DR - Allam Books 2014 General Cardiology
DR - Allam Books 2014 General Cardiology
DR - Allam Books 2014 General Cardiology
Subject
General
Sheet
History
page
1
personal history
complaint
past history
General examination
pulse
temperature
blood pressure
complexion
decubitus
neck vein
clubbing
oedema
2
4
5
6
8
9
10
15
17
21
22
25
26
30
31
33
Upper limb
Lower limb
Face - Head & Neck
33
35
36
Cardiology
inspection - palpation
percussion
auscultation
Investigations
Treatment
Valvular heart disease
Cardiology as long case
46
50
60
61
62
64
65
67
72
74
83
85
87
110
Clinical notes
V.1
Sheet
Dont forget talk about
1. History: which include
Personal history.
Complaint.
History of present illness:
Analysis of the complaint.
symptoms of the related system.
other systems.
investigations and treatment.
Past history.
Family history.
Socioeconomically state.
In females (menstrual and obstetric history).
2. Examination :
General.
Local.
3. Investigations.
4. Treatment.
5. Diagnosis.
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" " .
By: M. Allam
Clinical notes
V.1
By: M. Allam
History
GOOD HISTORY = GOOD DOCTOR
1.
2.
3.
4.
5.
6.
7.
Personal History
Complaint
History of present illness
Past history
Family history
Socioeconomically state
In females (Menstrual and obstetric history)
1. Name
1. Name
2.
2. Age
3. Sex
4. Occupation
5. Marital state
6. Residence
7. Habit
) (
N.B.
Tumors occur in children:
Wilm's tumor of the kidney.
Retinobalstoma.
Medullloblastoma.
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" " .
Clinical notes
V.1
By: M. Allam
3. Sex
Diseases in female
4. Occupation
lead worker: anemia nephropathy peripheral neuropathy.
Glass workers (Silicosis): interstitial pulmonary fibrosis (IPF).
Asbestosis: IPF bronchogenic carcinoma or mesothelioma.
Farmers: bilharziasis farmer's lung.
Medical staff: infection X-ray irradiation (bone marrow depression sterility).
5. Marital state
Ask about
a) Duration of marriage.
b) Number of children.
c) The age of the youngest one.
6. Residence & Address
May reflect socioeconomic condition and may occasionally point to a certain disease e.g.
Country: Bilharziasis exposure to animals (Brucellosis) insectcides.
Towns: anxiety hypertension IHD.
Sharkia: Filariasis!!!
7. Habit
Special habit is a habit that makes the patient more susceptible than others to a certain
disease.
a) Smoking
Ask about number of cigarettes/day and duration + type of smoking (pipe, cigarette)
Smoking index = No. Of Cigs/day X duration in years
Mild < 100.
Moderate 100 400.
Heavy > 400.
Calculating pack years of smoking
20 cigarettes = 1 packet
No. of cigarettes smoked per day x No. of years smoking
20
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" " .
Clinical notes
V.1
By: M. Allam
For example,
A smoker of 10 cigarettes a day who has smoked for 15 years would have smoked:
10 x 15 = 7.5 pack years
20
Hazards of smoking
(1) Chest
(2) C.V.s
(3) G.I.T.
(4) Other complications
Chronic
bronchitis,
emphysema
(COPD).
Bronchial
asthma.
Cancer lip and
tongue.
Post operative
pneumonia.
Arrhythmia.
Hypertension.
I.H.D.
Peripheral
vascular disease.
Peptic
ulcer.
Cancer
esophagus
Cancer
stomach.
Cerebrovascular
disease.
Cancer bladder.
Intra uterine growth
retardation.
Tobacco amblyopia.
b) Alcohol
Ask about the amount / day.
10 gm alcohol = 30 ml of whisky = 100 ml wine = 250 ml bear.
Excessive alcohol intake
Male consumes > 21 unit / week & female consumes > 14 unit /week.
Hazards of alcohol intake
(1) G.I.T.
Mallory-weiss syndrome
Alcoholic fatty liver
Alcoholic hepatitis then
cirrhosis.
Acute hemorrhagic
pancreatitis.
(2) C.N.S.
Wernicke's - Korsakoff
syndrome (amnesia +
confabulation).
Polyneuropathy.
Proximal myopathy.
Optic atrophy.
Hallucination - delirium
and coma.
(3) C.V.S.
cardiomyopathy
N.B.
Familial tremors are important in small amount of alcohol.
(2)
C/O + Duration
Complaint
" " .
Clinical notes
V.1
By: M. Allam
(3) HPI
1.
2.
3.
4.
Analysis of complaint.
Symptoms of the related system.
Other systems.
Investigation & treatment (related diseases).
Characterized by:
As long as possible
Contains medical terms
In chronological arrangement
In the form of a story.
N.B.
For analysis of pain = 8 as previous +3 (site, radiation and character)
For analysis any complaint in chest as usual (8) + 3 variants + 3 for any excreta.
For analysis any complaint (8) as usual
Onset - course - duration.
: onset
: duration course
Association.
Effect of treatment.
" " .
Clinical notes
V.1
By: M. Allam
3 variants
Postural.
bronchiectasis
abscess
Diurnal.
Seasonal.
For any excreta
haemoptysis or expectoration
expectoration haemoptysis analysis
Amount.
Content - Color - Consistency.
Odour.
(4)
Disease
D.M.
Hypertension.
T.B.
I.H.D.
Past history
Operative
Date.
Site.
Outcome.
Blood
transfusion.
Page |
Drugs
Drugs of chronic use as:
Long acting penicillin (Rh. F).
Corticosteroid.
Contraceptive pills.
Anti T.B.
Anti hypertensive.
" " .
By: M. Allam
V.1
Clinical notes
past history
Diabetes Mellitus
Hypertension
T.B.
Hepatitis
Bilharziasis
!!
D.V.T.
Major operations
)Drug intake (INH, steroid, Barbiturates, contraceptive pills
Fever
Trauma
Similar attack
| Page
" . "
Clinical notes
V.1
(5)
By: M. Allam
Family History
Consanguinity.
If ve
Similar conditions.
Irrelevant
Chronic diseases: - DM / hypertension / TB / IHD.
(6)
Socioeconomical state
(7)
Menstrual History
(8)
Obstetric History
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" " .
Clinical notes
V.1
By: M. Allam
General examination
Overview
B
C
D
E
F
1. Pulse
2. Temperature
3. Blood pressure
4. Respiratory rate
5. Built
6. Colours
7. Decubitus
8. Neck vein H & N (total)
9. Clubbing (upper limb)
10. Lower limb edema (lower limb)
11. Mentality ""
12. Face + general lock
N.B.
Other systems: More details
Other method for general examination
1. General condition
2. Mentality
3. Built
4. Decubitus
5. Face examination ( colours / temperature / others)
6. Neck examination ( neck vein / carotid artery / trachea / L.N. & thyroid)
7. U.L. examination:( pulse / B.P. / hand / L.N. & others )
8. L.L. examination ( odema & peripheral pulsations)
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" " .
Clinical notes
V.1
(1)
By: M. Allam
pulse
A pressure wave transmitted through arteries particularly if superficial & passed over a
bone due to ventricular ejection.
Encircling the wrist & palpating the radial artery by the middle
3 fingers (index & ring fingers for slight compression & the middle
Finger for palpation)
Comment on:
1. Rate
2. Rhythm
3. Volume
4. Equality (in volume) on both sides.
5. Special character.
6. Condition of the blood vessels
7. Peripheral pulsations.
8. Force.
9. Tension.
Rate
A. Normal HR: 60 - 100 beat / min under complete physical & mental rest.
B. Tachycardia: ( Rate> 100 / min)
C. Bradycardia: (Rate < 60 /m.)
N.B.
If pulse is regular you may count in 30 sec. and multiply by 2 ,,, or in 15 sec. and multiply by 4.
Rhythm
heart rate rate
A. Regular pulse:
B. Irregular pulse:
i.
Regular Irregularity:
Pulsus bigeminy or trigeminy: dropped beat at regular rate
i.
1.
2.
3.
4.
5.
Irregular Irregularity:
A.F. (complete irregularity)
Multiple extrasystoles (occasional irregularity)
Ventricular fibrillation
Ht. Block with changeable degree of block.
A. flutter with changeable degree of A-V block.
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10
" " .
Clinical notes
V.1
Extra systole
(with S. tachycardia)
Pulse
Occasional irregularity
Rhythm
Rate
Carotid massage
Exercise
Pulse deficit
Res. sinus rhythm
A wave
V wave
P
QRS
According to sinus
May increase irregularity
<10 beats/min
Positive
Neck veins
Normal with Occasional
irregularity
Heart sound
Normal with Occasional
irregularity
ECG
Premature beat followed by
compensatory pause
By: M. Allam
AF
Absent
markedly irregular
Volume
Volume: Pulse pressure (S - D) amplitude = 20 60 mmHg.
