History Taking and Physical

Examination of Cardiovascular
System-The Essentials
Assoc.Prof, D. Menekşe Gerede Uludağ
Ankara University School of Medicine,
Department of Cardiology
 History taking & Physical Examination

• Fundamental to accurate diagnosis!

• Cheap, fast, and powerful tools!!

Opening the consultation/ Warm up

• Introduce yourself – name / role

• Confirm patient details – name / DOB
• Explain the need to take a history & PE
• Informed consent
• Ensure the patient is comfortable
The history/Anamnesis taking process..
• History of presenting complaint
• Past medical history
• Drug history
• Family history
• Social history
• Systemic enquiry
• Summarizing
• Provisional diagnosis based on history
 Presenting complaint
• It’s important to use open questioning to elicit the
patient’s presenting complaint
– “What’s your complaint?” or “Tell me about your
symptoms”
• Allow the patient time to answer, trying not to
interrupt or direct the conversation.
• Facilitate the patient to expand on their presenting
complaint if required.
– “Ok, so tell me more about that” or “Can you explain
what that pain was like?”
• A patient with a cardiological problem is likely
to have one or more of six main symptoms:
 chest pain/discomfort
 shortness of breath/dyspnea
 fatigue
 palpitations
 syncope
 edema
Other symptoms..

Cough
Hemoptysis
Cyanosis
Claudication
Limb pain can indicate a vascular disorder !!
Skin discoloration
 History of presenting complaint
• Onset – When did the symptom start? / Was the onset acute or gradual?

• Duration – minutes / hours / days / weeks / months / years

• Severity – e.g. if symptom is chest pain, how bad is it on a scale of 1 to 10?

• Course – is the symptom worsening, improving, or continuing to fluctuate?

• Intermittent or continuous – is the symptom always present or does it come and go?

• Precipitating factors – are there any obvious triggers for the symptom?

• Relieving factors – does anything appear to improve the symptoms e.g. GTN spray

• Associated features –are there other symptoms that appear associated e.g. fever / malaise 

• Previous episodes – has the patient experienced this symptom previously?

 If the chest pain is a major symptom..
• Pain – if the pain is a symptom, clarify the details of the pain
using SOCRATES acronym.

• Site – where is the pain? 

• Onset – when did it start? / sudden vs gradual?
• Character – sharp / dull ache / burning
• Radiation – does the pain move anywhere else? 
• Associations – other symptoms associated with the pain? 
• Time course – worsening / improving / fluctuating / time of day dependent
• Exacerbating / Relieving factors – anything make the pain worse or better?
• Severity – on a scale of 0-10, how severe is the pain?
 The history taking process..
• History of presenting complaint
• Past medical history
• Drug history
• Family history
• Social history
• Systemic enquiry
• Summarizing
• Provisional diagnosis based on history
 Past medical history (Disease or risk factor)
• Cardiovascular disease:
Angina
Myocardial infarction – bypass grafts / stents
Atrial fibrillation
Stroke
Peripheral vascular disease
Hypertension
Hyperlipidemia
Rheumatic fever

• Habits- smoking, alcohol, drugs

• Other medical conditions – e.g. hyperthyroidism 
• Surgical history – bypass graft / stents / valve replacements
• Acute hospital admissions? – when and why?
 Drug history
• Cardiovascular medications:
Beta blockers
Calcium channel blockers
ACE inhibitors
Diuretics
Statins
Antiplatelets
Anticoagulants
Glyceryl trinitrate spray (GTN spray)
• Other regular medications
• Contraceptive pill – increased risk of thromboembolic disease 
• Over the counter drugs – NSAIDS / Aspirin
• Herbal remedies –  e.g. St John’s Wort – enzyme inducer (can
affect Warfarin levels)
• ALLERGIES – ensure to document these clearly
 Family history
• Cardiovascular disease at a young age 
(for men <55 years old, for women <65 years old in first
degree relatives)– myocardial infarction

• Are the parents still in good health? – 

if deceased sensitively determine age and cause
of death

• Any unexplained deaths in young relatives? –

e.g. long QT syndrome / channelopathies
 Social history
• Smoking – How many cigarettes a day? How many years have they smoked for?
• Alcohol – How many units a week? – type / volume / strength of alcohol
• Recreational drug use – e.g. Cocaine – coronary artery vasospasm 
• Diet – Overweight? Fatty foods? Salt intake? – cardiovascular risk factors
• Exercise – baseline level of patient’s day to day activity
• Living situation:
House/bungalow? – adaptations / stairs 
Who lives with the patient? – is the patient supported at home?
Any carer input? – what level of care do they receive?
 
