Methods of Examination 1 . Patients with diseases of the heart usually complain of dyspnoea, i.e


Patients with diseases of the heart usually complain of dyspnoea, i.e. distressing feeling of air deficit. Dyspnoea is a sign of the developing circulatory insufficiency, the degree of dyspnoea being a measure of this insufficiency. When questioning the patient, it is therefore necessary to find out the conditions under which dyspnoea develops. At the initial stages of heart failure, dyspnoea develops only during exercise, such as ascending the stairs or a hill, or during fast walk. Further, it arises at mildly increased physical activity, during talking, after meals, or during normal walk. In advanced heart failure, dyspnoea is observed even at rest. Cardiac dyspnoea is caused by some factors which stimulate the respiratory centre.

Attacks of asphyxia, which are known as cardiac asthma, should be differentiated from dyspnoea. An attack of cardiac asthma usually arises suddenly, at rest, or soon after a physical or emotional stress, sometimes during night sleep. It may develop in the presence of dyspnoea. In paroxysmal attacks of cardiac asthma, the patient would usually complain of acute lack of air; respiration becomes stertorous, the sputum is foamy with traces of blood.

Patients often complain of palpitation. They feel accelerated and intensified heart contractions. Palpitation is determined by the increased excitability of the patient's nerve apparatus that controls heart activity. Palpitation is a sign of affection of the heart muscle in cardiac diseases such as myocarditis, myocardial infarction, congenital heart diseases, etc., it may arise as a reflex in diseases of some other organs, in fever, anaemia, neurosis, hyperthyroidism, and after administration of some medicinal preparations (atropin sulphate, etc.). Palpitation may also occur in healthy persons under heavy physical load, during running, emotional stress, smoking or coffee abuse. Patients with serious heart diseases may feel palpitation constantly, or it may arise in attacks of paroxysmal tachycardia.

Some patients complain of intermissions (escaped beats) which are due to disorders in the cardiac rhythm. Intermissions are described by the patient as the feeling of sinking, stoppage of the heart. Questioning the patient is aimed at determining the circumstances under which intermissions

develop. They may arise at rest or during exercise, they may be intensified in special postures of the patient, etc.

Pain in the heart region is an important and informative sign. The character of pain is different in various diseases of the heart. The physician should determine (by questioning) the location of the pain, the cause or condition under which it develops (exercise, emotional stress, walking, attack of pain at rest, during night sleep), the character of pain (acute, boring, piercing, a feeling of heaviness or retrosternal pressure, small boring pain in the region of the apex), duration and radiation of pain, conditions under which the pain abates. Pain often develops due to acute insufficiency of the coronary circulation, which results in myocardial ischaemia. This pain syndrome is called stenocardia or angina pectoris. In angina pectoris pain is retrosternal or slightly to the left of the sternum; it most commonly radiates to the region under the left scapula, the neck, and the left arm. The pain is usually associated with exercise, emotional stress, and is abated by nitroglycerin. Angina pectoris pain occurs mostly in patients with coronary atherosclerosis but it may arise in inflammatory diseases of the vessels, e.g. rheumatic vasculitis, syphilitic mesaortitis, periarteritis nodosa, and also in aortal heart diseases and grave anaemia.

Pain is especially intense in myocardial infarction and, unlike in angina pectoris, it persists for a few hours, and sometimes for several days. It does not abate after vasodilatory preparations are given. Pain in dissecting aneurysm of the aorta is piercing (like in myocardial infarction). Unlike in myocardial infarction, pain radiates usually to the spinal column, and moves gradually along the course of the aorta. Myocarditis is characterized by intermittent and pressing pain; it is dull, mild, and is intensified during exercise. Pain in pericarditis is located at the middle of the sternum or throughout the entire cardiac region; the pain is stabbing or shooting, and is intensified during movements, cough, even under the pressure of a stethoscope; the pain may persist for several days or arise in attacks. Permanent pain behind the manubrium sterni that does not depend on exercise or emotional stress (the so-called aortalgia) occurs in aortitis. Stabbing pain at the heart apex that arises in emotional stress or fatigue is characteristic of cardioneurosis. It should be remembered that pain in the cardiac region may arise due to affections of intercostal muscles, nerves, pleura, or the adjacent organs (diaphragmatic hernia, cholecystitis, ulcer, gastric cancer).

