Lekcja 3: Badanie i Ocena Stanu Pacjenta | Patient Examination and Assessment

Cardiovascular History

Taking a detailed and structured cardiovascular history is essential in identifying risk factors and symptoms indicative of heart disease. The history should be patient-centered and include an understanding of the patient’s presenting complaint, associated symptoms, and past medical history.

Chief Complaint

The cardiovascular history begins with identifying the patient’s chief complaint. Common cardiovascular complaints include:

  • Chest pain
  • Dyspnea (shortness of breath)
  • Palpitations
  • Fatigue
  • Syncope (fainting or loss of consciousness)
  • Edema (swelling, particularly in the lower extremities)

History of Present Illness

A detailed history of present illness explores the characteristics, onset, progression, and factors associated with the patient’s current symptoms.

Chest Pain

Chest pain is one of the most common and concerning symptoms related to cardiovascular disease. It is crucial to evaluate the pain’s:

  • Quality: Ask the patient to describe the pain in their own words. Terms like “crushing,” “squeezing,” or “burning” may suggest ischemic pain (angina), whereas “sharp” or “stabbing” may suggest a pericardial cause or pleuritic pain.
  • Location: Central, left-sided chest pain often suggests ischemic heart disease. Radiating pain to the jaw, left arm, or back may indicate more severe underlying pathology, such as myocardial infarction.
  • Duration: Pain lasting for seconds is unlikely cardiac, while pain lasting for minutes to hours may suggest angina or myocardial infarction.
  • Precipitating factors: Pain triggered by exertion, stress, or meals is more likely cardiac in origin, particularly in cases of ischemic heart disease.
  • Relieving factors: Pain relieved by rest or nitroglycerin suggests angina, while pain exacerbated by lying down and relieved by sitting forward may indicate pericarditis.
  • Associated symptoms: Symptoms such as nausea, sweating, shortness of breath, or palpitations can provide clues to the severity and type of heart disease.

Dyspnea

Shortness of breath (dyspnea) is a common symptom in cardiovascular disease, often indicative of heart failure or pulmonary hypertension.

  • Type: Dyspnea can be exertional (occurring with activity) or at rest. Exertional dyspnea often points to left-sided heart failure or valvular heart disease.
  • Orthopnea: Difficulty breathing while lying flat suggests heart failure, as increased venous return to the heart in a supine position can exacerbate pulmonary congestion.
  • Paroxysmal Nocturnal Dyspnea (PND): Sudden shortness of breath at night that awakens the patient from sleep is highly suggestive of heart failure.
  • Severity: Ask the patient to quantify the dyspnea by describing their ability to perform everyday activities (e.g., walking upstairs, dressing). The New York Heart Association (NYHA) functional classification is commonly used to gauge the severity of heart failure.

Palpitations

Palpitations refer to the sensation of an abnormal or rapid heart rate. They may be described as “skipped beats” or “fluttering.”

  • Onset and offset: Sudden onset and offset of palpitations are often associated with paroxysmal supraventricular tachycardia (PSVT). A more gradual onset and offset may indicate sinus tachycardia.
  • Regularity: Irregular palpitations suggest atrial fibrillation or premature ventricular contractions (PVCs).
  • Associated symptoms: Dizziness, light-headedness, or syncope accompanying palpitations are concerning for a significant arrhythmia.

Syncope

Syncope is a transient loss of consciousness due to insufficient cerebral perfusion.

  • Preceding symptoms: Symptoms like dizziness, nausea, or palpitations before the event suggest a cardiovascular cause. Syncope without warning may indicate a more serious arrhythmia.
  • Activity at onset: Syncope during exertion is concerning for structural heart disease (e.g., aortic stenosis, hypertrophic cardiomyopathy), whereas syncope in the upright position may indicate a vasovagal response or orthostatic hypotension.

Fatigue

Fatigue is a non-specific symptom that can be related to heart failure, reduced cardiac output, or arrhythmias.

Edema

Peripheral edema, particularly in the lower extremities, is a key symptom of right-sided heart failure. It is important to ask about:

  • Distribution: Bilateral leg edema is more likely due to heart failure or venous insufficiency, while unilateral edema may suggest deep vein thrombosis (DVT).
  • Timing: Progressive edema throughout the day points to heart failure, while sudden onset may suggest an acute process.

Past Medical History

Understanding the patient’s past medical history provides valuable information about their cardiovascular risk profile.

