History taking and Physical examination to diagnose heart diseases

1. Leonardo Paskah Suciadi, MD
Cardiology & Vascular Medicine-Universitas Padjadjaran-
Bandung, Indonesia

2.  Clues from INSPECTION :
◦ General appearance; skin, face, eyes, edema,
extremities, chest, and abdomen; in correlation
with heart diseases
◦ Jugular veins pulsation
◦ precordial
 Clues from PALPATION:
◦ Arterial pulse
◦ Precordial – apical movement
 Clues from AUSCULTATION :
◦ Blood pressure
◦ Breath sounds
◦ heart sounds & heart murmurs

3.  Posture:
◦ Orthopnoe
◦ Distressed and leaning forward with shallow
breathing  acute pericarditis
◦ Cachexia  advanced HF
◦ Very obese + rather somnolent  Pickwickian synd
◦ Hoarseness  chronic MS, hypothyroidism
◦ Levine’s sign of angina
◦ ‘Coronary-prone’ profile

4.  ‘Coronary-prone’ physical profile + type A
personality

5.  Levine’s sign

8. Face :
◦ the facies of William’s syndrome; Down’s syndrome;
Moon face of Cushing syndrome; myxedema
◦ de Musset’s sign of severe AR (‘YES-YES’ sign)
◦ Malar rash vs butterfly rash
◦ Xanthelasma
◦ Diagonal earlobe crease (usually bilateral)

10. * eyes : jaundice, anemic, exopthalmos ,roth spots,
blue sclera
* Pitting oedema : bilateral vs unilateral vs
anasarca
* Chest-Lungs:
- respiration pattern: Kussmaul vs rapid-shallow
breathing vs prolonged
expiration; Cheyne-stokes respiration
(CSA), orthopnoe, accessory respiratory
muscles work, etc
- auscultation: bibasilar late inspiratory rales?
wheezing?, etc

11.  JVP is related to body position & respiration
 Measure JVP indirectly:
◦ Use right internal jugular vein
◦ 30’-45’ position
◦ Patient’s head looks to the left side
◦ Not too bright room lighting
◦ Maneuver : tangential lighting or cross viewing
◦ Find the top level of pulsation at inspiration
◦ Measurement in cm with angulus sterni of Louis as
the zero point
difficulties: position, respiration, distinguish from
carotid beat
* Compare to abdomino-jugular reflux

14.  Jugular vein pulsation:

15.  AbN jugular vein pulsation or pressure:
◦ Elevated JVP – abdominojugular reflux
◦ Kussmaul’s sign
◦ Prominent A wave; intermitten cannon A wave
◦ Prominent V wave  characteristic of TR 
+earlobes dancing or head shaking

16.  Measuring technique  related to accuracy
- Patient position and condition
- Manometer and manset
- Inflation and deflation technique
# KOROTKOFF sounds:
- K.1 = tapping
- K.2 = beating
- K.3 = back to tapping
- K.4 = muffling
- K.5 = diminihed sound
Blood pressure = K.1/K.5 mmHg (or K.1/K.4/K.5)
 Central arterial blood pressure accurate?

17.  Palpate for rate, rhythm, amplitude,
configuration.
 Clues from peripheral (radial/femoral) palpation:
◦ Pulsus alternans (+S3, +abdominojugular reflux)
◦ Pulsus paradoxus (misnomer)
◦ Pulsus deficit
 Clues from carotid palpation:
◦ Pulsus corrigan/ water-hammer/seller : brisk rapid-rising
◦ Pulsus parvus et tardus : small, slow-rising, late peaking
◦ Small and weak pulse
◦ Pulsus bisferiens
◦ Pulsus dicrotic
 Radio/brachio-femoral delay

18.  Inspection & palpation
 Normal apical impulse:
 1 inch in diameter; ICS V (s)-line
midclavicularis (s); at early systole
 AbN apical impulse findings:
◦ Diffuse & weak apical impulse
◦ Displacement to the left & downward
◦ LV tapping
◦ LV heaving (over pressure)
◦ LV thrusting (over volume)
◦ Palpable thrill related to murmurs

19.  Position of patients ; semi-supine, LLD, upright
leaning forward  to inhance hearing of some
heart sounds or murmurs
 Auscultatory area on the chest *(pic)
 Use diaphragm or bell ?
 Quality of stethoscope –circumstances-patients
 Other maneuvers;
◦ clenching fists left sided
◦ deep inhalation Right sided
◦ Full exhalation  AR, pericardial friction rubs
◦ valsalva, nitrate, standing  HOCM, MVP

21.  S1 (M1T1); S2 (A2P2)
 normal heard;
Accentuated, attenuated in some conditions
 systolic time = S1 to S2; diastolic= S2 to S1
 Additional sounds:
# Systolic : - Ejection sound  structural /functional
- midsystolic click  MVP
# Diastolic: - S3 (ventricular gallop)  CHF
- S4 (atrial gallop)  HHD, MCI
- OS  MS mild-moderate; flexible in
timing
 Splitting of S2; physiologic-wided-fixed
 Pericardial knock

24.  Caused by turbulent blood flow
 Assess :
◦ Timing (systolic or diastolic)
◦ Configuraton ( decressendo, cressendo, diamond shape,
holo, continuous)
◦ PM and referral points (left axilla, clavicle, carotid)
◦ Amplitude : systolic (1-6), diastolic (1-4); with thrill or
not
◦ Pitched/frequency  diaphragm or bell of stethoscope
◦ Manuever: position, valsava, nitrat, inspiration
(Carvallo’s sign), clenched hands
 Physiologic heart murmur = systolic murmur,
midsystolic (not holosystolic), 1/6 or 2/6, with
normal heart sounds

25.  Systolic heart murmurs:
◦ Midsystolic murmur : AS, PS, ASD, hyperdynamic
Late systolic murmur : MVP with AR
Holosystolic murmur : MR, TR, VSD
 Diastolic heart murmur
◦ early decressendo murmur: AR, PR (in PH)
◦ Mid-diastolic & late diastolic murmur: MS
 To and fro murmur : AS with AR
 Continuous murmur: PDA
 Pericardial friction rub : acute pericarditis

27. THANK.YOU