Patients with heart diseases often complain of cough which is due to congestion in the lesser circulation. The cough is usually dry; sometimes a small amount of sputum is coughed up. Dry cough is also observed in aortal aneurysm because of the stimulation of the vagus nerve. Haemoptysis in grave heart diseases is mostly due to congestion in the lesser circulation and

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rupture of fine bronchial vessels (e.g. during coughing). Haemoptysis mostly occurs in patients with mitral heart disease. It may occur in embolism of the pulmonary artery. When the aneurysm opens into the respiratory ducts, profuse beeding occurs.

Venous congestion in the greater circulation occurs in severe heart diseases (see " Circulatory Insufficienty" ). The patients would complain of oedema, which first develops only in the evening and resolves during the night sleep. Oedema occurs mostly in the malleolus region and on the dorsal side of the foot; shins are then affected. In graver cases when fluid is accumulated in the abdominal cavity (ascites) the patient would complain of heaviness in the abdomen and its enlargement. Heaviness most commonly develops in the right hypochondrium due to congestion and enlargement of the liver. In rapidly developing congestion, pain is felt in this region due to distention of the liver capsule. Patients may complain also of poor appetite, nausea, vomiting, and swelling of the abdomen. These symptoms are associated with disordered blood circulation in the abdominal organs. The renal function is upset for the same reason and diuresis decreases.

Patients with cardiovascular pathology often have dysfunction of the central nervous system, which is manifested by weakness, rapid fatigue, decreased work capacity, increased excitability, and deranged sleep. Complaints of headache, nausea, noise in the ears or the head are not infrequent in essential hypertension patients.

Some heart diseases (myocarditis, endocarditis, etc.) are attended by elevated (usually subfebrile) temperature; sometimes high fever may occur. The patient should be asked about the time of the day when the temperature usually rises, how long it persists and if this rise is accompanied by chills, profuse sweating, etc.

History of present disease. The time of the onset of the disease and its first symptoms should be determined such as pain, palpitation, dyspnoea, elevation of the arterial pressure, the character and intensity of these symptoms, connection with infections and other diseases of the past, cooling, and physical overloads. The character of development of the primary symptoms is important. It is also necessary to find out if any treatment was given and its effect, if any. If there were exacerbations of the disease, their course and causes should be established.

Anamnesis. Special attention should be paid to various possible causes of the present heart disease. Information should be carefully collected concerning diseases of the past, especially such diseases as rheumatism, frequent tonsillitis, diphtheria, syphilis, which would normally provoke cardiovascular pathology. It is important to know the unfavourable living and working conditions, chronic exposure to cold and high humidity, nervous

and psychic overstrain, hypodynamia, overeating, occupational hazards, smoking and alcohol abuse and other harmful habits. It is also important to ask the patient about cardiovascular diseases that occurred in his relatives, because familial predisposition to some heart diseases is possible. It is necessary to inquire women about past pregnancies and labour, the onset of menopause because sometimes symptoms of cardiovascular pathology develop in them during this period.

Physical Examination


The general appearance of the patient, his posture in bed, colour of the skin and visible mucosa, the presence or absence of oedema, the shapes of the terminal finger phalanges (drum-stick fingers) and of the belly should be assessed. Patients with a marked dyspnoea usually assume a half-sitting position; if dyspnoea is grave, the patient assumes a forced position; he sits in bed with the legs on the floor (orthopnoea). Greater portion of blood is retained in the vessels of the lower extremities in this position to decrease the volume of the circulating blood and congestion in the lesser circulation. Lung ventilation is thus improved. Furthermore, the diaphragm descends in the orthopnoeic position; if ascites is present, the pressure of the ascitic fluid on the diaphragm is lessened to facilitate respiratory excursions of the lungs and to improve gas exchange.

Patients with exudative pericarditis choose to sit in bed slightly leaning forward. Patients with enlargement of the heart lie on the right side because they feel discomfort when lying on the left side (the dilated heart more tightly presses the anterior wall of the chest).