Judged by the movement of the palpating finger produced by the arrival of the pulse wave.
Big pulse pressure:
Pulse pressure > 1/2 systolic blood pressure.
Pulse pressure > diastole.
Small volume
Big volume
(small pulse pressure = small amplitude)
(Big pulse pressure = large amplitude)
Hyperkinetic state:
H: - hypoxia hyperthyroidism Hepatic F. - hyperthermia
B: - Pregnancy Beri Beri Paget's
A: - Anemia - AV fistula Anxiety
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11
" " .
Clinical notes
V.1
By: M. Allam
A.F.
V. Tachycardia.
3rd H.B.
Pulsus alternans
Equality
Both radial arteries must be examined at the same time for equality as regard volume.
Thrombosis.
Embolism.
Special character
1- Water hammer pulse (collapsing pulse):
Sharp ascending and sharp descending with high amplitude
(e.g.: 160/50) less accurate pulse P. > 50
Causes of high pulse P. (see volume)
2- Plateau pulse = Anacrotic pulse:slow ascending and slow descending with low amplitude.
Causes:
a. A.S. ( moderate or severe cases)
b. B- blockers therapy
c. L.V.F.
3- Pulsus paradoxus:
Def.: Marked drop in the systolic pulse during inspiration (more than 10 mm Hg)
Causes:
1. Pericardial:- tamponade, constrictive or effusion
2. Severe congestive H.F.
3. COPD (especially severe asthma)
Detection: by sphygmomanometery
Measure B.P. during inspiration & during expiration.
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12
" " .
Clinical notes
V.1
By: M. Allam
4- Pulsus deficit:
HR on apex > radial pulse
Explain:
Contraction of an empty ventricle (so some weak beats are unable to reach the radial artery).
Causes:
A.F >10 beats/m
Extrasystoles < 10 beats / m.
5- Pulsus bisferiens = bifid = double hump:Best seen & felt at carotid artery
Causes:
1. A.I. combined with A.S. (double A)
2. Severe A.I.
3. Hypertrophic obstructive cardiomyopathy
6- Pulsus alternans
Alternation of strong & weak pulse waves with
Equidistance, as volume is reduced in every other beat.
Causes: Severe L.V.F.
Detection:
by sphygmomanometer
7- Pulsus bigeminy
Strong beat followed by weak beat then compensatory pause
Causes:1. Ventricular premature beats
2. Digitalis toxicity
3. Myocarditis
4. Myocardial infarction
8- Pulsus trigeminy, pulsus quadrigeminy
Causes:
multiple extra systole or
Dropped beats.
Special Character of pulse associated with Aortic valve diseases: Al:- Water hammer pulse (Collapsing pulse)
A.S.:- plateau pulse
A.I.+ A.S.:- pulsus bisferiens
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13
" " .
Clinical notes
V.1
By: M. Allam
Vascular wall
Rolling maneuver: - distal and proximal occlusion of small segment of that artery by the
index and ring fingers, rolling of the middle finger.
Osler's maneuver: - occlude the brachial a. by one hand (or by sphygmomanometer cuff)
& palpate the radial a. by the other hand.
Result:
Normally the arterial wall is not felt (or felt & elastic)
Causes of palpable arterial wall:
Systemic atherosclerosis.
Focal arteriosclerosis.
Polyarteritis nodosa: grape like along course of the artery.
Peripheral vascular
Other peripheral arterial pulsations & capillary pulsation
Radial
Lateral to the tendon of flexor carpiradialis.
Brachial
At the elbow medial to the biceps tendon.
Subclavian
Pressing downward above the middle of clavicle.
Medial to the sternomastoid muscle
Carotid
At the level of cricoid cartilage
Against the transverse process of 6th C. vertebrae.
At the patient midpoint of inguinal ligament while the thigh
Femoral
is flexed and abducted.
Middle of the popliteal fossa while the patient lies supine
Popliteal
with the knee slightly flexed.
Posterior tibial Behind the medial malleolus.
Lateral to the extensor hallucis longus tendon against
navicular bone on the dorsum of the foot.
Dorsalis pedis
In the 1st interossus space (normally absent in 15% of
population).
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14
" " .
Clinical notes
V.1
By: M. Allam
(2)
Temperature
Measurement:
1. Oral temp.: Under the tongue with closed lips for 3 min
N= 36.5 37.2 C.
False decrease:
a. Mouth breathing.
b. Incomplete closure of mouth.
c. Putting thermometer for too short time.
2. Rectal temp.: Left for 2 min. (0.5 C higher).
Indicated in:
Infants.
Irritable pts.
Painful oral lesions.
Insane.
Comatosed pt.
3. Axillary temp.: Put in axilla for 3 min. (1/2 C Lower).
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15
" " .
Clinical notes
V.1
By: M. Allam
Terms:
1. Subnormal Temp. < 36.5 C.
2. Fever > 37.2 C.
3. Hypothermia = 35 C.
4. Hyperthermia = > 41 C.
Types of fever:
Fluctuation
Base
Continuous
Remittent
Intermittent
Relapsing
Relative bradycardia
HR less than expected for body
temperature as typhoid F/
meningitis.
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16
" " .
Clinical notes
V.1
(3)
By: M. Allam
Blood pressure
1.
2.
3.
4.
Diastolic
Peripheral resistance (vascular tone) &
intact aortic valve.
Elasticity of Aorta.
Bl. Volume.
Bl. Viscosity.
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17
" " .
Clinical notes
V.1
By: M. Allam
Systolic BP
Diastolic BP
< 120
< 80
<130
< 85
130-139
85 89
Hypertension
mild (Stage I)
140-159
90 99
Moderate (Stage II)
160-179
100 109
Severe(Stage Ill)
> = 180
> = 110
Isolated Systolic Hypertension
grade I
> 140-159
< 90
grade II
> =160
< 90
Measurement of B. P.:
Direct: direct intra-arterial measurement.
Indirect: by sphygmomanometer (palpatory, Auscultatory)
Palpatory:
Advantage: avoidance of auscultatory gap.
Disadvantage: cant detect diastolic B.P.
auscultatory:
Advantage: disadvantage of palp.
Disadvantage: advantage of palp.
Kortakoff phases.
1. 1st sound heard.
2. Sounds markedly decreased or may disappear (mistaken for D).
3. Sounds reappear (mistaken for S).
4. Sudden muffling of the sounds.
5. Total disappearance of the sounds.
Some measurement:
Rt. & Lt. Sides: equal; difference normally is < 10mm Hg.
UL & LL.: Normally LL > UL. By 10 - 20 mm Hg.
During Standing & during lying: for postural hypotension.
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18
" " .
Clinical notes
V.1
By: M. Allam
Technique of measurement of B. P.
Patient
1. Position the patient's arm so the anticubital fold is of level with the heart.
2. Make sure that they do not have any tight clothing which may constrict their arm
3. Under complete mental and physical rest
Apply blood pressure cuff
1. The bladder of the cuff should encircle
80% of the arm / not tight nor loose.
2. The centre of the cuff bladder
should be placed over the line of the brachial artery.
3. Approximately 2 cm above the anticubital fold.
The doctor
1. Palpate the patient's radial pulse and inflate the cuff until you feel the exact
point when the pulse disappears (estimated systolic pressure).
2. Place the stethoscope over the brachial artery and inflate the cuff
30 mmHg above the estimated systolic pressure.
3. Release the pressure slowly, no greater than 5 mmHg per second.
The level at which you consistently
hear beats is the systolic pressure.
Continue to lower the pressure until
the sounds disappear. This is the diastolic pressure.
Lastly
Remove the cuff and thank the patient.
Important findings:
Blood pressure in lower limbs > blood pressure in upper limbs by less than 20 mmHg which
is normal and called "Hills phenomena" due to:
True increase: as arteries in lower limbs are in line with aorta.
False increase: as arteries in lower limbs are surrounded by bulky muscles,, so
muscle need high pressure in bag to occlude the artery.
If blood pressure in lower limb > blood pressure in upper limb by > 60 mmHg it is called:
"Hills sign" in AR.
If blood pressure in lower limb < blood pressure in upper limb it is called: "reversal of Hills"
and occur in co-arctation of aorta.
In postural hypotension (orthostatic hypotension = orthostatic syncope)
During Standing there is large fall in both systolic & diastolic B.P. (Normally there is a slight fall in
systolic B. P. < 20 mm Hg and increase in diastolic B. P. < l0mmHg).
