CV: History Taking + Exam Flashcards
According to Nobel Peace Prize Laureate Dr Bernard Lown the medical history provides sufficient information in what proportion of patient encounters to make the diagnosis before performing a physical examination and additional tests ?
75%
Describe the different parts of the consultation according to Roger Neighbor.
1) CONNECTING (build rapport, identify patient’s views and expectations)
2) SUMMARISING
3) HANDING OVER (agree on doctor and patient agenda, give ownership of management to patient)
4) SAFETY NETTING (follow-up, advice or referral)
5) HOUSEKEEPING (Dr recognises importance of looking after oneself)
What are some conditions to consider in past medical history, wrt CVS history ?
- History of Vascular disease: Coronary artery / Cerebrovascular /Peripheral vascular
- Diabetes
- Hyperthyroidism
- Renal disease
- Hypertension
- Hypercholesterolaemia
What constitutes a young age, for each of males and females, when considering family history of CV disease at a young age ?
1st degree male relative <55 years
1st degree female relative <65 years
What are possible symptoms to look for in a CV system enquiry ?
• Chest pain • Breathlessness (including Orthopnoea and Paroxysmal Nocturnal Dyspnoea) • Palpitations • Syncope / dizziness • Oedema • Peripheral vascular symptoms (Intermittent claudication etc.) • Fatigue
Identify the main risk factors of CV disease.
NON-MODIFIABLE:
- Age
- Gender
- Genetic factors
- Race and ethnicity
MODIFIABLE:
- High BP
- Smoking
- Diabetes
- Physical inactivity
- High blood cholesterol
- Obesity
Identify possible sites of chest pain and the associated CV cause of chest pain.
- Retrosternal —> Angina or MI
- Retrosternal/Interscapular —> Aortic dissection
- Retrosternal/Left-sided —> Pericardial pain
- Retrosternal/epigastric —> Oesophageal pain
Define angina and myocardial infarction (both causes of chest pain)
ANGINA = A clinical syndrome of chest pain or pressure precipitated by activities such as exercise or emotional stress which increase
myocardial oxygen demand
MYOCARDIAL INFARCTION = death of the cells of an area of the heart muscle (myocardium) as a result of oxygen deprivation, which in turn is caused by obstruction of the blood supply (usually due to occlusion of a coronary artery)
Define acute coronary syndrome (ACS).
Spectrum of acute myocardial ischaemia that includes MI, non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (NOT stable angina).
Distinguish MI from angina, especially wrt:
- Sites
- Precipitated
- Relieved
- Anxiety
- Sympathetic activity
- Nausea/vomiting
MI is part of acute coronary syndrome but not stable angina (unstable angina is part of ACS also).
- SITES: same between both (retrosternal, radiating to arm, epigastrium, neck, jaw)
- PRECIPITATED: by exercice or emotion (angina) vs spontaneous (MI)
- RELIEVED: rapidly by rest and nitrates (angina) vs by neither of those (MI)
- ANXIETY: Absent or mild (angina) vs severe (MI)
- Sympathetic activity: none (angina) vs increased (MI)
- Nausea or vomiting: unusual (angina) vs common (MI)
Distinguish oesophageal pain from angina, especially wrt:
- Sites
- Precipitation
- Relieved
- Wakes patient from sleep ?
