1. Introductory Clinical Skills Course Cardiovascular System Prof.Mohammad Salah Abduljabbar

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

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

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

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

7. Acute Anteroseptal MI

8. Dyspnoea Unexpected awareness of breathing Unexpected awareness of breathing At rest or on exertion At rest or on exertion Quantify exercise tolerance (yards walked, stairs climbed) Quantify exercise tolerance (yards walked, stairs climbed) Orthopnoea = shortness of breath on lying supine Orthopnoea = shortness of breath on lying supine Number of pillows Number of pillows Paroxysmal nocturnal dyspnoea Paroxysmal nocturnal dyspnoea

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

10. Pulmonary Oedema Normal Chest RadiographPulmonary Oedema

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

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

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

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

16. Risk factors for Ischaemic Heart Disease 1. Hyperlipidaemia 2. Diabetes mellitus 3. Smoking 4. Hypertension 5. Obesity 6. Family history

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

18. Medications Anti-anginal agents Anti-anginal agents Use of sublingual nitrate spray Use of sublingual nitrate spray Antihypertensive agents Antihypertensive agents Anti-arrhythmics Anti-arrhythmics Statins Statins Platelet inhibitors, e.g., Aspirin Platelet inhibitors, e.g., Aspirin Anticoagulants, e.g., Warfarin Anticoagulants, e.g., Warfarin Allergies Allergies NB Document in front of chart and inform nurses NB Document in front of chart and inform nurses

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

20. Family History Ischaemic heart disease Ischaemic heart disease Angina Angina MI MI CABG CABG Hypertrophic obstructive cardiomyopathy Hypertrophic obstructive cardiomyopathy Dilated cardiomyopathy Dilated cardiomyopathy

21. HOCM

22. Physical Examination General General Hands Hands Pulse Pulse Blood pressure Blood pressure Face Face Neck Neck Jugular venous pressure Jugular venous pressure Precordium Precordium Inspection Palpation Percussion Auscultation Back Back Abdomen Abdomen Lower limbs Lower limbs Other Other

23. Examination - General Position patient at 45 degrees Position patient at 45 degrees Respiratory rate Respiratory rate Cachexia Cachexia Marfan’s syndrome Marfan’s syndrome Down’s syndrome Down’s syndrome

24. Did Abraham Lincoln have Marfan’s Syndrome? High arched palate

25. Examination - Hands Clubbing Clubbing Splinter haemorrhages (infective endocarditis) Splinter haemorrhages (infective endocarditis) Osler’s nodes (tender) Osler’s nodes (tender) Janeway lesions (non-tender) Janeway lesions (non-tender) Xanthomata (Hyperlipidaemia) Xanthomata (Hyperlipidaemia)

26. Clubbing Splinter Haemorrhages

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

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

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

31. Eye signs in Hyperlipidaemia CORNEAL ARCUSXANTHELASMATA

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

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

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

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

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

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

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

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

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

47. Examination – Lower Limbs Peripheral oedema Peripheral oedema Pitting/non-pitting Pitting/non-pitting Upper level Upper level Achilles tendon xanthomata Achilles tendon xanthomata Capillary return Capillary return Trophic skin changes Trophic skin changes Palpate arteries Palpate arteries Femoral Popliteal Posterior tibial Dorsalis pedis Buerger’s test (peripheral vascular disease)

48. Dorsalis pedis pulsePosterior tibial pulse Peripheral Pulses

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

50. THE END