Kurniyanto, MD

Internal Medicine
UKI

Chest pain
Shortness of breath
Ankle swelling
Palpitations
Syncope
Intermittent claudication

Character of pain
Severity
Duration
Radiation
At rest or on
exertion
Previous episodes

Relieving factors
Worse on taking a
deep breath
(pleuritic)
Worse on movement
Autonomic symptoms

Sweating
Nausea

Cardiovascular
Angina

Stable
Unstable

Myocardial infarction
Aortic dissection
Myocarditis

Pleuropericardial
Pericarditis
Pleurisy
Pneumothorax

Gastrointestinal

Gastro-oesophageal
reflux
Oesophageal spasm

Chest wall

Coughing
Intercostal muscle
strain/myositis
Herpes zoster
Thoracic radiculopathy
Rib fracture
Rib tumour
Costochondritis

Unexpected awareness of breathing

At rest or on exertion
Quantify exercise tolerance (yards walked,
stairs climbed)
Orthopnoea = shortness of breath on lying
supine
Number of pillows
Paroxysmal nocturnal dyspnoea

Airways disease

COPD

Chronic bronchitis
Emphysema

Asthma
Bronchiectasis
Cystic fibrosis

Parenchymal disease
Pneumonia
Pulmonary fibrosis
Tumour
Pneumothorax

Pulmonary vasculature
Pulmonary embolism
Pulmonary hypertension

Chest wall

Pleural effusion
Rib fracture
Kyphoscoliosis
Neuromuscular

Left ventricular failure

Mitral valve disease
Cardiomyopathy
Pericardial effusion

Cardiac

Other

Anaemia
Acidosis
Psychogenic

Normal Chest
Radiograph

Pulmonary
Oedema

Unilateral or bilateral
Proximal extent of
oedema
Pitting/non-pitting
Cardiac

Congestive cardiac
failure
Right ventricular failure
Cor pulmonale
Constrictive pericarditis

Drugs

Calcium channel
blockers

Other

Cirrhosis
Nephrotic syndrome
Protein-losing
enteropathy
Deep vein thrombosis
Hypothyroidism
Lymphoedema

= Unexpected
awareness of
heartbeat
Ask patient to tap
palpitations on chest
Slow or fast
Regular or irregular
Duration
Speed of onset or
offset
Relieving manoeuvres

Sinus tachycardia
Ventricular
extrasystoles
Atrial fibrillation
Atrial flutter
Supraventricular
tachycardia
Ventricular
tachycardia

= Transient loss of consciousness due to

cerebral hypoperfusion
What was the patient doing at the time?
Standing for prolonged period
Standing up suddenly (postural
hypotension)
Coughing
Prodromal symptoms
Abnormal movements (epilepsy)
Sensation of room spinning (vertigo)

Pain in one or both calves, thighs or

buttocks
Brought on by walking a certain distance
(claudication distance)
Worse on walking uphill
Relieved by rest
Suggests peripheral vascular disease

1.
2.
3.
4.
5.
6.

Hyperlipidaemia
Diabetes mellitus
Smoking
Hypertension
Obesity
Family history

Rheumatic fever
Previous cardiac investigations
Previous myocardial infarction
Coronary angioplasty + stent insertion
Coronary artery bypass grafting
Pacemaker insertion

Anti-anginal agents

Use of sublingual nitrate spray

Antihypertensive agents
Anti-arrhythmics
Statins
Platelet inhibitors, e.g., Aspirin
Anticoagulants, e.g., Warfarin

Allergies

NB Document in front of chart and inform

nurses

Occupation
e.g., train driver, long distance truck driver

Smoking
Number of pack years

Alcohol intake
Stairs at home

Ischaemic heart disease

Angina
MI
CABG

Hypertrophic obstructive cardiomyopathy

Dilated cardiomyopathy

General
Hands
Pulse
Blood pressure
Face
Neck
Jugular venous
pressure

Precordium

Inspection
Palpation
Percussion
Auscultation

Back
Abdomen
Lower limbs
Other

Position patient at 45 degrees

Respiratory rate
Cachexia
Marfans syndrome
Downs syndrome

Clubbing
Splinter haemorrhages (infective
endocarditis)
Oslers nodes (tender)
Janeway lesions (non-tender)
Xanthomata (Hyperlipidaemia)

Splinter
Haemorrhages

Clubbing

Osler nodes

Radial artery
Rate (normal = 60100)
Bradycardia (<60)
Tachycardia (>100)

