CVS History, Physical Examination & ECG Notes --- PART 1: CVS HISTORY & PHYSICAL EXAMINATION --- CVS SYMPTOMS Chest Pain Cardiac chest pain is typically central
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 - Pulsus alternans — myocardial failure (alternating strong and weak beats) --- BLOOD PRESSURE MEASUREMENT - Patient resting, seated, empty bladder, no caffeine/smoking/exercise 30 min prior - Use validated upper-arm electronic device - Cuff: inflatable bladder ~80–100% arm circumference; lower edge 2–3 cm above elbow crease - Arm supported at heart level, legs uncrossed - For auscultation: inflate to 30 mmHg above point radial pulse disappears; deflate ~2 mmHg/heartbeat - Record to nearest 2 mmHg --- JUGULAR VENOUS PULSE (JVP) Distinguishing JVP from Carotid Pulse — "POLICE": - P — Palpation: JVP non-palpable - O — Occlusion: JVP readily occludable - L — Location: between heads of SCM; lateral to carotid - I — Inspiration: JVP drops with inspiration - C — Contour: biphasic waveform - E — Erection/Position: drops when sitting erect JVP Measurement: - Sternal angle (angle of Louis) is ~5 cm from centre of RA, constant regardless of position — reference point - Patient reclined at 30–90°, relaxed neck muscles - Measure vertical distance from sternal angle to top of venous column; add 5 cm - Normal JVP ≤7 mmHg (≤9 cm of JVP) - 1.3 cm of water = 1 mmHg Causes of Elevated JVP: Congestive heart failure, cor pulmonale, pulmonary embolism, RV infarction, tricuspid valve disease, tamponade, constrictive pericarditis, hypertrophic/restrictive cardiomyopathy, SVC obstruction, iatrogenic fluid overload --- PALPATION OF CHEST WALL Apex Beat — lowest and most lateral point where cardiac impulse is palpable - Normal: 5th intercostal space, midclavicular line - Displaced inferiorly/laterally → cardiac enlargement - Right ventricular enlargement → systolic thrust (heave) in left parasternal area --- AUSCULTATION OF THE HEART Areas: Apex (mitral), lower left sternal edge (tricuspid), upper left sternal edge (pulmonary), upper right sternal edge (aortic) - 1st heart sound (S1) — mitral and tricuspid valve closure at onset of systole - 2nd heart sound (S2) — aortic and pulmonary valve closure following ventricular ejection Routine for Auscultation: 1. Auscultate apex with diaphragm 2. Reposition patient to left side — listen with diaphragm (mitral regurgitation) then bell (mitral stenosis) 3. Return to 45°, auscultate lower left sternal edge (tricuspid regurgitation/stenosis, VSD) 4. Upper left sternal edge (pulmonary stenosis/regurgitation, PDA) 5. Upper right sternal edge (aortic stenosis, HOCM) 6. Sit forward — lower left sternal edge with diaphragm in held expiration (aortic regurgitation) 7. Carotid arteries (radiation of murmur, bruits) --- PART 2: ECG --- BASICS OF ECG What is the ECG? A recording of the heart's electrical activity. Cardiac cells at rest are electrically polarised (inside electronegative relative to outside), maintained by ion pumps (Na⁺, K⁺, Ca²⁺, Cl⁻). Depolarization = electrical activation; influx of Na⁺ and Ca²⁺ causes contraction Depo