Cyanotic skin is a common sign of heart diseases. In patients with circulatory disorders, cyanosis is more pronounced in parts of the body that are farther remoted from the heart, i.e. the fingers and toes, the tip of the nose, the lips, and the ear lobes. This phenomenon is known as acro-cyanosis. It depends on the increased content of reduced haemoglobin in the venous blood because of excessive oxygen absorption by tissues in slow circulation of the blood (see " Circulatory Insufficiency" ). In other cases, cyanosis becomes central in conditions of oxygen hunger of blood due to its insufficient arterialization in the pulmonary bed. The degree of cyanosis varies from a slightly detectable blue tinge to the dark blue colour. Cyanosis is especially pronounced in patients with congenital heart diseases and arteriovenous shunting. It should be remembered that cyanosis can arise in poisoning by chemicals or drugs that form methaemoglobin and sulphmethaemoglobin.

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The colour of the skin is important for diagnosis of some heart diseases. Mitral stenosis can be diagnosed by the violet-red colour of the patient's cheeks, mildly cyanotic colour of the lips, nose, and extremities. The skin and visible mucosa of patients with aortal heart diseases are usually pale. Cyanosis in combination with pallor (pallid cyanosis) is characteristic of stenosis of the orifice of the pulmonary trunk or thrombosis of the pulmonary artery. Icteric colour of the sclera and skin is characteristic of grave circulatory insufficiency. The skin of patients with persisting septic endocarditis has a peculiar colour resembling that of coffee with milk.

Oedema frequently attends heart diseases. If the patient stays out of bed, oedema is localized mainly in the malleolus, the dorsal side of the feet, and the shins, where a pressure of fingers leaves slowly levelling impressions. If the patient lies in bed, oedema is localized in the sacrolumbar region. If oedema is significant, it may extend onto the entire body while the ascitic fluid accumulates in various cavities of the body, such as the pleural cavity (hydrothorax), abdominal cavity (ascites), or in the pericardium (hydropericardium). Generalized oedema is called anasarca. The oedematous skin, especially the skin of the extremities, is pallid, smooth, and tense. In persistent oedema, the skin becomes rigid, its elasticity is lost, and the skin acquires a brown tinge due to diapedesis of erythrocytes from the congested vessels. Linear rhexes may develop in the subcutaneous fat of the abdomen in pronounced oedema, which resemble the scars of pregnancy. In order to assess objectively the degree of oedema, the patient should be weighed regularly and the amount of liquid taken and excreted should be strictly recorded.

Local oedema sometimes develops in cardiovascular pathology. When the superior vena cava is compressed, for example in exudative pericarditis or aneurysm of the aortal arch, the face, neck, and the shoulder girdle can be affected by oedema (the collar of Stokes). In thrombophlebitis of the shin or thigh oedema of the affected extremity forms; ascites develops during thrombosis of the portal vein or the hepatic veins.

The shape of the nails and terminal phalanges of the fingers is informative. Drum-stick (Hippocratic) fingers are characteristic of subacute septic endocarditis and some congenital heart diseases.

Inspection of the heart region and peripheral vessels. Cardiac " humpback" can be seen during inspection of the precordium. This is bulging of the area over the heart, the degree of protrusion depending on the enlargement and hypertrophy of the heart (provided these defects develop in childhood when the chest is liable to changes). General protrusion of the cardiac region and levelling of the costal interspaces are observed in massive effusive pericarditis. The cardiac humpback should be differen-

tiated from deformation of the chest caused by changes in the bones, e.g.

in rickets.

In patients with underdeveloped subcutaneous fat and asthenic body build, a limited rhythmic pulsation (the apex beat) can be seen in the fifth interspace, medially of the midclavicular line. This is caused by the thrust of the heart apex against the chest wall. In cardiac pathology, the apex beat may produce a stronger pulsation (see " Palpation of the Heart" ). If precordial depression is found instead of prominence, the apex beat is said to be negative. It occurs in adhesive pericarditis because of adhesion of the parietal and visceral layers of the pericardium.

