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CHAPTER 11: The History and Physical Examination: An Evidence Based

Approach
Ma. Arnee V. Anico-Tondo,M.D., FPCP (CGH)

 The diagnosis of heart failure in ambulatory patients derives from attention to:
THREE basic elements of the HISTORY SIX elements of the PHYSICAL EXAMINATION
1. Dyspnea at one flight of stairs 1. Displaced apex beat
2. Orthopnea 2. Rales
 Dyspnea occurring in recumbent position 3. An irregularly irregular pulse
3. Paroxysmal nocturnal dyspnea (of cardiac origin) 4. A heart murmur suggestive of MR
 Usually occurs 2 to 4 hours after onset of sleep 5. A heart rate greater than 60 beats/min
 Dyspnea is of sufficient severity to compel the patient 6. An elevated jugular venous pressure (JVP)
to sit upright or stand and then subsides gradually over
several minutes
THE HISTORY
Major signs and symptoms associated with cardiac disease include:
 Chest discomfort
 quality, location, radiation, triggers, mode of onset, and duration
 Dyspnea
 Fatigue
 Edema
 Palpitations
 Syncope
Platypnea  Dyspnea occurring in standing position
 Pulmonary embolism often is associated with dyspnea of sudden onset
The likelihood of a cardiac arrhythmia modestly increases with a known history of cardiac disease (LR, 2.03; 95% CI, 1.33 to
3.11) and decreases when symptoms resolve within 5 minutes (LR, 0.38; 95% CI, 0.22 to 0.63) or when associated with panic
disorder (LR, 0.26; 95% CI, 0.07 to 1.01)
Likelihood that atrioventricular nodal  Regular, rapid-pounding sensation in the neck (LR, 177; 95% CI, 25 to 1251)
reentrant tachycardia (AVNRT) is the  Visible neck pulsations associated with palpitations (LR, 2.68; 95% CI, 1.25 to 5.78)
responsible arrhythmia
Cardiac syncope  Occurs suddenly, with rapid restoration of full consciousness thereafter
Neurocardiogenic syncope  May experience an early warning sign (nausea, yawning)
 Appear ashen and diaphoretic
 Revive more slowly, albeit without signs of seizure or a prolonged postictal state
(altered state of consciousness after an epileptic seizure)

Goldman L, Hashimoto B, Cook


TA B L E 11-1 Comparison of Three Methods of Assessing Cardiovascular Disability from
EF, Loscalzo A: Comparative reproducibility and validity of systems for assessing cardiovascular functional
class: Advantages of a new specific activity scale. Circulation 64:1227, 1981.
CLASS NYHA FUNCTIONAL CCS FUNCTIONAL CLASSIFICATION SPECIFIC ACTIVITY SCALE
CLASSIFICATION
I Patients with cardiac disease Ordinary physical activity, such as Patients can perform to completion any
but without resulting walking and climbing stairs, does activity requiring >7 METs (e.g., can carry
limitations of physical activity not cause angina. Angina occurs 24 lb up eight steps; carry objects that
Ordinary physical activity does with strenuous or rapid or weigh 80 lb; do outdoor work [shovel
not cause undue fatigue, prolonged exertion at work or snow, spade soil]; do recreational
palpitation, dyspnea, or anginal recreation. activities [skiing, basketball, squash,
pain. handball, jog/walk at 5 mph]).
II Patients with cardiac disease Slight limitation of ordinary activity Patients can perform to completion any
resulting in slight limitation of Walking or climbing stairs rapidly, activity requiring >5 METs (e.g., have
physical activity walking uphill, walking or stair sexual intercourse without stopping,
They are comfortable at rest. climbing after meals, in cold, in garden, rake, weed, rollerskate, dance
Ordinary physical activity wind, or when under emotional [fox trot], walk at 4 mph on level ground),
results in fatigue, palpitation, stress, or only during the few hours but cannot and do not perform to
dyspnea, or angina pain. after awakening completion activities requiring ≥7 METs.
Walking more than two blocks on
the level and climbing more than
one flight of ordinary stairs at a
normal pace and in normal
conditions
III Patients with cardiac disease Marked limitation of ordinary Patients can perform to completion any
resulting in marked limitation physical activity activity requiring >2 METs (e.g., shower
of physical activity Walking one to two blocks on the without stopping, strip and make bed,
They are comfortable at rest. level and climbing more than one clean windows, walk 2.5 mph, bowl, play
Less than ordinary physical flight of ordinary stairs in normal golf, dress without stopping) but cannot
activity causes fatigue, conditions and do not perform to completion any
palpitation, dyspnea, or anginal activities requiring ≥5 METs.
pain.
IV Patients with cardiac disease Inability to carry on any physical Patients cannot or do not perform to
resulting in inability to carry on activity without discomfort— completion activities requiring ≥2 METs.
any physical activity without anginal syndrome may be present Cannot carry out activities listed for class
discomfort at rest III above.
Symptoms of cardiac
insufficiency or of the anginal
syndrome may be present even
at rest. If any physical activity is
undertaken, discomfort is
increased.
MET = metabolic equivalents.

