Introductory Clinical Skills Cardiovascular System Prof.Mohammad Salah Abduljabbar

“ For me, the only things of interest are those linked to the heart” (Audrey Hepburn)

Presenting Complaint Chest pain Shortness of breath Ankle swelling Palpitations Syncope Intermittent claudication

Chest Pain Character of pain Relieving factors Severity Duration Radiation At rest or on exertion Previous episodes Relieving factors Worse on taking a deep breath (pleuritic) Worse on movement Autonomic symptoms Sweating Nausea

Causes of Chest Pain Cardiovascular Chest wall Angina Coughing Stable Unstable Myocardial infarction Aortic dissection Myocarditis Pleuropericardial Pericarditis Pleurisy Pneumothorax Gastrointestinal Gastro-esophageal reflux Esophageal spasm Chest wall Coughing Intercostal muscle strain/myositis Herpes zoster Viral pleurodynia Thoracic radiculopathy Rib fracture Rib tumor Costochondritis

Dyspnea Unexpected awareness of breathing At rest or on exertion Quantify exercise tolerance (yards walked, stairs climbed) Orthopnea = shortness of breath on lying supine Number of pillows Paroxysmal nocturnal dyspnea

Causes of Dyspnea Chest wall Pleural effusion Rib fracture Kyphoscoliosis Neuromuscular Cardiac Left ventricular failure Mitral valve disease Cardiomyopathy Pericardial effusion Other Anemia Acidosis Psychogenic Airways disease COPD Chronic bronchitis Emphysema Asthma Bronchiectasis Cystic fibrosis Parenchymal disease Pneumonia Pulmonary fibrosis Tumor Pneumothorax Pulmonary vasculature Pulmonary embolism Pulmonary hypertension

Normal Chest Radiograph Pulmonary Edema Normal Chest Radiograph Pulmonary Edema

Ankle Swelling Unilateral or bilateral Proximal extent of oedema Pitting/non-pitting Cardiac Congestive cardiac failure Right ventricular failure Cor pulmonale Constrictive pericarditis Drugs Calcium channel blockers Other Cirrhosis Nephrotic syndrome Protein-losing enteropathy Deep vein thrombosis Hypothyroidism Lymphoedema

Palpitations Is Unexpected awareness of heartbeat Ask patient to tap palpitations on chest Slow or fast Regular or irregular Duration Speed of onset or offset Relieving maneuvers Sinus tachycardia Ventricular extrasystoles Atrial fibrillation Atrial flutter Supraventricular tachycardia Ventricular tachycardia

Syncope Transient loss of consciousness due to cerebral hypoperfusion What was the patient doing at the time? Standing for prolonged period Standing up suddenly (postural hypotension) Coughing Prodromal symptoms Abnormal movements (epilepsy) Sensation of room spinning (vertigo)

Intermittent Claudication Pain in one or both calves, thighs or buttocks Brought on by walking a certain distance (claudication distance) Worse on walking uphill Relieved by rest Suggests peripheral vascular disease

Risk factors for Ischemic Heart Disease Hyperlipidemia Diabetes mellitus Smoking Hypertension Obesity Family history

Past Medical History Rheumatic fever Previous cardiac investigations Previous myocardial infarction Coronary angioplasty + stent insertion Coronary artery bypass grafting Pacemaker insertion

Medications Anti-anginal agents Use of sublingual nitrate spray Antihypertensive agents Anti-arrhythmics Statins Platelet inhibitors, e.g., Aspirin Anticoagulants, e.g., Warfarin

Social History Occupation e.g., train driver, long distance truck driver Smoking Number of pack years Alcohol intake Stairs at home

Family History Ischemic heart disease Angina MI CABG Hypertrophic obstructive cardiomyopathy Dilated cardiomyopathy

Physical Examination -General -Abdomen -Lower limbs -Precordium Hands Pulse Blood pressure Face Neck Jugular venous pressure -Precordium 1-Inspection 2-Palpation 3-Percussion 4-Auscultation -Back -Abdomen -Lower limbs

General Position patient at 45 degrees Respiratory rate Cachexia Marfan’s syndrome Down’s syndrome

High arched palate

Examination – Face and Neck Jaundice Xanthelasmata Corneal arcus Malar flush (mitral stenosis) High arched palate (Marfan’s syndrome) Dental caries (infective endocarditis) Central cyanosis Carotid pulse character Slow rising (AS) Bisferiens (AS + AR) Collapsing (AR) Alternans (LVF) Jerky (HOCM) Carotid bruit

