Download Structure - Reocities

Clinical medicine – Cardiology
1
Anatomy of the heart
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Angle of Lewis : it’s the manubriosternal angle.
By putting finges at the suprasternal notch, and descending, feel
prominent bone Angle. This is at the 2nd rib.
Heart is an inverted cone :
Apex directed downwards, forwards & to the lt.
Base directed upward & backward.
Longitudinal axis of right. Heart is horizontal, L. axis of left. Is oblique.
Midclavicular line (MCL): Vertical line passing through MC point midway
bet Sternoclavicular junction & top of acromion
Parasternal line (PSL): vertical line midway bet. MCL & lateral margin of
sternum.
Dextrorotation of heart during embryological life.
Most anterior structure is the rt. Ventrical , while most posterior structure is
lt. Atrium .
Anatomical base of heart is formed by Two atria,
Clinical base of heart: Aorta & pulmonary trunk.
Mitral area is reveled by apex.
Area
Structure
(1) Apex
Apex of left ventricle
(2) Left PS area
Rt. Ventricle + Inter
ventricular septum
Tricuspid valve
(3) Tricuspid area
(4) Rt. border of
heart
(5) Pulmonary area
Upper ½: ascending
aorta
Lower ½: Rt. Border of rt.
Atrium
Pulmonary trunk
(6) 1st Aortic area
(A1)
(7) 2nd Aortic area
(A2)
(8) Waist of heart
Ascending aorta
(9) Lt. infraclavicular region
(10) Lt. border of
heart
Ductus arteriosus
Lt. Ventricular outflow
tract
Pulmonary artery, left
ventricular outflow tract ,
lt. a trial appendage
Apex - waist- pulmonary
trunk
Anatomical location
Left 5th intercostals space in
MCL
Left PSL to left MCL in 3rd ,4th
& 5th spaces
Lower end of lt. Sternal
border
Behind rt. Sternal border
Lt. 2nd intercostal space one
finger from edge of st
Rt. 2nd intercostal space one
finger from edge of st
Lt. 3rd intercostal space one
finger from edge of st
Lt. 3rd space. It measures from
midline, 1/2 distance from
midline to apex (any apex)
Clinical medicine – Cardiology
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Physiology
Cardiac cycle:
(1) Short systole :
 Closure of mitral & tricusped valves producing S1
 Isometric contraction phase.
 Silent opening of Aortic & pulmonary valves.
 Maximum ejection phase.
 Reduced ejection phase.
 Pre diastole.
(2) Long Diastole :
Closure of Aortic & pulmonary valves producing S2.
Isometric Relaxation phase.
Silent opening of Mitral & Tricuspid valves.
Maximum filling phase.
Reduced Filling phase.
Atrial Contraction = pre systole.
Pathology
Causes of Chamber Enlargement:
Left ventricle:
* L.V dilatation = Eccentric
(Volume Overload)
- MR
- AR
- VSD
- PDA
* L.V hypertrophy = Concentric
(Pressure Over load)
- AS
- A. Cortication
- Systemic hypertension
Right Ventricle :
* R.V dilatation (volume overload )
* R.V hypertrophy (Pressure Overload)
- PR
- TR
- VSD
- ASD
- PS
- PH
Corpulmonale
LSHF
LAF MS
LVF overload
CM, MC, MI
Left Atrium :
Aortic dilatation :
- MS
- MR
-Lt to Rt shunt
- Aortic aneurysm
- Post steno tic dilatation
Clinical medicine – Cardiology
Right Atrium :
- TR
- TS
- ASD
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Pulmonary dilatation :
- Pulmonary hypertension
Lt to rt shunt
- Post stenotic dilatation
Local Examination
Inspection & Palpation:
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1.
Right side of patient (pt.).
Expose him down to umbilicus.
Examine : skin – precordium - pulsation
Skin :
Dilated veins (DV):
Mostly due to superior or inferior vena caval obstruction
formation of new collateral
To differential clear the vein :then remove your finger if :
Filling from up : Superior V. caval obstruction
Filling from down : inferior V. caval obstruction
Scars:
 Site
 Direction
 Length
 Shape
 Healing
 Complications
Use :
2.
Midsternotomy
Lat. thoracotomy
Midline sternum
On apex
Vertical
Horizontal
Long
Short
Straight
curved
Secondary Intention
Keloid pigmentation - Delayed healing
Incisional hernia - Surgical emphsema
Bleeding – infection
Open heart CABG
Closed mitral
Valve repair commissurotomy :
Cronary artery bypass by tips of finger.
graft
Precordium:
 Part of chest wall overlying heart from 2nd to 6th ribs & from right sternal border to it MC
line.
Precordial bulges:
 Right: ventricular enlargement dating back to infancy due congenital or rheumatic heart
disease.
 Inspected tangentially from foot side of bed.
