b865_Chapter-01.

qxd 3/16/2010 4:46 PM Page 1

Chapter 1

Clerking Patients

Clerking patients may seem a daunting task initially, but it is an

important skill to master. A well performed history and examination
allows you to not only reach an appropriate differential diagnosis, and
thus request relevant investigations, but also to develop an effective
doctor–patient relationship. This chapter will ensure that you struc-
ture your history taking, and will point out the important questions
to ask. It will help you to focus on understanding symptomatology,
common abnormal examination findings and your presentation
technique.

1.1 History Taking

It is vital to have a structure, at least The key cardiac symptoms are:
in your head, on which to base your • Chest pain
history as the patient rarely gives • Dyspnoea
you the information needed in an • Palpitations
orderly fashion. • Oedema
• Syncope

1.1.1 Five simple steps to taking a cardiac history

Step 1: Ask about the presenting complaint:
Also make sure you cover the following, which are the main cardiac
symptoms:

• chest pain
• dyspnoea/shortness of breath

1
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 2

2 Chapter 1

• palpitations
• syncope
• oedema.

Bear in mind that none of the above symptoms are cardiac specific;
they can be caused by non-cardiac pathology, and therefore thought-
ful directed questioning of each symptom can help determine its
cause. If a patient presents with any one of these symptoms, do not
forget to enquire about the others. Try to keep in mind the causes of
each symptom, as this will help direct your questioning.

Step 2: Always ask about the five major risk factors, namely:

• high blood pressure

• hypercholesterolaemia
all modifiable
• smoking
• diabetes
• family history of cardiac disease — non-modifiable.

Step 3: Don’t neglect the past medical history, including:

• heart disease and previous cardiac investigations or procedures

including angioplasty/stent/bypass grafting
• history of stroke/transient ischaemic attack
• history of peripheral vascular disease
• asthma — as B-blockers and adenosine can cause bronchospasm
• rheumatic fever — predisposition to valve disease
• thyroid disease — can cause palpitations and exacerbate heart failure.

Step 4: A full drug history:

• remember that patients don’t often list aspirin or inhalers

spontaneously
• any drug allergies? Be specific — patients do not always understand
this question. Did the patient have an anaphylactic reaction/
rash/nausea/vomiting, or did they simply not benefit from taking
the drug?
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 3

Clerking Patients 3

Step 5: Patient’s social circumstances:

• occupation (for example, taxi drivers and airline pilots have strict
occupational health regulations)
• implications post-myocardial infarction
• who lives at home with the patient?
• pre-morbid health — before this admission what was the patient’s
level of independence and activity? Gives an idea on what to aim
for prior to discharge
• alcohol history — predisposition to hypertension, cardiomyopa-
thy and atrial fibrillation.

1.2 Chest Pain

Chest pain is a simple shorthand that we use to describe a wide vari-
ety of experiences. You’ll be surprised at how often you and the
patient may not be referring to the same thing! For example, does the
patient mean an ache, heartburn, or heaviness in the chest? Finding
out the nature or characteristics of the pain can provide important
clues as to whether or not the pain is cardiac in nature.
There are two critical features of cardiac chest pain:

1. Location of the pain may be typically symmetrical across the cen-

tre of the chest, potentially including both shoulders and arms,
and may radiate up the neck to the jaw. It may be more dominant
on the left side.
2. Exertional relationship — coronary pain will always get worse
when the patient is physically active. Pain that occurs randomly
at rest and during exercise with no exertional link is usually non-
cardiac in origin. Pain that has a habitual pattern of only occurring
at rest is very unlikely to be cardiac.

Ask about associated shortness of breath and autonomic symptoms

such as nausea and sweatiness. Glyceryl trinitrate (GTN) will usually
offer some symptom relief, whether the patient is experiencing angina
or a myocardial infarction. However, if pain lasts for more than
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 4

4 Chapter 1

20 minutes with or without relief by GTN, consideration of a myocar-

dial infarction (MI) is warranted.

1.2.1 The key features of cardiac chest pain

crushing pain/tightness over

central chest Levine’s sign = patient’s

+/− radiation to jaw/down the left using a clenched fist
arm to locate the site of

+/− autonomic symptoms, for the pain.
example, nausea, sweatiness

Other cardiac causes of chest pain include:

• Aortic dissection — this is a life-threatening condition where

blood is tracking between the layers of the wall of the aorta. Left
untreated, there is a high risk of rupture and death. This is char-
acterised by a ‘tearing’ central chest pain radiating to the back
between the scapulae. May be accompanied by haemodynamic
compromise.
• Pericarditis — this is inflammation of the pericardium which
causes chest pain worse on inspiration or lying flat.
• Arrhythmias — these can sometimes cause chest pain if the rate
becomes really fast.

The main non-cardiac causes of chest pain that are often mistaken for
angina can be divided into respiratory, gastrointestinal and mus-
culoskeletal causes. For example, sharp chest pain is often referred
to as pleuritic chest pain and is suggestive of a pleuritic/respiratory
cause, such as an infection (for example, pneumonia), inflammation
(for example, pleurisy), or infarction (for example, a Pulmonary
Embolism [PE]). It is caused by inflamed contact between the lung
and pleura.
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 5

Clerking Patients 5

Some important differentiating questions for pleuritic pain

include:

Is it worse on deep inspiration? On coughing? With movement?

Is the pain sharp? Like a sharp knife? Note that some patients will
use the word ‘sharp’ to mean ‘severe’ rather than to describe the
type of pain.

Consider a gastrointestinal cause such as oesophagitis, oesophageal

reflux or spasm if the chest pain is burning and is worse on lying flat
or is related to meals. Pain that is relieved on sitting forward may
suggest pancreatitis.

Is the pain worse in any one position? Such as lying flat?

Is the pain relieved by sitting forward?

Is the pain worse before/after eating?

