The document provides guidance on evaluating patients presenting with cardiovascular symptoms such as chest pain. It discusses taking a focused history and performing a thorough cardiovascular examination. The examination should follow a systematic approach and focus on listening to heart sounds and murmurs at different locations. Common cardiovascular conditions are reviewed, including how they may present on examination. For example, aortic stenosis may cause a slow rising pulse with a systolic murmur best heard at the right sternal border, while aortic regurgitation can lead to a collapsing pulse and diastolic murmur in the lower left sternal area. The document emphasizes practicing examination techniques and considering differential diagnoses.

1. Dr Ho-YanYvonne Chun
SpecialistTrainee Registrar in Stroke Medicine & Geriatric Medicine
Torbay Hospital

2.  Take a succinct and focused history of a patient
presenting with symptoms commonly associated with
cardiovascular diseases
 Clinical symptoms and signs of cardiovascular diseases
 Perform a cardiovascular examination competently and
professionally
 Signs of specific disorders
 Put together signs and symptoms to make a list of
differential diagnosis

3.  Chest pain
 Shortness of breath
 Palpitations
 Syncope
 (Intermittent claudication)

4. http://www.riversideonline.com/source/images/image_popup/r7_chest_pain10_13.jpg

5.  Always think serious conditions and aim to
rule them out with history, examination and
investigations

6.  Cardiac
 Acute coronary syndrome—
Myocardial infarction,
unstable angina
 Aortic dissection
 Pericarditis, myo-pericarditis
 Stable angina
 Aortic stenosis
 Pulmonary (pleuritic)
 Pneumothorax
 Pulmonary embolism
 Pneumonia
 Pleuritis
 Gastro-oesophageal
▪ Gastric/ oesophageal
perforation
▪ Gastro-oesophageal reflux
▪ Oesophageal spasm
 Other
 Musculoskeletal
 Skin: e.g. shingles
 ‘spinal’—radiculopathy
 Non-specific chest pain

7.  SOCRATES approach
 Site
 Onset
 Character
 Radiation
 Associating symptoms
 Time/ duration
 Exacerbating and relieving factors
 Severity

8.  Cardiac
 Acute coronary syndrome—
Myocardial infarction,
unstable angina
 Aortic dissection
 Pericarditis, myo-pericarditis
 Stable angina (+/-anaemia)
 Aortic stenosis
 Pulmonary (pleuritic)
 Pneumothorax
 Pulmonary embolism
 Pneumonia
 Pleuritis
 Gastro-oesophageal
▪ Gastric/ oesophageal
perforation
▪ Gastro-oesophageal reflux
▪ Oesophageal spasm
 Other
 Musculoskeletal
 Skin: e.g. shingles
 ‘spinal’—radiculopathy
 Non-specific chest pain
SOCRATES approach

9.  PC: chest pain
 HPC: central chest tightness radiating to jaw on walking
uphill only and relieved by GTN and rest.
 OtherCV symptoms: SOB, ankle oedema, PND,
orthopnoea, palpitations and syncope, intermittent
claudication
 Cardiovascular risk factors
 PMH:
 DH:
 FH:
 SH: smoking, alcohol, illicit drugs
 Systems review:

10.  Can have a normal CV examination
 You should specifically look for
 General:
▪ Nicotine stains, corneal arcus, xanthelsama, xanthoma
▪ Anaemia
 High BP
 Precordium:
▪ May or may not have heart murmur (AS)
 May have signs of heart failure:
▪ raised JVP, displaced apex, peripheral oedema, bibasal
crackles

11.  Investigations
 12 lead ECG—look for evidence of
▪ ST elevation, ST depression,T wave inversions or biphasicT
wave
▪ LVH, LBBB, abnormal rhythm etc.
 Chest x ray
▪ Cardiomegaly, pulmonary oedema
▪ Think about the differential diagnoses to exclude
 Blood tests
▪ FBC—anaemia, platelet
▪ Biochemistry—troponins, lipid profile, Hba1c

12.  Can be caused by cardiac or pulmonary
diseases
 Cardiac diseases causing shortness of breath
 Heart failure
 Ischaemic heart disease –during episode of angina
 Severe anaemia with ischaemic heart disease

