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Cardiovascular System (CVS) - Complete History & Examination

For MD Medicine Students

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PART I: CVS HISTORY TAKING

1. Introduction & Patient Identification

• Name, age, sex, occupation, domicile
• Referred by / presenting complaints (in patient's own words)
• Duration of each complaint

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2. Chief Complaints - The "Cardinal Symptoms" of Heart Disease

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3. History of Presenting Complaints (SOCRATES for each symptom)

A. CHEST PAIN

• Site: Central, retrosternal, left chest, epigastric
• Onset: Sudden vs. gradual; at rest vs. exertion
• Character:
  • Squeezing/crushing/pressure-like = ischaemic (angina/ACS)
  • Sharp, pleuritic, worse lying flat, relieved sitting forward = pericarditis
  • Tearing/ripping, radiating to back = aortic dissection
  • Burning, epigastric = GERD (differential)
• Radiation: To left arm, jaw, neck, back (aortic dissection)
• Associated symptoms: Sweating, nausea, vomiting, dyspnea, syncope
• Time: Duration (minutes = angina; >20 min = ACS; constant = pericarditis)
• Exacerbating/Relieving: Exertion, emotion, cold, heavy meals; relief with nitrates (angina), sitting forward (pericarditis)
• Severity: 1-10 scale

B. DYSPNEA

• Type: Exertional dyspnea (ED), orthopnea, paroxysmal nocturnal dyspnea (PND), dyspnea at rest
• NYHA Functional Classification for exertional dyspnea:
  • Class I: No symptoms with ordinary activity
  • Class II: Slight limitation; symptoms with moderate exertion
  • Class III: Marked limitation; symptoms with minimal exertion, comfortable at rest
  • Class IV: Symptoms at rest or with any activity
• Orthopnea: Number of pillows used (2-pillow, 3-pillow orthopnea); due to redistribution of fluid from legs to pulmonary circulation when lying flat
• PND: Awakens patient from sleep after 1-2 hours; relieved by sitting up or standing; caused by pulmonary oedema
• Cardiac vs. pulmonary dyspnea: Ask about wheeze, productive cough, history of smoking, occupational exposure

C. PALPITATIONS

• Character: Fast, slow, irregular, "fluttering," "thudding"
• Onset: Sudden/gradual, at rest/exertion
• Associated: Presyncope, chest pain, dyspnea
• Precipitating: Coffee, alcohol, thyroid disease, anxiety
• Duration and termination: Spontaneous, Valsalva manoeuvre
• Ask about: Prior ECG, ablation, medications

D. SYNCOPE

• Pre-syncope vs. true loss of consciousness
• Postural (orthostatic hypotension), exertional (AS, HOCM - high risk!), situational (micturition, cough, defaecation - vasovagal)
• Warning (prodrome): Lightheadedness, sweating = vasovagal vs. no warning = Stokes-Adams (complete heart block, VT)
• Recovery: Rapid = vasovagal; prolonged confusion = seizure
• Tongue bite, incontinence = suggest seizure

E. OEDEMA

• Location: Dependent (bilateral ankle/leg = cardiac), unilateral = DVT/venous insufficiency
• Duration, progression
• Worse at end of day, improved after recumbency (cardiac)
• Ask about ascites, facial puffiness (nephrotic syndrome differential)
• Associated: SOB, abdominal distension (ascites with RHF)

F. COUGH & HAEMOPTYSIS

• Dry nocturnal cough = LV failure, ACE inhibitor side effect
• Frothy pink sputum = acute pulmonary oedema
• Haemoptysis = mitral stenosis, PE, Eisenmenger syndrome

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4. Past Medical History (PMH)

• Previous cardiac events: MI, heart failure, cardiac surgery, PCI/CABG, pacemaker/ICD
• Hypertension (duration, control, medications)
• Diabetes mellitus
• Hyperlipidaemia
• Rheumatic fever (important for valvular disease, especially MS)
• Congenital heart disease
• Stroke/TIA
• Peripheral vascular disease
• Renal disease
• Thyroid disease
• Previous ECG/Echo/angiogram findings

