Cardiovascular History & Examination
- 1 Cardiovascular history
- 2 Cardiovascular Signs
Presenting Complaint - Core presentations
There are many potential differential causes for chest pain so it is essential to take a thorough history of the symptoms using SOCRATES
- Site - Where?
- Onset – When? Sudden or gradual?
- Character - What is the pain like?
- Radiation – Where to?
- Associations - Any other signs or symptoms?
- Time course - Any pattern?
- Exacerbating/Relieving factors - Anything change the pain?
- Severity - How bad?
Do you ever become aware of your own heartbeat? Again explore SOCRATES to determine the nature of the palpitations. It is important to ask about the character of the palpitations focussing on the rate and rhythm as this could be evidence of arrhythmias.
- Dyspnoea is the subjective sensation of SOB
- Tachypnoea is the objective evidence of SOB (increased respiratory rate)
- Orthopnoea is breathlessness when lying flat
- How many pillows do you use?
- Paroxysmal nocturnal dyspnoea
- Waking at night gasping for breath
There are many potential causes so there are several key points to establish in order to differentiate issues
- All the time
- Woken from sleep
- During exertion
- Relieving factors
- Exacerbating factors
- Associated symptoms
- Chest pain, palpitations
- Cough, wheeze, sputum, haemoptysis
- Ankle oedema
- Assess normal exercise tolerance
- Smoking/social history
- Cardiac causes
- Heart Failure
- Valve disease
- Myocardial Ischaemia
- Pericardial disease
- Non cardiac causes
- Pulmonary disease
- Anaemia, obesity or being unfit
Fainting, dizzyness or loss of consciousness can be associated with several conditions so it is important to determine if the syncope is cardiac in origin.
- How long did it last?
- Short duration suggests cardiac while longer durations suggest neurological
- Was there any other symptoms?
- Was it sudden or gradual in onset?
- Was there any warning or precipitating factors?
Past medical history
- Identify key cardiac risk factors early
- Previous MI/angina
- Previous investigations ECGs/Echocardiograms
- Procedures such as stents/bypass ops
- Corneal arcus, xanthelasma, xanthoma
- Diabetes mellitus
- Peripheral vascular disease
- Cerebrovascular disease (strokes)
Family history – cardiac
- Heart attack in 1st degree male relative (father/brother/son) <55
- Heart attack in 1st degree female relative (mother/sister/daughter) < 65
Note any cardiac medication such as beta blockers, ACE inhibitors, GTN, digoxin, statins (for cholesterol)
Confirm impact of symptoms on daily life. For example do they struggle to get up stairs with their angina pains?
- Check capillary refill
- Press nail bed for 5 seconds and release while timing how quickly the nail bed (or pulp) of the finger turns pink again
- >2 seconds is sign of poor circulation
- Check for clubbing
- Look for signs of infective endocarditis
- Janeway lesions (small non-tender lesions)
- Osler nodes (painful red raised lesions)
- Splinter haemorrhages
- Check radial pulse
- Comment on rate
- Bradycardia <60 beats per minutes
- Comment on rate
*** Tachycardia >100 beats per minute
- Comment on rhythm
- Regular or irregular
- If the rhythm is irregularly irregular then you should assume atrial fibrillation
- Comment on rhythm
- Check for collapsing pulse
- Ask patient if they have any pain in their arm (do not perform if likely to hurt patient)
- Palpate radial pulse with one hand while holding your alternative hand around patients arm just under the radial pulse
- Lift arm briskly while feeling for changes in radial pulse and if any blood hits the fingers of your other hand
- Collapsing pulse indicates aortic regurgitation
- Palpate carotid pulse
- Comment on character and volume
- Collapsing (falls off rapidly) implies aortic regurgitation
- Slow rising (takes time to build up) implies aortic stenosis
- At this point you could suggest checking the patient’s blood pressure (pulse pressure would help confirm diagnosis)
- Position patient at 45 degrees, ask them to turn their head to the left and encourage them to relax their neck
- Look for any pulsations in the neck
- The JVP should normally have a double waveform however this can change in certain pathologies
- To identify if a pulsation is the JVP feel for a pulse over the pulsation, only arterial pulsations should be palpable
- Alternatively occlude with minimal pressure, arterial pulsations will not occlude
- The JVP may be raised artificially using the hepato-jugular reflex by pressing into the liver. This raises the JVP and is a good sign that the pulsation observed is the JVP.