• Activities of daily living:
Is the patient independent and able to fully care for themselves?
Can they manage self hygiene / housework / food shopping?

• Occupation– sedentary jobs –  ↑ cardiovascular risk – e.g. lorry driver

 Systemic enquiry

• Systemic enquiry involves performing a brief screen for

symptoms in other body systems.

• This may pick up on symptoms the patient failed to mention

in the presenting complaint.

• Some of these symptoms may be relevant to the diagnosis

(e.g. reduced urine output in dehydration).
 Systemic enquiry
• Cardiovascular – Chest pain / Palpitations  / Dyspnea /  Syncope
/ Orthopnea  / Peripheral oedema 
• Respiratory – Dyspnea / Cough / Sputum /
Wheeze / Haemoptysis / Chest pain
• GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia /
Weight loss / Abdominal pain / Bowel habit 
• Urinary –  Volume of urine passed / Frequency / Dysuria  /
Urgency / Incontinence
• CNS – Vision / Headache / Motor or sensory disturbance/ Loss
of consciousness / Confusion
• Musculoskeletal – Bone and joint pain / Muscular pain 
• Dermatology – Rashes / Skin breaks / Ulcers / Lesions
Closing the consultation
• Thank the patient!
• Summarise the history!
An example: Mitral stenosis
PHYSİCAL EXAMINATION OF
CARDIOVASCULAR SYSTEM
 Physical Examination of Cardiovascular
system
• General appearance/Inspection of the patient
• Measurement of the blood pressure
• Examination of the arterial pulse
• The examination of jugular vein
• The examination of the precordium
• The examination of edema
 General Appearance
• The physical examination, including the general appearance
of the patient, is an extremely important component of
cardiology examinations!!

• It begins as soon as the physician sees the patient.

• Breathlessness, signs of anxiety or discomfort, cyanosis,

jaundice, and anaemia are very important.

• Important clues to a cardiac diagnosis can be obtained

from inspection of the patient.
• The examination begins with an evaluation of the
general appearance of the patient, including;
– His/her age
– Height, weight
– Posture (sitting or lying)
– Demeanor/behavior
– Respiratory pattern
– Chest shape (pectus excavatum, pectus carinatum)
– Skin color (pallor: anemia, cyanosis: peripheral or central,
jaundice)
– Extremities (edema, clubbing, splinter haemorrhages,
peripheral cyanosis)
– Face (xanthelasma, telangiectasia, high facial colouring,
central cyanosis and corneal arcus (abnormal below the age
of 50)).
– Conjunctivae (anaemia, jaundice and conjunctival
haemorrhages, and the tongue examined for cyanosis)
 Jaundice
Pallor of conjunctiva: anemia Xanthelesma: HL

Central cyanosis

Facial rush

Clubbing

Pectus carinatum
Cutaneous venous collaterals Acrocyanosis
Edema
 Cyanosis

• Cyanosis is a bluish discoloration of the skin and

mucous membranes resulting from abnormal
perfusion by either an increased amount of reduced
hemoglobin or abnormal hemoglobin.

– Central
– Peripheral
– Differential
• Central cyanosis is characterized by decreased arterial oxygenation
(in arterial saturation ≤ 85%). It is present with significant right-to-
left shunting at the level of the heart or lungs, which allows
deoxygenated blood to reach the systemic circulation.It is also a
feature of hereditary methemoglobinemia.

• Peripheral or acrocyanosis of the fingers, toes, nose, and ears

reflects reduced blood flow because of small vessel constriction
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 (PA) hypertension with right-to-left shunting at
the great vessel level.
 Clubbing
• Clubbing refers to the swelling of the soft
tissue of the terminal phalanx of a digit with
subsequent loss of the normal angle between
the nail and the nail bed.

