This document provides information on the history, physical examination, investigations, signs and symptoms, grading scales, and causes of various cardiorespiratory conditions. The physical examination section describes examination of the precordium, heart sounds, murmurs, jugular venous pressure, and cardiac borders determined by percussion and auscultation. Common symptoms discussed include dyspnea, chest pain, cough, hemoptysis, palpitations, and syncope. Investigations mentioned are chest X-ray, ECG, echocardiogram, angiography and biomarkers. References cited are practical cardiology textbooks.

1. By: Dr. Rekha Marbate

2.  History [ sign and symptoms]
 Physical Examination
1. General examination
2. Examination [ inspection, palpation, percussion and
auscultation]
 Investigations for confirmatory diagnosis

3.  Cardinal symptoms
1. Dyspnea or Breathlessness on exertion:
2. Chest pain
3. Cough
4. Expectoration
5. Hemoptysis
6. Palpitation and
7. Syncopal attack
8. Fever with chills
9. Other

4.  Def:- Dyspnoea is defined as an abnormally uncomfortable
awareness of breathing.
 Causes-
1. Cardiac origin-
a. Left heart failure
b. Congenital heart diseases (Shunts and valvular lesions)
c. Acquired valvular heart diseases
d. Coronary heart disease
e. Hypertensive heart disease
f. Cardiomyopathies.

5. 2. Dyspnea is the major symptom of left heart failure -
Respiratory
A. Bronchial asthma
B. Chronic obstructive lung disease—Chronic
bronchitis, emphysema
C. Chronic restrictive lung disease
1. Parenchymal Pneumoconiosis
2. Interstitial lung disease
3. Extra parenchymal- Myasthenia gravis, Guillain-
Barré syndrome, Ankylosing spondylitis
Kyphoscoliosis, Obesity
D. Pneumonias

6. E. Pulmonary neoplasm
F. Pulmonary embolism
G. Laryngeal or tracheal obstruction Inhalation of toxic
gases and fumes.
H. Haematological: Severe anaemia.
I. Miscellaneous: Anxiety,

7. NYHA
grade
Description
Class I No symptoms with ordinary pysical activity.
Class II Symptoms with ordinary activity, slight
limitation of physical activity
Class III Symptoms with less than ordinary activity.
Marked limitation of activity
Class IV Symptoms with any physical activity or even at
rest
Grading for dyspnoea, palpitation, fatigue and angina in
patients with cardiovascular disease.
Class I

8.  Dyspnoea that develops in recumbent position and is
relieved by sitting up or elevation of the head with
pillows.
 Orthopnoea occurs within 1-2 minutes after assuming
recumbency and recovery on sitting up is also
immediate.
 Causes -
1. Acute left heart failure
2. Extreme degree of CCF.

9.  Attacks of dyspnoea which occur at night and awaken the
patient from sleep.
 It occurs 2–5 hours after the onset of sleep and takes 10–30
minutes for recovery after assuming the upright posture.
 Causes-
1. Ischaemic heart disease
2. Aortic valve disease
3. Hypertension
4. Cardiomyopathy
5. Atrial fibrillation
6. Rarely in mitral disease or atrial tumours.
7. PND is the earliest symptom of left heart failure.

10.  Platypnoea is dyspnoea which occurs only in the
upright position.
 Causes-
1. Left atrial thrombus
2. Left atrial tumour
3. Pulmonary arteriovenous fistula.

11.  A discomfort in the chest and adjacent area due to
myocardial ischaemia.
 It is due to a discrepancy between myocardial oxygen
demand and supply.

12. Anginal grading Description
Grade I Angina on severe exertion
Grade II Angina on walking uphill or
climbing more than one
flight of ordinary stairs
Grade III Angina on walking on level
ground or climbing one flight
of ordinary stairs
Grade IV Angina at rest
.

13. Site Substernal
Nature Pressing, squeezing, strangling, constricting, ‘a
band across the chest’, ‘a weight in the centre of
the chest’. The patient cannot pinpoint the site of
pain
Radiation . To both the shoulders, epigastrium, back, neck,
jaw, teeth. Anginal pain can radiate in all
directions, as mentioned above, but more
commonly radiates to the left shoulder and ulnar
aspect of the left arm.
Duration 5 to 15 minutes
Aggravating
Factor
Exertion, emotion, after a heavy meal, or exposure
to cold
Reliving factor Rest, nitrates.