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19
" " .
Clinical notes
V.1
By: M. Allam
Uses of sphygmomanometer
1. B.P. & pulse changes:
a) Measurement of B.P.
b) Determination of pulse pressure (SD)
c) Detection of pulsus alternans: if pressure is between weak beat & strong beat the radial
pulse will drop by half as, the weak beats will be abolished.
d) Detection of pulsus paradoxus: systolic B. P. will drop during inspiration (more than 10
mm Hg.)
e) Detection of unequality of pulse in both sides (different blood pressure in Rt. & Lt limb).
3. Diagnostic tests:
a)
b)
c)
d)
4. Others:
a) Tourniquet in venesection.
b) Haemostasis.
20
" " .
Clinical notes
V.1
By: M. Allam
(4)
Respiratory rate
See chest
(5)
Built
(A) Height
Dwarf (stunted growth): as in
1. Cong. cyanotic H. Diseases:- F4
2. Prolonged H. dis. since childhood.
Tall: as in
Marfan's syndrome (tall, arachnodactyly, pes cavus, high arched palate, ectopic lens, up ward
sublaxation of lens and A.I.)
(B) Weight
It can be determined by body mass index (BMI) which is derived from the formula
Wt (Kg) / Ht (m 2)
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21
" " .
Clinical notes
V.1
By: M. Allam
Feature
1. The height and span are almost equal.
Height:- distance from the occiput to the heels in upright position.
Span:- distance between the tip of the fingers with outstretched
hands.
2. Lower and upper segments are usually equal
L. segment = distance between symphysis pubis and floor
U. segment = distance between occiput and symphysis pubis
(6)
a.
b.
c.
d.
e.
Complexion (colors)
Pallor
Jaundice
Cyanosis
Pigmentation
Skin rashes
Pallor
Site of examination:
1. Inner aspect of lips.
2. Skin of the face.
3. Nails.
4. Palm creases.
Never in Conjunctiva because of endemic trachoma in Egypt
N.B.
The degree of pallor depends on the state of capillaries, amount of blood within the
capillaries, Hb, pigmentation & thickness of the skin.
Examination of the mucous membranes may help to distinguish pallor of anemia from that
of other causes.
Q: Causes of pallor?
Anemia.
Shock or COP.
Toxemia e.g. infective endocarditis.
Edema of the face e.g. nephrotic syndrome.
Racial pallor (Far East).
Q: Causes of pallor with normal CBC?
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22
" " .
Clinical notes
V.1
By: M. Allam
Jaundice
Def. yellow discoloration of skin & mucous membranes
due to increase level of bilirubin > 2.5 mg %.
Sub clinical Jaundice: - Serum bilirubin = 1- 2.5 mg/dl.
Site of examination: In sclera of lower fornix in the day light.
A. Hepatocellular J :- e.g.:- Viral hepatitis, cirrhosis:
Orange yellow L.C. F. Manifestations Liver is enlarged & tender, later it may become firm and shrunken.
Atebrin
Hypercaroteinaemia (not in sclera)
Picric a. toxicity
Uraemia
Myxoedema
xanthomatosis.
Cyanosis
Def. & pathogenesis: it is bluish discolouration of skin & m.ms, due to presence of
more than 5 gm/dl reduced Hb.
Cyanosis is aggravated with ploycythaemia.
Dont forget
Site of exam: tongue, lips, hands; nails.
In jaundice level of bilirubin > 2.5
Examination in daylight is essential.
mg %.
Types:
In cyanosis presence of more than
Central.
5 gram / dl reduced Hb.
Peripheral.
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23
" " .
Clinical notes
V.1
Central cyanosis
By: M. Allam
Peripheral cyanosis
C- Ploycythaemia.
D- False (chemical) cyanosis:
Met-Hbaemia: cong. / nitrites
Sulph-Hbaemia: sulpha or bacteria
Site
Hand
Warming
Oxygen
PO2
Clubbing
Ploycythaemia
examination
Central cyanosis
All the body:
Skin, conjunctiva, inner lips &
tongue (and as in peripheral)
(Tongue is cyanosed)??
Warm (peripheral V.D.)
No effect
Improves cyanosis
(in pulmonary causes only)
Decreased arterial and
venocapillary blood
Page |
Peripheral cyanosis
Skin of peripheral parts:
Tip of fingers, hands, tip of nose, ears,
outer lips
(Tongue is normal)
Cold (peripheral V.C.)
Cyanosis improved
No effect
Decreased in venocapillary but normal
in arterial blood
-ve
-
24
" " .
Clinical notes
V.1
By: M. Allam
Why Tongue?
1.
2.
3.
4.
Pigmentation
Causes of general pigmentation
1. Familial / Racial.
2. LCF.
3. RF.
4. Addison's.
5. Pellagra.
6. Haemochromatosis.
Localized pigmentation
As butterfly area of the face
Red molar rash (MS)
Discoid SLE
Brown pellagra
In pregnancy (chloasma gravidarum)
(7)
Decubitus
1.
2.
3.
4.
tumours or hepatopulmonary.
Page |
25
" " .
Clinical notes
V.1
(8)
By: M. Allam
Neck vein
Page |
26
" " .
Clinical notes
V.1
By: M. Allam
Disappear
Relation
Arterial
Medial &upper to
stemomastoid in
ant. Triangle.
Better felt than
seen
One wave Have no
upper level
No
No
N.B.
To know the relation between neck veins and cardiac cycle you have to remember at first cardiac
cycle
S1
S2
S1
Systole
0.3 sec.
1. Iso metric contraction
phase.
2. Ejection phase.
diastole
0.5 sec.
1. Iso metric relaxation phase.
2. Passive filling 70%.
3. Atrial contraction 30 %.
wave
Physiology
Consists of three positives (A, C and V) and two negatives (X and Y).
The A wave is normally the highest wave.
The X wave is usually deeper than the Y wave.
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27
" " .
Clinical notes
V.1
By: M. Allam
Atrial contraction.
Presystolic
Elevation of the tricuspid valve at the start of
ventricular contraction
Transmitted pulsation of carotid artery.
Right atrial relaxation.
Systolic
Accumulation of venous blood in the right
atrium during ventricular systole.
Descent of blood from right atrium to right
ventricle (diastolic collapse)
Systolic
Diastolic
T.R.
Right sided heart failure
AF.
Canon waves
Pressure
Definition: - it is the vertical height between the top of venous pulse & angle of Louis when the
Pt. is lying at an angle of 45.
Measurement:
The Pt. is positioned at about 45 to the horizontal
plane.
The head is supported by a pillow & the neck is
slightly flexed to allow the skin & muscles overlying
the vein to relax.
The jugular V. pressure is measured as "The vertical
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28
" " .
Clinical notes
V.1
By: M. Allam
distance bet. the manubrio-sternal angle & the top of the venous column
N.B.
1.
Page |
29
" " .
Clinical notes
V.1
(9)
By: M. Allam
Clubbing
Causes of clubbing:
(I) Pale (toxaemic)
Cardiac
Chest
Infective endocarditis.
Suppurative lung S.
Bronchogenic carcinoma
Mesothelioma.
GIT
B polyposis
Cirrhosis especially
biliary Ulcerative colitis.
Steatorrhoea
COPD (if associated with bronchectasis)
(III) Familial
(IV) Occupational: some fingers e.g. index & thumb (shoemakers).
(V) Unilateral clubbing: causes of inequality of pulse on both sides,
(VI) Differential clubbing (in L.L.S only): causes of differential cyanosis.
Grades of clubbing:
1. Grade I: obliteration of the angle between nail and nail bed
(+ ve fluctuation test at nail base).
2. Grade II (parrot beak): I + increase convexity
of nails in its longitudinal curve.
3. Grade III (Drum stick): I + II +
hypertrophy of terminal phalanx.
4. Grade IV (hypertrophic osteoarthropathy): III + "tender"
Hypertrophy of distal ends of long bones at wrist &
ankle due to periosteal irritation & new bone formation.
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30
" " .
Clinical notes
V.1
By: M. Allam
Exam.
1. Look at fingers in profiles.
2. Window test (Schamroth's window test: pt's holds 2 index finger nails touching each
together: if normal, will show a diamond-shaped window).
3. Fluctuation test at the nail base.
N.B.
Causes of unilateral clubbing in one upper limb
Thoracic inlet syndrome (cervical rib pancost tumor).
Aortic aneurysm, arteriovenous fistula in dialysis patients.
(10) Oedema
Definition: means abnormal accumulation of fluid in the interstitial tissue due to disturbed
mechanisms of formation of interstitial fluid.