13.  Shortness of breath on exertion/ at rest
 NewYork Heart Association classification of heart failure
 I = no symptom at rest, dyspnoea on rigours exertion only
 II = no symptom at rest, dyspnoea on exertion
 III = mild symptoms at rest, symptoms with ordinary
activities
 IV = significant dyspnoea at rest, severe dyspnoea on very
mild exertion (less than ordinary activities)

14.  Shortness of breath
 Acute/ chronic
 Exertion/ rest
 Orthopnoea
 Paroxysmal nocturnal dyspnoea
 Ankle oedema (right heart failure)
 Has it increased recently?
 Cough—white frothy sputum
 Wheeze—differential diagnosis: obstructive airway
d

15.  PMH:
 DH: are they on HF treatment?
 SH:
 FH:
 Systems r/v
 What has caused the patient’s heart failure?

16. Rhythm
problem
Muscle problem
Volume overload
(excessive preload)
Outflow
obstruction
(Excessive
afterload)
Decreased
ventricular filling

17. Rhythm problem
Muscle problem
Volume overload
(excessive preload)
Outflow obstruction
(Excessive afterload)
Arrhythmias
e.g.Atrial
fibrillation, severe
brady/
tachycarrthymias
LVF:
Hypertension
Aortic stenosis
RVF:
Pulmonary stenosis
Pul HTN (primary or
secondary), PE
(Mitral stenosisPulHTN)
Any regurgitation:
AR, MR (LVF)
Fluid overload, NSAIDS
TR (RVF)
Ischaemic heart disease
Cardiomyopathy
Decreased ventricular filling
(restrictive)
Restrictive cardiomyopathy,
constrictive pericarditis,
cardiac tamponade

18.  High-output failure
 Anaemia
 Pregnancy
 Hyperthyroidism
 Pagets disease
 AV malformation
 Beri beri—wet beri beri secondary to thiamine deficiency

19.  Left ventricular failure (pulmonary oedema)
 Sitting up (orthopnoea), breathless at rest
 +/- displaced apex (LV dilatation), S3 gallop rhythm, murmurs of valve
disorders
 Bibasal crackles +/- wheeze
 +/- pleural effusions
 Right ventricular failure
 Raised jugular venous pressure
 +/- Pulsatile hepatomegaly
 Peripheral oedema—ankle, +/- ascites

20.  This is a good time to talk about
cardiovascular examination
 We will return to history taking for
palpitations and syncope
 We will talk about individual valve disorder
and conditions that are commonly examined

21.  Systematic approach
 Develop a (conventional) routine and stick
with it
 Practice is the most important, you want to
look slick!
 Really look for the sign when you say you are
looking for it

22. Easy points (to miss/ fail on)
 Wash hands
 Introduce self, ask for permission
 Be grateful to patient
 Position at 45 degrees
 Expose upper body (+ legs for scars)
 Ask about pain
 Remember not to cause pain!

23.  Spend time at foot of the bed and inspect!
 External paraphenalia
 Pt comfortable/ breathless at rest
 Does pt look pale? Flushed (malar rash)?
 Pacemaker?
 Scars—mid sternotomy +/- leg scars, apical
 If +: what operation?Valve? CABG?

24.  Hands:
 Clubbing (IE & congenital cyanotic heart d)
 Splinter haemorrhages, Janeway lesions, Osler’s
nodes (IE)
 Peripheral cyanosis, temperature of the hands and
capillary refill
 xanthoma
 Pallor
 Radial pulse:
 heart rate and rhythm (look for AF)
 Collapsing pulse (AR): ask about pain in the arm

25.  Brachial pulse
 Comment on character: normal, slow-rising (AS)
 BP
 Say you would check the BP at this stage
 Neck
 (Palpate carotid pulse)
 Inspect JVP

26.  Normal JVP is at 4cm above sternal angle at 45
degrees
 How to distinguish from carotid pulse?
▪ Bisferiens—double pulse for every arterial pulse
▪ Decreases on inspiration and and sitting up
▪ Rises with expiration and lying down
▪ Not usually palpable
▪ Can be obliterated by finger
▪ Rises with pressure on the abdomen (hepatojugular reflux)
 Raised JVP is a sign of right ventricular failure
 LargeV waves = tricuspid regurgitation
 CCF

