CHAPTER 1 The Cardiovascular History and Physical Examination Roger Hall and Iain Simpson Contents Summary 1 Summary Introduction 2 History 2 A cardiovascular history and examination are fundamental to accurate Introduction diagnosis and the subsequent delivery of appropriate care for an individual The basic cardiovascular history Chest pain patient. Time spent on a thorough history and examination is rarely wasted Shortness of breath (dyspnoea) and goes beyond the gathering of basic clinical information as it is also an Paroxysmal nocturnal dyspnoea Cheyne–Stokes respiration opportunity to put the patient at ease and build confi dence in the physi- Sleep apnoea cian’s ability to provide a holistic and confi dential approach to their care. Cough Palpitation(s) (cardiac arrhythmias) This chapter covers the basics of history taking and physical examination Presyncope and syncope of the cardiology patient but then takes it to a higher level by trying to ana- Oedema and ascites Fatigue lyse the strengths and weaknesses of individual signs in clinical examina- Less common cardiological symptoms tion and to put them into the context of common clinical scenarios. In an Using the cardiovascular history to identify danger areas ideal world there would always be time for a full clinical history and exami- Some cardiovascular histories which nation, but clinical urgency may dictate that this is impossible or indeed, require urgent attention The patient with valvular heart disease when time critical treatment needs to be delivered, it may be inappropri- Examination 12 ate. This chapter provides an insight into delivering a tailored approach in Introduction General examination certain, common clinical situations. Skills in clinical history and examina- Cardiovascular examination tion evolve with time and experience and this chapter provides a structured Cardiac palpation Auscultation approach to clinical cardiovascular history and examination which should Examination of other systems be seen as a framework on which to build clinical experience. It also pro- Examination scenarios vides a hierarchical approach to the importance of certain symptoms and Conclusion 25 Personal perspective 26 signs in a variety of cardiovascular conditions. Clinical history and exami- Key points 26 nation has changed with modern advances in cardiology and the develop- Further reading 27 ment of sophisticated imaging techniques. Eponymous signs beloved of the Online resources 28 ‘Old Masters of Examination’ are now of historical interest but are listed in E Table 1.20 for information. CCamm-Chap-01.inddamm-Chap-01.indd 1 77/17/2009/17/2009 110:42:350:42:35 AAMM 2 CHAPTER 1 the cardiovascular history and physical examination history, and rather than admit they cannot answer the ques- Introduction tion put to them will sometimes make up an answer simply An accurate history and a careful examination are prob- to please the doctor. The way the patient presents a history ably the least expensive and the fastest and most powerful will also depend on the level of their education, and the of the tools available to a physician [1]. Their effective use type of work that they do [3]. The doctor taking a history requires skill and experience. It is important to recognize must not make assumptions about the patient’s underly- that it is unusual to obtain the classic history of a condition ing medical knowledge. There is a tendency among doctors combined with all the classic physical signs. Variations in to slip into medical jargon which is poorly understood or history and diffi culty in eliciting physical signs need to be completely incomprehensible to the patient. A good exam- understood. It is always a serious mistake to massage the ple is that some patients do not understand the difference history and the physical signs to fi t a particular diagnosis. between a myocardial infarction and a cerebrovascular accident and the term ‘stroke’ may confuse them as they are not quite sure about what it is. Similarly the patient may History describe either a cardiac arrest or a myocardial infarction as ‘heart attack’. This problem can sometimes be avoided if it Introduction is clear that the patient is becoming confused by asking the There needs to be an awareness of potential diffi culties patient how the particular illness affected them rather than in obtaining a clear history [2]. Patients usually, but not by giving it a name. The same applies to the description of always, try to tell the truth, as they perceive it, to their phy- symptoms. For example, a patient may use the term ‘pal- sician who will develop an instinct for this, and must always pitation’ without really understanding what it means. This consider whether they are misinterpreting the information aspect of history taking is discussed in more detail in the given to them by the patient. sections dealing with specifi c symptoms. The interaction between the patient and doctor is com- Particular