Download Introductory Clinical Skills Course Cardiovascular - FROM 1:45-3

Introductory Clinical Skills Course
Cardiovascular System
Prof.Mohammad Salah
Abduljabbar
“For me, the only things of
interest are those linked to the
heart” (Audrey Hepburn)
Presenting Complaint
Chest pain
 Shortness of breath
 Ankle swelling
 Palpitations
 Syncope
 Intermittent claudication

Chest Pain






Character of pain
Severity
Duration
Radiation
At rest or on exertion
Previous episodes
Relieving factors
 Worse on taking a deep
breath (pleuritic)
 Worse on movement
 Autonomic symptoms



Sweating
Nausea
Causes of Chest Pain

Cardiovascular

Angina






Myocardial infarction
Aortic dissection
Myocarditis
Pleuropericardial




Stable
Unstable
Pericarditis
Pleurisy
Pneumothorax
Gastrointestinal


Gastro-oesophageal reflux
Oesophageal spasm

Chest wall








Coughing
Intercostal muscle
strain/myositis
Herpes zoster
Viral pleurodynia
Thoracic radiculopathy
Rib fracture
Rib tumour
Costochondritis
Acute Anteroseptal MI
Dyspnoea
Unexpected awareness of breathing
 At rest or on exertion
 Quantify exercise tolerance (yards walked,
stairs climbed)
 Orthopnoea = shortness of breath on lying
supine
 Number of pillows
 Paroxysmal nocturnal dyspnoea

Causes of Dyspnoea

Airways disease

COPD






Chronic bronchitis
Emphysema
Asthma
Bronchiectasis
Cystic fibrosis
Pneumonia
Pulmonary fibrosis
Tumour
Pneumothorax
Pulmonary vasculature


Pulmonary embolism
Pulmonary hypertension
Chest wall





Pleural effusion
Rib fracture
Kyphoscoliosis
Neuromuscular
Cardiac
Left ventricular failure
Mitral valve disease
 Cardiomyopathy
 Pericardial effusion


Parenchymal disease







Other
Anaemia
Acidosis
 Psychogenic


Pulmonary Oedema
Normal Chest Radiograph
Pulmonary Oedema
Ankle Swelling
Unilateral or bilateral
 Proximal extent of
oedema
 Pitting/non-pitting
 Cardiac

Congestive cardiac failure
 Right ventricular failure
 Cor pulmonale
 Constrictive pericarditis

Drugs


Calcium channel blockers
Other







Cirrhosis
Nephrotic syndrome
Protein-losing
enteropathy
Deep vein thrombosis
Hypothyroidism
Lymphoedema
Palpitations
= Unexpected awareness
of heartbeat
 Ask patient to tap
palpitations on chest
 Slow or fast
 Regular or irregular
 Duration
 Speed of onset or offset
 Relieving manoeuvres

Sinus tachycardia
 Ventricular extrasystoles
 Atrial fibrillation
 Atrial flutter
 Supraventricular
tachycardia
 Ventricular tachycardia

Syncope








Transient loss of consciousness due to cerebral
hypoperfusion
What was the patient doing at the time?
Standing for prolonged period
Standing up suddenly (postural hypotension)
Coughing
Prodromal symptoms
Abnormal movements (epilepsy)
Sensation of room spinning (vertigo)
Intermittent Claudication
Pain in one or both calves, thighs or
buttocks
 Brought on by walking a certain distance
(claudication distance)
 Worse on walking uphill
 Relieved by rest
 Suggests peripheral vascular disease

Risk factors for Ischaemic Heart Disease
1.
2.
3.
4.
5.
6.
Hyperlipidaemia
Diabetes mellitus
Smoking
Hypertension
Obesity
Family history
Past Medical History
Rheumatic fever
 Previous cardiac investigations
 Previous myocardial infarction
 Coronary angioplasty + stent insertion
 Coronary artery bypass grafting
 Pacemaker insertion

Medications

Anti-anginal agents

Use of sublingual nitrate spray





Antihypertensive agents
Anti-arrhythmics
Statins
Platelet inhibitors, e.g., Aspirin
Anticoagulants, e.g., Warfarin

Allergies

NB Document in front of chart and inform nurses
Social History

Occupation
 e.g.,

train driver, long distance truck driver
Smoking
 Number
of pack years
Alcohol intake
 Stairs at home

Family History

Ischaemic heart disease
 Angina
 MI
 CABG
Hypertrophic obstructive cardiomyopathy
 Dilated cardiomyopathy

Physical Examination







General
Hands
Pulse
Blood pressure
Face
Neck
Jugular venous
pressure

Precordium
Inspection
 Palpation
 Percussion
 Auscultation

Back
 Abdomen
 Lower limbs
 Other

Examination - General
Position patient at 45 degrees
 Respiratory rate
 Cachexia
 Marfan’s syndrome
 Down’s syndrome

Did Abraham Lincoln have Marfan’s
Syndrome?
High arched palate
Examination - Hands
Clubbing
 Splinter haemorrhages (infective
endocarditis)
 Osler’s nodes (tender)
 Janeway lesions (non-tender)
 Xanthomata (Hyperlipidaemia)