Don’t forget musculoskeletal/cutaneous chest pain which is confined

to the chest wall and may be tender on palpation, for example,
Tietze’s syndrome (costochondritis = inflammation of the costal
cartilages), or herpes zoster (shingles), which can also give rise to a
vesicular rash on the chest wall in a dermatomal distribution.
You can use the questions based on the well-known mnemonic
SOCRATES below to guide your history taking.

S —
Site: Where is the pain?
O —
Onset: When did the pain first start?
C —
Character: Describe the pain.
R —
Radiation: Does the pain spread anywhere?
A —
Associated symptoms: Any nausea, pallor, sweating or dizziness?
T —
Timing and duration: How long does the pain last?
E —
Exacerbating and relieving factors: This includes drug treat-
ment, that is, GTN.
S — Severity: Score out of ten. (Ten being the worse pain the patient
has ever experienced.)
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 6

6 Chapter 1

Despite learning all of these well recognised patterns of chest pain,

some patients may have atypical chest pain; that is, chest pain that
doesn’t follow the typical pattern of presentation for the disease.
For example, a patient with a myocardial infarction may present
with only left arm pain, or shortness of breath. They may even pres-
ent with pleuritic sounding, sharp chest pain or heartburn. Pain that
is very well localised or point-like, that is, a pain that the patient
can point to with a fingertip, rarely turns out to be coronary in
origin. Multifocal pain is also very unlikely to be cardiac in origin
as coronary chest pain is characteristically stereotyped within any
one single individual in the
core location in which it Multifocal pain describes pain
affects, although as it becomes that occurs randomly at various
more severe it can radiate to points across the chest which may
more areas. Furthermore, some all present at the same time.
patients may not experience
any chest pain at all, particu- Radiation on the other hand,
larly those who are elderly, implies a more temporal
with diabetes, and/or follow- relationship from the onset of pain
ing cardiac transplantation. It in one place followed by another.
is thought that the weakening
of the peripheral nerve func-
tion (through age, diabetes, or heart transplant surgery) prevents
the information travelling to the brain in the way that typically
causes pain.
Even asymptomatic patients can have coronary disease or a silent
myocardial infarction. In any admitted patient with multiple back-
ground risk factors for atherosclerosis, it is worth doing simple tests
such as an electrocardiogram (ECG).

1.3 Dyspnoea
Dyspnoea or shortness of breath is another common cardiac symp-
tom. It can be a symptom of heart failure, myocardial infarction or
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 7

Clerking Patients 7

valvular disease. Symptoms to illicit with patients who present with

dyspnoea include:

1. Orthopnoea (difficulty in breathing when lying flat) —

a) ‘Do you need to sleep propped up to avoid breathlessness?’
Sleeping on more than two pillows may be significant. Beware
though that orthopnoea can also occur in obese persons and
people suffering from lung disorders, and that patients with
back pain may also choose to sleep on several pillows.
b) ‘What happens to your breathing if you lie flat?’

2. Paroxysmal nocturnal dyspnoea (PND) —

‘Do you wake up in the night, gasping for breath, which can
be relieved by sitting up or getting out of bed?’
Orthopnoea and PND are two key symptoms of heart failure.
Difficulty in breathing is often worse when patients are lying flat
because fluid otherwise pooled in the lower limbs returns to the
heart, which backs up into the lungs.
The onset of dyspnoea often gives a clue as to whether the cause
is cardiac or non-cardiac in origin:

Did it come on suddenly? (Consider pulmonary embolism/

myocardial infarction.) Or did it come on gradually? (As in
angina, heart failure, chronic obstructive pulmonary disease
[COPD], pneumonia, or asthma.)

Has it been getting worse?

It is important to ascertain the severity of dyspnoea which gives you

a clinical indication of the severity of the disease. Although it is tradi-
tional to ask patients how far they can walk before they become short
of breath, when this has been studied formally, it has been found to
be unrelated to patients’ true exercise capacity, even after correcting
for their perception of distance.
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 8

8 Chapter 1

To quantify the severity of dyspnoea, the New York Heart

Association (NYHA) classification can be used:

Class 1: able to perform ordinary activities

Class 2: dyspnoea on ordinary activity, but not at rest
Class 3: dyspnoea on minimal exertion
Class 4: dyspnoea at rest

How many flights of stairs can you climb before becoming

breathless?

Do you get short of breath at rest?

To Impress!
Save time by asking key questions:
To distinguish between a patient in Class 1 and 2:

If you were walking along with other people of the same age and
sex, do they generally have to slow down for you? Or do you keep
up with them? If they keep up, they are in Class 1.

To distinguish between Class 2 and 3:

When you move around from room to room at home on the same
level, do you get breathless or fatigued? If yes, they are in Class 3.
If not, they are in Class 2.

Class 4 should be easy to identify!

Beware: Some patients may have limited exercise tolerance due to

arthritis or other conditions. See if they can tell you what symptom is
actually limiting them.

1.4 Palpitations
Palpitations can be a very difficult symptom to investigate. The
word ‘palpitation’ means the abnormal awareness of the hear beat-
ing in the chest, and again may mean different things to different
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 9

Clerking Patients 9

people. Some patients feel that their heart is beating abnormally fast
or slow. Other patients are aware that their heart is beating irregu-
larly. A third group feel the heart is beating at a normal rate and
regularly, but simply more intensely without good reason. It is
important to identify what the patient means by palpitations. It can
be helpful to ask the patient to tap out the rate and rhythm on the
table. Patients with genuine significant arrhythmias are keen to do
so. Patients with very brief and non-specific palpitations often
decline to even try.
Some of the key questions that will help you differentiate the
cause of the palpitation include:

Is it brought on by worry?

Does it occur on exercise or when The ectopic beat is
you’re excited? early, and followed

Do you notice it mainly when by a compensatory
you’re lying down? These features pause, leading to an
suggest a benign cause. increase in diastolic

Does it feel as though your heart filling time, and
drops or misses a beat? This sug- thus the subsequent
gests atrial or ventricular ectopics. normal beat is more

Do the palpitations have an abrupt forceful.
start or end? Many minutes to
hours of palpitations with an
abrupt start or end suggests significant pathology.

