This document provides guidance on evaluating patients with cardiovascular disease. It outlines how to take a thorough history, examine the patient, and identify relevant investigations. Key aspects of history taking include presenting complaint, review of symptoms, past medical history, and family history. The examination involves inspection for signs like cyanosis, palpation of pulses and precordium, and auscultation of heart sounds. Common symptoms like chest pain, dyspnea, palpitations, and edema are described. Relevant investigations include ECG, echocardiogram, chest X-ray, and cardiac enzymes.

1. Approach to patient with
cardiovascular disease.
HANNAH MUWANGUZI
SOROTI UNIVERSITY
MBCHB III
1901600073
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2. objectives
 To be able to obtain adequate history from a cardiac patient right from the
presenting complaint to the social and occupational history.
 To be able to understand common presenting complaints in a CVS patient
 To be able to examine a cardiovascular patient
 To be able to know the investigations relevant to cardiovascular conditions
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3. HISTORY TAKING IN CVS PATIENT
 PRESENTING COMPLAINT
 HISTORY OF PRESENTING COMPLAINT
 REVIEW OF OTHER SYSTEMS
 PAST MEDICAL HISTORY
 PAST SURGICAL HISTORY
 FAMILY HISTORY
 SOCIAL AND OCCUPATIONAL HISTORY
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4. CONT.
 Patients may present with any of the following signs or symptoms and any related
information about the signs or symptoms must be exploited thoroughly to be able to
come up with the right diagnosis.
• Dyspnea
• cough
• Chest pain
• Palpitations
• Hemoptysis
• Syncope
• Edema
• Cyanosis
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5. Chest pain
 Its an important symptom of a cardiac disease especially in ischemic heart disease.
However chest pain of cardiac origin has to be differentiated from that of non
cardiac origin.
 It can be acute or chronic
Conditions that cause acute severe chest pain
 Myocardial ischemia. This often results due to imbalance between myocardial
oxygen supply and demand, producing pain called angina. The pain is retrosternal
and squeezing in nature aggravated by exertion and relieved by rest. Often
radiating to the left neck, jaw, upper arm
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6. Cont.
 Pericarditis. This causes central chest pain, sharp in nature and aggravated by deep
inspiration, cough and postural changes.
 Aortic dissection. Tearing pain which may be of sudden onset. The pain extends along
great arteries as the dissection extends into them even to the lower limbs.
 Peripheral pulmonary embolism causes sudden-onset of sharp, pleuritic chest pain,
breathlessness and hemoptysis. Majorly, central pulmonary embolism presents with
breathlessness and chest pain that can be indistinguishable from ischemic chest pains
and syncope.
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7. Cont.
Chronic, recurrent chest pain is usually caused by;
 Angina
 esophageal reflux or musculoskeletal pain.
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8. Dyspnea ( breathlessness)
Definition
 Abnormal awareness of breathing which can occur at rest or during exertion. It is a
major symptom of many cardiac disorders, particularly left heart failure
 In acute pulmonary edema and orthopnea, dyspnea is due mainly to the elevated
left atrial pressure that characterizes left heart failure
Exertional dyspnea
 Exertional dyspnea is the most troublesome symptom in heart failure.
 Exercise causes a sharp increase in left atrial pressure and this contributes to the
pathogenesis of dyspnea by causing pulmonary congestion
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9. Cont.
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10. Cont.
Paroxysmal Nocturnal Dyspnea
 Frank pulmonary edema on lying flat wakes the patient from sleep with
distressing dyspnea and fear of imminent death.
 The symptoms are corrected by standing upright, which allows gravitational
pooling of blood to lower the left atrial and pulmonary capillary pressure, the
patient often feeling the need to obtain air at an open window.
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11. Cont
Mechanism of PND
When the patient assumes recumbency, the increase in venous return from the lower
limbs combined with the reabsorption of edema fluid leads to increased central blood
volume. In the failing heart, the left sided chambers cannot cope up with this
increased inflow and this leads to pulmonary congestion. This manifest with cough,
shortness of breath and frothy sputum.
