Cardiovascular History Taking
1. Presenting Complaints (PC)
Document the main symptom(s) with duration.
- Chest pain (angina pectoris, myocardial infarction) — ask onset, duration, character, site, radiation, precipitating factors, relieving factors, associated symptoms.
- Why: Chest pain character differentiates angina (exertional, relieved by rest) from MI (prolonged, not relieved by rest).
- Dyspnoea (shortness of breath) — classify as NYHA functional class I–IV.
- Why: Severity grading helps assess heart failure progression.
- Palpitations (subjective awareness of heartbeat) — ask about onset, regularity, triggers.
- Why: Can indicate arrhythmia (e.g., atrial fibrillation, SVT).
- Syncope / presyncope (transient loss of consciousness) — relation to exertion, position.
- Why: May suggest arrhythmia, aortic stenosis, or neurocardiogenic syncope.
- Fatigue, weakness (reduced cardiac output symptoms) — duration, daily impact.
2. History of Present Illness (HPI)
- Onset & progression — gradual vs. sudden onset symptoms.
- Temporal pattern — intermittent, persistent, worsening.
- Associated features —
- Orthopnoea (dyspnoea in supine position) — Why: Suggests left-sided heart failure.
- Paroxysmal nocturnal dyspnoea (PND) (sudden nighttime breathlessness) — Why: Due to pulmonary congestion from left heart failure.
- Claudication (pain in legs on walking) — Why: Indicates peripheral arterial disease.
- Triggering / relieving factors — exertion, emotional stress, rest, medications.
3. Past Medical History (PMH)
- Hypertension (HTN) — Why: Risk factor for CAD, heart failure, stroke.
- Diabetes mellitus (DM) — Why: Accelerates atherosclerosis.
- Dyslipidaemia — Why: Promotes plaque formation in coronary arteries.
- Rheumatic fever — Why: Leads to valvular heart disease.
- Previous myocardial infarction, angina, heart surgery — Why: Guides prognosis and therapy.
4. Drug History
- Cardiac drugs (beta-blockers, ACE inhibitors, diuretics, nitrates) — compliance, side effects.
- Anticoagulants / antiplatelets — risk of bleeding vs. thromboembolism prevention.
- Recent new medications — can cause drug-induced arrhythmias or fluid retention.
5. Family History
- Sudden cardiac death — Why: May indicate inherited arrhythmia syndromes (e.g., long QT, HCM).
- Ischaemic heart disease — early onset in family increases risk.
- Cardiomyopathy — genetic forms possible.
6. Personal & Social History
- Smoking (tobacco use) — Why: Major modifiable risk factor for CAD, PAD.
- Alcohol intake — excess causes cardiomyopathy and arrhythmias.
- Physical activity level — helps assess functional capacity.
- Dietary habits — high salt intake worsens hypertension, heart failure.
- Occupational stress — chronic stress linked to hypertension and CAD.
7. Systemic Review (Focused Cardiovascular)
Ask for symptoms in other systems that may indicate cardiovascular cause or complication:
- Respiratory — cough, haemoptysis (pulmonary congestion, mitral stenosis).
- Neurological — focal weakness, speech difficulty (embolic stroke from AF).
- Gastrointestinal — abdominal pain (mesenteric ischaemia), swelling (hepatic congestion in right heart failure).
8. Summary & Clinical Correlation
At the end, link the symptoms and risk factors to possible differentials:
- Angina + risk factors + exertional onset → likely stable coronary artery disease.
- Dyspnoea + orthopnoea + PND + leg swelling → suggests congestive heart failure.
- Palpitations + syncope + irregular pulse → think atrial fibrillation with possible embolic risk.
Step‑by‑step Cardiovascular System Examination
Preparation & safety
- Explain procedure & obtain consent [consent = patient’s informed agreement after explanation].
- Chaperone present [chaperone = third person (nurse/colleague) present for patient comfort and safety].
- Ensure patient is comfortable & exposed from neck to mid‑abdomen (drape otherwise).
- Record vital signs: heart rate [beats per minute], blood pressure (BP) [arterial pressure measured in mmHg], respiratory rate [breaths per minute], temperature, SpO₂ [peripheral oxygen saturation].
- Position patient sitting and supine (30–45°) as needed for different parts of exam.
- Warm your hands and stethoscope.
1) General inspection (from end of bed / on entry)
- Overall appearance & distress — signs of dyspnoea [difficulty breathing], cyanosis [bluish lips/tongue from low oxygen].
- Cachexia [severe weight loss/wasting] or obesity.
- Facial signs: xanthelasma [yellowish cholesterol deposits around eyelids], facial pallor [pale face from anemia].
- Neck: visible pulsations (e.g., jugular venous distension).