Comment on:
1.
2.
3.
4.
5.
Unilateral or bilateral
Pitting or non pitting
level (extent)
Tenderness.
Examination of serous membranes.
Examination of oedema:
1. Below the knee pressure for about minute over bony prominence (Posterior to medial
malleolus, dorsum of the foot and the chin of tibia)
2. Pinching test over the thigh
3. Pedou-orange over the anterior abdominal wall.
4. Examine back for sacral edema.
31
" " .
Clinical notes
V.1
By: M. Allam
Pitting
Before ascites: always L.L oedema precedes ascites except
in 2 conditions where ascites precedes (ascites precox):
a. pericardial effusion & constrictive pericarditis.
b. T.R. or T.S. due to marked congestion of liver
Bilateral
Unequal oedema occurs in case of deep venous thrombosis (DVT).
It may be on one side in Pts. preferring to sleep on one side.
Q : Pathogenesis of cardiac oedema ?
B- Renal oedema:
Occurs firstly in eye lids, generalized, pitting marked in the morning.
A-Nephritic: in acute nephritis
B- Nephrotic:
Oliguria
Hypertension (Na & water ret)
Haematuria
Epith & red casts in urine
Heavy albuminuria
Hypoproteinaemia
Generalized oedema
increased cholesterol
C- Hepatic oedema:
In advanced liver cirrhosis + other signs of L.C.F.
Localized edema
1. D.V.T.
2. Lymphedema :( non pitting)
Filariasis - Post mastectomy.
3. Varicose veins
Mainly in L.L.+ signs of varicosities.
Page |
32
" " .
Clinical notes
V.1
By: M. Allam
4. Orthostatic edema:
Mainly in L.L + diurnal variation Occupational Factors
5. Angioneurotic edema
Affecting the face (lips) asymmetrically, with history of allergy. Of sudden onset, self
limited
N.B.
1. Causes of edema in one UL or one L.L.: DVT, cellulitis, lymphedema trauma
2. Drugs causing oedema e.g. cortisone, pills, NSAID.
3. Non pitting edema occurs in Lymphedema, myxoedema and Angioneurotic
edema.
4. Occult Oedema: Up to 3 liters of excess fluid may be retained in the
interstitial tissue without apparent oedema Pitting oedema is usually
demonstrated if accumulating exceeds this amount (3 liters).
(11)
Mentality
Upper limb
1. Appearance and size of hand and fingers: e.g. spade hand (Acromegaly)
2. Temperature of hands.
a) Warm hands:
b) Cold hands:
Fever
Low C.O stales.
Hyperdynamic circ
Peripheral cyanosis.
Central cyanosis.
Neurotic enchiladas.
Page |
33
" " .
Clinical notes
V.1
By: M. Allam
3. Sweating
Thyrotoxicosis.
Toxaemia.
Neurosis.
Hyperhydrosis
4. Capillary refill
5. Osler's nodes / Jan way's patches / Splinter Hemorrhage (Inf. End)
6. S.C. nodules: - S.C. firm non tender nodules on extensor surface of arm & along tendons.(
Rh. Fever / Rheumatoid arthritis).
7. Nails: (see above)
8. Joint abnormalities: - (as Rh. A.)
9. Edema: (as above)
10. Lymph Nodes of the Upper Extremity:
a. Epitrochlear Nodes: in the inner aspect, just above the elbow.
b. Axillary Nodes:
Ask the patient to lift both arms away from the sides of his body.
Then extend the fingers of both your hands and gently direct them towards the
apices of the arm pits.
Describe the following
Size: Pathologic nodes are generally greater than 1 cm
Firmness: Malignancy makes nodes feel harder
Quantity: The greater the number of nodes, the more likely true
pathology exists
Pain: Often associated with inflammation (e.g. infection)
Relation to other nodes and surrounding tissue
Page |
34
" " .
Clinical notes
V.1
By: M. Allam
Page |
35
" " .
Clinical notes
V.1
By: M. Allam
Face
Parkinsonism
Myxoedema
Hyperthyroidism
Acromegaly
Cushing's
Congenital syphilis
Uremia
Myasthenia gravis
Facial palsy
Horner's syndrome
Myopathic face
Toxic look
Mongoloid face
Mitral face:
(malar flush)
Tricuspid face
Eye
1. Eyebrow :- Loss of hair in outer 1/3 of eyebrow:
Myxodema.
Leprosy.
Artificial.
Page |
36
" " .
Clinical notes
V.1
2. Eye ball
Exophthalmos
Thyrotoxicosis
cavernous sinus ( pulsetile)
leukaemic deposits behind eye ball
Congenital
By: M. Allam
3. Eyelids
Ptosis
Congenital.
Hysterical.
Mechanical.
Oculomotor nerve paralysis
Myasthenia gravis
Ectropion. Entropion
Blepharospasm
4. Sclera
Blue sclera:
Ankylostoma anemia
Congenital glaucoma
Children
T . B.
Osteogenesis imperfecta (V imp)
Healthy persons
Page |
37
" " .
Clinical notes
V.1
By: M. Allam
e. Pingueculae are triangular yellow deposits beneath the conjunctiva between the
canthus and the edge of cornea, they develop with advancing years, and are of no
clinical value.
f. Pterygium patch of progressive fibrosis may encroach upon the cornea.
6. Cornea
Arcus senilis in senile patients and young with hyperlipidaemia
Opacitis due to trauma or infection.
Kayser Fleisher ring Wilsons disease.
7. pupil
Irregular: - Argyll Robertson pupil
Miotic:- Horners syndrome
Mydriatic:- 3rd cr. N. paralysis / opiate / atropin
8. Lens :
a. Cataract occurs in:
Diabetes mellitus .
Cretinism.
Mongolism
Scleroderma.
Myotonia atrophica.
Hyperparathyroidism
Rubella: stigmas indicating maternal rubella infection:
- Cataract -Mental defect -Nerve deafness
- Associated with cardiac (PDA or P.S.)
b. Ectopic lens : in Marfan's syndrome
9. Iris and ocular tension
Iritis is often a manifestation of systemic disease e.g. ankylosing spondylitis and
Behcet's disease.
The ocular tension can be tested digitally, it is tested in patients with headache and
diminished visual acuity.
10. Fundus examination:
a. Optic neuritis and its causes.
b. Papilledema and its cause.
Page |
38
" " .
Clinical notes
V.1
By: M. Allam
c. Diabetes M.
d. Hypertensive retinopathy :
Grade I : mild sclerosis ( narrowing ) of retinal arteries .
Grade II: Moderate to marked sclerosis with compression of veins at crossing
Grade III : flame like hges + fluffy cotton exudates
Grade IV : Papilledema + as in III
e. Infective endocaditis .
Central retinal art. Occlusion by embolism.
Central spots: (due to vasculitis).
f. SLE :- hard exudates = cytoid bodies / hges.
g. Capillary pulsations in A.R.
11. Xanthelasma : It is a yellow eruption at inner side of the eyelids and peri-orbital skin
associated with hypercholesterolaemia.
Pale :- anemia
Red:- S.L.E & Cushing disease.
Malar flush: - M.S.
Brownish pigmentation: - pellagra.
Lips
Cheilosis due to riboflavine deficiency causing denuded epithelium at the line of colour of
the lips, peeling toward the mucocutaneous junction.
Page |
39
" " .
Clinical notes
V.1
By: M. Allam
Angular stomatitis (angular cheilosis) also in Vit.B2 and lron deficiency, also caused by
candida .
Cheilitis: painful vertical fissures mainly of lower lip caused by malnutrition or with Crohn's
disease.
Pallor, cyanosis (See complexion)
Angioedema, herpes labialis.
Teeth
Gum
Bleeding: Vitamin C deficiency, thrombocytopenia, chronic liver disease.
Hypertrophy: Epanutin, monocytic leukemia.
Blue line: lead poisoning.
Tongue
The surface of the tongue normally varies as regard colour and appearance.
A. Color:
Black: iron therapy Addison's.
Brown: smoking.
Blue: cyanosis.
Pale: anemia.
B. Atrophy: (Glazed red tongue)
With iron deficiency anaemia,
Hypovitaminosis e.g.: B12 \ pellagra.
C. Leucoplakia:
Due to chronic irritation, it is precancerous.
D. Moisture:
Dry tongue (under surface) = dehydration.
E. Strawberry tongue:
Scarlet fever
F. Macroglossia
Page |
40
" " .
Clinical notes
V.1
By: M. Allam
Myxoedema
Acromegaly
Amyloidosis
hemangioma
Pseudomacroglossia:- Down
Oedema :- Angioneurotic
G. Neurological ex.
Tremors of the tongue
o Thyrotoxicosis.
o Parkinsonism.
o Essential familial tremors.