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5. Drug History

• Current cardiac medications: antihypertensives, anticoagulants, antiplatelets, statins, diuretics, nitrates, digoxin, antiarrhythmics
• Cardiotoxic drugs: Doxorubicin, trastuzumab, clozapine
• Drugs causing QT prolongation: antipsychotics, macrolides, fluoroquinolones
• NSAIDs (worsen heart failure, increase BP)
• OCP (increases thrombotic risk)
• Over-the-counter/herbal medications
• Allergies: Drug name, type of reaction

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6. Family History

• First-degree relatives with:
  • Premature coronary artery disease (men <55 yrs, women <65 yrs)
  • Sudden cardiac death (especially at young age - suggests HOCM, channelopathies: LQTS, Brugada)
  • Hypertension, diabetes, hyperlipidaemia
  • Cardiomyopathy (familial dilated, HOCM)
  • Marfan syndrome, connective tissue disorders
  • Congenital heart disease

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7. Social History

• Smoking: Pack-years, current or ex-smoker, passive exposure
• Alcohol: Units per week (alcoholic cardiomyopathy, AF trigger, hypertension)
• Recreational drugs: Cocaine (coronary spasm, MI, dissection), amphetamines, anabolic steroids
• Diet: Saturated fat, salt intake
• Exercise: Level of physical activity (important for functional assessment)
• Occupation: Physical demands, occupational toxin exposure, stress
• Travel history: Endemic areas (Chagas disease, infective endocarditis risk)
• Socioeconomic: Affects access to care, medication compliance

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8. Systems Review (relevant to CVS)

• Respiratory: Wheeze, chronic cough, sputum
• GI: Nausea, vomiting (inferior MI), abdominal pain (mesenteric ischaemia, hepatomegaly)
• Renal: Oliguria, haematuria (endocarditis), nocturia (HF)
• Neurological: TIA, stroke, visual disturbances (emboli)
• Musculoskeletal: Joint pains (rheumatic fever, reactive arthritis)
• Endocrine: Sweating, heat intolerance, weight change (thyroid), polyuria/polydipsia (diabetes)

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PART II: CVS PHYSICAL EXAMINATION

STEP 1: GENERAL EXAMINATION (Begins before laying hands on the patient)

A. General Appearance

• Comfortable at rest vs. in distress, breathless, diaphoretic
• State of nutrition: Cachectic (cardiac cachexia in advanced HF), obese (metabolic syndrome)
• Position: Sitting upright/leaning forward (pericarditis), unable to lie flat (orthopnea)
• Cheyne-Stokes respiration (advanced heart failure, low cardiac output)
• Pallor, cyanosis (central vs. peripheral), jaundice

B. Skin & Nails

• Central cyanosis: Tongue + mucous membranes; significant right-to-left shunt (congenital HD, Eisenmenger)
• Peripheral cyanosis (acrocyanosis): Fingers/toes only; low flow states - HF, shock, peripheral vascular disease
• Differential cyanosis: Lower limbs only (PDA + pulmonary hypertension, right-to-left shunt at great vessel level)
• Clubbing: Chronic cyanotic congenital HD (ToF, TGA), infective endocarditis, lung disease
• Splinter haemorrhages: Infective endocarditis (also trauma)
• Osler's nodes: Painful red nodules on finger pads - infective endocarditis
• Janeway lesions: Painless haemorrhagic macules on palms/soles - infective endocarditis
• Koilonychia: Spoon-shaped nails (iron deficiency, high output failure)
• Xanthelasma, xanthomas: Hyperlipidaemia; tendon xanthomas = familial hypercholesterolaemia
• Arcus cornealis (arcus senilis): <45 yrs suggests dyslipidaemia
• Malar flush: Mitral stenosis (MS facies), scleroderma
• Petechiae: Infective endocarditis

C. Facies

• Malar flush (MS)
• Exophthalmos + lid retraction: Hyperthyroidism
• Expressionless face + ptosis: Myotonic dystrophy (associated with AV block, arrhythmia)
• Down syndrome facies, Turner's syndrome, Marfan habitus