• The clubbed finger on the right shows

increased profile and increased nail fold
angles.
– Distal phalangeal finger depth (DPD)–
interphalangeal finger depth (IPD) represents the
phalangeal depth ratio.
– In normal fingers, the IPD is greater than the DPD.
In clubbing, this relationship is reversed. DPD>IPD

• ‘’Schamroth sign’’ In the absence of

clubbing, nail to nail opposition of the index
fingers creates a diamond-shaped window. In
clubbed fingers, the loss of the profile angle
caused by the increase in tissue at the nail
Braunwald, 9. Edition, 2013
 Causes of Clubbing
• Pulmonary malignancy
• Chronic infection (or
inflammation): bronchiectasis, lung
abscess, empyema, pulmonary
tuberculosis, infective endocarditis, crohn
disease
• Cyanotic congenital heart
disease

Rutherford, Circulation. 2013;127:1997–1999

Clinical Clues to Specific Cardiac Abnormalities Detectable from the General
Examination (some examples)
Condition Appearance Associated Cardiac
abnormalities
Marfan syndrome Tall, Long extremities Aortic root dilatation, Mitral
valve prolapse
Jaundice Yellow skin or sclera Right-sided congestive heart
failure,
Prosthetic valve dysfunction
(hemolysis)
Thoracic bony abnormality Pectus excavatum Mitral valve prolapse
Straight back syndrome
Pickwickian syndrome Severe obesity, Somnolence Pulmonary hypertension

Right-to-left intracardiac Cyanosis and clubbing of distal Any of the lesions that cause
shunt extremities, Eisenmenger syndrome,
Differential cyanosis and clubbing Reversed shunt through patent
ductus arteriosus

Anaemia Pallor of the conjunctivae Chronic heart failure

Down syndrome Mental retardation Endocardial cushion defect

Simian crease of palm
Characteristic facies
Scleroderma Tight, shiny skin of fingers with Pulmonary hypertension
contraction
Characteristic taut mouth and
facies
 Physical Examination of Cardiovascular
system

• General appearance/Inspection of the patient

• Measurement of the blood pressure
• Examination of the arterial pulse
• The examination of jugular vein
• The examination of the precordium
• The examination of edema
 Measurement of the blood pressure

• Blood pressure should always be measured in

both arms.

• If systolic blood pressure differs between arms

by more than 10 mm Hg, it is abnormal.
Arterial blood pressure

Sherwood, Fundamentals of Human Physiology, 4.edition, CH 10, 2012

Measuring blood pressure

Use of a sphygmomanometer in determining

blood pressure
Blood flow through the brachial artery in relation to
cuff pressure and sounds
Important aspects of blood pressure
measurements

Braunwald’s Heart Disease, 9. Ed, 2013

 Physical Examination of Cardiovascular
system

• General appearance/Inspection of the patient

• Measurement of the blood pressure
• Examination of the arterial pulse
• The examination of jugular vein
• The examination of the precordium
• The examination of edema
 Examination of the pulse and heart rate

• A pulse wave is produced by

ventricular contraction during
systole.
• Three finger method: palpation
with 2nd–4th fingertips 
• Palpation of the common carotid
artery, radial artery, femoral
artery, popliteal artery, tibialis
posterior artery, and dorsalis pedis
artery.
• The thumb of the examiner
should never be used to take
the pulse as it has its own
strong pulse, which might be
mistaken for the patient's pulse!
 Carotid Arteries
• The pulse of the
carotid artery should never be
palpated bilaterally and
simultaneously!
Each side separately!
– Risk of compression of vessels →
cerebral hypoperfusion → syncope
– Risk of hyperstimulation of
the carotid
sinus reflex → bradycardia/low
blood pressure → cerebral
hypoperfusion → syncope
 Assesment of the arteriel pulse
• Abnormality can be in the:
– Rate (60-100 bpm)
– Rhythm (Regular, irregular)
– Volume
– Character
– Condition of vessel wall
– Radiofemoral delay
 Physical Examination of Cardiovascular
system
• General appearance/Inspection of the patient
• Measurement of the heart rate and blood
pressure
• Examination of the arterial pulse
• The examination of jugular vein (pulse/ pressure
/ distention)
• The examination of the precordium
• The examination of edema
Jugular venous examination (pulse/ pressure / distention)

• The left internal and external

jugular veins anatomically
are opened to the vena cava
superior by angling.

• The right internal jugular

vein connecting to the right
brachiocephalic vein is in
direct line with superior
vena cava, so right jugular
veins are used in the
assessment.
 Jugular venous
examination technique

• Ensure the patient is

positioned at 45°
• Examiner stands at the
right side of the table
• Ask patient to turn their
head away from you
• A penlight can help to
enhance visualization.
Assessment of Jugular venous distention
(JVD)
• JVD is when the increased
pressure of the superior
vena cava causes the jugular
vein to bulge, making it most
visible on the right side of a
person's neck.