Percussion or tapping for:
o Fasciculation.
o Myotonia.
Cranial nerve
o For 5th \ 7th \ 9th \ 12th
H. Scrotal or fissured tongue Down syndrome and acromegaly.
J. white coated :- typhoid F
K. Ptyalism (increased salivation)
Neurosis
Stomatitis
Reflex from GIT diseases.
41
" " .
Clinical notes
V.1
By: M. Allam
4. Breath:
a. Aceton :- diabetic ketoacidosis
b. Ammonical :- uremia
c. Foetor hepaticus :- hepatic failure
d. Foiled smell :- suppurative lung disease (Halitosis)
e. Other causes of halitosis :- Bad oral hygiene, Sinusitis, Tonsillitis or Dyspepsia
Parotid enlargement
Mumps
Sarcoidosis
Cirrhosis
Endemic parotitis
Stones or Tumor
Hypoproteinaemia.
Sjogren syndrome.
Neck
1. General ex.
a. Look for scars, lumps, rashes, hair loss, or other lesions.
b. Look for facial asymmetry, involuntary movements, or edema.
c. Palpate to identify any areas of tenderness or deformity.
2. Pulsation: - Arterial & venous. (See latter)
3. Thyroid enlargement:- (see latter)
4. L.N. :- (see latter)
5. Torticollis: - Hysterical, myositis of stemomastoid
6. Rigidity: - Meningeal irritation & cervical spondylosis
7. Trachea: - See the chest
8. Supra sternal pulsations:- (see latter)
Page |
42
" " .
Clinical notes
V.1
By: M. Allam
H&N
Extremities
Chest
Skeletal
Page |
43
" " .
Clinical notes
V.1
By: M. Allam
Page |
44
" " .
Clinical notes
V.1
By: M. Allam
Cardiology
Page |
45
" " .
Clinical notes
V.1
By: M. Allam
The upper limit of the heart reaches as high as the third costal cartilage on the right side of
the sternum and the second intercostal space on the left side of the sternum.
The right margin of the heart extends from the right third costal cartilage to near the right
sixth costal cartilage.
The left margin of the heart descends laterally from the second intercostal space to the
apex located near the midclavicular line in the fifth intercostal space.
The lower margin of the heart extends from the sternal end of the right sixth costal
cartilage to the apex in the fifth intercostal space near the midclavicular line.
Surface anatomy of the cardiac valves
P (pulmonary): deep to the left 2nd sterno-costal junction.
A (Aortic): opposite the left 3rd intercostal space.
M (mitral): deep to the left 4th sterno-costal junction. So the above three valves present
behind the left border of the sternum.
T (tricuspid): behind the center of the sternum opposite the left 5th intercostal space.
Page |
46
" " .
Clinical notes
V.1
By: M. Allam
To listen for valve sounds, position the stethoscope downstream from the flow of blood
through the valves
The tricuspid valve is heard just to the left of the lower part of the sternum near the fifth
intercostal space.
The mitral valve is heard over the apex of the heart in the left fifth intercostal space at the
midclavicular line.
The pulmonary valve is heard over the medial end of the left second intercostal space.
The aortic valve is heard over the medial end of the right second intercostal space.
Page |
47
" " .
Clinical notes
V.1
By: M. Allam
History
As before (dont forget)
1.
2.
3.
4.
5.
6.
7.
Personal History
Complaint
History of present illness
Past history
Family history
Socioeconomically state
In females (Menstrual and obstetric history)
Examination
As before (don't forget)
General examination as before but focus on the things related to cardiology "or leave it for
local examination"
Overview
1. Pulse (see before in details)
2. Temperature
A
3. Blood pressure (see before in details)
4. Respiratory rate
B
5. Built
C
6. Color
D
7. Decubitus
E
8. Neck vein H & N (total) (see before in details)
9. Clubbing (upper limb)
10. Lower limb edema (lower limb)
F
48
" " .
Clinical notes
V.1
By: M. Allam
Investigations
Dont forget these 4 items:
1. X-ray:
o Chamber enlargement.
o Pulmonary congestion in left sided diseases.
o Pleural effusion.
2. ECG:
o Chamber enlargement.
o Detect the cause.
3. Echocardiography:
o Chamber enlargement.
o Detect the cause.
o Paradoxical movement of the myocardium.
4. Catherterization:
o Chamber enlargement.
o Detect the cause.
N.B.
We add some investigations in certain cases like blood culture in case of infective
endocarditisetc.
Treatment
1. Treatment of the cause.
2. Treatment of the precipitating factors.
3. Specific treatment.
N.B.
Dont forget in case of valvular lesion:
Medical treatment.
Surgical treatment.
Some times (balloon dilatation).
Page |
49
" " .
Clinical notes
V.1
By: M. Allam
Symptoms of cardiology
Symptoms of the cardiology are
4C.
4P.
Others.
C
1. Pulmonary Congestion.
2. Systemic venous
Congestion.
3. Low Cardiac output.
4. Cyanosis.
1.
2.
3.
4.
P
Palpitation.
Pain.
Pressure manifestations.
Blood pressure changes.
Others
1. Fever.
2. Thrombo-embolic
manifestations.
Natural history
1. P congestion found to be the 1st C\O in MS & the last C\O in other left
sided valve lesions.
2. Aortic valve lesion usually presented with Chest pain??
3. Regular palpitation = regurge
MS = P. Congestion P.H. ( Low COP) Rt.V.F ( S. Congestion ) + A.F. (
irregular Palpitation )
MR = Palpitation Lt.V.F. (P. Congestion)
AS = Low COP Lt.V.F. (P. Congestion)
AR = Palpitation Lt.V.F. (P. Congestion)
TR = Palpitation Rt.V.F (S. Congestion) on top of Mitral lesion.
N.B.
Double mitral: - Regular Palpitation on top of P. Congestion or reverse
Irregular palpitation ---- AF ----- MS or Double M
Pulmonary congestion
Caused by: - M.S. \ LVF
Including:
(dyspnea, cough, haemoptysis & recurrent chest infection)
Page |
50
" " .
Clinical notes
V.1
By: M. Allam
Dyspnea
Is abnormally uncomfortable awareness of the act of breathing.
1. Exertional
2. Postural
Orthopnea -> dyspnea on lying flat relieved with erect position.
Platypnea -> dyspnea on erect position
Trepopnea -> dyspnea on lying on one side.
3. Nocturnal
51
" " .
Clinical notes
V.1
By: M. Allam
C. Chemical factors:
Pulmonary venous congestion and diminished tissue perfusion ( COP) lead to hypoxia,
which stimulate respiration.
Mechanism of PND
1. Increased V.R. during sleep leading to aggravation of pulmonary congestion.
2. Absorption of oedema fluid into the circulation causing further increase in V.R.
3. Diminished Sympathetic activity during sleep causing reduction of cardiac contractility.
4. Night mares lead to tachycardia and elevation of BP.
5. Slipping down from high pillows.
N.B.
PND is highly specific for cardiac cases.
Diagnostic for left sided HTF.
But we have to exclude B.A.
Page |
52
" " .
Clinical notes
V.1
Age
Other symptoms
Duration
Time of attack
Relieved
Dyspnea
Sputum
Cardiac A.
any age
+ cardiac symptoms
short duration
1 - 2 hrs after sleep
Spontaneously
Inspiratory
Frothy (may be blood
tinged)
By: M. Allam
Bronchial A.
young age
chest symptoms
long
Early in the morning
Bronchodilators
Expiratory
Thick.
Systemic congestion
In right ventricular failure (M.S. / T.R.)
Manifested by:1. Oedema L.L. usually before ascites
LL swellings
Ascites precox = ascites before LL oedema in cases of pericardial & tricuspid diseases.
2. Hepatic congestion:
Pain in right hypochondrium + Jaundice.
Page |
53
" " .
Clinical notes
V.1
By: M. Allam
Anginal pain
Kidney = Oliguria
Muscle = easy fatigability
Skin = pallor /cold.
Etiology of syncope
1. Vasomotor syncope.
A. Vasovagl syncope (neurogenic syncope):
It results from severe vagal stimulation which leads to: severe bradycardia,
hypotension, pallor & sweating.
It results from: sudden severe fear, pain, and trauma (e.g. to testicles).
It is the most common cause of syncope & is known as simple fainting.
B. Carotid sinus syndrome:
It results from pressure on hypersensitive carotid sinus baroreceptors: e.g.
during shaving.
2. Cardiac syncope
(Any cause of low COP ) especially:
Aortic stenosis (or any other valvular obstruction).