Clinical medicine – Cardiology
3.
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Pulsation:
 Of Apex, left parasternal area, pulmonary artery, aorta, Epigastium.
Rules of:
Inspection
Palpation
1- Ask pt. to hold his breath
1- Ask Pt. To hold his breath.
"‫" بعد ما يطلع نفسه‬
2- Position the Pt. In direction of
2- Good illumination to direction of
Gravitation :
pulsation.
- Apex : lateral deviation
3- Looking tangentially at pulsations
why / what :
- More forcible contraction
- More forcible sustained
- Wider in extent, shifts laterally 2-3
cms
- Base : leaning forwards
3- Using hand:
a- tips of middle 3 fingers (small
areas)
aortic
pulmonary
b- Palmar aspect of mid 3 fingers large
areas : Apex, Epigastrium
c- Heel of hand:
lt Parasternal area
d- Roots of finger : feel thrill
“Palpable murmur ”
1. Apex
 It is the outermost, lowermost palpable visible strongest and pulsating point over chest
wall.
 Outermost more than lowermost, and Palpable more than visible.
A) Inspection :
a. Site
b. Timing.
c. extent
N.B: Remember axes of both sides of heart
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Site :
Site
Anatomical
i.e in the 5th I.C
space.
Shifted outward
Cardiac causes
Normal - concentric
hypertrophy – mild dilatation
Extracardiac causes
Right ventricular
enlargement
Ipsilateral: fibrosis & collapse.
(pulling)
Contralateral: pleural effusion,
pneumothorax, tumor.
(pushing)
“ Acquired dextrocardia ”
Downwards :
 Upper mecliaslinal mass
 Long thin inclividual
 During standing
 Emphysema ?! (bilaleral)
Upwards
Normal in children
Supradiaphragmatic : fibrcsis
collapsa of it lung
Diaphragmalic : paralysis
(noted during inspiration)
Infradisphragmalic : ascitis /
pregnancy
This lesions affects apex if occur in lower aspect of lung,but if upper aspect  tracheal
shifting
Shifted inward
Out & down
Congenital dextrocardia
It ventricular enlargement
N.B : Site is a bad indicator for chamber enlargement eg. Apex 7th
space:
If outwards right.Enlargment.
If outwards & downwards  It enlargment.
Timing of pulsation:
 Wall of left ventricle 3 times more than the Wall of right ventricle. During
Systole …… Rotation of its apex anticlockwise
Method:
 Inspect apex while palpating carotid artery.
If : Together  Systolic bulge : Normal left V.E [ Anticlockwise rotation]
Alternating Systolic Retraction: Marked right V.E [clockwise rotation]
Internal rocking : of right ventricle : it
Bulge of
apex
systolic
Retraction of lt. PS area
Mechanism : Anticlockwise rotation of heart
Cause : lt.V.E
External rocking : of lt ventricle
Clinical medicine – Cardiology
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Retraction of apex
systolic
bulge of it PS area
Mechanism : Clockwise rotation of heart
Cause : Marked rt.V.E
Localised: lt.V.E >2.5 cm , if 2cm its normal.
Extent :
Diffuse: Right.V.E.
 Diameter of normal apex = 2 cm
 If > cardiomegaly.
 If apex with well defined edges localized
Left V.E left cardiomegaly
 If apex with ill defined edgesdiffuse
Right cardiomegaly
 Causes of invisible apex:
1- Dextrocardia
2- Weak contraction.
3- Pericardial effusion.
4- Emphysema .
5- Pleural effusion.
6- Apex behind rib.
7- Obesity.
8- Sclerosderma
B) palpation
Exact site
Character
Thrill
Rules of palpation :
1- Hold breath.
2- Choose the proper part of your hand.
3- If needed, Augmentation.
4- Let the patient lay on left side to palpate the apex.
1- Exact site.(to conferm inspection)
2- Character. Normal
Forcible non sustained = hyperdynamic
Due to:- volume overload of lt.V : AR, MR, VSD, PDA
- hyperdynamic circulation : No signs of cardio
megaly megaly )‫(بالطلب‬
Forcible sustained = heaving :
Due to:- pressure overload lt.V : AS, A. coarctation,
Hypertension.
- Marked volume over load )‫)بالطلب‬
Slapping = tapping : due to M.S.
NB : The apex is palpated during systole, exactly at isometric contraction phase
3- Thrill : Palpable murmur.
Diastolic : MS
Systolic : MR
Any thrill over the heart is systolic except MS which is diastolic.
Clinical medicine – Cardiology
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Causes of invisible apex :
1- Dextro cardia
2- weak contrction
3- Pericardial effusion
4- Emphyzema
5- Pleural effusion
6- Pleural fibrosis
7- Apex lying behind a rib
8- Obesity
9- Scleroderma
2- Left Parastenal area :
 Normally not felt.