14. 1. Coronary artery disease: Due to narrowing or spasm
of coronary artery.
2. Aortic stenosis: Due to decreased stroke volume,
reducing coronary perfusion and compression of
coronaries by hypertrophied myocardium,
decreasing O2 supply and increased O2 demand by
the hypertrophied myocardium. Decreased capillary
density and co-existent atherosclerosis increase the
ischaemic burden.

15. 3. Aortic regurgitation: Due to decreased coronary
perfusion as a result of run-off of blood back into the
LV and periphery during diastole; in syphilitic AR, in
addition there is coronary ostial stenosis.
4. Systemic hypertension: Due to decreased diastolic
coronary perfusion as a result of left ventricular
hypertrophy.
5. Severe anaemia
6. Connective tissue disorders (due to arteritis)
7. Extreme tachyarrhythmias.

16. Def:- Palpitation is defined as an unpleasant awareness
of forceful, arrhythmic or rapid beating of the heart.
 Causes-
1. Extrasystoles - Atrial, ventricular
2. Tachyarrhythmias - Atrial, ventricular
3. Endocrine – Thyrotoxicosis,Hypoglycaemia
4. High output states- Anaemia, pyrexia,Aortic
regurgitation, Patent ductus arteriosus.
5. Drugs- Atropine, adrenaline, aminophylline,
thyroxine, coffee, tea, alcohol

17.  Syncope may be defined as a transient loss of
consciousness due to inadequate cerebral blood flow
secondary to abrupt decrease in cardiac output.
 Depending on the duration of syncope, the symptoms
experienced by the patient may vary.
 If syncope lasts for 5 seconds- patient experiences
dizziness
 10 seconds- patient may become unconscious

18.  Causes-
1. Cardiac
i. Electrical abnormalities - Extreme bradycardia, Heart
block , tachyarrhythmias.
ii. Mechanical causes - Aortic stenosis, Hypertrophic
obstructive cardiomyopathy , Left atrial tumours and
thrombus , Pulmonary stenosis, Pulmonary
hypertension , Pulmonary embolism , Tetralogy of
Fallot.
2. Drugs
i. a. Antihypertensives
ii. b. Beta blockers
iii. c. Vasodilators—nitrates, ACE inhibitors.
3. Hypovolaemia: - Haemorrhage, fluid loss, diabetic
precoma

19.  Forceful expelling strategies of human body to remove
foreign particle outside the respiratory tract.
 Severity – On VAS
 Type-Dry/productive
 Frequency: occasional/ continous or
constant/intermittent

21.  Type: (As per miller’s Classification)mucoid, purulent,
mucopurulent
 Colour- Yellow, white, greenish, brownishng, with
bright red blood
 Consistency: thin/thick/viscous/tenacious /frothy
 Quantity/volume: scanty- few teaspoon,
 moderate- small cup
 copious- a pint
 Odour-

23.  Hemoptysis, expectoration of sputum containing
blood, varies in severity from slight streaking to frank
bleeding.

24.  Cyanosis is a bluish discolouration of the skin and
mucous membrane due to an increased quantity of
reduced haemoglobin > 4 g per dl or > 30% of total
Hb, and PaO2 < 85%, or due to the presence of
abnormal haemoglobin pigments in the blood
perfusing these areas.
Types
Central Peripheral

25. Features Central cyanosis Peripheral
cyanosis
Mechanism Right to left shunts
Peripheral stasis or
lung disorders
Peripheral stasis
Site Whole body Nail bed, nose tip,
earlobe, extremities
Associations Clubbing -
Extremities warm cold
On warming the
extremities
No change Disappears
O2 inhalation Slight improvement No change
Arterial blood Low < 85% Normal 85–100%
gas-PaO2

27. A. Build and nutrition

28. B. Nails and conjunctiva for pallor [mucus membrane of
lower eye lid],
icterus, clubbing, cyanosis.

29. C. Lymphadenopathy and thyroid swelling

31. D. Edema

32. E. Skin - for petechial hemorrhages, Osler nodes,
rheumatic nodules

33.  Rheumatic nodules

34. F. Skeletal system - Kyphoscoliosis, chest shape

35.  G. TPR, BP
 T- temperature [36.5-37.5 degree Celsius or 97.7 – 99.5
degree frenite]
 P- pulse
 R- respiratory Rate
 BP- Blood Pressure

36.  JVP

37.  Examination of the neck veins has a two purpose.
1. To assess approximately the mean right atrial
pressure.
2. To study the waveforms.
 Jugular Venous Pressure Jugular venous pressure (JVP)
is expressed as the vertical height from the sternal
angle to the zone of transition of distended and
collapsed internal jugular veins.
 When measured with the patient reclining at 45° is
normally about 4-5 cm.
 The right internal jugular vein is selected because it is
larger, straighter and has no valves.
 It is situated between two heads of sternomastoid.