Acute heart failure (e.g. AMI).
Arrhythmias (whether tachy- or brady-arrhythmia).
Adams-stokes attacks.
Page |
54
" " .
Clinical notes
V.1
By: M. Allam
3. Cerebral syncope
(Reduced cerebral blood flow)
Vertebrobasilar TIAs.
4. Hypoxic syncope
( O2 content of the cerebral blood flow)
Fallot's tetralogy & other cyanotic diseases or severe anemia.
5. Postural syncope
(Orthostatic syncope)
Normally, reflex VC of blood vessels of L.Ls occurs on standing to prevent pooling of blood
in lower limbs.
This effect is mediated through sympathetic stimulation.
If this mechanism is defective, BP will be markedly lowered in the standing position
(postural hypotension) & syncope may occur.
Causes include:
Autonomic neuropathy, e.g. Diabetes.
Sympatholytic drugs, e.g. ganglion blockers & vasodilators.
Lumbar sympathoectomy.
Hyponatremia.
Prolonged recumbency.
Elderly patient.
Huge varicose veins.
Hypovolaemia. e.g.: Haemorrhage or dehydration.
Weakness of the muscles of the lower limbs (muscle pump).
6. Situational syncope
Rare syncope caused by a variety of activities in susceptible individuals:
Cough syncope (Tussive syncope).
Micturition syncope (more common in old men especially at night).
Defecation syncope.
Underlying mechanism:
Straining decreased VR decreased COP syncope.
N.B.
Cardiac syncope
1. Usually exertional
2. Not accompanied by convulsions
Page |
55
" " .
Clinical notes
V.1
By: M. Allam
Cyanosis
a. Age of onset:
Since birth = Fallot's tetralogy.
Few years after birth = Fallot's triology.
In teenager = Eisenminger's syndrome (reversed shunt).
Above age of 40 years = COPD with or without Corpulmonale.
b. Cyanotic spells and squatting = Fallot's tetralogy.
c. Differential cyanosis = P.D.A with reversed shunt.
d. Exertional cyanosis = cases of cardiac shunts / cases of a cyanotic Fallot's / interstitial
pulmonary fibrosis.
Pain
Dont forget 11 points
1. Onset: sudden
2. Course: intermittent.
3. Duration: 30 sec. 30 min.
4. Association:
Angor animi.
Dyspnea.
Sweating.
5. What increase :
Exercise.
Sexual intercourse.
5 Hs.
Heavy meal.
Heavy smoking.
Hypothermia.
High attitude.
Stress
6. What decrease :
Rest.
Sublingual nitrate.
7. Effect of treatment: Respond
Page |
56
" " .
Clinical notes
V.1
By: M. Allam
Pressure manifestation
The most posterior chamber of the heart is the Lt Atrium, which is markedly enlarged in
M.S. /M.R. and press on
Pressure symptom
Palpitation
Complaint
Awareness of heart beats
Cause
1.
2.
3.
4.
Ask about
Is it regular or irregular?
Precipitating factors.
Page |
57
" " .
Clinical notes
V.1
By: M. Allam
Manifestations of hypertension
Hypertension symptoms:
Asymptomatic
Headache.
Blurring of vision.
Tinnitus.
Epistaxis.
N.B.
No symptoms of diagnosis of hypertension, only history of regular use of anti hypertensive drug.
Embolic manifestations
Embolus
Insoluble material in circulation
origin
Atrium
Left atrium in M.S.
and A.F.
Valve
Vegetation in infective
endocarditis
Ventricle
Myocardial infarction
Vessel
Aortic atheromatus
plaque
Effect:
Cerebrum
Coronary
artery
Hemiplegia.
Chest
pain.
Peripheral artery
Pulsless.
Pallor.
parasthesia or
Paralysis.
Page |
Eye
Renal artery
Blindness
Painless
haematuria.
58
" " .
Superior
mesenteric
artery
Abdominal pain
(intestinal
obstruction)
Clinical notes
V.1
By: M. Allam
Fever in cardiology
Aetiology
Cardiac
a. Endocardium
Infective
endocarditis
(serious).
Rheumatic fever
(commonest).
b. Myocardium
Myocarditis.
Myocardial
infarction.
c. Pericardium
Pericarditis.
Effusion.
Drugs: 6 Cs
Corticosteroids.
Licorice.
Contraceptives.
Amphetamine and thyroxin.
Carbenoxolone.
Anti Common Cold drugs.
Cyclosporin.
Vessels
Thrombophlebitis.
D.V.T.
Page |
59
" " .
Lung
Pulmonary
embolism.
Pulmonary
infection.
By: M. Allam
Clinical notes
V.1
( )
Cardiac output
( )
()
Cyanosis
Pain
Pressure manifestations
Palpitation
Blood pressure changes
Embolic manifestations
Fever
60
| Page
" . "
Clinical notes
V.1
By: M. Allam
Past history
Diseases: Rheumatic fever.
--------------------------------------------------------------------------------------------------------------------------EXAMINATION OF OTHER SYSTEMS IN CARDIAC CASE
Chest
Cause
Corpulmonale
Spleen
Result
1. Chest infection.
2. Pleural effusion.
3. Crepitations.
Association
Kartagner's syndrome =
Bronchectasis + dextrocardia +
absent frontal air sinus
Abdomen
1. Palpable = cirrhosis.
2. Palpable & tender = infective endocarditis.
Ascites
Liver
Normal sequels
Ascites precox = pericardial disease - T.R.
Page |
61
" " .
Clinical notes
V.1
A.
B. Built
Pulse.
Blood pressure.
Temperature.
Under built
In congenital heart disease. Or
Rheumatic disease since childhood.
Over built
Generalized edema.
C. Colors
Pallor
Associated anemia.
Edema (appears pale).
Shock.
C.O.P.
Rheumatic fever.
Infective endocarditis.
Cyanosis
Central
o Congenital heart disease.
o Hypoxic.
o Corpulmonale.
Peripheral
o Systemic venous congestion.
Jaundice 4 causes???
D. Decubitus
Orthopnea.
Squatting.
Praying position.
E.
-- neck vein
Clinical significance of neck veins
1. Normally:
They are non congested, & are pulsating with systolic collapse.
Page |
62
" " .
By: M. Allam
Clinical notes
V.1
By: M. Allam
2. Abnormally:
a. Abnormal pressure "congested neck vein"
Pulsating:
Right sided heart failure.
Pericardial effusion & constrictive pericarditis.
Hypervolemia.
Non-pulsating:
SVC obstruction (SVC thrombosis or Mediastinal syndrome).
b. Abnormal pulsations "abnormal waves"
a-wave:
Absent: AF.
Giant: pulmonary hypertension, PS, TS.
Cannon waves:
Regular: nodal rhythm.
Occasional: A-V dissociation.
Giant V:
obliterated (systolic expansion of neck veins):
1) TR.
2) AF.
3) Constrictive pericarditis.
Pericardial effusion.
4) Rt. H.f.
clubbing
Pale
Infective endocarditis.
Left atrial myxoma.
Blue
Congenital heart disease.
lower limbs
Right sided heart failure.
Pericardial disease.
Page |
63
" " .
Clinical notes
V.1
By: M. Allam
Diagnosis
The diagnosis should include the following four categories:
1. Aetiological
Rheumatic: multivalvular history of rheumatic fever.
Congenital: since birth + anomalies.
Ischemic.
Hypertensive.
Surgical.
2. Anatomical
Valve lesion.
Pericardium: constrictive pericarditis.
Myocardium: cardiomyopathy.
3. Pathological
Stenosis. Or
Regurge. Or
Double.
4. Functional
Compensated: no manifestations of LVF or RVF.
Non-compensated: manifestations of LVF or RVF.
Or complicated by:
A.F. or any arrhythmia.
Embolic manifestations e.g. hemiplegia.
Infective endocarditis.
Chest infection.
Examples
Rheumatic heart disease (M.S. M.I.) compensated, non-complicated.
Rh. Heart disease (M.I. - A.I,) left sided heart failure complicated with infective
endocarditis.
Congenital Heart disease (V.S.D.) compensated with no complications.
Page |
64
" " .
Clinical notes
V.1
By: M. Allam
Local examination
Dont forget these 4 items
1. Inspection.
2. Palpation.
3. Percussion.
4. Auscultation.
PATIENT POSITIONING:
Expose the patient's chest up to the umbilicus.
Position the patient supine with the head of the table slightly elevated.
Always examine from the patient's right side.
Make sure that the patient is comfortable in this position.
Page |
65
" " .
Clinical notes
V.1
By: M. Allam
Page |
66
" " .