Pulsation is sometimes observed to the left of the sternal line over a vast area extending to the epigastric region. This is the so-called cardiac beat. It is due to contractions of the enlarged right ventricle; a synchronous pulsation can also be seen in the upper epigastric region (below the xiphoid process).

Pulsation in the region of the heart base is sometimes observed. Pulsation of the aorta can be felt in the second costal interspace to the right of the sternum; it appears either during its strong dilation (aneurysm of the ascending part and of the arch of the aorta; aortic valve incompetence), or in sclerotic affection of the overlying right lung. In rare cases, the aneurysm of the ascending aorta can destroy the ribs and the sternum. Elastic throbbing tumour is then seen. Pulsation in the second and third costal interspace, that can be seen by an unaided eye, is caused by dilatation of the pulmonary trunk. It occurs in patients with mitral stenosis, marked hypertension in the lesser circulation, pttent ductus arteriosus with massive discharge of the blood from the aorta to the pulmonary trunk, and in primary pulmonary hypertension. Pulsation occurring lower, in the third and fourth interspace to the left of the sternum, can be due to the aneurysm of the heart in post-infarction patients.

Inspection of the vessels is very important for assessing the cardiovascular system. Swollen and tortuous arteries, especially temporal arteries, are found in patients with essential hypertension and atherosclerosis; this is the result of their elongation and sclerotic changes. Pulsation of the carotids can only be observed in healthy persons; this pulsation is synchronous with the apex beat. In pathological conditions, mainly in aortic valve incompetence, pronounced pulsation of the carotid arteries can be observed (carotid shudder). Synchronously with pulsation of the carotid arteries, the head of the patient may rhythmically move. This is de Musset's sign. Pulsation of arteries, e.g. subclavian, brachial, radial and other arteries can also be observed. Even arterioles may pulsate (the so-called capillary pulse). In order to reveal the capillary pulse, the finger nail should be slightly pressed in order to form a small white spot: the

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Chapter 6. Blood Circulatory System


margin between the red and blanched part will be seen to ebb and flow with each pulse beat. Similar pulsation can be seen on hyperaemic skin, e.g. of the forehead, after rubbing it. The name " capillary pulse" is not quite correct because it mostly depends on pulse variations in the arterioles. Capillary pulse can be found in patients with aortic valve failure and sometimes in thyrotoxic goitre.

During inspection of the veins the physician can observe their overfilling and dilation. This picture is found in general venous congestion and also in local disorders of blood outflow from the veins. The general venous congestion is caused by affection of the right heart and also by diseases that increase intrathoracic pressure and interfere with the outflow of venous blood through the venae cavae. The neck veins are dilated and become swollen. Local congestion is caused by compression of the vein from the outside (tumour, scars, etc.), or by its thrombosis. Local venous stasis is characterized by dilation of collaterals, while oedema is formed at the site where blood outflows through the corresponding vein. In conditions of difficult outflow of blood through the superior vena cava, dilated are the veins of the head, neck, upper extremities, and the anterior surface of the trunk. Via the collaterals the blood is delivered to the system of the inferior vena cava, i.e. the blood flow in the dilated veins (the subcutaneous veins of the chest included) is directed downward. In conditions of difficult blood outflow through the inferior vena cava, the veins of the lower extremities and lateral surfaces of the abdominal wall are dilated. The blood flow in this case is directed into the system of the superior vena cava, i.e. upwards. If the blood outflow through the portal vein is difficult, the collaterals, connecting the system of the portal vein with the vena cava, become arranged round the umbilicus to form the caput Medusae and the blood is directed through the dilated superficial veins to the system of the superior and inferior vena cava. In order to determine the direction of the blood flow in dilated veins, a length of a thick vein is pressed by the finger (after the blood is displaced from it). As the vein becomes filled, the direction of the blood flow can easily be determined: when it is directed downward, the vein portion lying above the compressed site is filled, it is directed upward when the part below this point is filled.

