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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
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Area
(1) Apex
Structure
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
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 left Atrium.
Anatomical base of heart is
formed by Two atria,
Clinical base of heart: Aorta &
pulmonary trunk.
Mitral area is reveled by apex.
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
intercostals space in
5th
Left
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 :
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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.
Closure of mitral & tricuspid
valves producing S1
Isometric contraction phase.
Silent opening of Aortic &
pulmonary valves.
Maximum ejection phase.
Reduced ejection phase.
Pre diastole.
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:
o LAF, MS
o LVF:
 overload
 CM, MC, MI
Left Atrium :
- MS
- MR
-Lt to right shunt
Right Atrium :
- TR
- TS
- ASD
Aortic dilatation :
- Aortic aneurysm
- Post steno tic dilatation
Pulmonary dilatation :
- Pulmonary hypertension
-Lt to right shunt
- Post stenotic dilatation
Clinical medicine – Cardiology
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Local Examination
(I) 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:
Midsternotomy
Lat. thoracotomy
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Site
Direction
Length
Shape
Healing
Complica
tions
Midline sternum
On apex
Vertical
Horizontal
Long
Short
Straight
curved
Secondary Intention
Keloid pigmentation - Delayed healing
Incisional hernia - Surgical emphsema
Bleeding – infection

Use :
Open heart CABG
Closed mitral
Valve repair commissurotomy :
Cronary artery bypass by tips of finger.
graft
2. 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.
3. Pulsation:
 Of Apex, left parasternal area, pulmonary artery, aorta, Epigastium.
Rules of:
Inspection
1- Ask pt. to hold his
breath
"‫" بعد ما يطلع نفسه‬
Palpation
1- Ask Pt. To hold his breath.
2- Position the Pt. in direction of Gravitation :
- Apex : lateral deviation
Clinical medicine – Cardiology
2- Good illumination
to direction of
pulsation.
3- Looking tangentially
at pulsations
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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
Site:
Site
Cardiac causes
Anatomical
i.e in the 5th I.C
space.
Shifted
outward
Normal - concentric
hypertrophy – mild
dilatation
Right ventricular
enlargement
Shifted inward
Out & down
Congenital dextrocardia
It ventricular enlargement
Extracardiac causes
Ipsilateral: fibrosis & collapse.
(pulling)
Contralateral: pleural
effusion, pneumothorax,
tumor. (pushing)
“ Acquired dextrocardia ”
Downwards :
 Upper mecliaslinal mass
 Long thin inclividual
 During standing
Clinical medicine – Cardiology
Upwards
Normal in children
 Emphysema ?! (bilaleral)
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.
N.B : Site is a bad indicator for chamber enlargement eg. Apex 7th space:
If outwards  right Enlargement.
If outwards & downwards  Left enlargement.
Timing of pulsation:
Wall of left ventricle is 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 is systolic:
 Bulge of apex
 Retraction of left PS area
Mechanism : Anticlockwise rotation of heart
Cause : left V.E.
External rocking: of left ventricle is systolic:
 Retraction of apex
 Bulge of it PS area
Mechanism: Clockwise rotation of heart
Cause: Marked right V.E.
Extent:
 Localized: left V.E >2.5 cm, if 2cm it's normal.
 Diffuse: Right V.E
o Diameter of normal apex = 2 cm
o If > cardiomegaly.
o If apex with well defined edges
localized
o Left V.E left cardiomegaly
o If apex with ill defined
edgesdiffuse
o Right cardiomegaly
o 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
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Clinical medicine – Cardiology
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B) palpation
a) Exact site
b) Character
c) 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 confirm inspection)
2- Character:
o Normal
o Forcible non sustained = hyperdynamic, due to:
- Volume overload of left V: AR, MR, VSD, PDA
- hyperdynamic circulation : No signs of cardiomegaly )‫(بالطلب‬
o Forcible sustained = heaving: due to:
- Pressure overload left V: AS, A. coarctation, Hypertension.
- Marked volume over load )‫)بالطلب‬
o 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
N.B.: Any thrill over the heart is systolic except MS which is diastolic.
Causes of invisible apex:
1- Dextro cardia
2- Weak contrction
3- Pericardial effusion
4- Emphyzema
5- Pleural effusion
2- Left Parastenal area:
6789-
Pleural fibrosis
Apex lying behind a rib
Obesity
Scleroderma
 Normally not felt.
 By inspection:
Pulsation:
 Marked L.A. dilatation due to severe M.R.
 RVE:
o Dilatation (non-sustained).
o Hypertrophy (sustained)
 By palpation: (as before i.e. by heel of your hand without your finger touching to
avoid transmission of apical pulsation)
If pulsations are felt  right V.E:
 Right V. Dilatation (non sustained).
 Right Hypertrophy (sustained).