Has the patient had a 24-hour monitor/ECG? Don’t forget the non-
cardiac causes which are important to exclude in your history. These
include:

• Drugs — that is, caffeine, nicotine, cocaine and any sympath-

omimetic, although remember they can both trigger pathological
arrhythmias and cause simple sinus tachycardia.
• Metabolic disorders — anaemia, hyperthyroidism, and
phaeochromocytoma (rare).
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 10

10 Chapter 1

1.5 Syncope
Syncope can be defined as the temporary impairment of conscious-
ness due to cerebral ischaemia. Taking an account of the attack can be
divided into three key parts:

1) What happened before the faint?

Did you have any warning before the faint?

Were there any specific triggers? For example, standing up?
Passing urine? Cold? The presence of a precipitant suggests a
non-cardiac cause.
2) What happened during the faint?

Discover whether there were any eye witnesses. If so, obtain
an eye witness account.

Was there any jerking, tongue biting, or incontinence? These
are features of epilepsy but can occur with prolonged cardiac
syncope.

How long did it last?
3) What happened after the faint?
In general, cardiac causes of syncope involve a loss of conscious-
ness for 1–2 minutes with complete recovery in seconds to
minutes with no subsequent confusion.
The common causes of cardiac syncope are:
• structural heart disease leading to obstruction to outflow, i.e.
seen in any of the valvular stenoses, for example, aortic steno-
sis and hypertrophic obstructive cardiomyopathy
• arrhythmias such as atrial fibrillation, supraventricular tachy-
cardias or ventricular tachycardia/fibrillation
• pulmonary artery hypertension (rare).

Stokes Adams attack describes a transient bradycardia, a decrease in

cardiac output and loss of consciousness in which there is no warning.
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 11

Clerking Patients 11

The patient becomes pale and drops to the floor. This can occur in
any position and was originally used to describe the consequences of
intermittent heart block.
Other commonly described syncopal events include vasovagal
attacks, situational and postural hypotension. Vasovagal attacks are
provoked by pain, fear, emotion, prolonged standing and warm envi-
ronments. The response is due to vasodilatation and/or
bradycardia. It doesn’t occur lying down. The patient may experi-
ence preceding nausea; sweatiness and dizziness then fall to the floor
and lose consciousness for 1–2 minutes.
Situational syncope is associated with specific triggers such as
coughing and micturition. Postural hypotension is common in the
elderly and causes dizziness or collapse on standing from lying or sit-
ting position. This is due to inadequate reflex vasoconstriction. This
response can be exacerbated if the patient is on anti-hypertensives or
anti-anginals.
Don’t forget to consider neurological causes such as epilepsy —
that is why an eye-witness account is important (to report tongue bit-
ing, urinary incontinence, confusion, and so on). Lastly, don’t forget
metabolic causes such as hypoglycaemia, and drug-induced syncope
(for example, blood pressure medications!).

1.6 Oedema
Peripheral oedema is the accumulation of fluid in the body’s tissues.
It can be divided into two types: non-pitting and pitting oedema. In
non-pitting oedema the skin cannot be indented by external pres-
sure and is due to reduced lymphatic drainage or thyroid disease.
Heart failure causes pitting oedema, which is due to an increase in
venous pressure secondary to ineffective pumping of the right side
of the heart, together with salt and water retention. It characteristi-
cally affects both legs, often worsens as the day progresses, and is
more severe the higher up the body it is located. The table below
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 12

12 Chapter 1

summarises a simple way to remember the causes of peripheral

oedema:

Table 1.1 Causes of non-pitting and pitting oedema

Non-pitting oedema Pitting oedema

Hypothyroidism Usually bilateral

(mucopolysaccharide deposition) High venous pressures
Impaired lymph drainage • heart failure, renal failure, excessive
• surgical, radiation, malignant IV fluids, steroids
infiltration, infectious (filariasis), Low albumin states
congenital (Milroy’s disease)
• liver failure, nephrotic syndrome,
Increased capillary permeability protein losing enteropathy
• angio-oedema Vasodilatation
• drugs: dihydropyridines (amlodipine)
and alpha-blockers (doxazosin)

Unilateral
Deep vein thrombosis
Local infection, including burns

1.7 Assessment of Cardiac Risk Factors

Once you have obtained a thorough history of each of the symptoms
above, a thorough assessment of the patient’s cardiac risk factors can
help to support or counter your diagnosis. You will be expected to be
able to rattle off the list of risk factors without hesitation and to have
asked the patient about each one. The
greater the number of cardiac risk fac-
Remember to avoid
tors present, the greater their risk of a
using jargon and
cardiac event.
stick to simple
terminology the
1.7.1 Previous cardiac history patient will
understand.
Start with asking about any previous
cardiac history.
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 13

Clerking Patients 13

Have you had any cardiac events before?

If so, were the symptoms similar to the current ones? What
happened on that occasion, that is, what tests were performed and
what were the results?

Have you had any previous interventional procedures such as a
balloon angioplasty, stent insertion or coronary artery bypass
surgery (CABG)? When did you have these procedures (dates)?

1.7.2 Hypertension
In patients with high blood pressure, ask about duration as an indica-
tion of severity. The longer the history of hypertension, the greater
the likelihood of cardiovascular disease. (See the Hypertension section
in Chapter 4 Commonly Encountered Patients for more information.)

How long have you had high blood pressure for?

What blood pressure medications have been tried before? (Why
were they stopped?)

What blood pressure medications are you currently taking?

Do you measure your blood pressure at home?

What are your recent blood pressure readings?

