Color Atlas of Cardiology: Challenging Cases Majid Maleki, Azin Alizadehasl
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History and Physical Examination of the HeartChapter 1

Majid Maleki
 
HISTORY
A complete cardiovascular physical examination needs a detailed cardiac examination. We must guess what physical examination findings are predicted by taking good present and past medical history.
The most common symptoms that should usually be asked are as follows:
  • Dyspnea
  • Palpitation
  • Easy fatiguability
  • Chest pain
  • Cyanosis
  • Edema
  • Hemoptysis
  • Vertigo
  • Syncope
  • General nonspecific symptoms
  • It is recommended to consider the quality, quantity, timing, location, associated symptoms and precipitating factors of each symptom.
For example regarding chest pain, it should be asked the location of the pain, its radiation, describing the pain, such as burning, stabbing and accompanying symptoms, such as shortness of breath, palpitation and so on.
Or when you are taking history from a patient with cyanosis, it must be asked:
  • How long has been the duration of cyanosis?
  • Is it sudden or gradual?
  • Is it congenital or family type? (Figure 1)
  • And about accompanied symptoms.2
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Figure 1: Micrognathia in a patient with congenital heart disease
 
PHYSICAL EXAMINATION
In spite of advanced technology in recent years in cardiovascular medicine, history taking and physical examination remain an important tool for general cardiologist, electrophysiologist, interventionist and echocardiologist.
In summary, cardiac examination includes inspection, palpation and auscultation. You have to inspect jugular venous pulse (JVP) and point of maximal impulse. You also have to note to chest deformity, such as pectus excavatum or carinatum (Figures 2 and 3).
 
General Inspection
Simple inspection can conclude different cardiac conditions.
How does the patient look? Unwell, ill, cyanotic, pallor, sweatiness, cachectic, jaundice, ascites, edema….
Physical appearances can lead to awareness of certain cardiac pathologies
It is also important to look at patient face, and teeth3
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Figure 2: Intercostals retraction in a child with congestive heart failure
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Figures 3A to C: (A and B) Chest deformity and (C) bulging of left hemithorax in a patient with severe right ventricular enlargement
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It must be remembered that there are many cardiac manifestations associated with different genetic abnormalities, such as:
  • Down syndrome: Atrioventricular septal defect
  • Turner's syndrome: coarctation of the aorta
  • Ankylosing spondilitis: Aortic regurgitation
  • Marfan syndrome: Aortic regurgitation, aortic dissection, bicuspid aortic valve
Cardiac conditions can be diagnosed by noting facial signs too.
  • Malar flush, redness around the cheeks (mitral stenosis)
  • Yellow deposit of lipids at palms or around the eyes (xanthoma)
  • Ring around the cornea (hyperlipidemia corneal arcus)
  • Projection of the eyeball (Graves’ disease, atrial fibrillation)
JVP can guide to guess the central venous pressure (CVP). It also gives you a view of probable cardiac abnormalities by looking at different parts of JVP, such as a,c,v,x and y wave. Many cardiac conditions, such as normal sinus rhythm, atrial fibrillation, ventricular tachycardia, complete heart block can be inferred. Also several cardiac abnormalities, such as tricuspid regurgitation, tricuspid stenosis, right ventricular dysfunction, cardiac tamponade and constrictive pericorditis, can be diagnosed by noting at JVP.
 
Jugular Venous Pulse (Figure 4)
  • Is it up or down?
  • Differential diagnosis of right sided heart failure, pulmonary emboli, acute dyspnea from pulmonary disease.
  • Large a wave in tricuspid stenosis, pulmonary stenosis, pulmonary hypertension
  • Absent a in atrial fibrillation
  • Canon a wave in complete heart block, VVI pace
  • Steep x and y descent in constrictive pericarditis
  • Large cv wave in tricuspid regurgitation
  • Kussmual's sign: increased JVP on inspiration in constrictive pericarditis.
 
Palpation
Point of maximal impulse (PMI), all kinds of lift and heave, accentuated heart sounds and pulse can be palpated and several cardiac abnormality can be diagnosed.
Place your left hand over the chest to feel the heave (right ventricular hypertrophy) or thrill (Aortic stenosis, ventricular septal defect) (Figure 5).
 