- Relation to heatburn
- Duration
- SITES: retrosternal, radiating to arm, epigastrium, neck, jaw (angina) vs retrosternal or epigastric, sometimes radiates to arm or back (oesophageal pain)
- PRECIPITATED: by exercice or emotion (angina) vs can be worsened by excretion but often present at other times (oesophageal pain)
- RELIEVED: rapidly by rest and nitrates (angina) vs not rapidly relieved by rest, often relieved by nitrates (oesophageal pain)
- WAKES PATIENT FROM SLEEP: seldom (angina) vs often (oesophageal pain)
- RELATION TO HEARTBURN: none but patients often have wind (angina) vs sometimes (oesophageal pain)
- DURATION: Typically 2-10 minutes (angina) vs variable (oesophageal pain)
Describe the main characteristics of pericarditis as a cause of chest pain, especially:
- Definition
- Causes
- Clinical Presentation
- Site
- Onset
- Nature of pain
- Exacerbating factors
- Alleviating factors
- Inflammation of the pericardium (Non Ischaemic), accompanied by pericardial rub
- CAUSES: mainly idiopathic (but most likely viral in origin)
- CLINICAL PRESENTATION: acute onset of chest pain (pleuritic in nature), eased by sitting up and leaning forward
- SITE: pain may be anywhere over the anterior chest wall, but it is usually retrosternal, may radiate to the arm or to trapezius ridge (i.e. back or shoulder, usually left shoulder) latter is specific for pericarditis related chest pain)
- ONSET: no obvious initial precipitating factor, tends to fluctuate in intensity
- NATURE: stabbing, raw (sharp)
- EXACERBATING FACTORS: Changes in posture, respiration
- ALLEVIATING FACTORS: By analgesics (especially NSAIDs)
Describe the main characteristics of aortic dissection as a cause of chest pain, especially:
- Definition
- Site
- Onset
- Nature of pain
- Definition: A defect in the tunica intima of the aorta allows an opening or tear to develop
- Site: Retrosternal/Interscapular, radiates to left shoulder/back.
- Nature: Tearing and deep
- Onset: sudden and severe
Define dyspnoea.
Shortness of breath
Identify questions to ask when enquiring about dyspnoea.
• Acute, chronic or acute-on-chronic?
• How disabling? At rest / on exertion / exercise
tolerance?
• Orthopnoea / Paroxysmal nocturnal dyspnoea (PND)?
• Response to diuretic?
• Associated symptoms e.g. cough / sputum / chest pain / palpitations ?
Define orthopnoea and paroxysmal nocturnal dyspnoea (PND).
- Orthopnoea= sensation of breathlessness in the recumbent position, relieved by sitting or standing (improved with more pillows)
- Paroxysmal nocturnal dyspnoea (PND)= sensation of shortness of breath that awakens the patient, often after 1 or 2 hours of sleep, and is usually relieved in the upright position
Identify the main causes of dyspnoea (a common symptom of CV disease).
1) CARDIAC CAUSES
- Cardiac failure (orthopnoea/PND)
- Associated with angina or MI
2) RESPIRATORY CAUSES
- Asthma, COPD, pneumothorax, pneumonia, bronchitis, bronchiectasis, pulmonary fibrosis
3) OTHER CAUSES
- Anaemia, obesity, hyperventilation, anxiety, metabolic acidosis
Define palpitations.
Unexpected awareness of heart beating in chest.
How fast and regularly do palpitations occur ?
May be fast, slow, regular and irregular.
Notably, may occur in:
- Sinus rhythm (normal heart beat) e.g. anxiety
- Intermittent irregularities of heartbeat e.g. Ectopic beats (extrasystoles)
- Abnormal rhythm (arrhythmia)
Do all patients with arrhythmias experience palpitations ?
Not all
Identify the main kinds of arrhythmias with their distinguishing feature.
1) VENTRICULAR OR ATRIAL EXTRASYSTOLES
- Heart flutters/misses a beat
2) ATRIAL FIBRILLATION
- Heart racing, associated breathlessness
- May be unnoticed!
3) SUPRAVENTRICULAR TACHYCARDIA
- Heart racing or fluttering, associated polyuria
4) VENTRICULAR TACHYCARDIA
- Heart racing or fluttering, associated breathlessness
- May be present as syncope rather than palpitations
Identify questions to ask when enquiring about arrythmia.
- Ask the patient to tap it out!
- Onset and termination
- Precipitating/ relieving factors
- Frequency and duration
- Associated symptoms (Chest pain / collapse / sweating / dyspnea)
- Past medical history (e.g. Cardiovascular/thyroid disease)
Define syncope.
Loss of consciousness and postural tone caused by diminished cerebral blood flow.
Identify the main causes of dizziness and syncope (symptoms of CV disease).
- Postural hypotension
- Neurocardiogenic (vasovagal)
- Micturition syncope
- Cardiac arrhythmias
- Hypoglycaemia
Identify questions to ask when enquiring about syncope/dizziness.