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12. Cont.
Orthopnea
 In patients with heart failure, lying flat causes a steep rise in left atrial and
pulmonary capillary pressure, resulting in pulmonary congestion and severe
dyspnea.
 To obtain uninterrupted sleep, extra pillows are required, and in advanced disease,
the patient may choose to sleep sitting in a chair
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13. Fatigue
 Exertional fatigue is an important symptom of heart failure and is particularly
troublesome towards the end of the day.
 Its aetiology is complex, but it is caused partly by deconditioning and muscular
atrophy.
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14. Palpitations
 Awareness of the heartbeat is common during exertion or heightened emotions.
 A description of the rate and rhythm of the palpitation is essential as are
exacerbating behaviors, such as exercise or caffeine intake.
 Rapid irregular palpitation is typical of atrial fibrillation. Rapid regular palpitation
of abrupt onset occurs in atrial, junctional and ventricular tachyarrhythmias.
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15. Dizziness and syncope
 Cardiovascular disorders produce dizziness and syncope by transient hypotension,
resulting in abrupt cerebral hypoperfusion.
 For this reason, patients who experience cardiac syncope usually describe either
brief lightheadedness or no warning symptoms at all prior to their syncopal
attacks.
 Recovery is usually rapid, unlike with other common causes of syncope(e.g. stroke,
epilepsy, overdose)
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18. HISTORY TAKING CONT.
 PAST MEDICAL HISTORY
• Any history of chronic illness
• Drug history is important because some drugs are potentially cardiotoxic. β-
blockers and some calcium channel blockers (diltiazem, verapamil), for example,
can cause symptomatic bradycardias, and tricyclic antidepressants and β-agonists
can cause tachyarrhythmias.
• Vasodilators cause variable reductions in blood pressure, which can lead to
syncopal attacks, particularly in patients with aortic stenosis
• The myocardial toxicity of certain cytotoxic drugs (notably doxorubicin and related
compounds) is an important cause of cardiomyopathy
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19. Cont.
 FAMILY HISTORY
• The family history should always be documented because coronary artery disease
and hypertension often run in families, as do some of the less common
cardiovascular disorders, such as hypertrophic cardiomyopathy.
• Indeed, in patients with hypertrophic cardiomyopathy, a family history of sudden
death is probably the single most important indicator of risk.
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20.  SOCIAL AND OCCUPATIONAL HISTORY
• Smoking is a major risk factor for coronary artery disease. Alcohol abuse
predisposes to cardiac arrhythmias and cardiomyopathy.
• The cardiac history should quantify both habits in terms of pack-years smoked
and units of alcohol consumed.
• The use of other recreational drugs (in particular cocaine) can be associated with
acute presentations of chest pain, and intravenous drug use is an increasingly
important cause of infective endocarditis
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21. Cardiac examination.
 Modalities include;
 Inspection
 Examination of the radial pulse
 Measuring of the blood pressure and the heart rate
 Examination of the neck ( for carotid and jugular vein pressure)
 Palpation of anterior chest wall
 Auscultation of heart
 Percussion
 Examination of peripheral pulse, auscultation of carotid and femoral bruits
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23. Inspection.
 Common signs to be inspected in a cardiac patient include;
 Pectus excavatum
 Anemia
 Cyanosis
 Clubbing of fingers
 Coldness of extremities
 Pyrexia
 edema
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24. Pectus excavatum.
 This is a condition in which a persons breastbone is sunken into his or her chest
which can interfere with the functions of the heart and the lungs.
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25. Illustration.
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26. Anemia.
 Pallor is best seen in the mucous membranes of the palpebral conjunctiva, lips
and tongue and the palms
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27. Illustration.
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28. Cyanosis.
 This is the bluish discoloration of the skin and mucous membranes caused by
increased concentration of reduced hemoglobin above 5g/dL
 Central cyanosis may result from the reduced arterial oxygen saturation caused by
cardiac or pulmonary disease like pulmonary edema and congenital heart
disease- tetralogy of fallot.
