Clinical Skills

Cardiac History Taking

Key Framework for Cardiac History

Main Symptoms to Ask About:
✔️ Chest Pain – SOCRATES (Site, Onset, Character, Radiation, Associations, Timing, Exacerbating/Relieving factors, Severity).
✔️ Dyspnea (Shortness of Breath) – Exertional? Orthopnea? Paroxysmal nocturnal dyspnea (PND)?
✔️ Palpitations – Fast or irregular? Triggers? Duration?
✔️ Syncope (Fainting) – Before, during, after details? Cardiac red flags?
✔️ Edema (Swelling) – Bilateral? Pitting? Associated with heart failure?
✔️ Claudication (Limb Pain on Walking) – Suggests peripheral arterial disease.

Risk Factor Assessment:

Hypertension, Diabetes, Smoking, Family History, Hyperlipidemia.

Physical Examination Guide

General Inspection

Signs of Heart Disease: Cyanosis, clubbing, peripheral edema.

  1. Skin & Nails: Splinter hemorrhages, Janeway lesions (infective endocarditis).

  2. Face & Neck: Malar flush (mitral stenosis), xanthelasma (hyperlipidemia).

Cardiac Auscultion & Special Maneuvers

Key Heart Sounds & Murmurs:

Normal Heart Sounds

  • S1: Closure of mitral & tricuspid valves.

  • S2: Closure of aortic & pulmonary valves.

Abnormal Heart Sounds

  • S3 (Gallop): Suggests heart failure or volume overload.

  • S4: Stiff ventricle in hypertrophic cardiomyopathy (HCM) or aortic stenosis.

Special Maneuvers to Enhance Findings

  • Valsalva (Straining): Increases murmur in hypertrophic cardiomyopathy (HCM).

  • Standing vs. Squatting: Increases HCM murmur, decreases aortic stenosis murmur.

  • Handgrip: Increases regurgitant murmurs (mitral/aortic regurgitation).

  • Inspiration: Increases right-sided heart murmurs.

A. Confirm the Basics

  • Patient Information: Ensure ECG belongs to the correct patient.

  • Calibration & Paper Speed: Standard settings are 25 mm/sec and 10 mm/mV

D. Analyze the P Wave, the PR Interval & the QT Interval

  • P wave morphology: Tall in right atrial enlargement, wide in left atrial enlargement.

  • PR Interval (Normal: 120-200 ms):

    • Short PR: Pre-excitation (e.g., WPW syndrome).

    • Prolonged PR: First-degree AV block..

  • QTc Prolongation (>460 ms in women, >450 ms in men): Risk for Torsades de Pointes.

  • Short QT: Can indicate hypercalcemia.

Vital Signs & Peripheral Vascular Examination

  1. Pulse: Rate, rhythm (regular/irregular), character (bounding, weak, pulsus paradoxus).

  2. Blood Pressure: Look for pulses paradoxus, orthostatic changes, and wide/narrow pulse pressure.

  3. Carotid Pulse: Slow upstroke in aortic stenosis, bounding in aortic regurgitation.

  4. Radial-Femoral Delay: Suggests coarctation of the aorta.

Volume Status Examination

  1. Peripheral Edema: Right heart failure, venous stasis.

  2. JVP (Jugular Venous Pressure): Elevated in right heart failure; Kussmaul’s sign in constrictive pericarditis.

Step-By-Step Approach to ECGs

B. Determine the Heart Rate & Assess the Rhythm

  • Method 1: 300 / number of large squares between R waves (for regular rhythms).

  • Method 2: Count QRS complexes in a 6-second strip and multiply by 10 (for irregular rhythms).

  • Is it regular or irregular?

  • Look at P waves:

    • Are they present before every QRS?

    • Is the PR interval constant?

    • Are there extra or missing P waves?

  • Common rhythms: Sinus rhythm, atrial fibrillation, atrial flutter, AV blocks

E. QRS Complex Analysis

  • Duration:

  • Narrow (<120 ms) = Supraventricular origin.

  • Wide (>120 ms) = Ventricular origin or bundle branch block.

  • Morphology:

  • RBBB: rSR’ in V1, wide S wave in Lead I.

  • LBBB: Deep S wave in V1, broad R wave in V6.

Precordial Examination

  1. Apical Impulse (PMI):

    • Displaced in cardiomegaly.

    • Sustained in aortic stenosis, diffuse in dilated cardiomyopathy.

  2. Parasternal Heave: Right ventricular hypertrophy (RVH).

  3. Thrills: Palpable murmurs, commonly in aortic stenosis.

Resources

Videos & Online Tutorials:

C. Evaluate the Axis

  • Normal Axis: -30° to +90° (Lead I and aVF both positive).

  • Left Axis Deviation: Seen in left ventricular hypertrophy, left anterior hemiblock.

  • Right Axis Deviation: Seen in right ventricular hypertrophy, pulmonary hypertension

F. ST Segment and T-Wave Analysis

  • ST Elevation: Myocardial infarction (STEMI criteria).

  • ST Depression: Ischemia, LVH strain pattern.

  • T Wave Changes: Peaked in hyperkalemia, flattened in hypokalemia, inverted in ischemia.