Transcript 1-History Taking

Cardiac history and
examination
Dr. Bakir M. Bakir
Consultant Cardiac
Surgery
The five finger approach to
cardiac diagnosis
 The
cardiac history
 The cardiac physical exam
 Electrocardiogram
 Chest X-ray
 Cardiac diagnostic laboratory tests.
A good history should be both:
 Concise.
 Cover
the important points.
Rules:
1.
Patient should be allowed to tell his
history in his own words.
2.
Leading questions must be avoided
unless the information can’t be
obtained by other means
Questions:
1.
2.
3.
4.
Complete
the
inadequate
description.
Elucidate the vague points.
Fill in the gaps in the history not
mentioned by patient.
Emphasize the important points.
Types of questions:
1.
2.
3.
Neutral questions.
Simple direct questions (yes/No).
Leading questions.
Personal data:
Name.
 Age.
 Sex.
 Occupation.
 Residence.

The patients complaint:
A simple statement in the patients own
words and its duration.
Present History:
This means detailed history of the patients present
illness which must provide answer for the
following questions:
1. Duration
2. Mode of onset (acute, sub acute, chronic).
3. Sequence of events:
I. Course
(progressive,
regressive
or
recurrent).
II. Appearance of new additional symptoms or
disappearance of others.
III. Treatment received during the course &
response.
4. Analysis of each particular symptom.
Past History:
 Childhood
diseases.
 Trauma.
 Residences
or travel abroad.
 Drug therapy.
 Operations.
 Prior illness (cardiac, noncardiac).
 Recent dental work
 Prior cardiac procedure
Habits:
 Smoking.
 Physical
efforts.
 Addiction.
Family History:
 Hereditary
factor.
 Exposure to same etiological
circumstances.
Coronary artery disease risk
factors
 Cigarette
smoking
 Hypertension
 Hyperlipidemia
 Family history of CAD
 Diabetes mellitus
Symptoms of Cardiac
disorders:
1. Symptoms due to lung
congestion:
 Dyspnea.
 Acute
pulmonary edema.
 Cough, hemoptysis.
 Recurrent chest infections.
2. Symptoms due to systemic
congestion:
 Pain
in the right hypochondrium.
 Dyspepsia.
 Swelling of lower limb.
 Swelling of the abdomen.
 Oliguria.
3. Symptoms due to low cardiac
output:
(tissue hypoxia →brain, muscles,
kidneys)
 Exertional
fatigue.
 Blurring of vision.
 Dizziness / Syncope.
 Oliguria, Angina.
4. Chest pain:
Of Cardiac Origin:
Ischemia, pericarditis,
Aortic Aneurysm.
1.
2.





Dissecting
aorta,
Other Causes:
Chest wall
Neurological
Mediastinum
Diaphragm
Abdominal. ( esophagus, stomach, gall
bladder, pancreas).
Analysis:
1. Site & radiation.
2. Provocation & relief.
3. Duration.
4. Character.
5. Associated features.
Pearls regarding CAD
 Many
patients don’t have the classic
text book symptoms
 Angina doesn’t always mean
coronary artery disease.
 A high index of suspicion is
necessary to avoid missing the
diagnosis of acute aortic dissection.
 Not all patients with acute MI
develop ECG changes.
5. Symptoms due to changes in
rate, Rhythm, or force →
palpitation.
( time, mode of onset & offset, relation
to exertion, duration, irregularity).
6. Symptoms due to pressure on
surrounding structures.
( esophagus, bronchi , nerves, spine)
Cardiac physical examination
Basic concepts:
 Try to secure, if possible, a welllighted quiet room.
 Perform examination from the
patients right side.
 Find recorded vital signs (or do them
yourself-after all, they are vital.)
General Examination
1.
2.
3.
4.
5.
General appearance.
Vital signs: pulse, temp. Blood pressure,
respiration.
Hands: (cold, warm, clubbing, cyanosis,
sweating)
Eyes
Neck:
I. Neck veins.
II. Pulsations (arterial vs. venous).
III. Carotid arteries.
IV. Trachea, thyroid gland.
6.
7.
Lower Limbs ( signs of PVD, edema,
pulsations).
Abdomen: feel for palpable
hepatomegaly and check if it is
pulsatile (tricuspid regurge). Look
for ascites ,splenomegaly(IE), and
an aortic aneurysm.
Local Examination
1. Combined Inspection and
palpation:
1.
2.
3.
4.
5.
6.
7.
8.
Shape.
Cardiac impulses (apex beat, parasternal
pulsations, epigastric, to the right of
sternum, suprasternal notch, 2nd left
space)
Thrills.
Palpable heart sounds
Position of the mediastinum
Tactile vocal fremitus
Chest movements
Local tenderness,pulsations,wheezes.
2. Percussion
 Types
of percussion notes
 Apices of the lungs
 Anterior chest wall
 Lateral chest wall
 Posterior chest wall
 Cardiac and hepatic dullness
 Rules of percussion.
3. Auscultation:
Apex, lower end of sternum (tricuspid
area), aortic area and pulmonary
area .
 Murmurs:
1. Timing
2. Character
3. Point of maximum intensity and
propagation
4. Relation to respiration
5. Intensity
6. ± Thrill.
Auscultation
 The
first and second heart sounds
reflect valve closure.normally, valve
opening is not heard.
 S1 is the sound of closure of the
mitral and tricuspid valves at the
start of ventricular systole.
 S2 is the sound of closure of the
aortic and pulmonary valves at the
start of ventricular diastole.
 Breath
sounds.
 Adventitious
sounds.(rhonchi,crepitations,rub)
 Vocal resonance .