 Peripheral cyanosis may result when cutaneous vasoconstriction slows down the
blood flow and increases oxygen extraction in the skins and the lips. It is also
physiological during cold exposure. It also occurs in heart failure when reduced
cardiac output produces reflex cutaneous vasoconstriction.
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29. Clubbing.
 This is the painless soft tissue swelling of the terminal phalanges.
 Common in congenital cyanotic heart disease and infective endocarditis.
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30. Illustration.
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32. Edema.
 It’s a tissue swelling due to an increased interstitial fluid
 Pressure should be applied over a bony prominence( tibial, sacrum or medial
malleoli)
 It’s a cardinal feature of congestive heart failure
 Its most prominent around the ankles in the ambulant patient and over the
sacrum in the bedridden patient
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33. Arterial pulse.
 This consists of rate, rhythm, character and symmetry.
 Rate and rhythm. This is measured in b/min. or it can be counted for 15 second then multiplied
by 4. normal sinus rhythm should be regular.
 Character of the pulse. this is the volume and wave form of the pulse and should be evaluated
at right carotid artery( pulse closest to heart and least subject to damping and distortion in
arterial tree.
 Symmetry. Symmetry of radial, brachial, carotid, femoral, popliteal should all be confirmed.
Reduced or absent pulse means obstruction proximally in arterial tree caused by arthrosclerosis
or thromboembolism.
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34. Measuring blood pressure.
 This is done using sphygmomanometer.
 Listen for the Korotkoff sound.
 Accurate BP measuring requires the patient sitting or lying
 Significant changes in BP occurs with exertion, anxiety,
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35. Measuring JVP.
 fluctuations in right atrial pressure during cardiac cycle generate a pulse that is transmit
backwards in to jugular vein
 Estimated with patient reclined at 45
 JVP should be assessed from wave form of IJV which lies adjacent to medial boarder of SCM
muscle
 JVP is measured in cm vertically from sternal angle to the top of venous wave form
 Normal upper limit is 4 cm approximately 9cm above RT atrium and 6mmHg
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36. Palpation of the precordium.
 The patient lies in a supine position or should be inclined at an angle 45 in bed.
 In precordium palpation, look for;
 The apex beat
 Palpable sounds
 Presence of thrills
 Precordial pulsation
 Left parasternal heave
 Right parasternal pulsations
 Pulsation in the second and third intercostal space.
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37. Auscultation of heart
 Heart Sound I corresponds to mitral and tricuspid pulmonary valve ; valve closure
at onset of systole
 Heart Sound II corresponds to aortic and pulmonary valves closure following
ventricular ejection
 3rd & 4th Heart Sounds :These sounds are best heard with stethoscope at cardiac
apex. They are caused by abrupt tensing of ventricular walls following diastolic
filling
-Rapid filling in early diastole gives s3
-Late filling in diastole due to atrial contractions give s4
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38. Con’t.
HEART MURMERS
 Caused by turbulent flow within the heart and great vessels
 Increase flow through normal valve occasionally causes murmurs
 -RHD also causes murmurs in undeveloped countries
SYSTOLIC CLICK AND PENING SNAP
 situation in which valve opening produces a click in early systole producing
ejection murmurs
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39. Investigations in cardiology.
 ECG- used to asses cardiac rhythm and conduction
-exercise ECG
- Ambulatory ECG
 Echocardiography (ECHO)
-Transthoracic ECHO -Evaluation of cardiac structure and function
-Doppler ECHO- provides information about blood flow
 chest x-ray-determining size and shape of the heart, and the state of the pulmonary blood
vessels and lung fields
 Cardiac markers-BNP
 Cardiac enzymes like creatinine phosphokinase, troponins to rule out myocardial infarction.
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40. References.
 Michael G. and William MD.(2018). Hutchinson's Clinical methods. An integrated
approach to clinical practice.Ed. 24th.Elsevier limited. London.
 Brian R.Et all(2022). Davidson's Principles and practice of medicine.Ed.24th. Elsevier
limited Edinburg.
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