GENERAL PHYSICAL EXAMINATION


 Pain of acute pericarditis, often diminishes with sitting up, leaning forward, or breathing shallowly
SKIN
Central cyanosis  Present with significant right-to-left shunting at the level of the heart or lungs
 Feature of hereditary methemoglobinemia
Peripheral cyanosis or acrocyanosis  Characteristic of the reduced blood flow that accompanies small-vessel constriction
of the fingers, toes, nose, and ears  Seen in severe heart failure, shock, or peripheral vascular disease
Differential cyanosis  Affecting the lower BUT NOT the upper extremities
 Occurs with a patent ductus arteriosus (PDA) and pulmonary artery hypertension
with right-to-left shunting at the great vessel level
Hereditary telangiectases on the  (a finding in Osler-Weber-Rendu syndrome)
lips, tongue, and mucous  Resemble spider nevi
membranes  When present in the lungs, they can cause right-to-left shunting and central
cyanosis
 Telangiectasias also are seen in patients with scleroderma with or without pulmonary hypertension
 Tanned or bronze discoloration of the skin in unexposed areas can suggest iron overload and hemochromatosis
 Ecchymoses often occur with either anticoagulant and/or antiplatelet use
 Petechiae characterize thrombocytopenia
 Purpuric skin lesions can be seen with infective endocarditis and other causes of leukocytoclastic vasculitis
Xanthomas within the palmar  SPECIFIC for type III hyperlipoproteinemia
creases
Pseudoxanthoma elasticum  Characterized by leathery, cobblestone, “plucked chicken” appearance of the skin
in the axillae and skin folds of a young person
 Disease with multiple cardiovascular manifestations, including premature
atherosclerosis
Extensive lentiginoses (freckle-like  May be part of developmental delay–associated cardiovascular syndromes
brown macules and café-au-lait spots (LEOPARD, LAMB, and Carney) with multiple atrial myxomas, atrial septal defect
over the trunk and neck) (ASD), hypertrophic cardiomyopathy, and valvular stenoses
Cardiovascular sarcoid  Should be suspected in the presence of lupus pernio, erythema nodosum, or
granuloma annulare in a patient with heart failure or syncope
HEAD AND NECK
High-arched palate  Feature of Marfan and other connective tissue disease syndromes
Large protruding tongue with  May suggest amyloidosis
parotid enlargement
Bifid uvula  Has been described in patients with Loeys-Dietz syndrome
Orange tonsils  Characteristic of Tangier disease
Ptosis and ophthalmoplegia  Suggest muscular dystrophies, and congenital heart disease often is accompanied
by hypertelorism, low-set ears, micrognathia, and a webbed neck, as with Noonan,
Turner, and Down syndromes
Proptosis, lid lag, and stare  Point to Graves hyperthyroidism
Blue sclerae, mitral or aortic  Observed in patients with osteogenesis imperfecta
regurgitation (AR), and a history of
recurrent nontraumatic skeletal
fractures
Lacrimal gland hyperplasia  Sometimes a feature of sarcoidosis
“mitral facies” of rheumatic mitral  (pink-purplish patches with telangiectasias over the malar eminences)
stenosis  Can accompany other disorders associated with pulmonary hypertension and
reduced cardiac output
Relapsing polychondritis  Suggested by inflammation of the pinnae and nasal cartilage in association with a
saddlenose deformity
“Dropped head myopathy”  Secondary to earlier treatment with mantle irradiation for lymphoma
 Loss of the anterior cervical strap muscles and permanent forward flexion
EXTREMITIES
Clubbing  Implies the presence of central shunting
Unopposable “fingerized” thumb  Occurs in Holt-Oram syndrome
Arachnodactyly  Characterizes the Marfan syndrome
Signs of infective endocarditis  Janeway lesions
 (nontender, slightly raised areas of hemorrhage on the palms and soles)
 Osler’s nodes
 (tender, raised nodules on the pads of the fingers or toes)
 Splinter hemorrhages
 (linear petechiae in the mid nailbed)
Homan’s sign  (calf pain elicited by forceful dorsiflexion of the foot)
 Neither specific nor sensitive for deep vein thrombosis
 Edema also can occur with dihydropyridine calcium channel blocker therapy
 Anasarca seldom occurs in heart failure, unless the condition is long standing, untreated, and accompanied by
hypoalbuminemia
CHEST AND ABDOMEN
pectus carinatum
(pigeon chest) or pectus excavatum (funnel chest), may accompany
connective tissue disorders
barrel chest of emphysema or may be associated with cor pulmonale
advanced kyphoscoliosis
severe kyphosis of ankylosing spondylitis should prompt careful
auscultation
for AR
“straight back syndrome” (loss of normal kyphosis
of the thoracic spine) can accompany mitral valve prolapse
(MVP).
A thrill may be present over well-developed intercostal artery
collaterals in patients with aortic coarctation.
systolic hepatic pulsations signify severe tricuspid regurgitation (TR).
THE CARDIOVASCULAR EXAMINATION
JUGULAR VEOUS PRESSURE AND WAVEFORM
JVP Aids in the estimation of volume status
elevated left EJV pressure may also signify a persistent left-sided SVC or compression
of the innominate vein from an intrathoracic
structure
estimated height of the venous pressure indicates the CVP or right atrial pressure
a wave  Reflects right atrial presystolic contraction
 Occurs just after the electrocardiographic P wave
 Precedes the first heart sound (S1)