- Measure JVP perpendicular to the floor, up from the sternal angle and across to the pulsation point
- Look for signs of anaemia
- Look for dyslipdaemia
- Corneal arcus
- Comment on dentition (potential route for infective endocarditis)
- Comment on any central cyanosis
- Note a midline stenotomy scar, the most likely explanation is previous bypass surgery. This could be confirmed by checking the legs/arms for a matching vein graft scar
- Check for heaves using the heel of the hand lightly over the left side of the sternum
- If your hand moves with the beating of the heart this implies right ventricular hypertrophy (which could also imply pulmonary hypertension causing pulmonary oedema)
- Feel for thrills using the ends of your fingers over the valve areas
- These would produce a noticeable vibration and are evidence of heart murmurs
- Locate the apex beat initially using your whole hand over the area just under the left nipple and over into the axillary area
- Once located confirm that it is in the 5th intercostals space mid-clavicler line and comment on its character
- Forceful apex beat could imply pressure overload such as hypertension
- Displacement of the apex beat could imply cardiomegaly (confirmed using percussion or imaging)
Auscultation of the chest
- End Expiration enhances lEft sided murmurs (decreased cardiac filling)
- End Inspiration enhances Right sided murmurs (increased cardiac filling)
Listen for the heart sounds while feeling for the carotid pulse. The first heart sound is made when the mitral and tricuspid valves close and indicates ventricular contraction and the start of systole. The second heart sound is made when the aortic and pulmonary valves close and indicates the beginning of diastole. The third heart sound (if present) can be heard in mid diastole and indicates reduced ventricular compliance in adults. The 4th heart sound (if present) can be heard just before systole (atrial contraction) and can indicate reduced ventricular compliance. There can also be splitting of the second heart sound. The presence of additional heart sounds is often referred to as a gallop rhythm. Metal heart valves should also be audible as a clear metallic click instead of a normal heart sound.
When listening for murmurs identify first if it is systolic or diastolic. The carotid pulse tells you when the first heart sound should be even if the first heart sound is obscured by the murmur (as can happen in mitral regurgitation).
Where the murmur is loudest can help identify the cause, but this is not always true. The loudness of the murmur is also not a good indicator of its severity. For example severe aortic stenosis can reduce blood flow into the aorta to the point where there is not enough blood to make a loud noise.
Murmurs are caused by turbulent blood flow and where sound radiates to can be a great way to identify the type of murmur as noise radiates where the blood travels. For example aortic stenosis (which is a common systolic murmur) can also be heard in the carotids because the noise is created when the blood flows past the stenotic valve and travels into the aorta. Conversely mitral regurgitation (which is also a systolic murmur) typically radiates to the axilla as blood flows back into the left atrium during systole.
Finally you should comment on what the murmur sounds like. Aortic stenosis tends to be a harsh sounding murmur just after the first heart sound and described as an ejection systolic murmur. There is normally a crescendo decrescendo (diamond shaped) pattern to the noise. Mitral regurgitation tends to be a pansystolic murmur which can obscure the first heart sound while enhancing the second. Unlike aortic stenosis this murmur sounds much softer.
When in doubt remember common things are common and uncommon presentations of common things are much more likely! Common systolic murmurs are aortic stenosis and mitral regurgitation. Common diastolic murmurs (but actually quite rare in general) are mitral stenosis (a rumbling mid diastolic murmur) and aortic regurgitation (an early diastolic decrescendo murmur).
- Ask the patient to roll to their left (in order to enhance a potential murmur) and listen over the apex using the bell and diaphragm. Ask the patient to take a deep breath in and then out and hold it for a few moments (i.e. end of expiration). Also check for any radiation into the axilla.
- Ask the patient to lean forward and listen over the lower left sternal edge (4th intercostals space), the left sternal edge (2nd intercostals space) and right sternal edge (2nd intercostals space). Ask the patient to hold their breath while you listen for any radiation to the carotids and carotid bruits (note these are not the same thing).
- Finally listen to the lung bases from the back. The presence of crackles could indicate pulmonary oedema. Also check for sacral oedema and pitting oedema in the legs.
Conclusions and further tests
- Summarise your findings succinctly for example no peripheral signs of infective endocarditis
- Mention any salient observations such as slow rising or collapsing pulse
- Comment on the heart sounds (present/absent, normal/abnormal and any additional sounds)
- Describe in detail any murmurs including whether they were systolic/diastolic, their sound/duration and if they radiated anywhere
- Further tests could be urine analysis and blood pressure
- If indicated a chest x-ray, echocardiogram, ECG and troponin levels (blood test) could also be requested