  • Hypertension: The most significant risk factor for heart disease. It leads to left ventricular hypertrophy, heart failure, and ischemic heart disease.
  • Diabetes Mellitus: Increases the risk of coronary artery disease (CAD) and accelerates atherosclerosis.
  • Hyperlipidemia: Elevates the risk of coronary artery disease through the formation of atherosclerotic plaques.
  • Previous Myocardial Infarction: Indicates pre-existing coronary artery disease and increased risk for future cardiac events.
  • Rheumatic Fever: A history of rheumatic fever, especially in childhood, increases the likelihood of valvular heart disease (commonly mitral stenosis).
  • Congenital Heart Disease: Anomalies present from birth, such as atrial septal defects or ventricular septal defects, can impact heart function later in life.

Family History

A detailed family history can uncover genetic predispositions to cardiovascular disease. Key conditions to ask about include:

  • Premature Coronary Artery Disease: First-degree relatives with CAD before age 55 in men or 65 in women suggest a hereditary component.
  • Sudden Cardiac Death: A family history of sudden unexplained death, especially in young individuals, raises suspicion of inherited arrhythmias (e.g., long QT syndrome) or hypertrophic cardiomyopathy.
  • Hypercholesterolemia and Hypertension: These conditions often have a familial tendency.

Social History

Social history is essential to understanding modifiable risk factors for cardiovascular disease.

  • Smoking: A major risk factor for coronary artery disease and peripheral vascular disease. Assess the patient’s smoking history in pack-years (number of packs per day multiplied by years of smoking).
  • Alcohol Use: Excessive alcohol intake is associated with dilated cardiomyopathy and arrhythmias, particularly atrial fibrillation.
  • Recreational Drug Use: Cocaine and amphetamines can induce myocardial infarction, arrhythmias, and hypertension, even in young patients without significant coronary artery disease.
  • Diet and Exercise: Sedentary lifestyle and diets high in saturated fats and sodium contribute to cardiovascular risk. Inquiry about exercise habits helps assess the patient’s baseline functional status.

Physical Examination

The physical examination of the cardiovascular system requires a methodical approach, including inspection, palpation, percussion, and auscultation. Each component provides valuable information about the heart’s structure and function.

General Inspection

During the initial inspection, look for signs that may suggest cardiovascular disease.

  • Cyanosis: Bluish discoloration of the lips or extremities suggests hypoxemia, which may occur with congenital heart defects or severe heart failure.
  • Pallor: Pale skin may indicate anemia or reduced cardiac output.
  • Jugular Venous Distention (JVD): Visible distension of the jugular veins is a sign of increased central venous pressure, typically seen in right-sided heart failure or fluid overload.
  • Edema: Peripheral edema, particularly in the lower extremities, suggests right-sided heart failure or venous insufficiency.
  • Clubbing: Enlargement of the distal fingers, known as clubbing, may indicate chronic hypoxia associated with congenital heart disease or pulmonary conditions.

Palpation

Palpation of the precordium and peripheral pulses helps assess cardiac function and peripheral circulation.

Apical Impulse (Point of Maximal Impulse – PMI)

The PMI is normally located at the 5th intercostal space at the midclavicular line.

  • Displacement: A laterally displaced PMI suggests left ventricular hypertrophy or dilation, often due to hypertension or heart failure.
  • Size and quality: A sustained and forceful PMI suggests left ventricular hypertrophy, while a weak PMI may indicate dilated cardiomyopathy or pericardial effusion.

Peripheral Pulses

Assessing the rate, rhythm, and amplitude of peripheral pulses helps in identifying abnormalities in circulation and cardiac output.

  • Pulse Deficits: A pulse deficit occurs when the heartbeats do not match the radial pulse, suggesting arrhythmias like atrial fibrillation.
  • Pulsus Paradoxus: A marked decrease in systolic blood pressure during inspiration is a classic sign of cardiac tamponade or severe asthma/COPD.

Percussion 

Percussion is less commonly used in modern cardiovascular exams due to the availability of imaging modalities but can still be useful in estimating heart size.

  • Cardiac borders: Percussion of the chest helps define the boundaries of the heart. A shift in the cardiac borders may indicate cardiomegaly or other structural abnormalities such as pericardial effusion.

Auscultation

Auscultation is one of the most critical components of the cardiovascular examination. It provides valuable insights into the mechanical and electrical activity of the heart, allowing clinicians to detect normal and abnormal heart sounds, murmurs, and other findings that may indicate underlying pathology.