• The right external jugular

vein is used for venous
distention assessment.
Examination of the Jugular Venous
Pressure (JVP)
• The JVP reflects pressure in the right
atrium (central venous pressure-CVP)

• Estimation of volume status (Non-

invasive hemodynamic assessment)

• Observe the neck for the JVP – located

inline with the sternocleidomastoid
muscle

• The right internal jugular vein is

preferred because the EJV is valved and
is not directly in line with the superior
vena cava and right atrium.

http://sfgh.medicine.ucsf.edu
 JVP Technique
• Find correct area – helps to
first identify SCM & triangle it
forms with clavicle

• Anatomy of Internal Jugular

Vein Straight line with RA

• Look for multi-phasic

pulsations (‘a’, ‘c’ & ‘v’ waves)

• Isolate from carotid

pulsations, respirations
 JVP Technique
• The JVP is estimated to be the
vertical distance between the
highest point of pulsation and the
right atrium.

• The distance between the angle of

Louis and center of RA is about 5
cm.

• It is measured as the vertical height

of the venous pulsation above the
angle of Louis by ruler- up to 4 cm
being considered normal
https://meded.ucsd.edu/clinicalmed/cvp_movie.htm
Courtesy Chinese University of Hong Kong
http:www.cuhk.edu.hk/cslc/materials/pclm1011/pclm1011.html
• JVP= 5 cm+ vertical
distance from sternal-
manubrial angle to top
of pulse wave

• Normal:
– JVP is 6 to 8 cm above
the right atrium
• Abnormal/ Elevated:
– JVP is > 9 cm above the
right atrium (> 4 cm
above the sternal angle)
 JVP
• Normal JVP  w/ inspiration and 
w/expiration.

• Kussmaul sign is a parodoxical rise in JVP on

inspiration. (constrictive pericarditis,
pulmonary embolism, or RV infarction)
 Elevated JVP causes
• Volume overload
• Right/left heart failure
• Pulmonary embolism
• Pulmonary hypertension
• Tricuspid stenosis or regurgitation
• Constrictive pericarditis
• Pericardial compression/tamponade
• Superior vena cava obstruction
 Juguler venous pulse waveform

• The right IJV is used the assessment

for the jugular venous pulsation.
‘

• The venous waveforms include three

positive waves–a,c and v ; negative
waves x, x’ and y
• A= atrial contraction
• The a wave reflects RA presystolic • X= atrial relaxation
contraction, occurs just after the • C= tricuspid valve
electrocardiographic P wave, and closure
precedes S1. • X’=ventricular systole
• V= atrial filling
• Y= atrial emptying
• The x descent reflects the fall in RA
pressure after the a wave peak.

• The c wave interrupts this descent as

ventricular systole pushes the closed TV
into the RA.

• The x′ descent follows because of atrial

diastolic suction created by ventricular
systole pulling the TV downward.
• A= atrial contraction
• The v wave represents atrial filling, occurs • X= atrial relaxation
at the end of ventricular systole, and • C= tricuspid valve
follows just after S2. closure
• X’=ventricular systole
• The y descent follows the v wave peak and
• V= atrial filling
reflects the fall in RA pressure after TV
opening. • Y= atrial emptying
• In normal individuals, the x′ descent is the
predominant waveform in the jugular venous
pulse.

• The a wave is normally larger than the v

wave, and the x descent is more marked than
the y descent.
Braunwald’s Heart Disease, 9. Ed, 2013
 Physical Examination of Cardiovascular
system
• General appearance/Inspection of the patient
• Measurement of the heart rate and blood
pressure
• Examination of the arterial pulse
• The examination of jugular vein (pulse/ pressure
/ distention)
• The examination of edema
• The examination of the precordium
 Check for pedal edema

• Over medial malleolus or 5 cm

above it with right thumb..

• Apply pressure for minimum 30

seconds…and look for dimple
pitting edema
Examination of Pedal edema

• Some medications (eg. Ca CB)

• Pregnancy
• Deep venous thrombosis
• Congestive heart failure
• Chronic renal disease
• Liver cirrhosis
 Physical Examination of Cardiovascular
system
• General appearance/Inspection of the patient
• Measurement of the blood pressure
• Examination of the arterial pulse
• The examination of jugular vein
• The examination of edema
• The examination of the precordium
 Physical Examination of
Cardiovascular system
• The precordial cardiac examination:
– 4 basic components:
• Inspection
• Palpation
• Percussion (omitted in cardiac exam)
• Auscultation
 Inspection
• Pay attention to:
– Chest shape (pectus excavatum, pectus
carinatum)
– Shortness of breath (rest or walking ?)
– Sitting upright? Able to speak?
– Visible impulse on chest wall from vigorously
contracting ventricle ?
 Chest wall deformities