D. Skeletal/Dysmorphic Features

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STEP 2: VITAL SIGNS

A. Heart Rate

• Normal: 60-100 bpm
• Method: Radial pulse for 60 seconds
• Rate: Bradycardia (<60) or tachycardia (>100)
• Character and rhythm

B. Blood Pressure

• Measure both arms: >10 mmHg difference = subclavian artery stenosis, aortic dissection, or coarctation
• Measure both arms AND at least one leg when coarctation of aorta suspected (BP higher in arms than legs in CoA)
• Pulsus paradoxus: >10 mmHg fall in SBP during inspiration = cardiac tamponade, severe asthma, constrictive pericarditis
• Hypertensive urgency/emergency assessment
• Wide pulse pressure: Aortic regurgitation, hyperthyroidism, severe anaemia, AV fistula
• Narrow pulse pressure: Aortic stenosis, cardiac tamponade, constrictive pericarditis, severe LV dysfunction

C. Respiratory Rate

• Tachypnoea (>20/min): Heart failure, pulmonary oedema

D. Temperature

• Fever: Infective endocarditis, pericarditis, myocarditis, acute rheumatic fever

E. Peripheral O2 Saturation (SpO2)

• <94% warrants further investigation

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STEP 3: THE HANDS, FACE, NECK (Peripheral Examination)

A. Hands

• Clubbing (grade I-IV)
• Splinter haemorrhages, Osler's nodes, Janeway lesions
• Peripheral cyanosis, capillary refill time
• Tremor (thyrotoxicosis)
• Temperature: Cold peripheries = low cardiac output

B. Eyes

• Xanthelasma (hyperlipidaemia)
• Corneal arcus
• Kayser-Fleischer rings (Wilson's disease - cardiomyopathy)
• Roth spots (infective endocarditis)
• Retinal artery occlusion (embolism from LA thrombus or myxoma)
• Subconjunctival haemorrhage
• Exophthalmos (hyperthyroidism)

C. Mouth

• Dentition and oral hygiene (source of bacteraemia - endocarditis risk)
• High-arched palate (Marfan syndrome)
• Bifid uvula (Loeys-Dietz syndrome)
• Orange tonsils (Tangier disease)
• Telangiectasias on tongue/lips (Osler-Weber-Rendu syndrome - source of R-to-L shunt if pulmonary AVMs)
• Cyanotic tongue (central cyanosis)

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STEP 4: CAROTID PULSE

• Method: Palpate one side at a time, gentle pressure, below the angle of the jaw
• Character of the carotid pulse:

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STEP 5: JUGULAR VENOUS PRESSURE (JVP)

A. How to Assess JVP

1. Position patient at 30-45° (use 45° initially; adjust to visualise the meniscus)
2. Turn head slightly to the left to examine the right internal jugular vein (preferred - directly in line with SVC and RA)
3. Identify the venous pulsation just lateral to the sternocleidomastoid muscle
4. Measure the vertical height of the venous pulsation above the sternal angle of Louis
5. Normal = <4.5 cm above the sternal angle at 45°
6. The sternal angle is approximately 5 cm above the mid-right atrium, so total CVP (cmH2O) = height above sternal angle + 5 cm
7. If JVP is elevated, sit the patient fully upright with legs dangling to better assess the upper limit
8. If not visible at 30-45°, check at 60° or even 90° (sitting)

B. JVP Waveform Components

C. Abnormalities of JVP Waveform

D. Abdominojugular Reflux (Hepatojugular Reflux)

• Apply firm pressure over right upper quadrant (upper abdomen) for >15 seconds
• Positive = sustained rise in JVP >3 cm
• Indicates elevated pulmonary capillary wedge pressure >15 mmHg
• Assess at 10 seconds (allow abdominal muscle tensing to subside)
• Caution patient not to Valsalva during test

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STEP 6: PRECORDIAL EXAMINATION