 By inspection : (look pulsation)
 By palpation: (as before i.e by heel of your hand without your finger touching to avoid
transmission of apical pulsation )
if pulsation are felt
rt.V.E
rtV Dilatation(non sustained)
rtV Hypertrophy (sustained)
it may be …..caused by marked (lt.atrial enlargment) due to sever
MR: -as with
every systol
marked filling of lt.atrium
pressing on rt.vent
lt.parasternal
pulsation .
if thrill
VSD….(systolic thrill)
3- Pulmonary :
 By inspection: (look pulsation)
 By palpation :
Pulsation
Palpable S2
Pulm. Dilatation, all causes except poststenotic
dilatation
(P.H.)
Diastolic shock
‫خليه يميل لألمام‬
if thrill
P.S ……(syst.thrill)
 By inspection:
 By palpation
4- Aortic :
(look pulsation)
pulsation…. Aortic dilatation (aneurysm)
palpable S2
( Systemic hypertension)
A.S…..( systolic thrill)
5- Epigustric :
 By inspection & palpation
pulsation
Finger tips
RVE
From rt.side
Hepatic enlargement
From pulmar aspect
Big pulse volume in Aorta
Pulse in Aorta :
Aortic aneurysm
Causes of big pulse volume Aortic Regurg.
if thrill
Clinical medicine – Cardiology
Pulse in liver :
T.R systolic Sl
T.S
Presystolic before Sl
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due to atrial contraction
ll Percussion :
Rules of lt hand :
 Fingers should be separated from each other.
 Pleximeter should be hyper extended & tightly applied, while other fingers are elevated
 Pleximeter should be parallel to area of expected dullness D
 Pleximeter should be move from Resonance to Dullness.
Rules ofrt. hand :
 The entire movement should be from the wrist ( low elbow )
 By tip of pleximeter middle phalanx of pleximeter.
( curved plexor )
 Withdraw your plexor rapidly after each percussion
Special Rules for cardia percussion :
 Heart is percussecl heavy percussion except bare area by light.
 Pleximeter is placed longitudinally except for tidal percussion
 Pleximeter moves from lateral R to medial D, except in tidal percussion from up R
downwards D
Cardiac percussion:
a- Tidal percussion : for upper border of the liver.
 Start at Rt. 2nd space, Mcl untill we get ( Normally at 4 th space ). Keep pleximeler at
it place
 Tell the patient to hold breath
 Percuss the same site
R
Infadiophragmatic as liver
D
move one space up (reversed tidal)
and percuss D diaphragmatic paralysis
R
supradiphragmatic as
pl. eff
b- Percussion of Rt. Border of heart :
 Dullness outside Rt. border .
 rt.A dilatation most important
 Pericardial eff
 Lung causes
 Dextrocardia
‫بالطلب‬
 Aneuryzm in Acrtic root
 Giat Lt. Atrium
c- Percussion outside apex .
 detect site of apex by inspection & palpation
 percuss from outside apex.
 Dullness outside apex :
 pericardial eff.
 Lung causes
 Vent aneuryzm
d- Percussion of pulmonary area
 Dullness over pulm area :
 Pulmonary dilatalion
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 Pericardial eff (Shifling cluness)
 Lung causes
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‫موجود و هو نائم‬
e- Percussion of Aortic area
 dullness over Aortic area
 Aortic oneuryzn
 Pericardial eff.
 Lung causes.
NB : Comporative percussion between Aortic and pumondry areas
f- Percussion of waist of heart :
 obliterated waist :
 pulmonary dilatation
 Lt. atrial
 Pericordid eff
 Lung causes
More than 1/2 distance from ML to apex.
g- Percussion of bare area :
* Dullness outside bare area
 R.V enlargement
 Pericardial eff.
 Lung causes
* Resonance over bare area
 Emphysema
 Pheumothorax
 Dextrocardia
Bare area :
 Midline between ribs 4 – 6
 Lt. PSL at rib 6
 Normally : 4 cm from Ml.
 In spaces 4,5
NB : Cardiac percussion is obsolete, except for pericardial effusion.
