CVS History & Physical Exam: Symptoms, Chest OmpathStudy

CVS History Taking & Physical Examination 1. CARDIAC SYMPTOMS Chest pain Acute, severe → myocardial ischaemia, pericarditis, aortic dissection, PE (most common causes) Chronic, recurrent → angina, oesophageal reflux, musculoskeletal pain Myocardial ischaemia — imbalance between myocardial O2 supply and demand → angina Pericarditis — central, sharp, worse on deep inspiration/cough/postural change, worse lying flat, better sitting forward Aortic dissection — severe tearing pain, front or back of chest, abrupt onset (unlike crescendo ischaemic pain) Pulmonary embolism — peripheral PE: sudden sharp pleuritic pain + breathlessness + haemoptysis; major/central PE: breathlessness + chest pain that mimics ischaemic pain + syncope Dyspnoea — abnormal awareness of breathing at rest or unexpectedly low exertion; major symptom of left heart failure Causes of heart failure (by mechanism) Mechanism Examples --- --- Restricted filling Mitral stenosis, constrictive pericarditis, restrictive cardiomyopathy, hypertrophic cardiomyopathy Pressure loading Hypertension, aortic stenosis, coarctation of the aorta Volume loading Mitral regurgitation, aortic regurgitation Contractile impairment Coronary artery disease, dilated cardiomyopathy, myocarditis Arrhythmia Severe bradycardia, severe tachycardia Orthopnoea — lying flat → steep rise in left atrial/pulmonary capillary pressure → pulmonary congestion + severe dyspnoea; relieved by pillows or sleeping upright in a chair Paroxysmal nocturnal dyspnoea (PND) — sudden breathlessness during sleep, waking the patient gasping; caused by frank pulmonary oedema; relieved by standing (gravitational pooling lowers left atrial/pulmonary capillary pressure); patient often seeks air at an open window Fatigue and palpitations Fatigue — typically exertional in heart disease Palpitations — common with exertion/emotion; may indicate abnormal rhythm Rapid irregular palpitations → atrial fibrillation Rapid regular , abrupt-onset palpitations → atrial, junctional, or ventricular tachyarrhythmias Dizziness and syncope Due to transient hypotension → abrupt cerebral hypoperfusion Usually brief lightheadedness or no warning at all before syncope Recovery is rapid (unlike stroke, epilepsy, overdose) Causes: Postural hypotension — syncope on standing; inadequate baroreceptor-mediated vasoconstriction; common in elderly Vasovagal syncope — autonomic overactivity from emotional/painful stimuli, or cough ("cough syncope")/micturition ("micturition syncope") Carotid sinus hypersensitivity — exaggerated response to carotid sinus pressure → bradycardia, vasodilation, hypotension, possible loss of consciousness Valvular obstruction — fixed aortic stenosis prevents normal rise in cardiac output on exertion → abrupt BP/cerebral perfusion drop → syncope; vasodilator therapy can cause similar syncope; left atrial myxoma/thrombus can intermittently obstruct the mitral valve Stokes-Adams attacks — periodic fainting from intermittent complete heart block/high-grade arrhythmia → loss of spontaneous circulation and cerebral blood flow --- 2. PHYSICAL EXAMINATION Full examination routine (standard sequence) 1. Wash hands; introduce yourself; recline patient at 45° 2. Observe general appearance — comfortable, breathless, pale? 3. Inspect hands — clubbing, splinter haemorrhages, nicotine staining 4. Examine radial pulse(s) — symmetry, rate, rhythm, character (collapsing?) 5. Measure blood pressure 6. Assess height and waveform of JVP 7. Examine carotid pulse — character (slow-rising?) and volume (Corrigan's sign?) 8. Inspect face, eyes, mucous membranes — xanthelasma, corneal arcus, anaemia, cyanosis 9. Inspect chest — scars, pulsations 10. Assess position and character of apex beat 11. Palpate praecordium — heaves and thrills 12. Auscultate the heart 13. Auscultate the lungs 14. Examine ankles and sacrum for oedema 15. Examine peripheral pulses Inspection findings Pectus excavatum — may compress heart, displace apex Median sternotomy scar — prior CABG and/or valve surgery Prominent venous collaterals on chest wall — SVC obstruction Pallor — anaemia may worsen angina and heart failure Cyanosis Peripheral — vasoconstriction slows blood flow, ↑ O2 extraction in skin/lips Central — reduced arterial O2 saturation from cardiac/pulmonary disease; affects skin AND oral mucous membranes Clubbing — enlargement of fingertips + downward sloping of nails; check with Schamroth sign (loss of diamond-shaped window when opposing nails placed together) Other general signs Cold extremities → reduced cardiac output in heart failure Pyrexia → consider infective endocarditis Pitting oedema → cardinal feature of CCF; press over bony prominence (tibia, lateral malleoli, sacrum) for effective compression Arterial pulse Rate and rhythm — palpate right radial pulse; rate = beats counted over 15 sec × 4 Normal sinus rhythm is regular; young patients may show sinus arrhythmia (phasic variation with respiration) Irregular rhythm → usually AF; also freq