lecture 1 Hx and Ex Flashcards
Hands – Inspection (Dorsum)
- Clubbing
- Splinter haemorrhages
- Quincke’s sign
- Koilonychia
- Tar staining of fingers
- Peripheral cyanosis
- Tendon xanthoma
Hands – Inspection (Palmar)
• Osler’s nodes • Janeway lesion • Palmar xanthoma • Palmar crease pallor (anaemia)
Hands – Palpation
- Temperature
- Sweatiness
- Capillary refill time – normal up to 2 seconds
Examination – Arms
• Radial pulse – rate – rhythm • Radio-radial delay • Collapsing pulse • Blood pressure • (Brachial pulse)
Examination – Face
- Facies (eg marfanoid)
- Conjunctival pallor (anaemia)
- Arcus senilis
- Xanthelasma
- Central cyanosis
- Dentition
Examination – Neck
- Jugular venous pulse (patient’s right only obvs)
* Carotid pulse (both sides)
Examination – JVP
• Internal jugular vein is collapsible, relatively inelastic and in direct continuity with the right atrium • JVP = visible pulsation at meniscus of column of blood in internal jugular vein (transition between collapsed and distended parts of internal jugular vein) • ⇒JVP is useful marker of right atrial pressure • Measured with patient at 45o, vertical height from sternal angle (normal £3 cm)
between the clavicaular and sternal head of the SCM and the mastoid process.
• Causes of raised JVP:
• Causes of raised JVP: – fluid overload – heart failure – valve disease – TR, TS, PR, PS – pericardial disease – tamponade, constriction – pulmonary hypertension – massive PE
Cannon wave JVP
Cannon wave = strikingly large ‘a’ wave (seen in AV
dissociation e.g. complete heart block)
(‘a’ wave coincides with atrial
systole/contraction)
Kussmaul’s sign JVP
Kussmaul’s sign = abnormal rise in JVP during inspiration
seen in cardiac tamponade
Examination – Carotid Pulse
• Assess volume and character
• Carotid pulse volume reflects left ventricular stroke volume:
– increased with exercise, fever and arteriovenous fistula
– decreased with poor cardiac output (heart failure) and during
tachycardia
– variable in AF
– pulsus alternans in heart failure
– pulsus paradoxus in cardiac tamponade
• Carotid pulse character can be: – normal – slow-rising in severe AS – collapsing in severe AR – bisferiens in HOCM
Examination – Precordium Inspection
Inspection • Scars • Pacemaker • Chest wall deformity • Visible apex beat • Other visible pulsations
Examination – Precordium Palpation
Palpation • Apex beat • Left parasternal heave (RVH) • Thrills (palpable murmurs) Examination
Examination – Precordium Apex Beat
Apex Beat
• Assess location and character
• Causes of displaced apex beat:
– cardiomegaly
– dextrocardia
– mediastinal shift
• Causes of absent apex beat: – obesity – emphysema – pleural effusion – pericardial effusion
• Characters of apex beat: – normal – tapping (severe MS) – heaving (LV pressure overload = LVH) – thrusting (LV volume overload, e.g. MR and AR) – diffuse/dyskinetic (endstage heart failure)
Examination – Precordium Auscultation
Auscultation
• Always palpate the carotid pulse at the same time (for timing) • Listen to all 4 areas + axilla + neck + manoeuvres for MS/AR • Identify S1 and S2 first • Assess murmurs: – location and radiation – timing: systolic, diastolic, etc – intensity: grade out of 6
Examination – Precordium Auscultation – A Suggested Sequence
- Mitral area (with diaphragm)
- Axilla (with diaphgram)
- MS manoeuvre (with bell, turned to left, in expiration)
- Tricuspid area (with diaphragm)
- Pulmonary area (with diaphragm)
- Aortic area (with diaphragm)
- Neck, both sides (with bell or diaphragm)
- AR manoeuvre (with diaphragm, sitting forward, in expiration)
Examination – Precordium Heart sounds
- First heart sound (S1) = coincides with carotid upstroke
- Second heart sound (S2) = occurs after carotid upstroke
• Physiological splitting of second heart sound
– = normal splitting of S2 into aortic and pulmonary components
(A2 before P2)
– more split in inspiration and less split in expiration
– more obvious in young people
• Third and fourth heart sounds = diastolic sounds, occur with
raised LV end-diastolic pressure
Examination – Precordium Murmurs
Causes of PSM:
Causes of PSM: MR, TR, VSD
Murmurs Causes of ESM
Causes of ESM: AS, HOCM, PS, ASD
Murmurs Causes of EDM:
Causes of EDM: AR, PR
Murmurs Causes of LDM:
Causes of LDM: MS, TS
Examination – Remainder
• Back of chest
– basal fine inspiratory crackles
– sacral pitting oedema
- Peripheral pitting oedema
- Vein harvest scar(s)
- ± pulsatile liver (if severe TR thought to be present)
• Offer to do – peripheral pulses – BP (if not done already) – fundoscopy – urinalysis
History – Chest Pain Differential diagnoses
• Cardiovascular – coronary artery disease (myocardial ischaemia) – pericarditis – myocarditis – aortic dissection
• Gastrointestinal – oesophageal spasm – gastro-oesophageal reflux – peptic ulcer disease – cholecystitis – pancreatitis
• Pulmonary – pneumothorax – pneumonia – pulmonary embolism – lung cancer
• Musculo-skeletal – myalgia – fibromyalgia – costochondritis (Tietze’s syndrome) – neuropathic pain – bone pain
• Psychiatric
History – Breathlessness Differential diagnoses
• Cardiovascular – heart failure – valve disease – pericardial disease – pulmonary hypertension – (coronary artery disease) – (arrhythmia)
• Miscellaneous – severe anaemia – obesity – poor cardiovascular fitness – psychiatric
• Pulmonary – obstructive airways disease – interstitial lung disease – pleural disease – pneumothorax – pneumonia / tuberculosis – pulmonary embolism – pulmonary hypertension