- Chest: surgical scars, chest wall deformities (pectus excavatum/carinatum) — may affect examination.
2) Hands & peripheral signs
- Temperature & colour of hands — cool/clammy suggests poor perfusion.
- Capillary refill time [time for blanched nail bed to regain colour; >2 sec suggests poor perfusion].
- Clubbing [bulbous enlargement of fingertips] — chronic hypoxaemia or infective endocarditis sequelae.
- Peripheral cyanosis [blue fingertips/toes] vs central cyanosis [tongue/lips].
- Signs of infective endocarditis:
- Osler’s nodes [tender subcutaneous nodules on fingers/toes],
- Janeway lesions [painless erythematous macules on palms/soles],
- Splinter haemorrhages [linear nail bed haemorrhages].
- Xanthoma/xanthelasma [cholesterol deposits] — hyperlipidaemia risk.
3) Carotid pulse & neck veins
- Carotid pulse palpation (one side at a time): assess rate, rhythm, volume (bounding/weak) and character (brisk, delayed).
- Bounding pulse [large volume] — e.g., thyrotoxicosis, aortic regurgitation.
- Slow rising (brachycardic) pulse — severe aortic stenosis.
- Carotid bruit [whooshing sound over artery heard with stethoscope] — suggests carotid artery stenosis (atherosclerosis).
- Jugular venous pressure (JVP) measurement: patient at 30–45°; identify internal jugular venous pulsation (soft, non‑palpable), measure vertical height above sternal angle (normal ≤ 3 cm) — elevated JVP indicates right‑sided heart failure/fluid overload.
- Hepato‑jugular reflux [sustained rise in JVP when firm pressure applied to liver] — supports right heart failure/volume overload.
4) Precordial inspection (anterior chest)
- Look for visible pulses / abnormal movement: precordial impulse, visible heaves.
- Precordial (apical) impulse / PMI [point of maximal impulse felt on chest wall] — normally 5th intercostal space (ICS), mid‑clavicular line (MCL).
- Displacement of PMI (lateral/downwards) → cardiomegaly [enlarged heart].
- Parasternal heave (lift) [sustained outward movement felt under hand] — right ventricular enlargement/pressure overload (e.g., pulmonary hypertension).
5) Palpation (systematic)
- Palpate apex beat (PMI): location, size, amplitude, duration.
- Hyperdynamic, displaced PMI → ventricular enlargement or volume overload.
- Palpate left parasternal area for heave [sustained outward impulse] (RV enlargement).
- Palpate for thrills [palpable vibration over chest produced by severe murmurs] — if present, localize.
- Palpate epigastrium for hepatic pulsation (tricuspid regurgitation / severe regurgitant lesions).
- Assess peripheral pulses: radial, brachial, femoral, dorsalis pedis, posterior tibial — compare rate, rhythm, symmetry, volume (e.g., femoral delay in coarctation/aortic dissection).
6) Percussion (brief)
- Cardiac percussion to estimate cardiac size (less used than imaging): percuss from left chest to detect dullness change from lung to heart — rough guide to cardiomegaly.
- (Note: chest X‑ray / echocardiography are preferred for accurate heart size.)
7) Auscultation — method & landmarks
- Use diaphragm (for high‑pitch sounds) and bell (for low‑pitch sounds) of stethoscope.
- Systematically auscultate with patient sitting leaning forward (for left‑sided/diastolic murmurs) and supine / left lateral decubitus (for mitral sounds).
- Auscultation points (landmarks):
- Aortic area: 2nd right ICS, sternal border.
- Pulmonic area: 2nd left ICS, sternal border.
- Erb’s point: 3rd left ICS, sternal border (useful for S2 and some murmurs).
- Tricuspid area: 4th–5th left ICS, sternal border.
- Mitral (apex) area: 5th ICS, mid‑clavicular line (PMI).
8) Heart sounds — what to listen for (definitions included)
- S1 (first heart sound) [closure of mitral & tricuspid valves at start of systole] — loud/soft variations.
- S2 (second heart sound) [closure of aortic & pulmonic valves at the end of systole]; split S2 [physiological or pathological splitting of aortic and pulmonary components during inspiration].
- S3 (third heart sound) [low‑pitched early diastolic sound after S2] — indicates increased volume/ventricular failure in adults (pathological); in young may be physiological.
- S4 (fourth heart sound) [late diastolic sound just before S1] — due to atrial contraction against a stiff ventricle (left ventricular hypertrophy, ischemia).
- Pericardial rub [scratching/pleural‑like sound] — suggests pericarditis [inflammation of pericardium].