1.7.3 Diabetes
Don’t just say ask if they have diabetes, find out roughly what age
they were diagnosed, whether
they went straight to insulin ther- HbA1c is a molecule formed
apy, the duration of their disease when glucose is attached to
and severity. There are two types haemoglobin in the blood. As
of diabetes. Type 1 typically pres- haemoglobin circulates in the
ents in childhood/youth and is blood for 8–12 weeks,
treated immediately with insulin. measurement of HbA1c gives an
Type 2 typically is of adult onset, indication of the average blood
commonly associated with obesity glucose in a patient over the last
and often treated with diet and 8–12 weeks.
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 14

14 Chapter 1

tablets first. Look for the presence of end organ damage to eyes,
nerves and kidneys.

Have you got any problems with your eyes or kidneys?

Do you get pins and needles in your hands or feet?

Finding out whether or not the patient is insulin dependent can give
you an idea as to the stage. Patients with diabetes have a two to four-
fold increase in relative risk of developing coronary heart disease. Aim
to keep the blood glucose values between 4 and 6 mmol/l and
HbA1c < 6%.

Do you measure your blood sugar at home?

If so, what is your usual range?

1.7.4 Hypercholesterolaemia
Often patients won’t know if
Familial hypercholesterolaemia is
they have high cholesterol,
defined by two criteria in the
therefore it is quite useful to
patient –– NOT the family!
ask if the patient is on any
cholesterol-lowering medica- 1) Total cholesterol concentration
tion instead. Occasionally, there >7.5 mmol/l, or Low Density
may be evidence of familial Lipoprotein (LDL) cholesterol
hypercholesterolaemia (a fairly >4.9 mmol/l.
rare group of severe genetic 2) Presence of tendon xanthoma
disease). or genetic mutation of LDL
receptor/apoB-100 in 1st/2nd
degree relative.
1.7.5 Smoking

Do you smoke? If so, how many cigarettes do you smoke
a day?

Have you tried to stop smoking? Have you sought any specialist
advice on how to stop smoking?

If you are an ex-smoker, how long ago did you give up?
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 15

Clerking Patients 15

Pack years
Textbooks and tutorials
The pack year assumes a standard pack of
often teach you to calcu-
cigarettes has 20 cigarettes, therefore 1
late the number of pack
pack year is equal to a patient smoking
years that a patient has
20 cigarettes a day for a year. You can
smoked. You will notice
easily calculate this by this formula:
experienced consultants
rarely actually elicit this Pack years = number of cigarettes per day
data in practice and cer- × no. of years
tainly never present it. 20
There are two reasons
for this. Firstly, the critical distinction to make is the division of
patients into three groups — never smoked, ex-smoker and current
smoker. This is because the ex-smokers and current smokers have
a substantially elevated cardiovascular risk compared to the non-
smokers. The extent of this elevation is relatively easy to judge from
the age of the patient if you assume most patients start smoking in
their teens. It saves time, when time is limited, not to get into the
ups and downs of the patient’s cigarette consumption over the years.
Secondly, the ‘current smoker’ group is vital to identify because
these patients are targets for aggressive intervention. There is good
evidence to show that patients who are offered advice and counselling
on smoking cessation have higher odds of quitting than those with-
out any help.

1.7.6 Alcohol
Small amounts of alcohol, around One unit of alcohol equals
1 unit per day, are consistently • Small glass of wine
associated with reduced cardiac • Half a pint of normal strength
event rates for reasons that are less beer
clear. Higher amounts of alcohol, • Single 25 mls shot of spirit
however, can cause hypertension,
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 16

16 Chapter 1

cardiomyopathy and atrial fibrillation. Ask about weekly alcohol

consumption:

How much alcohol do you drink a week? In units?

Is this in the form of beer? Spirits? Wine? Other?

Try to quantify consumption as much as possible (see above).

Keeping their alcohol consumption below the recommended limits,
of up to 21 units per day for men and up to 14 units per day for
women, is advisable.

1.7.7 Family history

Family history of cardiovascular disease (CVD) and or stroke,
especially present in first degree relatives under the age of 65 in males
and 55 in females, increases a patient’s risk of heart disease by 1.5.
In addition to the five major risk factors discussed, physical inac-
tivity, obesity and a high fat and high salt diet are also risk factors,
although less easily quantifiable. The drug history may also highlight
any medical problems the patient may have forgotten to tell you

Figure 1.1 Combinational effect of each additional risk factor on cardiovascular

risk
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 17

Clerking Patients 17

about, for example, the patient may have neglected to tell you about
their hypothyroidism as they have become so accustomed to it but
this can be easily picked up when the patient tells you that they take
thyroxine regularly.

1.8 Social Circumstances

Don’t forget the implications of the symptoms and the disease to the
patients.

What physical activity do you need to do for your work?

A myocardial infarction may cost a construction worker his job but

not an office worker. What family support or responsibility does the
patient have? What physical activity could the patient manage at home
prior to the disease? This will help work out a realistic goal for post-
discharge rehabilitation.

1.9 Implications in Primary Care

Primary prevention of cardiovascular disease in the community, even in
apparently healthy individuals, is increasingly practiced. In the UK, all
adults over the age of 40 undergo a comprehensive cardiovascular risk
assessment in primary care once every five years. Many risk assessment
models exist including the Framingham equation, Sheffield risk tables,
the European coronary risk chart and the New Zealand risk assessment
tool. The coronary risk prediction chart is the one recommended by
the joint British societies and is based on assessment of all the risk fac-
tors including ethnicity, smoking, family history, weight, blood
pressure and lipid levels. It stratifies patients according to their per-
centage risk over a ten-year period. These charts are useful in deciding
the degree of intervention necessary, that is, simple lifestyle measures
or initiating drug therapy with aspirin, anti-hypertensives and lipid
lowering medications. However, the disadvantages of these charts are
that they underestimate the risk in some ethnic groups and also in
diabetics, patients with renal failure and inherited dyslipidaemias.
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 18

18 Chapter 1

(See the joint British societies’ risk prediction chart: http://

www.bhsoc.org/Cardiovascular_Risk_Prediction_Chart.stm.)

Low risk patients (green area) = calculated cardiovascular risk

<10% over the next ten years.