Splinter
Haemorrhages
Clubbing
Examination - Pulse


Radial artery
Rate (normal = 60-100)



Rhythm



Bradycardia (<60)
Tachycardia (>100)
Regular
Irregular
Radiofemoral delay
(coarctation of the aorta)




Character and volume
assessed from carotid artery
Collapsing pulse (aortic
regurgitation)
Pulsus alternans (left
ventricular failure)
Pulse deficit (atrial
fibrillation)
Examination - Blood Pressure





Sphygmomanometer
Systolic/diastolic
pressure
Normal <140/90 mmHg
(lower in diabetes)
Korotkoff sounds
Use larger cuff width
for large arms
Deflate at 4 mmHg/s
 Difference between arms
of <10 mmHg
 Pulsus paradoxus =
exaggerated reduction in
BP with inspiration (>10
mmHg)
 Postural hypotension

Examination – Face and Neck






Jaundice
Xanthelasmata
Corneal arcus
Malar flush (mitral
stenosis)
High arched palate
(Marfan’s syndrome)
Dental caries (infective
endocarditis)
Central cyanosis
 Carotid pulse character







Slow rising (AS)
Bisferiens (AS + AR)
Collapsing (AR)
Alternans (LVF)
Jerky (HOCM)
Carotid bruit
Eye signs in Hyperlipidaemia
CORNEAL ARCUS
XANTHELASMATA
Jugular Venous Pressure
Patient at 45 degrees
 Good lighting
 Internal jugular vein
 Reflects right atrial pressure
 Zero point = sternal angle
 Visible but not palpable
 Complex wave form (a, c, v
waves)
 Decreases on inspiration




Fills from above
Hepatojugular reflux
Abnormal if >3 cm above
zero point:







RV failure
RV infarct
Tricuspid stenosis
Tricuspid regurgitation
Pericardial effusion
SVC obstruction
Fluid overload
Precordium - Inspection

Scars

Median sternotomy




CABG
Valve replacement
Lateral thoracotomy
Infraclavicular
(pacemaker)
Pectus excavatum
 Pacemaker box
 Apex beat

Sternotomy scar
Pectus
excavatum
Precordium - Palpation

Apex beat


Location
Character







Left parasternal heave
Thrills (palpable murmurs)




Heaving
Thrusting
Double
Tapping
Paradoxical
Systolic
Diastolic
Palpable P2 (pulmonary
hypertension)
Pacemaker box
Precordium – Auscultation
Heart Sounds





Bell – low pitched
sounds
Diaphragm – high
pitched sounds
Mitral  Tricuspid 
Pulmonary  Aortic
areas
S1 (first heart sound)
S2 – Splitting (A2, P2)
Abnormalities of Heart Sounds
Loud S1
 Soft S1
 Loud A2
 Loud P2
 Soft A2
 Splitting of S1
 Increased splitting of S2
 Fixed splitting of S2
 Reversed splitting of S2

S3 (third heart sound)
 S4 (fourth heart sound)
 Summation gallop
 Opening snap
 Systolic ejection click
 Mid-systolic click
 Tumour plop
 Pericardial knock
 Metallic click

Precordium – Auscultation
Murmurs

Timing of murmur



Systolic
Diastolic
Continuous
Site of maximal intensity
 Loudness
Pitch
 Radiation
 Dynamic manoeuvres



Grades I-VI
 Thrill

Respiration




Left-sided  on exp.
Right-sided  on insp.
Valsalva
Squatting
Heart Murmurs

Systolic


Pansystolic
Diastolic

Mitral regurgitation
 Tricuspid regurgitation
 Ventricular septal defect
Aortic regurgitation
 Pulmonary regurgitation




Ejection systolic
Aortic stenosis
 Pulmonary stenosis
 HOCM
 Atrial septal defect



Mitral valve prolapse


Mitral stenosis
Tricuspid stenosis
Atrial myxoma
Continuous

Late systolic

Mid-diastolic



Early diastolic
Patent ductus arteriosus
Arteriovenous fistula
Pericardial friction rub
Examination – Back

Percuss and auscultate lung bases
 Left
ventricular failure
 Pleural effusion

Sacral pitting oedema
 Right
heart failure
Examination - Abdomen
Patient lying with one pillow (if tolerated)
 Tender hepatomegaly
 Pulsatile liver (tricuspid regurgitation)
 Ascites
 Splenomegaly
 Abdominal aortic aneurysm

Examination – Lower Limbs

Peripheral oedema


Pitting/non-pitting
Upper level
Achilles tendon
xanthomata
 Capillary return
 Trophic skin changes


Palpate arteries
Femoral
 Popliteal
 Posterior tibial
 Dorsalis pedis
 Buerger’s test
(peripheral vascular
disease)

Peripheral Pulses
Dorsalis pedis pulse
Posterior tibial pulse
Examination - Other

Urinalysis


Fundi



Haematuria (infective
endocarditis)
Hypertensive
retinopathy
Roth spots (infective
endocarditis)
Temperature chart

Infective endocarditis
THE END