diffi culties can arise when the history is taken plex and determined by many factors (E Table 1.1 ). Patients via an interpreter and under these circumstances much with a moderate rather than good command of the lan- more time must be put aside and strenuous efforts made to guage may have diffi culty in expressing subtle aspects of try to establish that the doctor is being given a clear account their story and may agree to suggestions made to them by by the patient rather than by the interpreter. There is a the doctor, rather than admitting they do not completely strong tendency for the interpreter to make up their own understand what is being said to them. Many patients have version of the history and deliver it to the doctor rather a poor perception of parameters such as time and dis- than asking the patient exactly what the symptoms are and tance, which are frequently important in the cardiovascular describing them in detail. This may be prominent when there are major cultural differences between the doctor and the patient (and interpreter). In some situations, par- Table 1.1 History taking: factors that may lead to problems ticularly where women do not speak the language and their Patient-based factors husband acts as an interpreter, there may be very consider- Command of language (usually patient)/history via an interpreter able interpretation of the history rather than the language. Patient’s cultural background It may be impossible to overcome these problems, but it is Education and employment important that the doctor is aware of the diffi culties and Inaccurate perception of variables, e.g. time and distance how they may obscure the transmission of information (see Underplaying/exaggeration E Key point 1, p. 26). Responses altered by: The reaction of a patient to their symptoms is often com- Alcohol plex [4]. Florid descriptions of symptoms (e.g. ‘I had seven Recreational drugs heart attacks’ when in fact there had been one myocardial infarct and some episodes of angina) may become impor- Physician-based factors tant to the patient, particularly if the patient is validated Badly structured questions by their illness. In addition, it becomes real to the patient Assumptions about patient’s medical knowledge with repeated re-telling of the history. Conversely, in emer- Lack of patience gency situations, particularly with young patients, there Asking ‘leading questions’, i.e. suggesting the required answer may be a major downplaying of symptoms particularly CCamm-Chap-01.inddamm-Chap-01.indd 2 77/17/2009/17/2009 110:42:350:42:35 AAMM history 3 Box 1.1 Scenario 1: downplaying symptoms — the patient who Table 1.2 Cardiovascular history wants to go home Past and family history A 45-year-old Asian male who smokes 20 cigarettes a Risk factors day arrives in the emergency department at 02.00 hours. Employment: may be affected by the presence of cardiac problems, There is a history of a heavy feeling in the central and e.g. professional drivers, pilots, divers etc. lower chest present for 45min, but easing off before the Chest pain ± radiation patient arrived. The patient admits to two or three alco- Shortness of breath/cough holic drinks and a spicy meal at 21.00 hours the previous Palpitations: awareness of irregular heartbeat evening. He now maintains that his problem is ‘just indi- ‘Dizziness’ and unsteadiness gestion’, but the electrocardiogram (ECG) shows some Syncope and falls minor ST/T wave changes. Despite the protestations of Fatigue the patient, the chances of an acute coronary syndrome Ankle oedema (a symptom and a sign) are high and this must be excluded. Less common symptoms: Abdominal pain if the patient is keen to leave the emergency room and go Vomiting with acute MI home ( E Box 1.1 ). This is particularly common in young Polyuria associated with tachycardia and middle-aged males who are presenting for the fi rst Pulsating in the neck associated with tachycardia and with tricuspid time with ischaemic chest pain. Generally patients do not regurgitation present as emergencies unless they or their spouse, partner, Abdominal swelling — ascites or family have been alarmed by the event which has caused Weakness of legs them to come to hospital (see E Key points 2 and 3, p.26). Back pain Doctors should be extremely cautious when confronted with the patient who has arrived in the A&E department symptom remains the same, but it is extremely important in the early hours of the morning, who does not have a that a systematic approach is always taken (E Table 1.3 ). lengthy past medical history, and then begins to downplay Patients may have inaccurate perceptions of time and dis- their symptoms. These patients are usually ill. tance ( E Boxes 1.2 and 1.3 ). If a patient has a recurrence The doctor has to navigate this complex situation to of a particular cardiovascular condition their symptoms obtain an accurate history and nowadays may also have are usually very similar on each occasion.