Intermediate risk patients (orange area) = cardiovascular risk
between 10–20% in the next ten years.

High risk patients (red area) = cardiovascular risk over 20% in the
next ten years. These patients should be targeted and treated to
prevent disease progression.

1.10 Examination of a Patient

Introduce yourself to the patient, explain what you would like to do
and gain their permission. By shaking the patient’s hand, you are not
only being friendly, but also have the opportunity to assess his/her
peripheral circulation.
Remember to be systematic in your approach to the patient:

general → hands → BP → neck → face → chest → oedema → finish

Adequately expose the patient’s chest and position the patient at

45 degrees.

1.10.1 General examination

Stand at the end of the bed and briefly observe the patient’s general
condition. Does the patient look well or do they look unwell? Are
there any devices by the bedside that would give you clues such as
inhalers, cardiac monitor, external pacing, or walking aids? Does the
patient look in pain or in respiratory distress? Does the patient have
any dysmorphic features that may allude to an underlying congenital
heart disease, for example:

• Down’s syndrome — look for upslanting palpebral fissures, bilat-

eral epicanthal folds (almond shaped eyes), protruding tongue
and low set ears.
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 19

Clerking Patients 19

• Marfan’s syndrome — tall stature, abnormally long and slender

limbs (arachnodactyly).
• Turner’s syndrome — short stature, webbing of the neck, low
set ears.

Mechanical prosthetic valves can sometimes be heard from the end of

the bed!
As part of your general examination, ‘without touching the
patient, examine the chest in a swift and focused manner for:

• Scars and external devices

A midline sternotomy scar could indicate a previous coronary
artery bypass graft (CABG) or valve replacement.

A lateral thoracotomy scar could indicate mitral valve surgery.

A subclavicular scar and bump under the skin could indi-
cate pacemaker/automated implantable cardiac defibrillator
(AICD).

Vein harvesting scars on legs and radial artery harvesting scars
could be a sign of bypass surgery.

With the introduction of minimally invasive interventional tech-

niques, patients who have had angiography or other interventions
may only have a small scar in the groin crease (usually the right) which
you are unlikely to see. Antecubital fossa brachial artery scars are more
likely to be observed.

1.10.2 Hands
Take your patient’s hands. Warm hands suggest adequate perfusion
(unless the patient is pyrexial). Start by looking at the fingertips.
Look for clubbing which can be described in four stages:

1. Increased fluctuancy of nail bed

2. Loss of nail bed angle
3. Increased longitudinal curvature of nail
4. Drum stick appearance of the nail caused by expansion of the
terminal phalanx.
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 20

20 Chapter 1

To detect clubbing, ask the patient to hold the nails of both index fin-
gers, facing each other. In the absence of clubbing, a diamond-shaped
space can be seen, caused by the angulation of both nail beds. In
patients with clubbing, the diamond shape is obliterated.
The cardiac causes of clubbing can be remembered by ABC:

• Atrial myxoma (rare)

• Bacterial endocarditis (subacute)
• Cyanotic congenital heart disease.

However, you would be expected to know a few non-cardiac causes

of clubbing. Use the following mnemonic to help you remember
both cardiac and non-cardiac causes:

• congenital Cyanotic heart disease

• Lung abscess, fibrosis
• Ulcerative colitis/Crohn’s disease
• Biliary cirrhosis
• Bronchiectasis
• Infective endocarditis
• Neoplastic disease, for example, lung cancer and Hodgkin’s disease
• Gastrointestinal malabsorption.

Look closely at the nails also for signs of bacterial endocarditis charac-
terised by splinter haemorrhages (which can also occur due to trauma,
for example, in manual labourers), Janeway lesions and Osler nodes
(see section on Endocarditis in Chapter 2: Bedside teaching). A simple
thing to comment on (which shows you are observant) is tar staining
on the fingers, as smoking is a risk factor for cardiovascular disease.
Look for hypercholesterolaemic deposits in the skin as yellow
nodules known as tendon and palmar xanthomas.

1.10.3 Radial pulse

Feel for the pulse for at least 15 seconds and comment on the rate
and rhythm. Is it slow (bradycardic) or fast (tachycardic), regular or
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 21

Clerking Patients 21

irregular? A congenital condition known as coarctation of the aorta is

where there is a narrowing somewhere along the descending aorta.
This manifests as radial-radial delay or radial-femoral delay which can
be detected by feeling pulses in two places simultaneously. Most aor-
tic coarctations are distal to both subclavian arteries so only the
radio-femoral delay is abnormal.

1.10.4 Blood pressure

Moving up the arm in your examination ensures you don’t miss the
blood pressure. Comment on it, if it’s available, otherwise say you
would like to measure it. (See the Appendix on how to measure blood
pressure for tips.) The pulse pressure is the difference between the
systolic and diastolic pressures. The pulse pressure is typically wide in
aortic regurgitation and although many textbooks say it is narrow in
aortic stenosis, this is simply not the case and patients with aortic
stenosis often have normal pulse pressures. There is also a phenome-
non known as pulsus paradoxus where there is a drop in systolic
blood pressure during inspiration of 10 mmHg. It is something you
might get asked about on ward rounds as it is associated with peri-
cardial constriction, tamponade and severe asthma. Look also for
pulsus alternans, the alternating of strong and weak beats sometimes
seen in severe left ventricular systolic impairment. Comment on any
postural blood pressure changes. A postural drop in blood pressure is
defined as a drop in systolic BP of >15 mmHg or a diastolic drop
of >10 mmHg after a patient stands from lying down.

