What is included in a comprehensive adult physical examination for a patient with a history of smoking or exposure to tobacco and a family history of cardiovascular disease?

Comprehensive Adult Physical Examination

For an adult with smoking history and family history of cardiovascular disease, the physical examination must include vital signs with blood pressure measurement, comprehensive cardiovascular assessment including heart auscultation and femoral pulse evaluation, assessment for clinical congestion, and a detailed 3-generation family history to identify inherited cardiac conditions. 1, 2

Essential History Components

Personal Medical History

• Chest pain, discomfort, tightness, or pressure related to exertion 1
• Unexplained syncope or near-syncope episodes 1
• Excessive dyspnea, fatigue, or palpitations associated with exercise 1
• Tobacco use history including current and past consumption, given the 2.45-fold increased risk of acute myocardial infarction and 2.75-fold increased cardiovascular mortality in current smokers 3, 2
• Hypertension, diabetes mellitus, and dyslipidemia status 2
• Prior cardiac testing or restriction from activities 1
• Sleep-disturbed breathing symptoms 2
• Alcohol consumption patterns (current and past) 2
• Exposure to cardiotoxic agents including anthracyclines, trastuzumab, or high-dose cyclophosphamide 2

Family History (3-Generation)

• Premature death before age 50 (sudden and unexpected) attributable to heart disease in ≥1 relative 1
• Premature cardiovascular disease defined as first-degree male relative with MI before age 55 or female relative before age 65 4, 2
• Disability from heart disease in close relative <50 years of age 1
• Specific genetic cardiac conditions including hypertrophic or dilated cardiomyopathy, long-QT syndrome, ion channelopathies, Marfan syndrome 1, 2
• History of myocardial infarctions, strokes, or peripheral arterial disease in family members 2
• Sudden cardiac death in relatives 2

Note: Family history confers a 1.5-2.0 fold increased cardiovascular risk independent of other risk factors, and almost 75% of individuals with premature coronary heart disease have a positive family history 4, 2

Physical Examination Components

Vital Signs

• Blood pressure measurement in sitting position is essential 1
• Heart rate and rhythm assessment including orthostatic vital signs 1
• Assessment for clinical congestion at each encounter, as this guides medication management and provides prognostic information independent of natriuretic peptides 2

Cardiovascular Examination

• Heart auscultation with assessment of heart sounds (S1, S2, presence of S3 or S4) 1
• Evaluation for heart murmurs with attention to timing, location, radiation, intensity, and quality 1
• Femoral pulses assessment to exclude aortic coarctation 1
• Jugular venous distention evaluation as a marker of clinical congestion 2
• Assessment for leg edema 2
• Evaluation for orthopnea and bendopnea as signs of congestion 2

General Observation

• Physical stigmata of Marfan syndrome should be assessed 1
• Signs of thyroid disease (both hyperthyroidism and hypothyroidism can cause or contribute to heart failure) 2

Laboratory and Diagnostic Testing

Initial Laboratory Work

• Complete blood count 2
• Serum electrolytes (including calcium and magnesium) 2
• Glycohemoglobin 2
• Blood lipids (fasting lipid panel) 2
• Renal function tests 2
• Hepatic function tests 2
• Thyroid-stimulating hormone 2
• Urinalysis 2

Cardiac Testing

• 12-lead ECG to identify arrhythmias, conduction abnormalities, ventricular hypertrophy, signs of ischemia or prior infarction, and features suggestive of channelopathies (Brugada syndrome, long QT syndrome) 1
• Chest radiograph 2
• Echocardiography when indicated based on abnormal findings on history, physical examination, or ECG to assess ventricular function, valve function, and cardiac structure 1

Special Considerations for This Patient Population

Enhanced Screening Due to Smoking History

Given that smoking increases risk of virtually all cardiovascular disease subtypes and at least doubles the risk of many conditions including acute myocardial infarction (HR 2.45), cerebrovascular disease (HR 2.16), and heart failure (HR 2.23), enhanced cardiovascular surveillance is warranted 3

Enhanced Screening Due to Family History

• Earlier lipid screening (age 20 rather than age 40) is recommended for adults with family history of premature cardiovascular disease 4
• Coronary artery calcium scoring is appropriate for patients with family history of premature CAD and low global CAD risk score 4
• Risk doubling should be applied when calculating cardiovascular risk in the presence of family history of premature ASCVD 4

Critical Pitfalls to Avoid

• Inadequate auscultation environment can lead to inaccurate assessment of heart sounds 1
• Incomplete murmur characterization without documenting timing, location, radiation, and response to maneuvers can result in missed diagnoses 1
• Failure to assess for clinical congestion (jugular venous distention, orthopnea, bendopnea, leg edema) misses important prognostic information that guides therapy 2
• Incomplete family history limited to only one generation rather than three generations may miss inherited cardiac conditions 2, 1
• Discrepancies between physical examination and other testing warrant further investigation rather than dismissal 1