Jugular veins can be seen pulsating on the neck. Blood flow in the jugular vein is slowed down during atrial systole and accelerated during ventricular systole. The neck veins somewhat swell when the blood flow slows down, and collapse when the blood flow is accelerated. It follows that the veins collapse during systolic dilation of the arteries. This is the so-called negative venous pulse. It is hardly noticeable in healthy persons and becomes more evident when the veins are filled with blood due to congestion. Pulsation of the jugular veins caused by pulsation of the carotid

arteries can be mistaken for the venous pulse. It should therefore be remembered that pulsation of the carotid artery can be seen medially of the sternocleidomastoid muscle, while pulsation of the vein laterally of this muscle. Moreover, if the vein is pressed by a finger along its course, the transmitted vibrations of the peripheral portion of the vein become more visible, whereas pulsation of this portion discontinues in genuine venous pulse. Distinct pulsation of the neck vessels in the presence of a slow pulse on the radial artery is caused by venous and not by arterial pulsation.


Palpation of the heart helps reveal more accurately the apex beat, the presence of the cardiac beat, the visible pulsation, or detect cat's purr symptom. In order to determine the apex beat, the palm of the right hand is placed on the patient's chest. (The left mammary gland in women is first moved upward and to the right.) The base of the hand should be rested on the sternum, while the fingers should be directed toward the axillary region, between the 3rd and 4th ribs. The terminal phalanges of three fingers should be flexed to form a right angle to the surface of the chest, and moved slowly along the interspaces toward the sternum until the moderately pressing fingers feel the movement of the heart apex. If the apex beat is felt over a considerable area, its borders are outlined by locating the extreme left and lower points of the protruding area, which is considered to be the point of the apex beat. The apex beat can be better detected if the patient slightly leans forward, or by palpation during a deep expiration: in this position the heart is pressed closer to the chest wall.

A normal apex beat is found in the fifth interspace, 11.5 cm toward the sternum from the left midclavicular line. When the patient lies on his left side, the beat is displaced 34 cm to the left, and 1-1.5 cm to the right when the patient lies on the right side. Stable displacement of the apex beat may depend on the changes in the heart itself or the adjacent organs. For example, if the left ventricle is enlarged, the apex beat is displaced to the left to the axillary line, and downwards to the 6th and 7th interspace. If the right ventricle is dilated, the apex beat may be displaced to the left as well because the left ventricle is moved to the left by the distended right ventricle. In cases with abnormal congenital heart position, e.g. in dextrocardia, the apex beat is felt in the fifth costal interspace, 1-1.5 cm toward the sternum from the right midclavicular line.

The position of the apex beat depends also on the diaphragm. Increased pressure in the abdominal cavity (in pregnancy, ascites, meteorism, tumours) displaces the apex beat upward and to the left because the heart is not only lifted but also turned to the left to assume a horizontal position. If

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the diaphragm is low (after childbirth, wasting, visceroptosis), the apex beat is displaced downward and slightly to the right to assume the more vertical position.

In the presence of effusion or gas in the right pleural cavity, the apex beat is displaced to the left accordingly. Pleuropericardial adhesions and sclerotic affection of the lungs due to growth of connective tissue in them displace the heart to the involved side. In patients with left-sided pleurisy with effusion and in accumulation of the fluid in the pericardial region, the apex beat disappears. In about one third of cases the apex is impalpable (covered by the rib).

If the apex beat is palpable, its properties are determined: width (or area), height, strength, and resistance. If the area exceeds 2 cm in diameter, apex beat is considered diffused; if the area is smaller, the apex beat is restricted. Most frequent and important diagnostic cause of diffuse apex beat is enlargement of the heart, especially of the left ventricle. The width of the apex beat may increase also due to a closer contact of the heart apex to the chest wall, in patients with thin thoracic wall, wide interspaces, sclerotic affection of the lower border of the left lung, displacement of the heart anteriorly by a growing tumour of the mediastinum, etc. The area of the apex beat decreases in patients with developed or oedematous subcutaneous fat tissue, narrow interspaces, emphysema of the lungs, and low diaphragm.

The height of the apex beat is the amplitude of vibration of the chest wall at the apex beat area. High and low apex beats are thus differentiated. This property of the apex beat usually varies with the width. Moreover, the height of the apex beat depends on the contractile strength of the heart. When a person is excited, performs exercises, or has fever, or thyrotox-icosis, the height of the apex beat increases due to the increased contractions of the heart.