27.  Face:
 malar flush (Mitral stenosis)
 Eyes:
 Xanthelesmata, corneal arcus, conjunctival pallor
 Mouth/ tongue:
 Central cyanosis

28.  Closer inspection of the precordium
 Pacemaker, scars, hear any ‘clicks’ of metallic heart valve
 Palpation
 Apex: mid-clav line at 5th intercostal space
▪ Displaced apex (left ventricular dilatation)
 Apex beat character: normal or ‘hyperdynamic’
▪ Tapping (mitral stenosis)
▪ Sustained (LVH)
 Thrills and heave
▪ Thrills—palpable murmur
▪ Parasternal heave (Right ventricular dilatation)

29. http://classconnection.s3.amazonaws.com/418/flashcards/992418/png/screen_shot_2012-02-
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30.  Develop a routine for manouvres
1)Apex
 Identify S1 and S2 or any murmur
▪ Do they sound normal? Mechanical?
▪ any added sounds or murmurs? Can you time murmur to carotid
pulse?—systolic/ diastolic?
 Pansystolic murmur radiating to axilla best heard on max.
expiration (MR)
 Mid-diastolic rumbling murmur best heard in left lateral
position over apex on max. expiration with bell (MS)

31. 2) Lower left sternal edge
 Pansystolic murmur best heard here and on inspiration (+ raised JVP +
giant ‘v’ wave) =Tricuspid regurgitation
 Pansystolic murmur best heard here can also beVSD
3) Right sternal border second intercostal space
 Ejection systolic murmur radiating to carotids best heard on
expiration = AS
 Is there any diastolic murmur? Move pt forward and listen at
lower left sternal edge
▪ Early diastolic murmur best heard sitting forward on expiration
(+collapsing pulse) = aortic regurgitation

32.  So far you have listened for all the left-sided murmurs (MR,
MS,AS, AR) andTR
 (VSD as a differential for MR,TR)
4) Left sternal border 2nd intercostal space
 Pulm stenosis:
 ejection systolic murmur radiating to left clavicle best heard on
inspiration
 (Pulm regurg:early-diastolic murmur best heard here on inspiration)
 (Tricuspid stenosis: mid-diastolic murmur best heard on inspiration)

33.  Left-sided murmurs best heard on maximal
expiration
 Right-sided murmurs best heard on max. inspiration
 Diastolic murmurs are difficult to hear and require
special manouvres
 MS—apex, left lateral position with bell on
expiration
 AR—sit forward, lower left sternal edge on
expiration

34.  Sit patient forward and listen to the lung
bases
 Bibasal crackles—pul oedema (or other lung d)
 Check for peripheral oedema
 Sacral oedema
 ankle/ leg oedema
 Peripheral pulses—DP, PT, Femoral
 (young pt with HTN—Radio-fem delay)

35.  We will practice tomorrow

36.  To palpate the peripheral pulses
 Check observation charts for fever, BP, urine
dip (IE)
 ‘I would also like to do an ECG, CXR’
 Hb to look for anaemia
 WC, CRP, ESR—evidence of infection
 ECHO
 IfAF, mechanical valve
 Think warfarin and check INR

37.  Aortic Stenosis:
 Slow-rising pulse, narrow pulse
pressure
 Apex not displaced by
hyperdynamic
 Palpable thrill
 S1 + quiet S2, ESM best heard
right sternal edge 2nd ICS on
expiration radiating to carotids
 +/- signs of LVF or CCF
 +/- signs of IE
Aetiology:
• Congenital bicuspid
• Age-related degeneration
and calcification
• Rheumatic fever

38.  AR
 Collapsing pulse
 Corrigan’s sign
 Apex is displaced and
hyperdynamic
 Soft S2, ESD best heard
over lower left sternal
edge on max expiration
and leaning forward
 +/- LVF, RVF
 +/- IE
Aetiology
• Marfan’s
• Ankylosing spondylitis
• Rheumatoid arthritis
• SLE
• HTN
• Rheumatic fever
• Syphilis
• Endocarditis

