cardiac vascular

ischemia MI aortic dissection aortic aneurysm esophageal spasm esophagitis mediastinitis lymphoma pericarditis pleurisy

Written by: Mohammad Al-Marhoon Dr.Marhoon@gmail.com Reference: Clinical Examination (Talley)

mediastinal

Causes

Pleuropericardial

pneumonia pneumothorax mesothelioma tumor

tracheitis airway intubation central bronchial carcinoma gastroesophageal reflux chest pain wall persistent cough nerve compression rib fracture duration determine location quality agg/reliv factors crushing, heaviness, central, radiate to jaw or arms pleurisy or pericarditis pleuritic pain Character worse by inspiration relieved by sitting up or leaning forward chest wall pain sharp & localized tearing, sever, radiate to back sudden, dyspnoea, cyanosis, collapse

Major Symptoms

angina

dissecting aneurysm massive pul. embolism pneumothorax

sharp, localized, severe dyspnoea

cardiac dyspnoea is chronic & occur with exertion Dyspnoea palpitation postural syncope micturition tussive vasovagal Rt ventricular/biventricular failure 2ndary to lung dis. progression legs/thigh/genitalia pain in calves/thighs/buttocks after walking a distance peripheral vascular dis. with poor blood supply orthopnoea PND more suggestive of cardiac failure

ankle swelling

intermittent claudication dizziness Fatigue previous ischemic heart dis. Hypercholesterolemia smoking Hypertension family DM LDL <100

Risk factors for coronary artery dis.

Optimal lipids levels

HDL 40-60 Total <200 Triglycerides <200

Past History

previous angina or MI rheumatic fever

Written by: Mohammad Al-Marhoon Dr.Marhoon@gmail.com Reference: Clinical Examination (Talley) Guide to physical examination (Bates)
palpate femoral a., popliteal, pos. tibial, dorsalis pedis edema Achilles tendon xanthomata cyanosis without finger clubbing >>Patent ductus arteriosus reduced or absent pulse femoral systolic bruits pallor calf pain or tenderness changes in vessel wall change in blood flow change in constitution of blood prolonged immobilization cardiac failure trauma DIC Contraceptive pills thrombus in heart 2ndary to: 1-MI 2-atrial fibrillation 3-infective endocarditis Janeway lesion causes DVT Osler's node mechanism Splinter hemorrhage peripheral vascular dis. Clubbing infective endocarditis vasculitis in rheumatoid arthritis polyarteritis nodosa infective endocarditis on pulps of finger or thenar or hypothenar eminence tender infective endocarditis on pulps of finger or palms non-tender Tendon xanthomata acute arterial occlusion Palmar xanthomata hand & arm Type 2 hyperlipidemia Type 3 hyperlipidemia elbows & knees Type 3 hyperlipidemia Bradycardia <60 Tachycardia > 100 Rhythm Volume enlarged tender liver pulsatile liver <<tricuspid regurgitation ascites <<Rt heart failure splenomegaly <<infective endocarditis percussion & auscultation of lung bases pitting edema of sacrum Character inspiratory crackles pleural effusion Pulsus paradoxus pulsus bigeminus Medial to sternomastoid stenosis or insufficiency of aortic valve never palpate both small weak pulse >>cardiogenic shock bounding pulse >>aortic insufficiency pulse character reflects right atrial pressure Internal JV is medial to sternocleidomastoid raise head 30 degrees & turn it to other side use tangential light to find vein between sternal & clavicular head of sternomastoid identify highest oscillation point measure vertical distance from sternal angle visible but not palpable pulse twice decrease with inspiration in applying pressure at base of neck, obliterated then filled from above normal 2-3 cm Rt ventricular failure volume overload atrial contraction S1 Carotid pulse Tricuspid valve closure atrial relaxation atrial filling rapid ventricular filling (atrial emptying) test for Rt ventricular failure a wave xanthelasma >3 cm Height JVP jaundice in sclera difference from arterial pulse Postural hypotension Measurement Pulsus paradoxus Carotid a. Normal systolic <140 Normal diastolic <90 Korotkoff sounds systolic BP vary by 10 mmHg Inspiration >>BP decrease exaggerated decrease in BP in inspiration fall in BP with paradoxical rise in pulse rate constrictive Pericarditis pericardial effusion severe asthma in standing: fall of systolic >15 fall of diastolic >10 Vessel wall pulsus bisferiens Radio-radial delay Radiofemoral delay Coarctation of aorta atherosclerosis aneurysm assessed by brachial or carotid collapsing pulse pulsus alternans aortic regurgitation Lt ventricular failure Cardiac tamponade, pericardial constriction premature ectopic beat regular irregular clubbing ill or well respiration Cachectic 45 degrees

inspect long & short saphenous veins hard >>thrombosis tender >>thrombophlebitis fluid thrill after pt. cough if saphenofemoral valve is incompetent cough impulse test Trendelenburg test Perthes' test leg ulcer due to venous stasis Palpation Varicose veins

Tuboeruptive xanthomata

Rate

congestive cardiac failure hepatic congestion prosthetic heart valve-induced hemolysis of RBC cholesterol deposits around eyes type 2 or 3 hyperlipidemia high arched palate Marfan's synd.