The strength of the apex beat is estimated by the pressure that the heart apex thrusts against the palpating fingers. Like the former two properties, the strength of the thrust depends on thickness of the chest wall and the distance from the heart apex to the examining fingers; but it depends mostly on the strength of contractions of the left ventricle. Forced apex beat occurs in hypertrophy of the left ventricle; if hypertrophy is concentric, the beat strength may increase, the width of the beat remaining the same.

Resistance, i.e. density of the heart muscle, is another property of the apex beat that can be determined in addition to its height, width, and strength. Density of the left ventricular muscle considerably increases with its hypertrophy to cause resistant apex beat. Hypertrophy of the left ventricle is characterized by diffuse, high, forced, and resistant apex beat. In pronounced hypertrophy of the left ventricle attended by its dilation, the

apex of the heart becomes tapered and can be felt by the palpating fingers as a dense and firm dome.

Extra-apical pulsations. Aortic pulsation is not palpable in healthy subjects (except in asthenic persons with wide costal interspaces). Palpation can be used to detect pulsation of the aorta during its distension. If the ascending part of the aorta is dilated, pulsation can be felt to the right of the sternum, and if the aortic arch is dilated, the pulsation can be felt in the region of the sternal manubrium. Aneurysm or pronounced dilation of the aortic arch is characterized by pulsation in the jugular fossa (retrosternal pulsation). Thinning and usure of the ribs or the sternum can be caused by the pressure of the dilated aorta.

Epigastric pulsation, i.e. visible protrusion and retraction of the epigastric area, is synchronous with the heart work, and may depend not only on hypertrophy of the right ventricle, but on the pulsation of the abdominal aorta and the liver. Epigastric pulsation due to hypertrophy of the right ventricle is usually felt under the xiphoid process and becomes especially vivid during deep inspiration, whereas pulsation caused by the abdominal aorta is slightly lower and becomes less marked during deep inspiration. Intact abdominal aorta can pulsate in asthenic patients with a flaccid abdominal wall.

Pulsation of the liver can be detected by palpation. True and transmitted pulsations of the liver are distinguished. The true liver pulsation is the so-called positive venous pulsation; it may be seen in patients with tricuspid valve incompetence. During systole, the blood flows back from the right atrium to the inferior vena cava and hepatic veins. The liver therefore swells rhythmically with each heart contraction. The transmitted pulsation depends on the impulses transmitted by the contracting heart. Each systolic contraction displaces the entire mass of the liver in one direction.

The symptom of a cat's purr, i.e. low vibrating murmur, resembles purring of a cat. It is of great value in the diagnosis of heart diseases. This sign depends on the same causes that are responsible for the murmur arising in stenosed valve orifices. In order to determine the thrill, the palpating hand should be placed flat on the points where the heart is normally auscultated. Cat's purr palpated over the heart apex during diastolic contraction is characteristic of mitral stenosis, and thrills felt over the aorta during systole indicate stenosed aortic orifice.


Percussion is used to determine the size, position and shape of the heart and the vascular bundle. The right contour of dullness of the heart and the vascular bundle is formed (from top to bottom) by the superior vena cava

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Chapter 6. Blood Circulatory System


to the upper edge of the 3rd rib and by the right atrium at the bottom. The left contour is formed by the left part of the aortic arch at the top, then by the pulmonary trunk, by the auricle of the left atrium at the level of the 3rd rib and downward by a narrow strip of the left ventricle. The anterior surface of the heart is formed by the right ventricle. Being an airless organ, the heart gives a dull percussion sound. But since it is partly covered on its sides by the lungs, dullness is dual in its character, i.e. it is relative (deep) and absolute (superficial). The relative cardiac dullness is the projection of its anterior surface onto the chest. It corresponds to the true borders of the heart, while the absolute dullness corresponds to the anterior surface of the heart that is not covered by the lungs. Percussion can be done with the patient in both erect and lying position. It should, however, be remembered that the area of cardiac dullness in the vertical position is smaller than in the horizontal. This is due to mobility of the heart and the displaceqient of the diaphragm as the patient changes his posture.

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