1.10.5 Neck
There are two important structures in the neck in the cardiovascular
examination, the jugular venous pulse (JVP) and the carotid pulse.
The internal jugular vein (IJV) gives an indirect measure of the pres-
sure in the right atrium (RA) and provides some information about
cardiac function — this is because there are no valves between the RA
and IJV. The IJV enters the neck just behind the mastoid process,
passes deep to the sternocleidomastoid muscle (SCM) and then runs
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 22

22 Chapter 1

Figure 1.2 Measuring the JVP

between the sternal and clavicular heads of the SCM before entering
the thorax. The IJV itself is not visible.
To measure the JVP, sit the patient at a 45 degree angle, with the
neck muscles relaxed and head turned slightly to the left. Look for dif-
fuse pulsations. The JVP is the vertical height of the pulse in the IJV
above the sternal angle. The normal JVP is <4 cm.
A common question you are likely to encounter is how you would
differentiate between the JVP and the carotid pulse.

The six key features to distinguish JVP from carotid artery:

The JVP:
1) pulsation is easily obliterated by finger pressure
2) has two pulsations for each single arterial pulse
3) is much weaker in force (impalpable)
4) varies with respiration
5) varies with position
6) rises transiently with pressure on the liver (hepatojugular reflux)
or on the abdomen (abdominojugular reflux).
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 23

Clerking Patients 23

Two important things to note about the JVP are the height and
waveform.
A raised JVP can be a sign of:

• fluid overload
• right-sided heart failure To Impress!
• SVC obstruction Positive hepatojugular reflux
• constrictive pericarditis. sign is not simply the
elevation of the JVP on
In constrictive pericardi- hepatic compression as this
tis, an elevated JVP is occurs in everyone but rather
characteristically associ- that the JVP remains elevated
ated with a paradoxical for a 15 second compression.
rise in inspiration — This is because the RV is
known as Kussmaul’s unable to pump out the
sign. increased venous return — a
To understand wave- sign of RV heart failure.
form abnormalities, it is
important to understand
the actual waveform. The waveform corresponds to the changes in
right atrial pressure. There are two peaks and two descents.
The normal JVP goes down in systole (x descent). Systole starts
with the brief c wave and then proceeds with the x descent as the right
atrial floor moves down as a result of right ventricular contraction.
Late in systole, the veins start to fill the atrium faster than its capacity
is being increased by ventricular contraction and so there is a passive
accommodation of blood and therefore increase in pressure which
corresponds to the v wave.
The abnormalities can be divided broadly into a wave and v wave
abnormalities.

‘A wave’ abnormalities
An absent a wave (and so the JVP rate is similar to the pulse rate) indi-
cates no atrial contraction and occurs in atrial fibrillation. A large a wave
is hard to diagnose clinically but in an exam you need to understand
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 24

24 Chapter 1

a wave: atrial systole

c wave: closure of tricuspid valve
x descent: drop in atrial pressure during ventricular systole
v wave: passive venous filling of atria with closed tricuspid valve
y descent: tricuspid valve opening

Figure 1.3 Height of JVP against time

that this occurs when the right atrium is contracting against resistance,
that is, in pulmonary hypertension and pulmonary stenosis. Cannon ‘a’
waves are caused by a right atrium contracting intermittently against a
closed tricuspid valve, which occurs in complete heart block.

V wave abnormalities
In tricuspid regurgitation, right ventricular contraction does not only
pull down the floor of the right atrium, but also ejects a lot of blood
into the right atrium, hence the JVP goes up. This is not passive
venous filling, so it is not a large v wave. In fact, it starts at the c wave
and continues to the end of the v wave. Its proper name is a giant CV
wave, and can be thought of as an upside down x descent. The JVP
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 25

Clerking Patients 25

may be so high in the neck that it can

only be seen by looking behind the ear —
a large v wave can cause the ears to wag-
gle!
In practice, it is difficult to pick up a
JVP waveform abnormality, and valvular Figure 1.4 Giant CV wave
heart disease is rarely diagnosed on the
basis of an abnormal JVP waveform. However, it is important to
recognise whether the JVP is raised or not, and to know what condi-
tions are associated with the different waveform abnormalities both
for written and clinical examinations. Tricuspid regurgitation and
atrial fibrillation are two common examination cases. In addition,
there is some evidence that an elevated JVP in patients with heart fail-
ure is associated with an increased risk of hospital admission, death
and subsequent hospitalisation for heart failure.

The carotid pulse

The carotid artery can be found by placing the thumb gently on the
trachea and sliding the thumb laterally until it hits the sternocleido-
mastoid where the carotid pulse should be palpable. Four things
should be noted about the pulse — the rate, rhythm, volume and char-
acter. The rate and rhythm should already have been assessed when
examining the radial pulse. The volume and character should be
assessed at the carotid rather than the radial as it is closer to the heart.
The volume may be:

• low — in shock and heart failure, or

• large — in aortic regurgitation, vasodilatation (exercise, fever).

There are several distinct character pulses:

• slow rising occurs in aortic stenosis

• collapsing pulse occurs in regurgitation
• bisferens pulse, where two distinct systolic peaks are present,
characteristic of aortic regurgitation and stenosis.
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 26

26 Chapter 1

Don’t forget to listen for carotid bruits — ask patients to hold their
breath whilst simultaneously listening with the bell of the stethoscope
(it’s a good idea to hold your breath with the patient as it reminds you
how long you’re asking them to do this). The presence of carotid
bruits can suggest local disease or radiation from elsewhere, that is, in
aortic stenosis. Ask yourself whether the patient has any other clinical
features of peripheral arterial disease and remember in an exam situa-
tion to at least offer to palpate peripheral pulses at the end of the
examination.

1.10.6 Face
Start from top down — look at the eyes for evidence of cataracts,
which can be a result of diabetes or hypertensive retinopathy. A pale
conjunctiva is indicative of anaemia. Pallor with jaundice suggests
haemolytic anaemia. Lid lag and exophthalmos indicates thyroid dis-
ease. Look for the presence of corneal arcus, a grey opaque line
surrounding the cornea and xanthelasmata which are yellow fatty
deposits commonly found around the eyes. Both of these signs are
associated with raised cholesterol levels.
Jaundice can signify haemolysis which can result as a complication
of prosthetic valves. Central cyanosis on the tongue can indicate
congenital heart disease.