A. INSPECTION

1. Chest shape: Barrel chest, pectus excavatum (compresses heart, can produce systolic murmur), pectus carinatum, kyphoscoliosis (cor pulmonale), asymmetry
2. Scars:
   • Midline sternotomy = CABG, valve surgery, congenital HD surgery
   • Left submammary/lateral thoracotomy = mitral valvotomy (old closed commissurotomy), BT shunt
   • Right infraclavicular scar = pacemaker/ICD implant
3. Visible pulsations:
   • Apex beat (visible in ~50% of normals)
   • Visible left parasternal heave = RV hypertrophy
   • Epigastric pulsation = aortic aneurysm, right ventricular enlargement
   • Pulsatile neck veins (see JVP section)
4. Dilated veins on chest wall: SVC obstruction, caval obstruction

B. PALPATION

• Location: Normally in the 5th intercostal space, midclavicular line (MCL)
• Character:

  Type	Description	Association
  Normal	Tapping, localised, <2.5 cm	Normal
  Heaving (sustained, forceful)	Hyperdynamic, displaced, lifts finger	LVH (pressure overload: AS, hypertension)
  Hyperdynamic (thrusting, volume-loaded)	Vigorous, displaced laterally	Volume overload: AR, MR, VSD
  Tapping	Palpable S1, sharp	Mitral stenosis (loud S1 palpable)
  Diffuse/dyskinetic	Broad, unsustained, multiple areas	LV aneurysm, dilated cardiomyopathy
  Double impulse	Two distinct pulsations	HOCM (systolic + atrial), LV aneurysm
  Absent	Not palpable	Obesity, emphysema, pericardial effusion, dextrocardia

• Displacement: Lateral (LV dilatation/LVH), downward, mediastinal shift

• Place heel of hand over left parasternal area (2nd-4th ICS)
• Sustained heave lifting the hand = right ventricular hypertrophy/overload (pulmonary hypertension, pulmonary stenosis, severe MS, large ASD)

• A palpable murmur (grade 4+ murmur): Systolic thrill = AS, VSD, PS; Diastolic thrill = MS (rare), AR
• Location as per murmur site

• Palpable S1 (tapping apex) = MS
• Palpable P2 in pulmonary area = pulmonary hypertension

• Limited use in cardiac exam
• May help delineate cardiac borders
• Shifting of cardiac border to the right (dextrocardia - confirmed by apex beat)
• Dull left costophrenic angle (pleural effusion in heart failure)

C. AUSCULTATION

• Diaphragm (high-frequency): S1, S2, AR, MR, pericardial rub, ejection clicks
• Bell (low-frequency, light pressure): S3, S4, MS (mitral diastolic murmur)

1. Aortic area: 2nd right intercostal space, right sternal border (2RICS)
2. Pulmonary area: 2nd left intercostal space, left sternal border (2LICS)
3. Erb's point (left 3rd ICS): AR often best heard here in leaning-forward position
4. Tricuspid area: Lower left sternal border (4-5th ICS, LLSB)
5. Mitral area (Apex): 5th ICS, MCL - left lateral decubitus position for low-frequency sounds

Heart Sounds

• Closure of mitral (M1) and tricuspid (T1) valves at onset of systole; M1 precedes T1
• Heard best at the apex
• Loud S1: MS (restricted leaflet excursion, mobile but not closing fully until high LA pressure), hyperdynamic states (fever, anaemia, thyrotoxicosis), short PR interval
• Soft S1: LV dysfunction, calcified/immobile MV, prolonged PR interval (1° AV block), MR
• Variable S1: AF, complete AV dissociation

• Closure of aortic (A2) and pulmonary (P2) valves; A2 precedes P2
• Heard best at base (2nd ICS)
• Splitting of S2:

  Type	Behaviour	Cause
  Physiological splitting	Widens on inspiration, closes on expiration	Normal
  Wide splitting	Wide but moves with respiration	RBBB, pulmonary stenosis, ASD
  Fixed splitting	Wide, does NOT change with respiration	ASD (classic)
  Paradoxical (reversed) splitting	Narrows on inspiration	LBBB, severe AS, HOCM
  Absent P2	P2 not audible	Severe PS, pulmonary atresia
  Loud P2	Accentuated, may be palpable	Pulmonary hypertension
  Loud A2	Systemic hypertension