Rhythm
Regular
Irregular

Radiofemoral delay
(coarctation of the
aorta)

Character and volume

assessed from carotid
artery
Collapsing pulse (aortic
regurgitation)
Pulsus alternans (left
ventricular failure)
Pulse deficit (atrial
fibrillation)

Sphygmomanometer
Systolic/diastolic
pressure
Normal <140/90
mmHg (lower in
diabetes)
Korotkoff sounds
Use larger cuff width
for large arms

Deflate at 4 mmHg/s
Difference between
arms of <10 mmHg
Pulsus paradoxus =
exaggerated
reduction in BP with
inspiration (>10
mmHg)
Postural hypotension

Jaundice
Xanthelasmata
Corneal arcus
Malar flush (mitral
stenosis)
High arched palate
(Marfans syndrome)
Dental caries
(infective
endocarditis)

Central cyanosis
Carotid pulse
character
Carotid bruit

CORNEAL
ARCUS

XANTHELASMATA

Internal
Jugular vein

Patient at 30-45 degrees

Good lighting
Internal jugular vein
Reflects right atrial
pressure
Zero point = sternal
angle
Visible but not palpable
Complex wave form (a,
c, v waves)
Decreases on inspiration

Fills from above

Hepatojugular reflux
Abnormal if >3 cm above
zero point:

RV failure
RV infarct
Tricuspid stenosis
Tricuspid regurgitation
Pericardial effusion
SVC obstruction
Fluid overload

Scars
Median sternotomy
CABG
Valve replacement

Lateral thoracotomy
Infraclavicular
(pacemaker)

Pectus excavatum
Pacemaker box
Apex beat

Sternotomy
scar

Pectus
excavatum

Apex beat

Location
Character

Heaving
Thrusting
Double
Tapping
Paradoxical

Left parasternal heave

Thrills (palpable murmurs)
Systolic
Diastolic

Pacemaker box

To identify left and right limit of heart

Right heart limit : determine the hepaticlung borders in midclavicle line then up for
2 fingers then percuse gentle to the medial,
note the changing from soner dall
Left heart limit : determine the gastric-lung
borders in anterior axilaris line then up for 2
fingers then percuse gently to the medial,
note the cahnging from sonor --? dall

Bell low pitched

sounds
Diaphragm high
pitched sounds
Mitral Tricuspid
Pulmonary
Aortic areas
S1 (first heart
sound)
S2 Splitting (A2,
P2)

Loud S1
Soft S1
Loud A2
Loud P2
Soft A2
Splitting of S1
Increased splitting of
S2
Fixed splitting of S2
Reversed splitting of
S2

S3 (third heart sound)

S4 (fourth heart
sound)
Summation gallop
Opening snap
Systolic ejection click
Mid-systolic click
Tumour plop
Pericardial knock
Metallic click

Timing of murmur
Systolic
Diastolic
Continuous

Site of maximal
intensity
Loudness

Grades I-VI
Thrill

Pitch
Radiation

Describe

Intensity: Grade
I

Very faint

II

Faint

III
IV

Moderately loud
Loud

Very loud

VI

Very loud

Hardly heard

Clearly audible but quiet

Associated with thrill
Thrill easily palpated
Visible heave or lift
Heard with stethoscope not in contact with chest

Systolic

Early diastolic

Pansystolic

Aortic regurgitation
Pulmonary regurgitation

Mitral regurgitation
Tricuspid regurgitation
Ventricular septal defect

Mid-diastolic
Mitral stenosis
Tricuspid stenosis
Atrial myxoma

Ejection systolic
Aortic stenosis
Pulmonary stenosis
Atrial septal defect

Diastolic

Continuous
Patent ductus arteriosus
Arteriovenous fistula

Late systolic
Mitral valve prolapse

Pericardial friction
rub

Percuss and auscultate lung bases

Left ventricular failure
Pleural effusion

Sacral pitting oedema

Right heart failure

Patient lying with one pillow (if tolerated)

Tender hepatomegaly
Pulsatile liver (tricuspid regurgitation)
Ascites
Splenomegaly
Abdominal aortic aneurysm

Peripheral oedema
Pitting/non-pitting
Upper level

Capillary return
Trophic skin changes

Palpate arteries

Femoral
Popliteal
Posterior tibial
Dorsalis pedis
Buergers test
(peripheral vascular
disease)

Dorsalis pedis
pulse

Posterior tibial
pulse

ECG
Echocardiography
Doppler
Treatmill
Cardiac catheterization
Blood laboratories
Others .......