CVS History, Physical Exam & ECG: Master Clinical Assessment

CVS History, Physical Examination & ECG Notes --- PART 1: CVS HISTORY & PHYSICAL EXAMINATION --- CVS SYMPTOMS Chest Pain Cardiac chest pain is typically central/retrosternal, crushing or pressure-like, radiating to the left arm or jaw, associated with sweating and dyspnea. Relieved by nitrates (angina) or persisting 20 min (MI). Dyspnea Exertional dyspnea — earliest symptom of heart failure; graded by NYHA classification Orthopnoea — breathlessness on lying flat due to increased left atrial and pulmonary capillary pressure; requires extra pillows Paroxysmal nocturnal dyspnoea (PND) — sudden breathlessness waking patient from sleep due to frank pulmonary oedema; relieved by sitting/standing upright Fatigue and Palpitation Exertional fatigue common in heart disease Palpitations during exertion or emotion may indicate arrhythmia Rapid irregular palpitations → atrial fibrillation Rapid regular palpitations of abrupt onset → atrial, junctional, or ventricular tachyarrhythmias Dizziness and Syncope Cardiovascular syncope results from transient hypotension → cerebral hypoperfusion Little or no warning, rapid recovery (distinguishes from stroke, epilepsy, overdose) Vasovagal syncope — autonomic overactivity triggered by emotion, pain, coughing, micturition Postural hypotension — syncope on standing; inadequate baroreceptor-mediated vasoconstriction; common in elderly Carotid sinus hypersensitivity — exaggerated response to carotid sinus pressure → bradycardia, vasodilation, hypotension, LOC Valvular obstruction (aortic stenosis) — fixed obstruction prevents normal rise in cardiac output during exertion → cerebral hypoperfusion → syncope Atrial myxoma/thrombus obstructing mitral valve also causes syncope --- NYHA HEART FAILURE CLASSIFICATION Class Description ------- ------------- I No limitation; ordinary activity causes no symptoms II Slight limitation; ordinary activity causes symptoms III Marked limitation; less than ordinary activity causes symptoms; comfortable at rest IV Discomfort with any activity; symptoms present at rest Causes of Heart Failure (by pathophysiology): Restricted filling → mitral stenosis, constrictive pericarditis, restrictive/hypertrophic cardiomyopathy Pressure loading → hypertension, aortic stenosis, coarctation of aorta Volume loading → mitral/aortic regurgitation Contractile impairment → coronary artery disease, dilated cardiomyopathy, myocarditis Arrhythmia → severe brady- or tachycardia --- CVS INVESTIGATIONS ECG CXR Echocardiogram (ECHO) Cardiac enzymes (troponins) --- PHYSICAL EXAMINATION — ROUTINE Position patient at 45° 1. Wash hands, introduce yourself 2. Observe general appearance — comfortable, breathless, pale? 3. Inspect hands — clubbing, splinter haemorrhages, nicotine staining, pallor 4. Examine radial pulse — rate, rhythm, character 5. Measure blood pressure 6. Assess JVP height and waveform 7. Examine carotid pulse character 8. Inspect chest — scars, pulsations, deformities 9. Palpate praecordium — apex beat, heaves, thrills 10. Auscultate heart 11. Auscultate lungs 12. Examine ankles and sacrum for oedema 13. Examine peripheral pulses --- INSPECTION OF PATIENT Chest wall deformities (pectus excavatum) — may compress heart, displace apex Median sternotomy scar — previous CABG or cardiac valve surgery Superior vena cava obstruction — prominent venous collaterals on chest wall Pallor — anaemia may exacerbate angina and heart failure Cyanosis — blue discolouration of skin and mucous membranes from increased reduced haemoglobin Peripheral cyanosis — cutaneous vasoconstriction; affects skin and lips Central cyanosis — reduced arterial O₂ saturation from cardiac or pulmonary disease; affects skin and mucous membranes of mouth --- HANDS & PERIPHERAL SIGNS Clubbing of fingers and toes — enlargement of fingertips with downward sloping of nails; loss of Schamroth's diamond sign Causes (mnemonic CLUBBING ): C — Cyanotic heart disease, Cystic fibrosis L — Lung cancer, Lung abscess U — Ulcerative colitis B — Bronchiectasis B — Benign mesothelioma I — Infective endocarditis, Idiopathic pulmonary fibrosis N — Neurogenic tumours G — Gastrointestinal disease Signs of Infective Endocarditis: Splinter haemorrhages (nails) Osler's nodes (painful, fingertips) Janeway lesions (painless, palms/soles) Roth spots (retinal haemorrhages) Conjunctival haemorrhages Hematuria Other: fever, splenomegaly, murmurs, cardiac arrhythmias, signs of CHF --- ARTERIAL PULSE Rate and Rhythm Assessed at right radial pulse Rate = beats in 15 sec × 4 Normal sinus rhythm is regular (young patients may have sinus arrhythmia with respiration) Irregular rhythm → atrial fibrillation, ectopic beats, paroxysmal arrhythmias Character (best assessed at carotid artery) Pulse volume reflects stroke volume — small in heart failure, large in aortic regurgitation Waveform patterns: Normal Waterhammer (collapsing) — aortic regurgitation Slow-rising — aortic stenosis Pulsus bisferiens — aortic stenosis + regurgitation, HOCM Pulsu