c point x descent v wave y descent Hepatojugular reflux normal JVP Character

mouth

teeth hygiene cyanosis

infective endocarditis

gap before S2 Aortic or Pulmonary stenosis children anemia, pregnancy, fever Innocent Physiologic

Ejection systolic (Midsystolic)

Supine Lt lateral decubitus sitting & leaning forward median sternotomy in valve surgery or open heart surgery

scars systolic Pansystolic (Holosystolic)

pectus excavatum kyphoscoliosis apical impulse 5th Lt intercostal space 1cm medial to midclavicular line

Mitral or Tricuspid regurgitation VSD

use finger pads not felt >>Lt lateral decubitus Location Mitral prolapse preceded by systolic clicks Late systolic displaced in cardiomegaly

Diameter (normal <2.5 cm)

Amplitude

Early diastolic Aortic or Pulmonary regurgitation

Timing
Duration

2/3 of systole

Normal diastolic Mid-diastolic Mitral or Tricuspid stenosis

apical impulse

assess with pt. on Lt lateral decubitus pressure loaded Dyskinetic forceful & sustained aortic stenosis or HTN felt over large area Lt ventricular dysfunction

Late diastolic (pre-systolic) Mitral or Tricuspid stenosis Character

double impulse tapping

hypertrophic cardiomyopathy

when S1 is palpable (abnormal) mitral stenosis obesity thick chest wall emphysema pericardial effusion shock dextocardia

pericarditis louder in sitting & leaning forward Lt 3rd interspace above medial 1/3 of clavicle radiate to 1st & 2nd interspace

pericardial friction rub impalpable Venous hum PDA continuous

Lt 2nd interspace radiate to Lt clavicle air in mediastinum post-surgical aspiration of pericardial effusion pneumothorax causes

parasternal impulse (heave)

Apical thrills

using heel of hand on parasternal edge Rt ventricular enlargement severe Lt atrial enlargement pt. rolled over Lt side sitting up leaning forward with full expiration

mediastinal crunch (Hamman's sign)

Thrills Area of maximal intensity

Loud murmur of aortic stenosis radiate to neck

Base of heart

Systolic or diastolic

Radiation

Crescendo Decrescendo Crescendo-Decrescendo Plateau very faint, heard after concentrating Quiet, heard immediately loud with thrills very loud with thrills thrills heard without stethoscope grade 1 grade 2 grade 3

Shape S1
mitral & tricuspid valve closure (mitral 1st) beginning of vent. systole aortic & pulmonary valve closure (aortic 1st) beginning of diastole

Praecordium
Intensity

S2

shorter & higher pitch splitting is audible in pulmonary area & Lt sternal border splitting is wider in inspiration mitral area with bell then diaphragm

grade 4 grade 5 grade 6

Areas

Tricuspid area Pulmonary area Aortic area

low, medium, high blowing, harsh, rumbling, musical

Pitch
loud S1

mitral & tricuspid stenosis reduced diastolic filling time (tachycardia) prolonged diastolic filling time (heart block, mitral regurgitation) loud A2 >>systemic hypertension loud P2 >>pulmonary hypertension aortic valve calcification aortic regurgitation timing area of maximal intensity radiation Intensity

Quality intensity
soft S1 loud S2 Soft A2

early systolic in aortic or pulmonary area congenital aortic or pulmonary stenosis systolic in mitral area mitral valve prolapse, ASD diastolic in lower Lt sternal edge sudden open of mitral valve mitral stenosis mid-diastolic, low-pitched cause gallop rhythm louder at apex & on expiration -Lt vent. failure & dilatation -aortic & mitral regurgitation -VSD -PDA louder at Lt sternal edge & in inspiration -Rt vent. failure -constrictive pericarditis Rt vent. S3 Lt vent. S3

systolic ejection click

non-ejection systolic click

opening snap

Murmurs

Lt lateral decubitus

use bell on mitral area for mitral stenosis, S3, S4 Exhale & hold use diaphragm on apex & Lt sternal border

Aortic regurge

S3 sit & lean forward

Splitting of S2

normally accentuated on inspiration Delayed closure of pulmonic valve increased Rt bundle branch block pulmonary stenosis fixed reversed ASD Delayed closure of aortic valve Lt bundle branch block

late diastolic, low-pitch cause gallop rhythm due to poor vent. compliance -Aortic stenosis -acute mitral regurgitation -systemic hypertension -ischemic heart disease Pulmonary hypertension pulmonary stenosis inaudible S3 & S4 combine to produce audible sound occur if rate >120 S3 & S4 are present severe vent. dysfunction cessation of vent. filling due to constrictive pericardial dis.

S4
Lt vent. S4 squatting

murmur of mitral prolapse outflow obstruction (hypertrophic cardiomyopathy) murmur of aortic stenosis

Rt vent. S4

standing

opposite to squatting straining has effect of standing release has effect of squatting

Summation gallop quadruple rhythm

Valsalva manoeuver Isometric exercise Written by: Mohammad Al-Marhoon Dr.Marhoon@gmail.com Reference: Clinical Examination (Talley)

sustained hand grip for 30 seconds

diastolic pericardial knock prosthetic heart valve sound

Guide to physical examination (Bates)

Areas related to sounds of heart valves