Pectus carinatum Pectus excavatum Barrel chest

(pigeon chest) (funnel or sunken chest)
• Pectus carinatum= the sternum and ribs are prominently in an outward position
• Pectus excavatum= the sternum and ribs are prominently in an inward position
• Barrel chest= Elevated anteroposterior torax diameter, the AP to transverse
diameter is 1:1, seen in COPD.
• Thoracic deformities can affect the functions of the heart and lungs.
 Palpation
• Apical impulse
• Thrills
• Parasternal lift
 Apex beat
• The apex beat also called the apical
impulse, is the pulse felt at the point
of maximum impulse (PMI).

• The PMI is normally over the left

ventricular apex in the midclavicular
line at the 5th intercostal space.

• It is <2 cm in diameter, and moves

quickly away from the fingers.

• It is best felt at end-expiration, when

the heart is closest to the chest wall.

http://fourthstage2017.byethost16.com/
[OSCE]/Cardiovascular%20Examination
 Apex beat
• Supine position
• Left lateral decubitis
position

• The apical impulse of LV

enlargement is usually
widened or diffuse (>3 cm
in diameter), can be
palpated in 2 interspaces,
and is displaced leftward.
 Parasternal lift
• Precordial motion in
the lower sternal area
usually reflects RV
motion.

• RV pressure overload
(eg, in pulmonary
stenosis) or volume
overload (eg, in ASD)
causes a sustained
outward lift. It is called
‘’parasternal lift’’.
http://fourthstage2017.byethost16.com/[OSCE]/
Cardiovascular%20Examination%20HDD.pdf?i=1
 Thrills
• Palpable vibrations

• Thrills signify turbulent,

high-velocity blood flow,
and help localize the origins
of heart murmurs.

• It can be palpated in
murmurs of 4th degree and
above.
http://fourthstage2017.byethost16.com/[OSCE]/
Cardiovascular%20Examination%20HDD.pdf?i=1
Auscultation: Using your stethescope

 Diaphragm Higher pitched sounds

 Bell  Lower pitched sounds
 Auscultation Technique
• Patient lying at 30-45 degree incline position
• Don’t examine over clothes
–need to see area where placing stethescope
–stethescope must contact skin
• Stethescope with diaphragm at first (higher
pitched sounds)
 Angle of Louis
• The sternal angle (also known as
the angle of Louis or
manubriosternal junction) is the
synarthrotic joint formed by the
articulation of the manubrium
and the body of the sternum.

• The sternal angle is a palpable

clinical landmark in surface
anatomy.
Joshi S et al, Indian J Crit Care Med 2010;14:180-4. 
https://www.earthslab.com/anatomy/sternal-angle/
 Auscultatory sites
• There are four important areas used
for listening to heart sounds.
• These are:
– Aortic area 2nd intercostal space to
the right of the sternum
– Pulmonic area 2nd intercostal space
to the left of the sternum
– Tricuspid area 5th intercostal space
to the left of the sternum
– Mitral Area (Apex)  The intersection
of the 5th intercostal space with the
midclavicular line

http://www.stethographics.com/heart/main/sites.htm
 What are we listening for?

• Normal valve closure creates sound

• First Heart Sound = S1 closure of Mitral, Tricuspid valves
• Second Heart Sound = S2 closure of Aortic, Pulmonic valves
 What are we listening for?
• Systole =time between S1 &
S2;
• Diastole = time between S2 &
S1
• Normally, S1 & S2 = distinct
sounds
• Physiologic splitting =S2
components of second heart
sound (Aortic & Pulmonic
valve closure) audible with
inspiration
References
• Essentials of Bedside Cardiology (2nd Edition); Jules Constant; Humana
Press, New Jersey, 2003.
• Braunwald’s Heart Disease, 9. edition, 2013
• Sherwood, Fundamentals of Human Physiology, 4.edition, 2012
• Mayo Clinic Cardiology: Concise Textbook, 4.edition, 2013
• Bates’ Guide to Physical Examination and History Taking (12th Edition);
Lynn S. Bickley; Wolters Kluwer, 2017.
• Charlie Goldberg, Exam of the CVS, images on ppt
• https://www.slideshare.net/AryaAnish/pulse-abnormal-findings-59418571
• https://www.amboss.com/us/knowledge/Cardiovascular_examination
• https://geekymedics.com/cardiovascular-history/
Thank you…