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Introductory Clinical Skills Cardiovascular System
Prof.Mohammad Salah Abduljabbar
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“ For me, the only things of interest are those linked to the heart” (Audrey Hepburn)
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Presenting Complaint Chest pain Shortness of breath Ankle swelling
Palpitations Syncope Intermittent claudication
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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
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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
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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
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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
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Normal Chest Radiograph
Pulmonary Edema Normal Chest Radiograph Pulmonary Edema
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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
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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
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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)
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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
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Risk factors for Ischemic Heart Disease
Hyperlipidemia Diabetes mellitus Smoking Hypertension Obesity Family history
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Past Medical History Rheumatic fever Previous cardiac investigations
Previous myocardial infarction Coronary angioplasty + stent insertion Coronary artery bypass grafting Pacemaker insertion
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Medications Anti-anginal agents Use of sublingual nitrate spray
Antihypertensive agents Anti-arrhythmics Statins Platelet inhibitors, e.g., Aspirin Anticoagulants, e.g., Warfarin
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Social History Occupation
e.g., train driver, long distance truck driver Smoking Number of pack years Alcohol intake Stairs at home
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Family History Ischemic heart disease
Angina MI CABG Hypertrophic obstructive cardiomyopathy Dilated cardiomyopathy
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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
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General Position patient at 45 degrees Respiratory rate Cachexia
Marfan’s syndrome Down’s syndrome
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High arched palate
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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
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Eye signs in Hyperlipidemia
CORNEAL ARCUS XANTHELASMATA
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Hands Clubbing Splinter hemorrhages (infective endocarditis)
Osler’s nodes (tender) Janeway lesions (non-tender) Xanthomata (Hyperlipidemia)
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Splinter Haemorrhages
Clubbing
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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)
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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
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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
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Precordium - Inspection
Scars: Median sternotomy CABG Valve replacement Lateral thoracotomy Infraclavicular (pacemaker) Pectus excavatum Apex beat Sternotomy scar Pectus excavatum
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Precordium - Palpation
Apex beat Location Character Heaving Thrusting Double Tapping Paradoxical Left parasternal heave Thrills (palpable murmurs) Systolic Diastolic Palpable P2 (pulmonary hypertension)
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Precordium – Auscultation Heart Sounds
Bell (low pitched) Diaphragm (high pitched) Mitral Tricuspid Pulmonary Aortic areas S1 (first heart sound) S2 – Splitting (A2, P2)
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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
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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
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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
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Examination – Back Percuss and auscultate lung bases
Left ventricular failure Pleural effusion Sacral pitting edema Right heart failure
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Examination - Abdomen Patient lying with one pillow (if tolerated)
Tender hepatomegaly Pulsatile liver (tricuspid regurgitation) Ascites Splenomegaly Abdominal aortic aneurysm
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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
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Posterior tibial pulse
Peripheral Pulses Dorsalis pedis pulse Posterior tibial pulse
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Examination - Other Urinalysis Fundi Temperature chart
Hematuria (infective endocarditis) Fundi Hypertensive retinopathy Roth spots (infective endocarditis) Temperature chart Infective endocarditis
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THANKS
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