Clinical notes
V.1
By: M. Allam
b. Auscultation:
Accentuated pulmonary component of the second heart sound.
Ejection systolic click.
Ejection systolic murmur due to relative pulmonary stenosis.
Early diastolic murmur due to functional pulmonary regurge (Graham Steel).
S4 over the tricuspid area.
8. Evidence of arrhythmias:
Change in the rate or rhythm of the heart beats.
Inspection
Observe the chest carefully through tangential view.
Specifically note for:
Shape of chest & chest wall lesion :- (See chest)
Dilated vein on chest wall > (S.V.C. obstruction).
Scar of previous operation
i. Median sternotomy (open heart surgery) e.g.; valve replacement or coronary bypass.
ii. Inframammary = lateral thoracotomy (closed heart surgery) e.g.: mitral valvotomy.
Precordial bulge:- indicates cardiac enlargement during childhood e.g. R.V. enlargement pericardial effusion.
Pulsation of different area (mainly for apical pulsation).
Palpation
Usually inspect and palpate at the same time
Palpation for detection of:1. Pulsation
2. Thrill
3. Palpable sound
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By: M. Allam
pulsation
Areas of palpation
Area
1- Supra sternal
Aetiology
Technique
RV++
Aortic P (thin/
Hyperdynamic/aneurysm)
3- Aortic area
Hypertension
A. aneurysm / S
4- Pulmonary area
5- Rt. parasternal
6-Lt. parasternal
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Clinical notes
V.1
By: M. Allam
7) The apex.
Technique
(Inspection palpation left lateral position)
Firstly, by inspection
Place your hand over the left hemi-thorax region
Feel for the outer most and lower most pulsation.
Left lateral position (for detection of weak P)
Count the intercostal spaces (first identify the angle of
Louis = the rib attached alongside this is the 2nd rib and the space below the rib is the 2nd
space).
N.B.
Percussion or auscultation may be used for detection of absent apex.
Apex
Produced by the anterior movement of the left ventricle during early systole, occurs
during isometric contraction of the left ventricle.
The normal apex felt as a GENTLE NONSUSTAINED TAP
N.B.
the point of maximal impulse may not the apex as in rheumatic mitral valve stenosis
the PMI may be the right ventricle.
Apex = Outermost and lowermost visible and palpable part of the heart.
apex
apex apex
" "
Question
Absent apex: (OPERA):Definition: Not visible or palpable apex even on left lateral position.
O Obesity.
P Pericardial effusion pleural effusion.
E Emphysema.
R Rib "under rib".
A Anomalies "dextrocardia".
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Clinical notes
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By: M. Allam
Comment on apex
1.
2.
3.
4.
5.
6.
7.
(1)
Site
Normally in the Lt. 5th intercostal space just inside the M.C.L (3.5 inch from the midline)
Apical shift
Upward:
Upper lobe fibrosis.
Infra diaphragmatic causes as
ascites.
Inward
Lt pleural
effusion
Lt
pneumothorax.
Rt lung fibrosis.
Dextrocardia.
Down
Viscero-ptosis
Thin person
(2)
Outwards
RV ++
Rt Pleural effusion
Rt Pneumothorax.
Lt Lung fibrosis or
collapse.
Area "extend"
70
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Clinical notes
(3)
V.1
By: M. Allam
Character
(4)
Thrill
a. Diastolic thrill in M.S.
b. Systolic thrill in M.I.
Palpable sounds 1st H.S.:- in M.S.
(5)
( 7) Rocking
Left ventricle ++:- Apical bulge + left parasternal retraction (anti-clockwise)
Right ventricle ++:- the reverse (clock-wise).
Double apex:
Ventricular aneurysm: - systolic diastolic pulsation (paradoxical).
Hypertrophic Cardiomyopathy: - systolic systolic pulsation.
Thrill
Better to be detected by the palm
Apex
Left para sternal
Systolic = MR Systolic = VSD
Diastolic = MS
Base
Aortic area
Systolic = P.S.
Continuous = PDA
Page |
Pulmonary area
Systolic = P.S.
Continuous = PDA
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Clinical notes
V.1
By: M. Allam
Palpated sound
Better to be detected by the tip
1. Apex
Palpable S1 in M.S.
Palpable S3 or S4.
Palpable rub.
2. Aortic area
Palpable A2 "syphilitic A.R.".
3. Pulmonary area
Palpable pulmonary component of S2 in PH++.
Percussion
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V.1
By: M. Allam
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Clinical notes
V.1
By: M. Allam
Auscultation
Technique
1. Stethoscope.
2. Site of auscultation.
3. The maneuver of auscultation.
Auscultatory findings
1. Heart sounds: S1 & S2
2. Additional sounds: - S3, S4, opening snap and clicks.
3. Murmurs.
Pericardial rubs / L. crepitations.
a) Ideal stethoscope
1. Optimal stethoscope tubing length is twelve inches (30 cm)
2. Make sure that the earpieces are fit in the external ear.
3. Make sure no air leaks occur between the chest wall and the stethoscope earpiece.
The Cone (bell)
The diaphragm
is best listened to low pitched sounds e.g.: S3 /
Identifies high pitched sounds e.g.: normal
S4 / rumbling murmur of MS.
heart sounds and the murmur of aortic
incompetence.
Remember
N.B.
Pulmonary & tricuspid valves are anterior
So, heard at their anatomical sites
But the aortic & mitral valves are posterior
So, heard at the direction of blood flow.
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Clinical notes
V.1
By: M. Allam
b) Site of auscultation
!!!!
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Clinical notes
V.1
76
" " .
By: M. Allam
Clinical notes
V.1
By: M. Allam
Auscultatory findings
1. Heart sounds
Formed
Site
Time
Accentuated
Weak
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Clinical notes
V.1
Wide splitting:
From the start the P valve is
delayed so accepted as two
sounds
By inspiration the pulmonary
flow is increased so the splitting
will be increases
Causes:- PS / RBBB / ASD
Paradoxical splitting
From the start the A valve is
delayed so accepted as tow
sounds
By inspiration the pulmonary
flow is increased so the splitting
will disappear
Causes:- AS / LBBB / VSD
78
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By: M. Allam
Clinical notes
V.1
By: M. Allam
2. Additional sounds
Def
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Clinical notes
V.1
By: M. Allam
Ejection click
Def: - Opening of the normal aortic (or pulmonary) valve
is soundless while opening of the stenosed aortic (or Pulmonary)
valve produce ejection click sound due to doming of this stenosed valve.
Chr.: Clicky sound.
Site
Aortic area (A.I.)
Pulmonary area
Causes
A.S. (valvular) S.
P.S. (valvular). PH +++
hypertension.
N.B.
No ejection systolic click with subvalvular or Calcific A.S.
Opening Snap
Def: - Snapy sound in M.S due to rigid periphery & pliable centre of the mitral valve in M.S.
Timing: - Early diastolic / separated from S2 by the isometric relaxation phase / heard by cone
Site: - Between M & T areas.
Significance: a. Diagnostic for M.S.
b. Non calcified.
c. Detect severity of M.S.
(Diminished distance between O.S. & S2 = sever lesion).
Murmur
Mechanism of Turbulence (murmur):
1. Passage of blood through
Stenosis (A.S. / M.S / P.S)
Irregularity (congenital bicuspid aortic valve)
Shunt (VSD / P.D.A.)
2. Abnormal direction of Blood (M.R. and A.R.)
3. Over blood flow (relative stenosis)
4. Passage of blood into a relatively dilated structure (ejection systolic murmur in PH ++ or S
hypertension)
Comment on SCRIPT
Site.
Character.
Relation to respiration & position
N.B.
Left sided heart murmurs are louder on expiration.
Right sided heart murmurs are louder on inspiration.
Intensity.
Propagation.
Timing.
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Clinical notes
V.1
By: M. Allam
Timing:
A.S / M.R / T.R. / VSD = systolic.
A.R./ M.S. = Diastolic.
Chr:.
A.S. = Harsh.
A.R. = Soft blowing.
M.S. = Rumbling.
M.R. = Soft (80%), harsh = (20%)
Site:
According to the diseased valve.
N.B, : A.R. murmur at A2 (Left 3rd I.C. space)
Propagation:
M.R. : Axilla / Sternum & base.
A.S. : Carotid & Apex.
Increased by:
Mitral murmur: by
1. Left lateral position.
2. Exercise.
Aortic murmur: by
1. Leaning forward.
2. Expiration.
Right. Sided murmurs: by Inspiration "karvallo's sign"
N.B.
