* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download cardiology1
Survey
Document related concepts
History of invasive and interventional cardiology wikipedia , lookup
Coronary artery disease wikipedia , lookup
Cardiac contractility modulation wikipedia , lookup
Electrocardiography wikipedia , lookup
Heart failure wikipedia , lookup
Cardiac surgery wikipedia , lookup
Lutembacher's syndrome wikipedia , lookup
Hypertrophic cardiomyopathy wikipedia , lookup
Aortic stenosis wikipedia , lookup
Quantium Medical Cardiac Output wikipedia , lookup
Arrhythmogenic right ventricular dysplasia wikipedia , lookup
Mitral insufficiency wikipedia , lookup
Atrial septal defect wikipedia , lookup
Dextro-Transposition of the great arteries wikipedia , lookup
Transcript
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 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 2 Physiology Cardiac cycle: 1. Short systole : 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 3 Local Examination (I) 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: Midsternotomy Lat. thoracotomy 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 4 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 Systolerotation 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 edgesdiffuse 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 5 Clinical medicine – Cardiology 6 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 7 Clinical medicine – Cardiology 8 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 10 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 11 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 12