Clinical medicine – Cardiology
It may be caused by marked left atrial enlargement) due to severe MR: -as with every
systole marked filling of left atrium  pressing on right ventricle  left parasternal
pulsation. If thrill  VSD (systolic thrill)
3- Pulmonary:
 By inspection:
(look pulsation)
 By palpation:
If Pulsation Pulmonary dilatation (all causes except post-stenotic dilatation)
Palpable S2  P.H. (Diastolic shock)
If thrill  P.S. (systolic thrill)
4- Aortic:
 By inspection:
(look pulsation)
 By palpation
Pulsation  Aortic dilatation (aneurysm)
Palpable S2  (Systemic hypertension)
if thrill  A.S ( systolic thrill)
5- Epigustric:
 By inspection & palpation
Pulsation:
Finger tips RVE.
From right side  Hepatic enlargement.
From pulmar aspect  Big pulse volume in Aorta.
Pulse in Aorta :
Aortic aneurysm
Causes of big pulse volume Aortic Regurg.
Pulse in liver :
T.R systolic Sl
T.S  Presystolic before Sl  due to atrial contraction
(II) Percussion :
Rules of left 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 of right 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
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Clinical medicine – Cardiology
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Cardiac percussion:
a- Tidal percussion: for upper border of the liver.
 Start at Rt. 2nd space, MCL until we get (Normally at 4 the space). Keep pleximeter at
its place.
 Tell the patient to hold breath.
 Percuss the same site:
R Infra-diaphragmatic as liver
D  move one space up (reversed tidal) and percuss:
 D  diaphragmatic paralysis
 R supradiphragmatic as pleural effusion.
b- Percussion of Rt. Border of heart:
 Dullness outside Rt. border.
 Right atrium dilatation most important
 Pericardial effusion
 Lung causes
 Dextrocardia
 Aneurysm in Aortic root
 Giant Lt. Atrium
c- Percussion outside apex:
 Detect site of apex by inspection & palpation
 Percuss from outside apex.
 Dullness outside apex:
 Pericardial effusion.
 Lung causes.
 Vent aneurysm
d- Percussion of pulmonary area:
 Dullness over pulmonary area:
 Pulmonary dilatation
 Pericardial effusion (Shifting dullness)
 Lung causes
‫موجود و هو نائم‬
e- Percussion of Aortic area:
 Dullness over Aortic area
 Aortic aneurysm
 Pericardial effusion
 Lung causes.
NB : Comporative percussion between Aortic and pumondry areas
f- Percussion of waist of heart:
 Obliterated waist.
 Pulmonary dilatation
 Left atrial.
g- Percussion of bare area:
* Dullness outside bare area
 R.V enlargement
 Pericardial effusion
 Lung causes
 Pericordid eff
 Lung causes
* Resonance over bare area
 Emphysema
 Pneumothorax
 Dextrocardia
Clinical medicine – Cardiology
Bare area:
 Midline between ribs 4 – 6
 Lt. PSL at rib 6
9
 Normally: 4 cm from Ml.
 In spaces 4,5
NB: Cardiac percussion is obsolete, except for pericardial effusion.
(III) Auscultation :
 Diaphragm is used for high pitched sounds
 Cone is used for low pitched sounds
 Auscultatray areas:
1- Apex (cone then diaphragm).
2- Tricuspid (cone then diaphragm).
3- Pulmonary
4- A1
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
o S1 é impulse
o S2 not é impulse
 Additional
o S3
o S4
o OS
o EC
Diaphragm
N.B.:
 Accentuated S1: Ms, TS
 Muffled S1:MR, TR
 Verient S1: Atrial fibrillation
 Accentuated S2: PH,
Hypertension
 Muffled S2: PS, AS
 Sounds:
Comment on S1 (apex)
Comment on S2  base
S3
Maximum filling
Normal in children
Pathological in adults
Early diastolic
Low pitched (one) & not propagated
Causes: ++compliance
4F (systolic dysfunction)
Volume over load
Os = Opening Snap
Clicky, propagated
Early diastolic as S3
S4
Atrial contraction
as
as
Presystolic, splitted S1
as
Causes
Ventricular hypertrophy (dysfunction )
EC = Ejection Click
Clicky, propagated
Early systolic between S1, S2
Clinical medicine – Cardiology
Non calcific MS, TS
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Non calcific AS, PS
NB: Tertiary or Quaternary heart sound + tachycardia are called:
Gallop Rhythm
 Murmurs:
Definition: 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
Tricuspid : TS, TR, double T
Pulmonary: PS, PR, double P
H.P.S
: VSD
H.I.C
: PDA
2) Site of main propagation: depends on blood Flow direction.
ALMR: axilla
PLMR: T. A2
‫ السليم‬leaflet ‫الدم يتزحلق على الـ‬
MS
: Not propagated
AS
: Rt. Root of neck + apex
AR
: apex
PS
: left root of neck
PR
: Tricuspid area
TS
: Not
TR
: apex ‫شاذة‬
VSD : Concentric
PDA : Pulmonary area
3) Character:
1- Low frequency murmur rumbling by cone diagnose stenosis (MS, TS).
2- Medium frequency murmur  Harsh [AS, PS, shunt (VSD, PDA)].
3) High frequency murmur
SOFT:
Diagnose
o Soft = Soft to harsh MR, TR
regurge
o Very soft = Soft hemic
AR, PR
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 with pulse.
Diastolic not with pulse.
 Pansystolic: MR, TR, VSD
 Ejection mid systolic: AS, PS
 Early diastolic:
AR, PR
 Mid diastolic é presystolic accentuation  MS, TS.
 Systolic + Diastolic:
 To & from double lesion
 Continuous  PAD (machinery murmur)
Clinical medicine – Cardiology
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Sound
Normal
S1 S2 S3
N
↑↑
Additional
S4 OS EC