lll) Auscultation :
 Diaphragm is used for high pitched sounds
 Cone is used for low pitched sounds
 Auscultatray areas :
1- apex
Cone, then diaphragm
2- Tricusped
3- Pulmonary
4- A1
Diaphragm
5- A2
6- Lt P.S
VSD
Congenital diseases
7- Lt IC
PDA
8- Roots of neck
Propagation from base
9- Axilla
Propagation from apex
N.B:Auscultation
Murmur
Sound
Normal
Additional
S1 é impulse
S2 nat é impulse
S3
S4
OS
EC
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N.B Accentuated S1:
Muffled S1:
Verient S1:
Accentuated S2 :
Muffled S2 :
N.B
Ms, TS
MR, TR
Atrial fibrillation
PH, Hypertension
PS, AS
‫تحت‬
base
Comment on S1
Comment on S2
S3
S4
Maximum filling
Atrial contraction
Normal in children
as
Pathological in adults
as
Early diastolic
Presystolic, splitted S1
Low pitched (one) & not propagated
as
Causes: ++compliance
Causes
4F (systolic dysfunction)
Ventricular hypertrophy
Volume over load
(dysfunction )
Os = Opening Snap
Clicky, propagated
Early diastolic as S3
Non calcific MS, TS
EC = Ejection Click
Clicky, propagated
Early systolic between S1, S2
Non calcific AS, PS
VB : Tertiary or Quaternary heart sound + tachycardia is called :
Gallop Rhythm
Murmurs
Def : Continuous noisy sound caused by turbulent blood flow due to passage through
abnormal direction [Regurge], abnormal lumen [Stenosis, Incompetence] or both [shunt]
1)Site of maximal intensity :
Apex
: MS, MR, double M
A1, A2
: AS, AR, double A
Tricusped : TS, TR, double T
Pulmonary : PS, PR, double P
H.P.S
: VSD
H.I.C
: PDA
2)Site of main propagation :
depends on bl. Flow direction.
ALMR : axilla
PLMR : T. A2
‫ السليم‬leaflet ‫الدم يتزحلق على الـ‬
MS
: Not propagated
AS
: Rt. Root of neck + apex
AR
: apex
PS
: lt root of neck
PR
: Tricusped area
TS
: Not
TR
: apex ‫شاذة‬
VSD : Concentric
PDA : Pulmonary area
Clinical medicine – Cardiology
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3)Character :
1- Low frequency murmur
Rumbling by cone
MS, TS
diagnose stenosis
2- Medium frequency murmur
Harsh
AS, PS, shunt (VSD, PDA)
3) High frequency murmur
SOFT
Soft = Soft to harsh MR, TR
very soft = Soft hemic
AR, PR
diagnose regurge
NB : In regurge, bl. Passes between 2 chambers é high pressure gradient leading to high
frequency murmur. The opposite occurs in stenosis.
4)Timing :





Systolic éSystolic
pulse é pulse
Diastolic not pulse
Pansystolic :
MR, TR, VSD
Ejection mid systolic:
AS, PS
Early diastolic :
AR, PR
Mid diostolic é presystolic accentuation
Systolic + Diastolic
To & Fro
Continuous
Sound
Normal
Additional
S1 S2 S3 S4 OS EC
N
↑↑

M.I
MS, TS
double lesion
PAD (machinary murmur)
M.P
apex
‫ــ‬
↓↓
N

apex
axilla
↑↑
N

apex
axilla
N
↑↑
A1
N
N
A2
Troot
oof
aeit +
upex
apex
N
N
N
N
Lt.IC Pulm
Lt.P Conc
S

Murmur
Char
diagnosis
Timing
Rumbling mid diastolic é
presystolic
soft
Pansystolic
blowing
soft
Pansystolic
blowing
harsh
Ejection mid
systolic
MS
Soft
hemic
harsh
harsh
early distolic
AR
continuous
pan systolic
PDA
VSD
MR
Double
M=MR+S1
AS
NB 1 : Relation to respiration:
 Rt sided murmur (T, P) become louder after deep inspiration due to venous return (carvallo
sign) .
 T. murmur ‫ تشبه‬those of m. but max intensity is over T. area and become louder after deep
insp.
Clinical medicine – Cardiology
 P. murmur ‫ تشبه‬those of A. but max intensity is over P. area and become louder after deep
insp.
NB 2 : Relation to position
Apical murmurs become louder on Lt. lateral position.
Basal murmurs become louder on leaning forwards.
NB 3 : Auscaltatory findings in pulmonary hypertension:
↑↑ S2 on pulmonary area .
Functional
P.S
PR
[ Graham Steel mumur ]
Peripheral signs of Aortic Regurge :
 Pulse pressure = Systolic P – Diastolic P.
 In A.R
systolic P.
Diastolic
Big pulse volume
Neck :
1- Visible carotid pulsations (Corigan’s sign)
2- Systolic nodding of head (De Mussel sign)
3- Carotid thrill = shudder = felt murmur
upper limb :
1- Water hammer pulse : pulse felt against soft tissue .
2- Wide pulse pressure > 60 mm Hg, with diastolic < 60
3- Digital pulsations : When pressing finger tips against each other, you
will find red part moving out & in with syst. And diastole
Lower limb :
1- Pistol shot : ( Droizie Sign ) Diastole = O
2- Systolic – Systolic murmur of femoral artery after partial compression
by diaphragm of stethoscope.
3- Hill’s sign : Systolic Blood pressure of LL > UL by:
> 20
mild
> 40
moderate
(20 mmHg. Normally)
> 60
severe
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