Auscultatory Areas

Auscultation should be performed in specific areas of the chest that correspond to the locations where heart sounds and murmurs are most prominent.

Auscultatory AreaLocationValve Assessed
Aortic AreaRight second intercostal spaceAortic valve
Pulmonary AreaLeft second intercostal spacePulmonary valve
Tricuspid AreaLeft lower sternal borderTricuspid valve
Mitral AreaFifth intercostal space, midclavicular lineMitral valve

Proper auscultation involves listening with both the diaphragm and bell of the stethoscope. The diaphragm is used to hear higher-pitched sounds such as S1 and S2, while the bell is more effective for detecting lower-pitched sounds like S3, S4, and murmurs associated with mitral stenosis.

Heart Sounds

The heart produces two primary sounds during a normal cardiac cycle. During auscultation the first (S1) and second (S2) heart sounds are the primary sounds heard. These correspond to the closure of the heart valves during the cardiac cycle:

  • S1 is caused by the closure of the mitral and tricuspid valves at the onset of systole, best heard at the apex of the heart.
  • S2 corresponds to the closure of the aortic and pulmonic valves at the end of systole and is best heard at the base of the heart, near the second intercostal spaces.

Note: During inspiration, there may be physiological splitting of S2 due to delayed closure of the pulmonic valve. However, a wide or fixed splitting of S2 can be pathological and may indicate conditions such as right bundle branch block or atrial septal defect.

Extra Heart Sounds (S3 and S4)

Additional heart sounds may also be heard under certain pathological conditions:

  • S3 (ventricular gallop) occurs after S2 and suggests volume overload, as seen in heart failure. It is a low-pitched sound, best heard with the bell of the stethoscope at the apex.
  • S4 (atrial gallop) occurs just before S1 and is associated with a stiff or hypertrophied ventricle, commonly seen in hypertrophic cardiomyopathy or chronic hypertension. Like S3, it is best heard at the apex with the bell of the stethoscope.
Heart SoundTimingAssociated ConditionBest Heard
S1Beginning of systoleNormal closure of mitral/tricuspid valvesApex of the heart
S2End of systoleNormal closure of aortic/pulmonic valvesBase of the heart (2nd intercostal spaces)
S3Early diastoleHeart failure, volume overloadApex with bell of stethoscope
S4Late diastoleHypertrophic cardiomyopathy, hypertensionApex with bell of stethoscope

Murmurs

Heart murmurs are caused by turbulent blood flow through the heart, often due to structural abnormalities such as valve stenosis, regurgitation, or septal defects. They are classified based on their timing within the cardiac cycle:

Systolic Murmurs

Systolic murmurs occur between the first heart sound (S1) and the second heart sound (S2), during ventricular contraction. Common conditions include:

ConditionDescriptionLocation Heard BestRadiation
Aortic StenosisCrescendo-decrescendo murmur (increases then decreases in intensity)Right second intercostal spaceRadiates to the neck
Mitral RegurgitationHolosystolic (constant intensity throughout systole) murmurApex of the heartRadiates to the axilla

Diastolic Murmurs

Diastolic murmurs occur between the second heart sound (S2) and the first heart sound (S1) of the next cycle, during ventricular filling. Common conditions include:

ConditionDescriptionLocation Heard BestPosition for Optimal Hearing
Aortic RegurgitationDecrescendo murmur (starts loud, then diminishes)Left sternal borderPatient leaning forward
Mitral StenosisLow-pitched, rumbling murmurApex of the heartLeft lateral decubitus position

Continuous Murmurs

Continuous murmurs occur throughout the cardiac cycle, both during systole and diastole, indicating abnormal blood flow that persists continuously. A common condition associated with a continuous murmur is:

ConditionDescriptionLocation Heard Best
Patent Ductus ArteriosusA continuous “machinery-like” murmur heard throughout systole and diastoleLeft upper sternal border

Key Characteristics of Murmurs

  • Timing: Is the murmur systolic, diastolic, or continuous?
  • Location: Where is the murmur heard best (e.g., aortic area, mitral area)?
  • Radiation: Does the murmur radiate to other regions (e.g., neck, axilla)?
  • Intensity: Graded on a scale of 1 to 6, with 1 being barely audible and 6 being heard with the stethoscope lifted off the chest.

Pericardial Rubs

A pericardial friction rub is a scratching or grating sound caused by inflamed pericardial layers rubbing against each other. It is often heard in patients with pericarditis.