Kurniyanto, MDInternal MedicineUKI

Chest painShortness of breathAnkle swellingPalpitationsSyncopeIntermittent claudication

Character of painSeverityDurationRadiationAt rest or on exertionPrevious episodes

Relieving factorsWorse on taking a deep breath (pleuritic)Worse on movementAutonomic symptomsSweatingNausea

CardiovascularAnginaStableUnstableMyocardial infarctionAortic dissectionMyocarditisPleuropericardialPericarditisPleurisyPneumothoraxGastrointestinalGastro-oesophageal refluxOesophageal spasm

Chest wallCoughingIntercostal muscle strain/myositisHerpes zosterThoracic radiculopathyRib fractureRib tumourCostochondritis

Unexpected awareness of breathingAt rest or on exertionQuantify exercise tolerance (yards walked, stairs climbed)Orthopnoea = shortness of breath on lying supineNumber of pillowsParoxysmal nocturnal dyspnoea

Airways diseaseCOPDChronic bronchitisEmphysemaAsthmaBronchiectasisCystic fibrosisParenchymal disease PneumoniaPulmonary fibrosisTumourPneumothoraxPulmonary vasculaturePulmonary embolismPulmonary hypertension

Chest wallPleural effusionRib fractureKyphoscoliosisNeuromuscularCardiacLeft ventricular failureMitral valve diseaseCardiomyopathyPericardial effusionOtherAnaemiaAcidosisPsychogenic

Normal Chest RadiographPulmonary Oedema

Unilateral or bilateralProximal extent of oedemaPitting/non-pittingCardiacCongestive cardiac failureRight ventricular failureCor pulmonaleConstrictive pericarditis

DrugsCalcium channel blockersOtherCirrhosis Nephrotic syndromeProtein-losing enteropathyDeep vein thrombosisHypothyroidismLymphoedema

= Unexpected awareness of heartbeatAsk patient to tap palpitations on chestSlow or fastRegular or irregularDurationSpeed of onset or offsetRelieving manoeuvresSinus tachycardiaVentricular extrasystolesAtrial fibrillationAtrial flutterSupraventricular tachycardiaVentricular tachycardia

= Transient loss of consciousness due to cerebral hypoperfusionWhat was the patient doing at the time?Standing for prolonged periodStanding up suddenly (postural hypotension)CoughingProdromal symptomsAbnormal movements (epilepsy)Sensation of room spinning (vertigo)

Pain in one or both calves, thighs or buttocksBrought on by walking a certain distance (claudication distance)Worse on walking uphillRelieved by restSuggests peripheral vascular disease

HyperlipidaemiaDiabetes mellitusSmokingHypertensionObesityFamily history

Rheumatic feverPrevious cardiac investigationsPrevious myocardial infarctionCoronary angioplasty + stent insertionCoronary artery bypass graftingPacemaker insertion

Anti-anginal agentsUse of sublingual nitrate sprayAntihypertensive agentsAnti-arrhythmicsStatinsPlatelet inhibitors, e.g., AspirinAnticoagulants, e.g., Warfarin

Allergies NB Document in front of chart and inform nurses

Occupatione.g., train driver, long distance truck driverSmokingNumber of pack yearsAlcohol intakeStairs at home

Ischaemic heart diseaseAnginaMICABGHypertrophic obstructive cardiomyopathyDilated cardiomyopathy

GeneralHandsPulseBlood pressureFaceNeckJugular venous pressurePrecordiumInspectionPalpationPercussionAuscultationBackAbdomenLower limbsOther

Position patient at 45 degreesRespiratory rateCachexiaMarfans syndromeDowns syndrome

Clubbing Splinter haemorrhages (infective endocarditis)Oslers nodes (tender)Janeway lesions (non-tender)Xanthomata (Hyperlipidaemia)

ClubbingSplinter HaemorrhagesOsler nodes

Radial arteryRate (normal = 60-100)Bradycardia (100)RhythmRegularIrregularRadiofemoral delay (coarctation of the aorta)

Character and volume assessed from carotid arteryCollapsing pulse (aortic regurgitation)Pulsus alternans (left ventricular failure)Pulse deficit (atrial fibrillation)

SphygmomanometerSystolic/diastolic pressureNormal

JaundiceXanthelasmataCorneal arcusMalar flush (mitral stenosis)High arched palate (Marfans syndrome)Dental caries (infective endocarditis)

Central cyanosis Carotid pulse characterCarotid bruit

CORNEAL ARCUSXANTHELASMATA

Internal Jugular vein

Patient at 30-45 degreesGood lightingInternal jugular veinReflects right atrial pressureZero point = sternal angleVisible but not palpableComplex wave form (a, c, v waves) Decreases on inspiration

Fills from aboveHepatojugular refluxAbnormal if >3 cm above zero point:RV failureRV infarctTricuspid stenosisTricuspid regurgitationPericardial effusionSVC obstructionFluid overload

ScarsMedian sternotomyCABGValve replacementLateral thoracotomyInfraclavicular (pacemaker)Pectus excavatumPacemaker boxApex beat

Sternotomy scarPectus excavatum

Apex beatLocationCharacterHeavingThrustingDoubleTappingParadoxicalLeft parasternal heaveThrills (palpable murmurs)SystolicDiastolicPacemaker box

To identify left and right limit of heartRight heart limit : determine the hepatic-lung borders in midclavicle line then up for 2 fingers then percuse gentle to the medial, note the changing from soner dallLeft heart limit : determine the gastric-lung borders in anterior axilaris line then up for 2 fingers then percuse gently to the medial, note the cahnging from sonor --? dall

Bell low pitched soundsDiaphragm high pitched soundsMitral Tricuspid Pulmonary Aortic areasS1 (first heart sound)S2 Splitting (A2, P2)

Loud S1 Soft S1Loud A2Loud P2Soft A2Splitting of S1Increased splitting of S2Fixed splitting of S2Reversed splitting of S2S3 (third heart sound)S4 (fourth heart sound)Summation gallop Opening snapSystolic ejection clickMid-systolic clickTumour plopPericardial knockMetallic click

Timing of murmurSystolicDiastolicContinuousSite of maximal intensityLoudnessGrades I-VIThrill

PitchRadiation

DescribeIntensity: GradeIVery faint Hardly heardIIFaint Clearly audible but quietIIIModerately loudIVLoudAssociated with thrillVVery loudThrill easily palpatedVIVery loudVisible heave or liftHeard with stethoscope not in contact with chest

SystolicPansystolicMitral regurgitationTricuspid regurgitationVentricular septal defectEjection systolicAortic stenosisPulmonary stenosisAtrial septal defectLate systolicMitral valve prolapseDiastolicEarly diastolicAortic regurgitationPulmonary regurgitationMid-diastolicMitral stenosisTricuspid stenosisAtrial myxomaContinuousPatent ductus arteriosusArteriovenous fistulaPericardial friction rub

Percuss and auscultate lung basesLeft ventricular failurePleural effusionSacral pitting oedemaRight heart failure

Patient lying with one pillow (if tolerated)Tender hepatomegalyPulsatile liver (tricuspid regurgitation)AscitesSplenomegalyAbdominal aortic aneurysm

Peripheral oedemaPitting/non-pittingUpper levelCapillary returnTrophic skin changesPalpate arteriesFemoralPoplitealPosterior tibialDorsalis pedisBuergers test (peripheral vascular disease)

Dorsalis pedis pulsePosterior tibial pulse

ECGEchocardiographyDoppler Treatmill Cardiac catheterization Blood laboratoriesOthers .......