_normal_and_abnormal_heart_sounds.svg/250px-Phonocardiograms_from_normal_and_abnormal_heart_sounds.svg.png
Aortic stenosis
Heart Sounds
S1
Mitral valve closure & Tricuspid valve closure
S2
Aortic valve closure & Pulmonary valve closure
Systole
After S1
Diastole
After S2
S3 &4
Pathological
Describing Murmurs
Grading
Grades 4,5,6
Associated with palpable thrill
Usually a grade 3 on exams?
Grades 1-6
Systolic or Diastolic murmurs
Generally you will hear aortic stenosis and mitral regurg so say systolic
Loudest Area
Aortic stenosis
Aortic valve area
Mitral regurg / setnosis
Mitral valve area
Inspiration / Expiration
RILE
RIGHT sided Inspiration
Tricupsid
Pulmonary
LEFT sided Expiration
Aortic
Mitral
Radiation
Aortic
Cartoids
Mitral regurgitation
Left axilla
Lung Bases
Crackles
Heart failrue
Difficult to differentiate from pulmonary fibrosis
Liver
Hepatomegaly
Heart failure
Pulsatle liver
Tricuspid regurgitation
Peripheral Oedema
Severity
Level
Below knee
Above knee
Sacral
Umbilical
Upperlimb
Mid shin
Mid Thigh
Bony prominence
Pitting oedema - fluid
Odema Causes
Not always HF
Popular Eponymous in Cardicolgy
Austin flint
Carrigan's pulse
Haneway lesions
Oslers nodes
Closed Questions to asks in addition to SOCRATES
#