- History from witness if possible
- Frequency/duration
- Loss of consciousness ?
- Associated symptoms (before, during and after): chest pain, palpitations, sweating, dyspnoea, convulsions, tongue biting, incontinence, drowsiness afterward
Identify questions to ask when enquiring about oedema.
- Localised or generalised ?
- Legs: uni or bilateral ?
- Duration/getting better or worse
- Exacerbating/alleviating factors
Identify the main causes of pitting oedema.
- Secondary to increased venous pressure or to reduced oncotic pressure
- Idiopathic
Explain the significance of unilateral vs bilateral oedema.
BILATERAL indicates a systemic cause
(e.g. cardiac failure, cirrhosis, sepsis, pregnancy, renal failure) whereas UNILATERAL tends to reflect local pathology (DVT, compartment syndrome, chronic veinous insufficiency)
Define Lymphoedema.
Swelling as a result of obstruction of lymphatic vessels or lymph nodes and the accumulation of large amounts of lymph in the affected region.
Identify the main causes of fatigue (a symptom of CV disease).
1) CV CAUSES
- Inadequate systemic perfusion in Cardiac Failure
- Side-effects of medication e.g. β-blockers.
2) OTHER CAUSES
- Infection, dehydration, psychiatric factors, medications etc.
Define heart failure (a cause of fatigue).
Heart has lost the ability to pump enough blood to the body’s tissues.
Identify the main symptoms of left and right sided heart failure.
RIGHT SIDED HEART FAILURE
- Peripheral veinous pressure
- Distended jugular veins
- Ascites
- Enlarged liver and spleen
- Oedema
LEFT SIDED HEART FAILURE
- PND
- Orthopnea
- Pulmonary congestion (tachypnea, wheezes etc.)
Identify the main steps in a CV Exam.
1) INTRO
• Stand at end of bed.
• Look around and at the patient (esp. for breathlessness, discomfort, pain)
2) GENERAL AND CLOSE INSPECTION
- Examine hands to assess circulation for warmth, capillary refill, evidence of peripheral cyanosis, tar staining (sign of smoking), clubbing, splinter haemorrhages, Janeway lesions, Osler’s nodes, and koilonychia
- Examine face, eyes and mouth for signs of e.g. malar flush, pallor, clinical anaemia, butterfly rash, xanthelasmata, corneal arcus, and central cyanosis
3) PALPATION
- Palpate radial and carotid pulses
4) PERCUSSION
5) AUSCULTATION
- Listen (in all 4 keys areas) for: Heart sounds (distinguish 1st and 2nd heart sounds), added sounds, murmurs (turbulent blood flow), using the bell and diaphragm
6) OTHER AREAS
- Auscultate lung bases (looking for pulmonary oedema), look for sacral oedema, offer abdominal examination (inspect, palpate, percuss for hepatomegaly, listen for renal and femoral bruits, feel for radio-femoral delay and palpate for pulsatile, expansile mass suggesting abdominal aortic aneurysm), peripheral vascular examination, check for ankle oedema, check BP, fundoscopy, urinalysis, observation chart.
7) CONCLUSION
What is a normal capillary refill time ?
Less than 2 seconds
Define malar flush. Why do we look for it in a CV exam ?
- A high colour over the cheekbones, with a bluish tinge caused by reduced oxygen concentration in the blood.
- Sign of mitral valve disease, which often follows rheumatic fever (BUT not always present in mitral stenosis)
Define butterfly rash. Name any precipitating factors for it.
- Characteristic skin lesion of systemic lupus erythematosus (SLE) (but may precede SLE by weeks or months), where erythema occurs in a butterfly distribution on the cheeks of the face and across the bridge of the nose.
- Frequently precipitated by sun exposure.
- Another differential that is common is Acne Rosacea
Define Koilonychia and explain its cause.
- Abnormality of the nails that is also called spoon-shaped (concave) nails
- Manifestation of chronic iron deficiency, which may result from a variety of causes, such as malnutrition; gastrointestinal blood loss; worms; gastrointestinal malignancy; and coeliac disease.
Define clubbing. Describe its onset.
