6 Cardiovascular semiology simplified

This book is not a medical treatise. It has neither the attributes nor the competence to provide the elements necessary for a complete medical diagnosis. As manual therapists, we must continue to train our hands, and this is no small thing. It demands a long, complex, and never ending apprenticeship.

On the other hand, some patients misguidedly attribute their symptoms to purely mechanical causes, when they may in fact be of some other origin. We have had patients consult us for thoracic pain, neglecting to mention their previous myocardial infarctions.

Because of this, it is necessary to appreciate the terrain of the patient. The explanation of common pathologies reveals that cardiovascular symptoms can be far from specific, are often absent, or remain quiet for a long time, and that it is sometimes necessary to have a bit of a ‘nose’ to avoid pitfalls in daily practice. Be rigorous in your work by relying on objective findings such as risk factors, a detailed interview, and a thorough clinical examination.

• The evaluation of risk factors provides an initial and fairly accurate picture of the quality of the vascular terrain of a patient and at the same time, the advisable level of vigilance.

• The interview, tailored to cardiovascular symptoms, provides more detail as to the possible existence of underlying pathology.

• Finally, the clinical examination can reveal an established illness, or one still in the early stages, prompting referral to a specialist.

6.1 Interview

• Find out whether the patient has had:

– an infarction

– coronary insufficiency

– a pneumothorax

– a cardiopulmonary intervention.

• Ask whether they have any of the following:

– cardiac malformation

– arterial malformation

– valve anomalies

– hiatus hernia.

• Ask whether they have:

– an artificial valve

– an endovascular prosthesis (stent)

– a pacemaker (heart stimulator).

• Ask whether they have ever had one of the following diseases:

– acute articular rheumatism (risk of valve problem)

– diabetes or other systemic illness (connective tissue disorder, lymph or reticuloendothelial system disorders, etc.)

– congenital or acquired vascular fragility

– recurrent tonsillitis.

• Inquire about lifestyle:

– sedentary lifestyle

– eating habits (excess sugar, fat, alcohol)

– toxic habits (smoking, addictions, etc.)

– escalating psychoemotional tension.

• Ask patients:

– whether they know what their normal blood pressure is

– whether they take antihypertensive medication.

• Question patients about pain:

– Does it arise spontaneously without apparent cause?

– Does it arise with activity, exertion?

– After eating? (a postprandial full stomach is a common cause of angina pectoris)

– Does it occur on exposure to cold or wind?

– Do they have pain while lying down?

– When sleeping, does the pain oblige the patient to stand or sit up?

– Is it accompanied by shortness of breath?

– Does it occur when lying down?

• Ascertain the location of the pain:

– retrosternal

– retrocostal

– constrictive pain in the chest

– radiating to the neck, mandible, arm, little finger.

• Inquire about the intensity of the pain:

– discomfort, numbness, or burning sensations

– constriction

– excruciating pain preventing all activity

– nausea, palpitations, painful heat beats, lack of coordination.

• Ask about the duration of the pain:

– Does it stop when activity is over, letting up rapidly at rest?

– Is it accompanied by belching as the pain subsides?

• Ask about the following signs, which could indicate arterial hypertension:

– bedazzlement, seeing sparks and flickers

– other visual disturbances

– buzzing in the ears

– the impression of having a heavy head

– morning occipital headache

– cervical pain

– tension or pain in the mandible without mechanical reason

– palpitations on exertion

– nonpositional vertigo.

• Do not hesitate to refer the patient to a physician in case of:

– precordial pain when walking or on exertion (possibly signifying a transitory insufficiency of oxygen supply to the myocardium)

– thoracic pain that stops rapidly with the cessation of activity

– squeezing sensation, clamping or clawing in the chest, obliging the patient to cease all activity

– profound sense of anguish: it is very rare that a patient expresses this fear without a substantial reason; they sometimes have the feeling they are going to die

– sudden headache, violent and random (risk of aneurysm or brain tumor)

– sleep apnea: an absence of spontaneous respiration, or the inability to breathe on exertion that resolves at rest

– pain in the medial aspect of the left arm, reaching the little finger

– vagal syncope

– dyspnea with exercise (shortness of breath disproportional to the activity)

– palpitations with irregular heart rhythm, translating as hyposystolia (contractions of low intensity)

– pain accompanied by dysphasia and dysphonia (can indicate mediastinal tumor or thoracic aortic aneurysm).

Recall the features of mechanical pain:

• It is triggered by activity and effort. It does not subside within minutes, but remains constant.

• It is aggravated by movement and activity.

• It diminishes considerably by lying down or assuming different positions.

In addition, pain that is mechanical in nature is never or almost never accompanied by:

• cough

• dysphasia (speech impairment)

• fever

• anxiety attacks

• lipothymia (feeling of malaise, abundant perspiration, nausea, short respiration, and weakness)

• hypertension or hypotension

• and finally, it does not provoke deep anguish.

6.2 Visual inspection

The visual inspection is a major part of the examination. Osteopaths, even the ‘tactile’ ones, cannot forget to look at their patients. We do not pretend to reduce the inspection to these few lines, but our purpose is to confine our remarks to the most relevant elements.

A careful examination of particular parts of the body can reveal a number of small indicators related to cardiovascular pathology.

6.2.1 The face

Complexion

Diffuse facial pallor can indicate:

• Anemia: Examination of the mucous membranes and discolored conjunctiva reinforces this hypothesis. Anemia has multiple causes. In women, abundant periods of long duration are a frequent and benign cause. These can be simply due to an intrauterine device.

• Iron deficiency

• Toxicity: Facial color can be linked to occupational hazard or to an aesthetic treatment with products containing phenol derivatives. Certain mediations are another possible underlying cause.

Hyperpigmentation of the face can have these causes:

• Metabolic, e.g. hemochromatosis, where there is a build-up of iron in the skin.

• Endocrine, the classic example being Addison’s disease. However, Cushing syndrome can manifest as acromegaly, pheochromocytoma, and hyperthyroidism.

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