1.10.7 Praecordium
Examine for scars particularly at the
apex where they can be easily missed. Top tip: When you
Feel the position of the apex by plac- know the apex beat
ing the palm of your right hand over is abnormal but do
the left chest wall: is it displaced? If so, not know if it is
where — for example, laterally? heaving or thrusting
Downwards? Be specific. The normal say ‘forceful’.
position of the apex is in the fifth
intercostals space, mid-clavicular line. Abnormal characteristics of the
apex beat can be described as 1) heaving, which occurs in volume
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 27

Clerking Patients 27

overloaded conditions like mitral and aortic regurgitation; 2) thrust-

ing, which occurs in pressure overloaded conditions like aortic
stenosis.

Volume overload — conditions: mitral or aortic regurgitation

— leads to dilatation of the LV → displacement of the
apex
— detectable on Chest X-ray (CXR) if severe
Pressure overload — conditions: aortic stenosis, hypertension
— leads to concentric hypertrophy of the LV →
thicker LV wall (hypertrophy)
— detectable on ECG (sometimes).
Only echocardiography is truly reliable for detecting these.

If the apex is displaced, this is due to either mediastinal shift or dilata-

tion of the heart:

Mediastinal shift: large pleural

effusion, pneumothorax,
pneumonectomy

Displaced apex beat

Dilatation of heart: due to
volume overload: mitral
regurgitation (MR), aortic
regurgitation (AR), ventricular
septal defect (VSD)/atrial septal
defect (ASD)

To feel for thrills, keep your hand over the apex and then palpate over
both sides of the sternum. A thrill is a palpable murmur — it feels like
a purring cat. Now feel for a right ventricular (RV) heave by placing
your hand in the left parasternal position. A RV heave is a palpable
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 28

28 Chapter 1

beat and suggests RV enlargement, which can occur in cor pulmonale

or pulmonary stenosis.

Cor pulmonale is right ventricular failure secondary to chronic

pulmonary hypertension which can be a result of lung disease,
pulmonary vascular disorders, neuromuscular and skeletal diseases.

Stenosis of the pulmonary artery causes increased pressure in the right

ventricle and leads to hypertrophy.

1.10.8 Auscultation of the heart

Most stethoscopes have a bell and diaphragm. When auscultating, you
are listening for:

• normal heart sounds

• added heart sounds, that is, murmurs (due to turbulent blood
flow) or a third or fourth heart sound.

The bell is best used for low pitched sounds:

• diastolic murmurs, for example, mitral stenosis

• third and fourth heart sounds.

The diaphragm is better for detecting higher pitched sounds:

• normal heart sounds

• systolic murmurs
• aortic regurgitation.

With the patient sitting at 45 degrees first listen at the apex, tricuspid,
pulmonary and aortic areas with the bell and then again with the
diaphragm. Place your thumb on the patient’s carotid pulse whilst
auscultating the heart sounds — this helps to differentiate the first
(S1) and second (S2) heart sounds and any murmurs.
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 29

Clerking Patients 29

Right 2nd Left 2nd intercostal

intercostal space = space = pulmonary S1 = closure of mitral and
aortic area area tricuspid valves, marks the onset
of systole.

S2 = closure of pulmonary and

aortic valves, marking the onset
of diastole.

Left sterna edge = fifth intercostal

tricuspid area space = mitral area

Figure 1.5 Key areas of auscultation

Splitting of the second heart sound:

S2 has two components: A2 (closure of aortic valve) and P2 (closure of
pulmonary valve). In most people S2 is heard as one sound. However,
it is normal to hear a split S2 on inspiration in the young.
Why is this? — On inspiration, intrathoracic pressures drop which leads
to an increase in venous return to the right heart. This in turn leads to a
delay in right heart emptying and so the pulmonary valve remains open
for longer, closing later (after the aortic valve).

Abnormal splitting:
Wide ‘fixed’ splitting in atrial septal defect (ASD): S2 remains split in
inspiration and expiration.
Wide ‘physiological’ splitting in right bundle branch block (RBBB): S2 is
split in expiration, but more so in inspiration.
Reverse splitting in left bundle branch block (LBBB): S2 is split in
expiration and not inspiration.

Roll the patient onto the left side and listen at the apex for mitral mur-
murs and then in the axilla for any radiation of the murmur. Sit the
patient up and leaning forwards. This time listen in the aortic and tri-
cuspid areas with the diaphragm. If a murmur is heard, determine the
timing (that is, systolic or diastolic). Ask the patient to take a deep
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 30

30 Chapter 1

breath in and hold their breath. Then get the patient to take a deep
breath in, out and hold their breath at the end of the expiration.
Right-sided murmurs are louder on inspiration and left-sided mur-
murs louder on expiration — RILE. For a more detailed description
on murmurs see Chapter 2 Bedside Teaching. Listen to the bases of the
lungs for bilateral crepitations (as in pulmonary oedema) or reduced
air entry and dullness (pleural effusions). Feel for sacral oedema.
To complete examination:

• Check the abdomen for: an enlarged liver (right-heart failure), a

pulsatile liver edge occurs in tricuspid regurgitation or midline
pulsatile mass (aortic aneurysm).
• Check the legs and sacrum for pitting oedema: use a finger to
gently but firmly push against a bony surface and look to see if the
indentation remains.
• Dip the urine for haematuria (in infective endocarditis), glucose
(diabetes — a risk factor for cardiovascular disease).