Changes in the area under and around the fingernails and toenails that occur with some disorders:
- The nail beds soften. The nails may seem to “float” instead of being firmly attached (fluctuation of the nail bed)
- The last part of the finger may appear large or bulging. It may also be warm and red.
- The nail curves downward so it looks like the round part of an upside-down spoon.
Clubbing can develop quickly, often within weeks. It also can go away quickly when its cause is treated.
Identify the main causes of clubbing.
HEART AND LUNG DISEASES THAT REDUCE THE AMOUNT OF OXYGEN IN BLOOD:
- Lung Cancer
- Congenital Cyanotic Heart Disease
- Chronic lung infections in people with cystic fibrosis, lung absesses
- Interstitial lung disease
- Coeliac disease
- Cirrhosis of liver and other liver diseases
- Overactive thyroid gland
- Other cancers
- Infective endocarditis
Name the main features of infective endocarditis.
- Fever
- Murmurs
- Petechiae (Common, but nonspecific, finding)
- Subungual (splinter) hemorrhages: Dark-red, linear lesions in the nail beds
- Osler nodes: Tender subcutaneous nodules usually found on the distal pads of the digits
- Janeway lesions: Nontender maculae on the palms and soles
- Roth spots (=Litten spot): Retinal hemorrhages with small, clear centers
Distinguish Osler nodes from Janeway lesions in terms of:
- Location
- Size/shape
- Tender
- Course
- Type of endocarditis
LOCATION: Soles, palms, thenar and hypothenar eminences, plantar surfaces of toe (Janeway) vs finger and toe tips, thenar and hypothenar eminences (Osler)
SIZE AND SHAPE: Macules of variable size and irregular shape (Janeway) vs Nodules of 1 mm to over 1 cm (Osler)
TENDER: No (Janeway) vs Yes (Osler)
COURSE: Days to weeks (Janeway) vs Hours to days (Osler)
TYPE OF ENDOCARDITIS: Acute (Janeway) vs Subacute (Osler)
Explain what a Roth’s spot (=Litten spot) is. Where (other than endocarditis) can Roth’s spots be seen ?
• Retinal hemorrhages with small, clear centers (white center usually represents fibrin-platelet plugs)
Seen most commonly in acute bacterial endocarditis
• Roth spots can also be seen in leukaemia, diabetes, intracranial hemorrhage, hypertensive retinopathy, cerebral malaria and in HIV retinopathy.
Define Xanthelasma palpebrarum. What is its main demographic incidence ?
- Xanthelasma palpebrarum (XP) is characterized by sharply demarcated yellowish flat plaques on upper and lower eyelids.
- Commonly seen in women with a peak incidence at 30–50 years
What pathological processes are Xanthelasma palpebrarum and corneal arcus signs of ?
- XP is considered as the cutaneous marker of underlying atherosclerosis along with the disturbed lipid metabolism.
- XP and corneal arcus are associated with increased levels of serum cholesterol and low- density lipoprotein (LDL) cholesterol.
What do you look for when palpating the pulses in a CV Exam ?
RADIAL PULSES
- Check both are equal
- Assess and comment on rate and rhythm on right radial pulse.
- Assess for collapsing pulse.
CAROTID PULSES
-Assess for volume and character
(never feel both simultaneously)
MEASURE AND RECORD BP
Identify the ways in which a pulse can be abnormal wrt rate and rythm, and the cause of each kind of abnormality.
FAST REGULAR (tachycardia) e.g. exercise, anxiety, pain, fever, medication, hyperthyroidism
SLOW REGULAR (bradycardia) e.g. athletic training, hypothyroidism, medication.
SLOW IRREGULAR
e.g. Sick sinus syndrome, second degree heart block, complete heart block.
REGULARLY IRREGULAR
e.g. ectopic beat
IRREGULARLY IRREGULAR
e.g. atrial fibrillation (fast if uncontrolled)
BOUNDING (strong throbbing)
THREADY (scarcely perceptible)
Identify the ways in which a pulse can be abnormal wrt character and volume, and the cause of each kind of abnormality.
LOW VOLUME
e.g. hypovolaemia, left ventricular failure
HIGH VOLUME
e.g. anaemia, fever, thyrotoxicosis
CHARACTER SLOW RISING PULSE
Aortic stenosis
COLLAPSING PULSE
Aortic regurgitation
What angle should the patient be lying in for an internal jugular pulse assessment ? Why ?