M.I
M.P
apex
‫ــ‬
↓↓
N

apex
axilla
↑↑
N

apex
axilla
N
↑↑
A1
N
N
A2
Left
root
of
neck
+
apex
apex
N
N
N
N
Lt.IC Pulm.
Lt.P Conc
S
entric

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 diastolic
AR
continuous
pan systolic
PDA
VSD
MR
Double
M=MR+S1
AS
NB 1: Relation to respiration:
 Right sided murmur (T, P) become louder after deep inspiration due to venous
return (Carvallo's sign).
 T. murmur ‫ تشبه‬those of M. but max intensity is over T. area and become louder
after deep inspiration.
 P. murmur ‫ تشبه‬those of Aortic but max intensity is over pulmonary area and
become louder after deep inspiration.
NB 2 : Relation to position
Apical murmurs become louder on left lateral position.
Basal murmurs become louder on leaning forwards.
NB 3



: Auscaltatory findings in pulmonary hypertension:
↑↑ S2 on pulmonary area.
Functional P.S
Functional PR [Graham Steel murmur].
Peripheral signs of Aortic Regurge :
 Pulse pressure = Systolic P – Diastolic P.
 In A.R
 systolic Pressure
 Diastolic pressure. Big pulse volume
Neck:
1- Visible carotid pulsations (Corrigan’s sign)
2- Systolic nodding of head (De Mussel sign)
3- Carotid thrill = shudder = felt murmur
Clinical medicine – Cardiology
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 systolic and
diastole.
Lower limb:
1- Pistol shot: (Duroizier 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 mmHg normally:
> 20  mild
> 40  moderate
> 60  severe
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