Cardiovascular System examination

  

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I. History Taking Points

1. Chief Complaints:

• Chest pain: Character (sharp, crushing, burning), site (retrosternal, left-sided, diffuse), radiation, severity, aggravating/relieving factors.
  • Possibilities:
    • Retrosternal, crushing → MI.
    • Localized, stabbing → Pericarditis.
    • Exertional, squeezing → Angina.
    • Burning epigastric → GERD, mimicker.
• Palpitations: Onset (sudden/gradual), duration, regularity, associated symptoms (syncope).
  • Possibilities: Arrhythmia (AF, SVT), hyperthyroidism, anxiety.
• Dyspnea: Graded (NYHA I-IV), orthopnea, paroxysmal nocturnal dyspnea.
  • Possibilities: LV failure, pulmonary hypertension, pericardial disease.
• Syncope/Presyncope: Circumstances (exertional, positional), duration, recovery.
  • Possibilities: Aortic stenosis, arrhythmia, vasovagal.
• Edema: Pitting, bilateral/unilateral, progression.
  • Possibilities: Right heart failure, nephrotic syndrome, DVT (unilateral).
• Fatigue, effort intolerance, dizziness.

2. Associated Symptoms:

• Nocturia → CHF.
• Abdominal distension → RHF, constrictive pericarditis.
• Cough, hemoptysis → Pulmonary congestion, MS.
• Hoarseness → Ortner’s syndrome (LA enlargement).
• Claudication, cold extremities → PVD.
• Constitutional symptoms → Infective endocarditis.

3. Past History:

• Hypertension, diabetes, dyslipidemia, rheumatic fever, coronary artery disease, stroke, surgeries (valve replacement, angioplasty).

4. Family History:

• Cardiomyopathies, sudden cardiac death, hypertension.

5. Personal & Drug History:

• Smoking, alcohol, illicit drug use.
• Medications: Antihypertensives, anticoagulants, statins.

6. Risk Factors:

• Obesity, sedentary lifestyle, sleep apnea.

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II. Clinical Examination Points (Structured)

A. General Physical Examination:

• Build, nutrition: Cachexia in CHF.
• Pallor: Anemia, infective endocarditis.
• Cyanosis:
  • Central: Congenital cyanotic heart disease, Eisenmenger syndrome.
  • Peripheral: Low-output states.
• Clubbing:
  • Congenital cyanotic heart disease, infective endocarditis.
• Edema: Pitting pedal edema in RHF.
• Jaundice: Hepatic congestion.
• JVP:
  • Elevated: RHF, constrictive pericarditis.
  • Prominent ‘a’ wave: TR, PS.
  • Absent ‘a’ wave: AF.
  • Cannon ‘a’ wave: Complete heart block.
  • Prominent ‘v’ wave: TR.
• Pulse:
  • Rate, rhythm, volume, character, radio-femoral delay.
  • Collapsing pulse: AR.
  • Anacrotic pulse: AS.
  • Pulsus alternans: Severe LV dysfunction.
  • Pulsus paradoxus: Cardiac tamponade, severe asthma.
  • Irregularly irregular: AF.
• BP:
  • Pulse pressure variations: Wide in AR, thyrotoxicosis; Narrow in AS, tamponade.
  • Postural hypotension.

B. Precordial Inspection:

• Shape of chest: Pectus excavatum → compressive effect.
• Visible apex beat: Hyperdynamic in MR, AR; heaving in AS.
• Precordial bulge: Congenital heart disease.

C. Palpation:

• Apex Beat:
  • Location, character:
    • Displaced laterally → LV enlargement.
    • Hyperdynamic → Volume overload (AR, MR).
    • Heaving → Pressure overload (AS).
    • Tapping → MS.
  • Double apex beat → HOCM.
• Parasternal heave → RV hypertrophy.
• Thrills:
  • Systolic → AS, VSD.
  • Diastolic → MS.
• Palpable P2 → Pulmonary hypertension.

D. Percussion:

• Cardiac borders:
  • Right border → RA enlargement.
  • Left border → LV enlargement.
  • Superior border → LA enlargement.
  • Increased transverse dullness → Pericardial effusion.

E. Auscultation:

• Heart Sounds:

  • S1:
    • Loud: MS.
    • Soft: MR, LV dysfunction.
  • S2:
    • Loud P2: Pulmonary hypertension.
    • Widely split: ASD.
    • Reversed split: LBBB, AS.
  • S3: Volume overload (MR, CHF).
  • S4: Pressure overload (HTN, AS).

• Added Sounds:

  • Opening snap: MS.
  • Ejection click: AS, PS.
  • Midsystolic click: MVP.
  • Pericardial rub: Pericarditis.

• Murmurs:

  • Systolic:
    • Ejection: AS, PS.
    • Pansystolic: MR, TR, VSD.
  • Diastolic:
    • Mid-diastolic: MS, TS.
    • Early diastolic: AR, PR.
  • Continuous: PDA.
  • Radiation:
    • To carotids: AS.
    • To axilla: MR.
    • To back: Coarctation.

• Dynamic Auscultation:

  • Murmur variation with position, respiration, handgrip, squatting.
  • Maneuvers to differentiate HOCM vs AS.

F. Peripheral Vascular Examination:

• Peripheral pulses: Radiofemoral delay → Coarctation.
• Bruits: Carotid, renal arteries.
• Capillary refill time, temperature, trophic changes → PVD.

G. Bedside Investigations:

• ECG, Chest X-ray.
• NT-proBNP levels in CHF.
• 2D-Echo.
• Doppler for carotids & peripheral arteries.

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III. Advanced Clinical Clues & Differential Interpretations

• Elevated JVP with clear lungs: Constrictive pericarditis, RHF.
• Displaced apex with S3 & MR murmur: DCM.
• Heaving apex with ejection systolic murmur & slow-rising pulse: AS.
• Hyperdynamic apex, collapsing pulse, early diastolic murmur: AR.
• Mid-diastolic murmur with tapping apex, loud S1: MS.
• Raised JVP, hypotension, muffled heart sounds: Cardiac tamponade.
• Tachycardia with irregularly irregular pulse: AF.
• Clubbing + continuous murmur: PDA.
• Systolic murmur increasing on standing, decreasing on squatting: HOCM.
• Prominent ‘v’ wave in JVP, pansystolic murmur increasing on inspiration: TR.
• Midsystolic click with late systolic murmur: MVP.

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