Eye signs in Hyperlipidemia CORNEAL ARCUS XANTHELASMATA

Hands Clubbing Splinter hemorrhages (infective endocarditis) Osler’s nodes (tender) Janeway lesions (non-tender) Xanthomata (Hyperlipidemia)

Splinter Haemorrhages Clubbing

Pulse Radial artery Character and volume assessed from carotid artery Rate (60-100) Bradycardia (<60) Tachycardia (>100) Rhythm Regular Irregular Radio femoral delay (coarctation of the aorta) Character and volume assessed from carotid artery Collapsing pulse (aortic regurgitation) Pulsus alternans (left ventricular failure) Pulse deficit (atrial fibrillation)

Blood Pressure Sphygmomanometer Systolic/diastolic pressure Normal <140/90 mmHg (lower in diabetes) Korotkoff sounds Use larger cuff width for large arms Deflate at 4 mmHg/s Difference between arms of <10 mmHg Pulsus paradoxus = exaggerated reduction in BP with inspiration (>10 mmHg) Postural hypotension

Jugular Venous Pressure Patient at 45 degrees Good lighting Internal jugular vein Reflects right atrial pressure Zero point = sternal angle Visible but not palpable Complex wave form (a, c, v waves) Decreases on inspiration Fills from above Hepatojugular reflux Abnormal if >3 cm above zero point: RV failure RV infarct Tricuspid stenosis Tricuspid regurgitation Pericardial effusion SVC obstruction Fluid overload

Precordium - Inspection Scars: Median sternotomy CABG Valve replacement Lateral thoracotomy Infraclavicular (pacemaker) Pectus excavatum Apex beat Sternotomy scar Pectus excavatum

Precordium - Palpation Apex beat Location Character Heaving Thrusting Double Tapping Paradoxical Left parasternal heave Thrills (palpable murmurs) Systolic Diastolic Palpable P2 (pulmonary hypertension)

Precordium – Auscultation Heart Sounds Bell (low pitched) Diaphragm (high pitched) Mitral  Tricuspid  Pulmonary  Aortic areas S1 (first heart sound) S2 – Splitting (A2, P2)

Abnormalities of Heart Sounds Loud S1 Soft S1 Loud A2 Loud P2 Soft A2 Splitting of S1 Increased splitting of S2 Fixed splitting of S2 Reversed splitting of S2 S3 (third heart sound) S4 (fourth heart sound) Summation gallop Opening snap Systolic ejection click Mid-systolic click Tumor plop Pericardial knock Metallic click

Precordium – Auscultation Murmurs Timing of murmur Systolic Diastolic Continuous Site of maximal intensity Loudness Grades I-VI Thrill Pitch Radiation Dynamic manoeuvres Respiration Left-sided  on exp. Right-sided  on insp. Valsalva Squatting

Heart Murmurs Systolic Diastolic Continuous Pericardial friction rub Pansystolic Mitral regurgitation Tricuspid regurgitation Ventricular septal defect Ejection systolic Aortic stenosis Pulmonary stenosis HOCM Atrial septal defect Late systolic Mitral valve prolapse Diastolic Early diastolic Aortic regurgitation Pulmonary regurgitation Mid-diastolic Mitral stenosis Tricuspid stenosis Atrial myxoma Continuous Patent ductus arteriosus Arteriovenous fistula Pericardial friction rub

Examination – Back Percuss and auscultate lung bases Left ventricular failure Pleural effusion Sacral pitting edema Right heart failure

Examination - Abdomen Patient lying with one pillow (if tolerated) Tender hepatomegaly Pulsatile liver (tricuspid regurgitation) Ascites Splenomegaly Abdominal aortic aneurysm

Examination – Lower Limbs Peripheral edema Pitting/non-pitting Upper level Achilles tendon xanthomata Capillary return Trophic skin changes Palpate arteries Femoral Popliteal Posterior tibial Dorsalis pedis

Posterior tibial pulse Peripheral Pulses Dorsalis pedis pulse Posterior tibial pulse

Examination - Other Urinalysis Fundi Temperature chart Hematuria (infective endocarditis) Fundi Hypertensive retinopathy Roth spots (infective endocarditis) Temperature chart Infective endocarditis

THANKS