9) Murmurs — classification & common patterns (with definitions)
- Murmur [abnormal sound caused by turbulent blood flow across valves or defects] — characterize by timing (systolic/diastolic/continuous), shape (crescendo, decrescendo, holosystolic/pansystolic), location, radiation, intensity (grade I–VI), pitch and response to manoeuvres.
Common examples:
- Aortic stenosis (AS): harsh systolic ejection murmur at aortic area, radiates to carotids; slow‑rising (parvus et tardus) carotid pulse.
- Mitral regurgitation (MR): pansystolic (holosystolic) murmur best heard at apex, radiates to axilla [armpit].
- Aortic regurgitation (AR): early decrescendo diastolic murmur best heard at left sternal edge; bounding pulse (water‑hammer) may be present.
- Mitral stenosis (MS): mid‑diastolic rumble with opening snap [high‑pitched sound immediately after S2 when stenotic mitral valve opens]; best at apex with patient in left lateral position.
- Tricuspid regurgitation (TR): pansystolic murmur at left lower sternal border, increases with inspiration.
- Ventricular septal defect (VSD): harsh pansystolic murmur at left sternal border, often loud.
10) Dynamic manoeuvres (definitions + typical effects)
(Use in cooperative, stable patients only.)
- Inspiration [breathing in] — increases right‑sided murmurs (more venous return).
- Expiration / leaning forward — accentuates left‑sided murmurs and AR/AS.
- Valsalva manoeuvre (strain phase) [forced expiration against closed glottis → reduces venous return] — most murmurs decrease, but hypertrophic obstructive cardiomyopathy (HOCM) murmur increases.
- Handgrip [patient squeezes hand → increases afterload] — increases intensity of MR/TR/AR murmurs, decreases intensity of AS and HOCM murmurs.
- Squatting / passive leg raise [increases venous return & afterload] — increases AS, MR murmurs; decreases HOCM murmur.
- Standing from squatting [decreases venous return] — increases HOCM murmur; decreases AS and MR.
(Clinical correlation: use these changes to help identify murmur origin — e.g., HOCM vs AS.)
11) Peripheral vascular & volume status assessment
- Peripheral pulses: compare radial/femoral pulses (delay in femoral suggests coarctation/aortic obstruction).
- Ankle‑brachial index (ABI) [ratio of ankle to brachial systolic BP] — assesses peripheral arterial disease.
- Peripheral oedema [pitting vs non‑pitting] — scale 1+ to 4+; bilateral pitting → heart failure; unilateral → DVT/local cause.
- Liver size & tenderness: hepatomegaly [enlarged liver] in chronic right heart failure (congestive hepatopathy).
- Ascites [fluid in peritoneal cavity] — may occur in advanced right heart failure.
12) Bedside investigations & when to request
- ECG (electrocardiogram) [records cardiac electrical activity] — arrhythmias, ischaemia, prior MI.
- Chest X‑ray (CXR) [radiograph] — cardiac size, pulmonary oedema, vascular congestion.
- Echocardiography (ECHO) [ultrasound of heart] — valve function, chamber size, wall motion, ejection fraction.
- BNP/NT‑proBNP [blood markers of cardiac stretch] — suggest heart failure.
- Cardiac enzymes (troponins) — for acute coronary syndrome.
- Carotid duplex / CT angiography — for suspected carotid stenosis/aortic disease.
13) Red flags / urgent findings
- New loud systolic murmur with hypotension/acute pulmonary oedema → possible acute MR (papillary muscle rupture) or large MI complication — urgent cardiology/surgical review.
- Syncope with exertion + systolic murmur → suspect severe aortic stenosis — urgent evaluation.
- Worsening orthopnoea, rising JVP, hypoxia → acute heart failure/pulmonary oedema — immediate management.
- Unequal BP in arms (difference >20 mmHg) or sudden severe chest/back pain → suspect aortic dissection — emergency.
14) Documentation checklist (concise)
- Consent & chaperone. Vitals. General impression. JVP (measured height). Carotid findings. PMI location & character. Presence of heave/thrill. Murmurs: timing, location, radiation, grade, effect of manoeuvres. Peripheral pulses (rate/volume/symmetry). Peripheral oedema and hepatomegaly. Impression & immediate plan (ECG, CXR, ECHO, labs, urgent referrals).
Quick clinical correlations (one‑line reminders)
- Raised JVP + hepatomegaly + peripheral oedema → right‑sided heart failure / cor pulmonale.
- Displaced, diffuse PMI → left ventricular enlargement (dilated cardiomyopathy).
- Loud S3 in adult → systolic heart failure (volume overload).
- Systolic murmur radiating to carotids + slow rising pulse → severe aortic stenosis.
- Pansystolic murmur at apex radiating to axilla → mitral regurgitation.
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