Pulse
One of the simplest and informative part of physical examation is taking the pulse. At the same time you can look for any abnormalities, such as clubbing fingers and peripheral signs of inflective endocarditis, such as Osler nodes, splinter hemorragia, etc. (Figures 6 to 8).5
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Figure 4: Elevated jugular venous pressure in dilated cardiomypathy in a patient with heroin addiction
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Figure 5: How to palpate the chest pain for heave, lift, thrill etc.
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Figure 6: Clubbing fingers due to bacterial endocarditis
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Figure 7: Clubbing fingers in complex cyanotic congenital heart disease
You must consider the following points with pulse taking:
  • Rate and rhythm of the pulse
  • The character and volume
  • Check for unequal volume of radial and femoral pulse (coarctation of aorta, Takayasu's disease)
  • Check both radial simultaneously (aorta dissection, anomalous origin of subclavian artery, atherosclerosis…)7
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    Figure 8: Severe cachexia in advanced heart failure
  • Peripheral pulse should be checked for probable peripheral vascular disease, such as femoral, popliteal, posterior tibial and dorsalis pedis
  • Peripheral vascular disease is an important predictor of coronary artery disease.
 
Point of Maximal Impulse
The PMI in usually palpable. It is related to left ventricular (LV) contraction. The PMI is usually located at the 5th or 6th intercostals space in midclavicular line. In 25% of normal people you cannot palpate PMI.
The PMI duration is short and if it persists it may be sign of LV failure or left ventricular hypertrophy. Lift or heave means intense PMI.
 
Auscultation
There are many physiologic and abnormal conditions which can make noises in the heart.
Physiologic phenomenon, such as pregnancy and noncardiac conditions, such as anemia, hyperthyroidism and atriovenous fistula can make murmurs due to increased flow across normal heart valves.
Any kind of abnormal valve closing or insufficiency, such as mitral, tricuspid (S1) aortic and pulmonic (S2) can produce abnormal sounds and murmurs, including abrupt halt of LV with consequent third and fourth heart sounds.8
I recommend to listen to the heart from the point with the least intensity of the heart sounds, i.e. lower right sternal border and then to come up inch by inch until you reach to the apex with usually the highest intensity. When you describe auscultation features it is noteworthy to report it as following:
  • First heart sound characteristics (S1)
  • Second heart sound (S2)
  • Third and fourth heard sounds (S3, S4)
  • Abnormal and additional heart sounds, such as opening snap (mitral stenosis), pericardial sound (constrictive pericarditis), tumor plop (atrial myxoma) pacemaker sound and ejection or nonejection click
  • Normal or abnormal prosthetic valve sounds, such as metallic sounds, opening or closing click
  • Physiologic or abnormal murmur, including location, radiation, timing, intensity features of heart sounds.
 
Features of Heart Sounds
S1, starts at the beginning of systole and its loudest location is at the apex or left sternal border (LSB). It is the result of closure of atrioventricular valves.
It is important during heart sounds listening note their volume if it is normal, increased or diminished. Also splitting whether physiologic or abnormal should be reported (Tables 1 and 2)
Table 1   Heart sounds in different cardiac conditions
Sounds
Loud
Soft
Splitting
S1
Mitral stenosis
Mitral regurgitation
S2
A2
Hypertension
Aortic regurgitation Calcified Aortic Valve
Inspiration RBBB
P2
Pulmonary hypertension
PS/TF
ASD (fixed) PS
S3
Normal in children MR, TR, LV failure, RV failure
S4
Hypertension, myocardial infarction, AS, HOCM Aortic stenosis, heart block
Opening snap
Mitral stenosis
Tricuspid stenosis
Systolic click
AS, PS, MVP
ASD, atrial septal defect; HOCM, hypertrophic obstructive cardiomyopathy; LV left ventricular; MR, mitral regurgitation; PS, rulmonic stenosis; RBBB, right bundle branch block; RV, right ventricular; AS aortic stenosis; TF, tetralogy of Fallot; TR, tricuspid regurgitation
9
Table 2   Cause of heart murmur and timing
Timing
Cause of murmur
Early systole
Acute MR, VSD, TR
Mid systole
AS (supravalvular and subvalvular)
PS (supravalvular and subvalvular)
ASD, dilated PA
Late systole
MVP, TVP
Holo systole
MR, TR, VSD
Early diastolic
AI, PI
Mid diastolic
MS, TS, MR, VSD
Late diastolic
Presystolic accentuation of MS Austin flint
Continuous
PDA, AV fistula, ruptured sinus of Valsalva, venous hum, ASD, coronary artery stenosis
AS, aortic stenosis; ASD, atrial septal defect; MR, mitral regurgitation; MVP, mitral valve prolapse; PDA, patent ductus arteriosus; PS pulmonic stenosis; TR, tricuspid regurgitation; TVP, tricuspid valve prolapse; VSD, ventricular septal defect
BIBLIOGRAPHY
  1. Advantage of a new specific activity scale. Circulation. 1981;64:1227.
  1. Braunwald E, Perlof JK. Physical examination of the heart and circulation. Tenth edition; 2015.
  1. David T, Linker, (Editor) 1. Practical echocardiography of congenital heart disease; 2001.
  1. HURST, JW, Morris PC. The history, symptoms and past events related to cardiovascular disease. The heart lathed. Newyork. MC Graw-Hill;  2001.