1.11 Worked Example

Below is a worked example to highlight the key points in clerking and
presenting a patient complaining of chest pain:
Student: Good morning. Can I
check that I have come to Greet the patient,
the right person? What is introduce yourself
your name? and explain what
Patient: My name is Mr. R. you intend to do.
Student: My name is X. I’m one of
the student doctors and I
would like to ask you some questions. Is that alright?
Patient: Yes, that’s fine.
Student: How old are you?
Patient: 72.
Student: Are you retired now?
Patient: Yes. Six years now. I used to be an electrician.
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 31

Clerking Patients 31

Step 1 Presenting Complaint

Student: What brought you into
hospital? Use open-ended
Patient: Well, I just wasn’t feeling questions and avoid
right yesterday. too many leading
Student: In what way? questions.
Patient: I had this discomfort across
my chest.
Student: Where was this discomfort on your chest?
Patient: Here on the left side.
Student: Did it spread anywhere else?
Patient: Not really, but I did start to get a heaviness in my left hand.
Student: Can you describe the chest
discomfort?
Use of SOCRATES
Patient: It was like a pressure — like
questions.
someone sitting on my
chest.
Student: When did it start?
Patient: Probably about 1pm. I was walking the dog and had just
reached the hill.
Student: What did you do then?
Patient: I carried on walking for a few minutes but the pain became
unbearable, so I stopped and sat on one of the park
benches.
Student: Did this help?
Patient: A little. It definitely helped me get my breath back.
Student: Were you feeling short of breath at the time?
Patient: Yes. That’s strange for me — I never get short of breath
when I’m walking the dog.
Student: Going back to the chest discomfort, at its worst, how
severe was the pain on a scale of one to ten, where ten is
the worst discomfort that you’ve ever felt?
Patient: I’d say about nine.
Student: What did you do after sitting on the bench?
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 32

32 Chapter 1

Patient: Well after ten minutes, the pain was still there so I got up
and went back home. My wife said I looked really pale and
called the ambulance.
Student: Did you feel clammy at all?
Patient: Yes and nauseous.
Ask about associated
Student: Did you actually vomit?
symptoms.
Patient: No.
Student: Any dizziness?
Patient: No.
Student: Did you blackout at any point?
Patient: No.
Student: Did you feel your heart fluttering in your chest?
Patient: No.
Student: Do you ever get short of breath on lying flat?
Patient: No.
Student: How many pillows do you
If patient starts to
sleep with?
ramble, gently guide
Patient: Only the one.
the conversation
Student: Do you ever find that your
back.
ankles become puffy or
swollen?
Patient: No, but I do often get these
pains in my ankles and knees. My GP said it was probably
arthritis. I hope I don’t need an operation. My wife had to
have her knees replaced last year.
Student: Ok, we will talk about the arthritis a bit later. Can I just
clarify a few things… Going back to the chest discomfort —
did anything make it better?
Patient: Not really. It only went away after I reached the hospital.
Student: Were you given anything at the hospital or by the para-
medics that helped ease the pain?
Patient: Oh yes — the oxygen really helped, but I also had a tablet
and a spray under my tongue.
Student: How long did you have the pain for in total?
Patient: About an hour or so.
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 33

Clerking Patients 33

Step 2 Cardiac Risk Factors

Student: Have you ever had this kind
of discomfort before or any
Risk factors for
chest pain in the past?
cardiovascular
Patient: No, not at all.
disease.
Student: Have you ever had a heart
attack?
Patient: No, but my father has.
Student: How old was he when he Here’s where you
had the heart attack? discover your patient
Patient: He was 59 I think. who previously told
Student: Do you have diabetes? you he didn’t have
Patient: No. high cholesterol does
Student: Do you have high blood not have high
pressure? cholesterol because
Patient: Not anymore. I’m on he is being controlled
tablets. with a statin!
Student: Do you smoke?
Patient: No, never have done.
Student: What about your cholesterol?
Patient: I think my cholesterol is fine doctor.

Step 3 Drug History

Student: Are you on any medication?
Patient: Yes, I take a cholesterol tablet once a night and a water tablet.

Step 4 Past Medical History

Student: Have you ever been admitted to hospital before?
Patient: No, I’ve never been sick in my life.
Student: Have you ever had any operations?
Patient: No.
Student: Do you have any medical problems?
Patient: No.
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 34

34 Chapter 1

Step 5 Social History

Student: Who do you live with?
Patient: I live with my wife.
Student: Do you live in a house? Flat?
Patient: In a house.
Student: Do you manage the stairs ok?
Patient: Yes.
Student: Do you drink any alcohol?
Patient: Yes, 2–3 pints only on Sundays.
Student: Have you ever tried recreational drugs? Such as cocaine.
Patient: Oh no, I would never touch those things.

1.12 Presenting Patients

When presenting patients, for example on a ward round, it is impor-
tant to be logical and coherent. Some consultants may have specific
ways in which they wish to have the information presented, but on
the whole the following can be used.

1.13 Summarising Your History

In the first opening statement you should include:

• name
• age
• occupation
• sex
• brief presenting complaint (in patient’s own words)
• any previous cardiac disease
• any cardiac risk factors.

When presenting the history, it is important to mention the relevant

positive and negative findings. For example, in a patient in whom you
suspect congestive cardiac failure you must mention whether he/she
reports any orthopnoea, paroxysmal nocturnal dyspnoea (PND), or
ankle swelling, and what their exercise tolerance is.
b865_Chapter-01.qxd 3/16/2010 4:46 PM Page 35

Clerking Patients 35

1.13.1 An example of a presentation based

on the previous history
Student: Mr R is a 72-year old retired electrician who presented to the
Emergency Department yesterday complaining of ‘chest discomfort’.
He has no previous history of ischaemic heart disease but his cardiac
risk factors are hypertension, hypercholesterolaemia and a positive
family history.
The chest pain occurred on exertion, whilst the patient was walk-
ing his dog, was not relieved by rest and lasted a total of one hour. It
was located on the left of the chest and was radiating to the left arm.
Associated symptoms were nausea, dyspnoea and feeling clammy.
There were no palpitations, loss of consciousness or dizziness,
orthopnoea or ankle swelling. With regards to cardiac risk factors he
has hypertension and high cholesterol, for which he is being treated
and his father suffered a myocardial infarction aged 59 years. He has
not had a previous myocardial infarction, denies ischaemic heart dis-
ease and is not diabetic. He is a non-smoker, lives with his wife and is
independent of his activities of daily living.