Cardiovascular Assessment: History, Physical Examination, Hemodynamic Monitoring and Diagnostic Testing
Focused assessment
Start with the history: chest discomfort (onset, provocation, quality, radiation, severity, timing), dyspnea, palpitations, syncope, edema, claudication, and risk factors. Ask about medications, including over-the-counter drugs and supplements. In the physical exam, note general appearance, JVD at 30–45 degrees, carotid bruits, heart sounds, murmurs, lung crackles, peripheral pulses, capillary refill, and edema. Measure bilateral blood pressures when coarctation or dissection is suspected.
Hemodynamics and diagnostics
Know what each number means: MAP = (SBP + 2×DBP)/3; CVP estimates right-heart filling but is not a volume gauge; PA catheter gives cardiac output, PA pressures, and SVR. A low cardiac index with high SVR suggests cardiogenic shock; high output with low SVR suggests sepsis or vasodilation. ECG and troponin are time-sensitive; BNP supports but does not confirm heart failure; echocardiography defines structure and function.
Traps
Questions often confuse S3 (volume overload, low compliance) with S4 (stiff ventricle, atrial kick). A normal early troponin does not exclude MI. JVD can be hard to see in obesity and may be low in hypovolemia. Do not treat a monitor number without assessing the patient.
Rule of thumb
Trend data and correlate with the exam: a rising CVP plus new crackles and weight gain points to congestion; a falling MAP plus cool extremities and oliguria points to low output.