• Aortic ejection click: 2RICS, does NOT vary with respiration - aortic stenosis, bicuspid aortic valve, aortic root dilatation
• Pulmonary ejection click: 2LICS, disappears on inspiration - pulmonary valve stenosis

Heart Murmurs

• PDA: "Machinery murmur" - left infraclavicular area
• Ruptured sinus of Valsalva aneurysm
• AV fistula
• Coarctation of aorta (also intercostal/back)

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STEP 7: LUNG EXAMINATION (Cardiovascular Assessment)

• Bibasal crepitations (fine): Pulmonary oedema / LV failure
• Wheeze: Cardiac asthma (bronchoconstriction from interstitial oedema)
• Dullness at lung bases: Pleural effusion (LV failure - typically bilateral; unilateral right > left)
• Reduced air entry: Pleural effusion

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STEP 8: ABDOMINAL EXAMINATION

• Hepatomegaly: Tender, smooth liver edge = congestive hepatopathy (RHF)
  • Pulsatile hepatomegaly: Tricuspid regurgitation (systolic expansion)
• Hepatojugular reflux: Press on RUQ; JVP rises = elevated PCWP, RHF
• Ascites: Congestive cardiac failure (right-sided), constrictive pericarditis
• Splenomegaly: Infective endocarditis (septic emboli), LV failure (portal hypertension)
• Aortic pulsation: Abdominal aortic aneurysm (pulsatile, expansile mass in midline)
• Arterial bruits: Renal artery bruits (renovascular hypertension), iliac bruit

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STEP 9: PERIPHERAL VASCULAR EXAMINATION

• Peripheral pulses: Radial, brachial, carotid, femoral, popliteal, posterior tibial, dorsalis pedis - note presence, character, symmetry
• Radio-femoral delay: Coarctation of the aorta (femoral pulse delayed relative to radial)
• Radio-radial inequality: Subclavian artery stenosis, aortic dissection
• Absent peripheral pulses: PVD, embolism
• Ankle-Brachial Index (ABI): <0.9 = peripheral arterial disease
• Varicosities, venous insufficiency, DVT signs
• Peripheral oedema: Pitting/non-pitting; bilateral (cardiac, hypoalbuminaemic) vs. unilateral (DVT, lymphoedema)
  • Note: Pitting oedema also caused by dihydropyridine calcium channel blockers
  • Homans' sign (dorsiflexion calf pain) - neither sensitive nor specific for DVT

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STEP 10: COMPLETING THE EXAMINATION

• Thank and cover the patient
• State: "To complete my examination I would also like to:
  • Measure blood pressure in both arms (and legs if coarctation suspected)
  • Perform fundoscopy (hypertensive/diabetic retinopathy, Roth spots)
  • Check urine dipstick (haematuria in endocarditis, proteinuria in renal disease)
  • Review 12-lead ECG, chest X-ray, echocardiogram
  • Perform pulse oximetry
  • Examine the back (kyphoscoliosis, sacral oedema in bedridden patients)
  • Sacral oedema: Always check in bedridden/immobile patients"

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PART III: SUMMARY TABLES

NYHA vs. CCS vs. Specific Activity Scale

Signs That Indicate Specific Conditions

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Sources

• Harrison's Principles of Internal Medicine, 22nd Edition (2025), McGraw Hill - Chapter 246: Physical Examination of the Cardiovascular System, pp. 1902-1909
• Goldman-Cecil Medicine, International Edition - Chapter 39: Physical Examination for Detection of Signs of Cardiovascular Disease, pp. 391-393
• Fuster and Hurst's The Heart, 15th Edition - Clinical Cardiovascular Examination
• Braunwald's Heart Disease, 2-Volume Set, A Textbook of Cardiovascular Medicine