45 degrees.
In health, at 45 degree incline the upper limit of the venous column lies just behind the right sternoclavicular joint, which is at the same horizontal level as the sternal angle.
When right atrial pressure is increased as in right-sided heart failure, the venous column is seen above the right sterno- clavicular joint and the vertical height of this column is measured to express the increase in venous pressure.
What is the significance of the jugular vein pulse ?
The jugular vein closely reflects the pressure changes within the right atrium.
What features of the praecordium would you be looking at upon inspection ?
- Shape
- Respiratory rate
- Scars
- Visible apex beat
- Pacemaker
- Apex beat (find it then check position)
What is the normal position of the apex beat ?
5th intercostal space mid-clavicular line
Identify possible abnormalities found upon inspection of the praecordium.
HEAVES
- Felt in left sternal edge
- Occurs in right ventricular enlargement
THRILLS
- Palpable murmurs
- Apex, upper praecordium, sternal notch
Describe the 4 main heart sounds.
S1: Mitral and Tricuspid valve closure
S2: Aortic and Pulmonary valve closure
S3: Rapid ventricular filling during early diastole
S4: Atrial contraction and decreased ventricular compliance during late diastole
Identify some manoeuvres
to accentuate murmurs.
- Bell at apex in expiration in left lateral position. Accentuation of diastolic murmur of mitral stenosis.
- At left axilla with diaphragm. Radiation of systolic murmur of mitral regurgitation.
- At lower left sternal edge with patient sat forwards. With diaphragm in expiration. Accentuation of diastolic murmur of aortic regurgitation.
- Over carotids. With diaphragm in held inspiration. Accentuation of murmur of aortic stenosis radiation / carotid bruits.
Identify the best sites for hearing abnormality in a cardiac auscultation, and the normal and abnormal sounds you may hear at each site. m
CARDIAC APEX
First heart sound
Third and fourth heart sounds
Mid-diastolic murmur of mitral stenosis
LOWER LEFT STERNAL BORDER
Early diastolic murmur of aortic and tricuspid regurgitation
UPPER LEFT STERNAL BORDER Second heart sound Opening snap of mitral stenosis Pulmonary valve murmurs Pansystolic murmur of ventricular septal defect
UPPER RIGHT STERNAL BORDER Systolic ejection (outflow) murmurs (e.g. aortic stenosis, hypertrophic obstructive cardiomyopathy)
LEFT AXILLA
Radiation of pansystolic murmur of mitral regurgitation
BELOW LEFT CLAVICLE
Continuous ‘machinery’ murmur of a persistent patent ductus arteriosus
Identify the main grades of intensity of murmur.
Grade 1- Heard by an expert in optimum conditions
Grade 2- Heard by a non-expert in optimum conditions
Grade 3- Easily heard, no thrill
Grade 4- A loud murmur, with a thrill
Grade 5- Very loud, often heard over a wide area, with thrill
Grade 6- Extremely loud, heard without stethoscope
Identify the main categories of murmurs, as well as the main kinds of murmurs within each of these categories.
SYSTOLIC MURMURS
- Aortic stenosis
- Pulmonary stenosis
- Mitral regurgitation
- Tricuspid regurgitation
- Mitral valve prolapse
- Atrial septal defect
- Ventricular septal defect
- Hypertrophic cardiomyopathy
DIASTOLIC MURMURS
- Aortic regurgitation
- Pulmonary regurgitation
- Mitral stenosis
- Tricuspid stenosis
- Austin-Flint murmur
CONTINUOUS MURMURS
- Patent ductus arteriosus
- Combination murmurs
Distinguish between innocent and pathological murmurs.
INNOCENT
- Systolic
- Ejection
- Soft or vibratory
- Grade 1-2/6
- Normal S1, S2
- No extra sounds
- Louder when supine
PATHOLOGIC
- Diastolic
- Holosystolic
- Harsh
- Grade > or = 3/6
- Abnormal split S2
- Extra sounds ‘click’
- Louder when standing