39.  Malar flush
 AF
 (+/- scar for valvotomy)
 Tapping apex, parasternal heave (RVH) and loud
P2 (pul HTN)
 Loud S1, mid diastolic rumbling murmur best
heard over the apex in left lateral position on
expiration with the bell

40.  TR
 JVP raised, giantV waves
 Pulsatile hepatomegaly,
peripheral oedema
 Parasternal heave
 Pansystolic murmur
 RVF
Functional:
• pulmonary hypertension—primary
or secondary
• Mitral stenosis, Cor
pulmonale
Isolated: IE, IVDU, Carcinoid,
Ebstein’s anomaly

41.  MR
 AF
 Hyperdynamic apex and displaced
 Parsternal heave +/- P2
 Soft S1, PSM radiating to axilla
 LVF +/- RVF
 +/- IE

42.  Aortic valve—S2
 Mitral valve—S1
 Metallic
 Bioprosthetic
 Identify which is prosthetic S1, S2
 Mention any evidence of
 infective endocarditis
 regurgitation murmur
 heart failure
 anticogulation

43.  Palpitations
 Syncope

44.  HPC
 Describe/ tap it out
 Regular, irregular, fast/ slow
 Associated symptoms
 presyncope
 Syncope
 Chest pain
 Shortness of breath
 PMH, DH, SH, FH
 System r/v: thyroid syx

45.  Sinus tachycardia
 Thyroid function, systemic illness, excess caffeine, PE
 (Sinus bradycardia)
▪ Medications, hypothyroid
 Tachyarrhythmias
 Atrial fibrillation with fast rate
 Atrial flutter
 Other atrial tachycardias
 Ventricular tachycardias (!)
 Bradyarrhythmias
 Heart block—first degree, secondary degree, complete heart
block
 Check DHx

46.  Cardiac
 Hypertension
 IHD
 Any heart problem—cardiomyopathy
 Respiratory
 Pneumonia
 COPD,OSA, pneumonia
 Metabolic/ electrolyte
 Hypokalaemia, hypomagnesaemia
 Toxin
 Caffeine, alcohol
 Endocrine
 hyperthyroidism
 Idiopathic
 age

47.  ECG
 FBC: infections
 Biochemistry: electrolyte disturbance
 Thyroid function tests
 CXR: causes for tachycardia—infection/
pneumonia
 24hour ECG

48.  Transient loss of consciousness usually leading
to falling. Rapid onset, subsequent recovery
usually spontaneous, complete and usually
prompt
 Temporary cessation of cerebral function
(reticular activating system)
 Results from transient and sudden reduction of
blood flow to the brain

49.  PC: ‘collapse with loss of consciousness’
 HPC:
 Witnessed account
 Preceding symptoms:
▪ None (!)
▪ Dizzy, dizzy on standing
▪ Chest pain, palpitations
▪ Micturition, defecation
▪ Hot stuffy environment, standing for prolonged period

50.  Any injury to head/ face
 Any features of seizures
 Recovery—immediate, quick, prolonged with
confusion
 History of similar episodes?
 Postural dizziness?
 PMH
 DH: antihypertensives
 FHx: sudden cardiac death

51.  Arrhythmia
 Sinus node dysfunction (brady-tachy syndrome)
 Atrioventricular conduction disease
 Supraventricular
 Ventricular tachycardia
 Inherited: Long QT, Brugada syndrome, implantable device
malfunction, drug induced proarrhythmias
 Structurally cardiac/ cardiopulmonary disease
 Valvular heart diseae
 MI/ ischaemia
 Obstructive cardiomyopathy, atrial myxoma
 Acute aortic dissection
 Pericardial disease/ tamponade
 PE, pulmonary hypertension

52.  Neurally-mediated syndromes
 Vasovagal, situational syncope
 Cardiac arrhythmias
 Structural cardiac or cardiopulmonary disease
 Orthostatic
 Disorders misdiagnosed as syncope
 TIA vertebrobasilar origin
 Hypoglycaemia, metabolic disorders
 Epilepsy
 Alcohol and other intoxications
 Hyperventilation with hypocapnia

53.  Lying standing blood pressure
 Blood glucose
 12 lead ECG
 24hour tape
 ECHO
 Syncope mimics
 Brain imaging--seizure