absent with atrial fibrillation (AF).
Patients with reduced right
ventricular (RV) compliance from any cause can have a prominent
a wave.
cannon a wave occurs with atrioventricular (AV) dissociation and right atrial contraction
against a closed tricuspid valve
Presence of cannon a waves in a patient with wide complex tachycardia identifies the rhythm as ventricular
in origin.
x descent reflects the fall in right atrial pressure after the a wave peak
c interrupts this descent as ventricular systole pushes the closed
wave valve into the right atrium
x¢ descent follows because of atrial diastolic suction created by ventricular
systole pulling the tricuspid valve downward. In normal persons, the
x¢ descent is the predominant waveform in the jugular venous pulse.
v wave represents atrial filling, occurs at the end of ventricular
systole, and follows just after S2.
v wave is smaller than the a wave because of the normally compliant right atrium

In patients with ASD, the a and


v waves may be of equal height;
in TR, the v wave is accentuated
With TR, the v wave will merge with the c wave because
retrograde valve flow and antegrade right atrial filling occur
simultaneously
y descent follows the v wave peak and
reflects the fall in right atrial pressure after tricuspid valve opening.
Resistance to ventricular filling in early diastole blunts the y descent,
as is the case with pericardial tamponade or tricuspid stenosis
y descent will be steep when ventricular diastolic filling occurs early
and rapidly, as with pericardial constriction or isolated, severe TR
A rise in venous pressure (or
its failure to decrease) with inspiration (Kussmaul
sign) is associated with constrictive
pericarditis, and also with restrictive cardiomyopathy,
pulmonary embolism, RV infarction,
and advanced systolic heart failure
abdominojugular reflex or passive leg
elevation can elicit venous hypertension
sustained rise of more than 3 cm
in the venous pressure for at least 15 seconds
after resumption of spontaneous respiration is
a positive response

abdominojugular reflex can predict heart failure


and a pulmonary artery wedge pressure higher than 15 mm Hg.

MEASURING OF BLOOD PRESSURE

AUSCULTATION OF THE HEART


Heart Sounds
First Heart Sound (S1)
Comprises mitral (M1) and tricuspid (T1) valve closure
Normal splitting of S1 Accentuated with complete right bundle branch block

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