Bader Al- Mukhtar RCSI SC (2)

CVS System
History taking:

1. Presenting complaint + History of Presenting Complaint:

What brought you to the hospital?

Common CVS Symptoms:

1. Chest pain
2. SOB
3. Palpitation
4. Dizziness
5. Syncope
6. Lower limb edema
7. Intermittent Claudication

Chest pain
o Onset (suddenly or gradually)
o Duration
o Frequency
o Location
o Radiation
o Character
o Progression
o Severity
o Aggravation factors (effect of exercise, emotion, position, food, coughing
and breathing)
o Relieving factors (effect of rest, GTN, antacid)
o Associated symptoms
Nausea, vomiting, sweating, anxiety, impending doom

SOB
o Onset
o Duration
o Frequency
o Progression
o Severity
On exertion OR at rest?
How far can you walk before you get SOB (distance or duration)
and how many flights can you climb before you get SOB?
o Associated symptoms
Orthopnea (SOB when lying flat, how many pillows you have to
use?)
PND (SOB wakening you up at night to grasp air?)

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Palpitation
o Onset
o Duration
o Frequency
o Circumstance (what were you doing when you got it?), (is it related to any
particular time)?
o Describe it?
Regular, irregular?
Fast, slow?
Strong, weak?
o Progression
o Aggravating factors (effect of caffeine coffee, tea, specific medication)
o Relieving factors (vagal maneuver or valsalva maneuver)

Dizziness
o Onset
o Duration
o Frequency
o Circumstance
Standing up suddenly, standing for prolonged time
Coughing
While passing urine
With sudden emotional distress
o Describe it
You are the one whos turning around or does the world spins
around you (VERTIGO)?
o Progression
o Aggravating factors
o Relieving factors

Syncope (faint)
o Onset
o Duration
o Frequency
o Circumstance
o Ask about
Prodromal symptoms cardiac (chest pain, SOB, dizziness) or
neurological (aura, headache, speech disturbance)
During the episode was there any up rolling of the eyes, tongue
biting, limb jerking, urine incontinence)
Recovery rapid or prolonged and associated with drowsiness

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Lower limb edema:

o Duration
o Location (unilateral or bilateral)
o Severity (extent)
o Is it worse at any particular time of day? (Typically cardiac oedema is
worse toward the evening and resolved somewhat overnight as the oedema
redistributes itself.)

Intermittent Claudication
o Calf pain during walking?
o All the pain questions
o Severity determine the Claudication distance and rest time
o Relieving factors hanging the leg beside the bed

2. Past Medical History:

Have you ever had similar problem before?
o If yes what type? For how long you have it? Is it controlled with
your medications?
Have you ever been admitted to hospital for any reason?
Do you have any medical conditions or health problems of any kind?

3. Past Surgical History:

Have you ever had any operations no matter how minor before?
o If yes When and what type? Any complications arised?
Have you had any trauma before? When? What happened?

4. Medications/Allergy:
Are you on any medications?
How about over the counter medications
Any herbal remedies?
Do you have any allergy against certain drugs/Food/dressings?

5. Family History:
Common question: Are there any medical conditions that run in the family?
Parents: Are your parents still alive? How is their health? or What was
the cause of their passing?
Siblings: Do you have brothers and sisters? How is their health?

6. Social History:
Wife and children: Are you married? Do you have kids? How is their health?

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Smoking (how much and how long?).

Alcohol intake (how much and how long?)

o Important to ask about the CAGE questions to confirm alcoholism

if suspected:
A. Have you ever felt you should cut down on your drinking?
B. Have people annoyed you by criticising your drinking?
C. Have you ever felt bad or guilty about your drinking?
D. Have you ever had a drink first thing in the morning to steady
your nerves or get rid of a hangover (eye-opener)?

Occupation (his job).

Home circumstances: Including
o Who is with the patient at home and the general health of that person
o Home layout and where he is living
o Home modifications.

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Physical examination:

General inspection

Nails and hands:

Acrocyanosis (peripheral cyanosis)
Kilonychia
Clubbing (causes include: cyanotic CHD, infective endocarditis, atrial myxoma)

Splinter hemorrhage
Osler's nodes
Janeway lesions
Pallor of the palmar creases

Four staging/criteria confirm clubbing:

a. Increased the nail bed fluctuation, increase the bulk of soft tissue over the
terminal phalanges "spongy feel".
b. Loss of normal angle between the nail and the nail bed. (loss of the
diamond shape between the two nails)
c. Increased nail curvature in later stages
d. Hypertrophic pulmonary osteoarthropathy. Pronounced clubbing of
fingers and toes associated with pain and swelling affecting the wrist and
ankles.

Arms:
Radial pulse
Brachial pulse
o Rate
o Rhythym
o Volume
o Character (AS slow rising), (AR collapsing pulse, water-hammer)
o Radio-radial symmetry
o Radio-femoral delay

Xanthomata
BP

Eyes:
Xanthalasma
Jaundice (sclera)

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Pallor (conjunctiva)

Mouth:
Tooth decay
Central cyanosis (deoxy Hb > 5/dl)
High-arched palate (Marfan's syndrome)

Neck:
Carotid arteries (palpate and listen)
JVP (IJV, btw the 2 halves of the SCM, then add 5 cm above the sternal angle to
measure it, normally < 8 cm)
Raised in: RVF, TR, SVC obstruction, PE, cardiac tamponade, fluid overload

o Difference btw Carotid and JVP, the JVP:

2 peaks/ heartbeat
Visible but Impalpable
Can be Occluded
Dependent on (respiration decrease with inspiration AND
position increase when lying flat AND abdominal pressure
hepato-jugular reflux)

Precordium inspection:
Skeletal abnormalities
o Pectus carinatum depressed sternum
o Pectus excavatum protruded
o Barrel chest increased AP diameter
o Kyphosis and scoliosis

Scars (sternotomy, thoracotomy)

Precordium inspection:
Apex beat (5th ICS MCL)
o Displaced LVF
Parasternal heaves:
o Left parasternal border RV hypertrophy
Thrills:
o Palpable murmurs (all the murmur areas)

Precordium auscultation:
Mitral (5th ICS MCL)
Tricuspid (4th ICS Left sternal edge) below the xiphoid process

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Pulmonary (2nd ICS left sternal edge)

Aortic (2nd ICS right sternal edge)

S1
(beginning of the ventricle systole) mitral and tricuspid valves closure
Best heard over the apex

S2
(end of the vent systole) aortic and pulmonary valve closure
Best heard over the aortic area

S3
Coincide with rapid ventricular filling

S4
Coincide with forceful atrial contraction against non-compliant stiff ventricle

Murmurs
1. Timing:
Systolic: pansystolic (MR, TR, VSD) AND ejection systolic (AS,
PS)
Diastolic: early diastolic (AR, PR) AND mid-diastolic (MS, TS)
2. Location:
The area of the maximum intensity
3. Radiation:
MR left axilla
AS carotid arteries
4. Grade:
Grade 1: very soft
Grade 2: soft
Grade 3: moderate, no thrills
Grade 4: loud, thrills just palpable
Grade 5: very loud, thrills easily palpable
Grade 6: v. very loud, can be heard without placing the stethoscope
over the chest
5. Dynamic maneuvers:
Respiration: (right sided murmurs louder on inspiration) AND
(left sided murmurs louder on expiration)
Posture: (MS with the bell over the apex beat, patient lying in
left lateral position) AND (AR with the diaphragm, patient
sitting and lean forward in full expriation)

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To complete the examination:

Lung bases (dull bases and crackles)
Abdomen (ascites and hepatomegaly, renal bruits)
Peripheral edema