38. 1. Precordium- is the anterior aspect of the chest
 Normally the precordium has a smooth contour,
slightly convex and symmetrical with part of the
chest wall on the right side.
A. Bulging: Precordium may be bulging in:
1. Enlarged heart
2. Pericardial effusion
3. Mediastinal tumor
4. Pleural effusion
5. Scoliosis

39.  B. Flattened: Precordium may be flattened in the
following conditions:
 1. Fibrosis of lung
 2. Old pleural or pericardial effusions
 3.Congenital deformity
2. Apex Impulse:- is the lowermost and outermost part
of cardiac impulse seen.
 Normally, it is in the fifth left intercostal space just
inside the mid clavicular line.
 The impulse may not be visible if it is lying just
behind a rib.

40. 1. Apex Beat
 Apex beat is the lower most and outer most point
where maximum cardiac impulse is felt.
 It gives a gentle thrust to the palpating finger.
 Normally, it is located in the fifth left intercostal
space within the mid-clavicular line.

41. 2. Parasternal heave
 Systolic impulse in the left parasternal region commonly
felt in right ventricular enlargement is parasternal heave.
3. Thrills
 Thrills are palpable vibrations (like the purring of a cat that
is felt by the hand) associated with heart murmurs.
 felt with the palm of the hand.
 It is intensified if the chest wall is thin, site of production
is near the surface of the chest wall and the blood flow is
rapid.
 Presence of a thrill is a definite evidence of the presence of
an organic disease of the heart. They may be systolic (AS,
PS, MR, TR, ASD, VSD, PDA)

42.  Percussion is mainly done to determine the
boundaries of the heart.
 I. Left Border: The patient must be percussed in the
fourth and fifth space in the mid-axillary region and
then medially towards the left border of the heart. The
resonant note of the lung becomes dull. Normally the
left border is along the apex beat.
 If it is outside apex beat suggest pericardial effusion.

44.  11. Upper border: The patient must be percussed in the
second and third left intercostal spaces in the
parasternal line, which is the line between the mid-
clavicular and the lateral sternal line. Normally there is
resonant note in the second space and dull note in the
third space.
 If there is a dull note in the second space it suggests: 1.
Pericardia! effusion 2. Aneurysm of aorta 3. Pulmonary
hypertension 4. Left atrial enlargement 5. Mediastinal
mass rder:

45.  Right border: patient must be percussed anteriorly in
the mid-clavicular line on the right side until the liver
dullness is percussed.
 Then the percussion is done one space higher from
the mid-clavicular line medially to the sternal border.
Normally the right border of the heart is retrosternal.
 If the dullness is parasternal it suggests: l. Pericardia!
effusion 2. Aneurysm of ascending aorta 3. Right atrial
enlargement 4. Dextrocardia

46.  Auscultation is done to describe
 I. Heart Sounds
 II. Murmurs
 III. Other sounds

48. Heart sound Produced by Characterstics
S1 closure of atrioventricular
valves, Mitral (M1) and
Tricuspid (T1).
It is a high frequency sound
heard best with the diaphragm
of the stethoscope.
S2 closure of the aortic (A2) and
pulmonary (P2) valves
it is a high frequency sound,
heard better in the aortic and
pulmonary area
S3 S3 is produced by initial passive
filling of the ventricles
Low frequency sound,
normally inaudible
S4 S4 is produced by a rapid
emptying of the atrium into
non-compliant ventricle.
Low frequency sound,
normally inaudible
Murmur Murmurs are abnormal heart
sounds caused by vibration of
the valves or the wall of the
heart or great vessels.
Murmurs may be systolic (ifit is
between first and second heart
sound) or diastolic (if between
the second and first heart
·sound) or continuous

49.  Chest X-Ray
 ECG
 2 D ECHO
 Angiography
 Biomedical markers

50.  1. PJ Mehta’s Practical Medicine 20th edition
 2. R. Algappan Manual of Practical medicine 4th
edition.