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Clinical medicine – Cardiology 1 Anatomy of the heart 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 2 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 3 Pulmonary dilatation : - Pulmonary hypertension Lt to rt shunt - Post stenotic dilatation Local Examination Inspection & Palpation: 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. 4 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 Clinical medicine – Cardiology 5 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 6 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 edgesdiffuse 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 7 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 8 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 Clinical medicine – Cardiology Pericardial eff (Shifling cluness) Lung causes 9 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 Clinical medicine – Cardiology 10 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 11 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 12