Severity of the lesion detected by duration of the murmur not by grad. As duration of murmur
depends on the pressure gradient across the valve
No thrill Thrill
Grades (Intensity):
Intensity of a murmur is described in grades as follows:
Grade I: Just audible in a quiet room. (Heard by an expert)
Grade II: Quiet- (Heard by a non expert)
Grade III: Loud without thrill. (Easily heard)
Grade IV: Loud with thrill.
Grade V: Very loud with the thrill. (Heard over wide area)
Grade VI: Audible without a stethoscope. (Extremely loud)
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Clinical notes
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By: M. Allam
Types of murmur
(1) Organic murmur
Murmur produced by structural
lesions
Most of them are diastolic
Loud
Long
Harsh (usually)
Propagated
With Thrill
WithC/P
Pericardial Rub
Superficial, gritty, high pitched sound caused by friction of parietal & visceral layer of
pericardium.
It is best heard at the left of the lower sternum with the patient breathing out using the
diaphragm of the stethoscope.
Timing: To & Fro = Systolic & Diastolic.
D.D.
Pleural rub:- disappeared by withholding breath
Friction of stethoscope: disappeared by firm pressure
Crepitaion
Medium sized
Coarse
Fine B.B.C.
MS LVF
Chest infection
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Clinical notes
V.1
Investigations
Scheme for investigations
1. Laboratory: - Urine/ stool/ blood/ others.
2. ECG
3. Images: X ray :- Plain or with Contrast
Echocardiography & Doppler.
4.
5.
6.
7.
1. Laboratory: Indication
1. Arthralgia
2. Fever
3. Pallor
Values
For diagnosis of Rheumatic fever.
For diagnosis of infective endocarditis.
For diagnosis of anemia.
2. ECG
Indications
All cardiac cases
Valuese
1. Chamber enlargement (hypertrophy).
2. Arrhythmia as A.F.
3. Ischemia (angina & M.I.).
3. Images: -
A) X ray :Indication
All cardiac
cases
Plain
Values
Chamber
enlargement.
Pulmonary
vasculature.
Calcific valve.
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Clinical notes
V.1
By: M. Allam
Indication
All cardiac cases
Doppler
Values
For blood flow:
1. Direction:
Regurge.
2. Pressure: PH +++.
3. Velocity.
Catheterization
It is a long, elastic, radio-opaque, thin cord like with a central lumen.
Pathway
Right sided catheter
Left sided catheter
Any vein I.V.C. R.A. tricuspid vlave Any artery aorta aortic vlave left
Rt. Vent. Pulmonary artery.
ventricle.
Mitral valve
As right sided RA artificial ASD LA
M valve
Values: - As Echo & Doppler but superior in IHD
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Clinical notes
V.1
By: M. Allam
Treatment
Medical
Interventional
Surgical
Indications
1. Failure of medical treatment.
2. Severe cases.
3. Complicated cases.
Includes:
1. Mitral valvotomy of MS
Balloon--- valvoplast
Isolated MS non calcific
valves.
2. In cases of IHD
May be complicated by :
coronary angioplasty
Restenosis- iatrogenic MR.
2. Valve repair in regurge:
Symptomatic:
usually failed.
a. Treatment of AF.
3. Valve replacement:
b. Treatment of HF.
Tissue valve:
c. Treatment of thrombosis.
Short life span.
No anticoagulant.
Curative
Used for:
Only in cases of AR by:
Old age.
Vasodilators to reduce the peripheral
Female in child bearing
resistance and prevent blood
period.
regurge though the aorta.
Prosthetic valve:
Long life span.
Anticoagulant needed.
May be complicated by:
Dysfunction.
Hemolytic anemia.
Endocarditis.
Heart surgery
Opened heart surgery (OHS)
Heart lung machine used
Needs high experience.
High
Median sternotomy
The other cases.
85
" " .
Clinical notes
V.1
Valve replacement
Which valve is replaced by
a. History.
b. Metallic H.S
S1 = Mitral.
S2 = Aortic.
Function of the replaced valve:
No symptoms or signs of the disease.
Local examination i.e. no murmur.
Complications of the replaced valve : Dysfunction
Haemolytic anemia.
Haemolytic jaundice.
Prosthetic valve endocarditis
anticoagulant use
N.B.
Valve replacement should be involved in the diagnosis.
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86
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By: M. Allam
Clinical notes
V.1
By: M. Allam
Pathophysiology
In mild cases:
The blood flow through the mitral valve remains normal.
No symptoms occur.
In severe cases: (valve area less than 2 cm2):
The blood flow through the mitral valve is decreased.
Blood stagnate in pulmonary veins (pulmonary venous congestion).
Later on:
Vasoconstriction of pulmonary arterioles occurs to pulmonary congestion, but this will
lead to: pulmonary hypertension.
Finally:
RV enlargement & then RVF will occur secondary to pulmonary HTN.
Therefore four stages will occur in patient with MS
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Clinical notes
V.1
By: M. Allam
Clinical picture
There is a latent period of several years between the initial attack of rheumatic carditis & the
development of manifestations of mitral stenosis.
Symptoms
Does the patient with MS always symptomatize???
1. Stage one:
No symptoms.
2. Stage two:
Symptoms of pulmonary congestion (but pulmonary oedema is not common).
Symptoms of low CO.
3. Stage three:
Symptoms of pulmonary congestions: improve.
Symptoms of Low CO: increase.
4. Stage four:
Symptoms of systemic congestion.
Dyspnea is the most common symptom
Signs
General:
1. Stage one: No signs.
2. Stage two: signs of pulmonary congestion.
3. Stage three: signs of low cardiac output.
4. Stage four: signs of systemic congestion.
Cardiac:
A. Precordial examination:
Stage one & stage two:
Apex: normal site & slapping character.
Diastolic thrill: ending in a palpable S1.
Stage three & stage four:
The previous findings.
Signs of: pulmonary hypertension.
Signs of: right ventricular enlargement.
B. Auscultation
Stage one & stage two (over the mitral area)
1. Accentuated first heart sound: due to:
Fibrosis of the mitral cusps.
Forcible closure of the mitral cusps: because:
They are displaced downwards due to high LA pressure.
The mitral valve is opened as wide as possible during the diastole.
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Clinical notes
V.1
By: M. Allam
89
" " .
Clinical notes
V.1
By: M. Allam
Stage four
The previous findings.
Auscultation over tricuspid area:
o Pan systolic murmur of functional tricuspid regurge.
o Prtodiastolic gallop (S3) due to RVF.
Complications
1. In the mitral valve:
o Rheumatic activity.
o Calcification.
o Infective endocarditis.
2. In the left atrium:
a) Arrhythmias, especially AF.
b) LA enlargement, causing symptoms:
On esophagus: dysphagia.
On left bronchus: dyspnea & cough.
On left recurrent laryngeal nerve: hoarseness of voice.
c) Thrombo-embolic complications:
Systemic embolization: e.g. Cerebral, peripheral, renal.
Ball & valve embolus: leading to syncope & sudden death.
3. In the right ventricle:
RVF.
4. In the left ventricle:
No LVF in isolated mitral stenosis.
5. In the lung:
Hemoptysis.
Pulmonary infection.
Pulmonary embolism (secondary to DVT).
Pulmonary oedema is not common in mitral stenosis.
6. Complications of surgery.
Investigations
1. Chest X-ray:
a) Stage one: no abnormality.
b) Stage two:
In postero-anterior view:
o Obliteration of the waist of the heart
o Double contour of the right border of the heart
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90
" " .
Mitralization =
LA enlargement
Clinical notes
V.1
By: M. Allam
Treatment
1.
Medical:
a) Prophylaxis against: rheumatic activity, infective endocarditis (uncommon).
b) Symptomatic for: complications e.g. HF, AF, infection, embolization.
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Clinical notes
2.
3.
V.1
By: M. Allam
Surgical:
a) Indications:
o Tight mitral stenosis (valve area is < 1 cm2).
o Marked symptoms not responding to adequate medical treatment.
o Embolization with no serious deterioration of the condition of the patient.
b) Types of operations:
i. Mitral commissurotomy: closed or open:
ii. Valve replacement:
By a prosthesis (tissue or synthetic).
Indications:
o Calcification.
o Associated mitral regurge.
o Recurrent stenosis after commissurotomy.
c) Complications:
1. Embolization.
2. Arrhythmias.
3. Mitral incompetence.
4. Restenosis.
5. Post-cardiotomy syndrome:
o Pleuro-pericarditis that may occur 10 15 days following the operation.
o It is possibly an allergic process due to injury of the pericardium during surgery.
6. Complications of artificial valves:
o Infective endocarditis.
o Thrombo-embolism.
o Mechanical dysfunction.
o Hemolytic anemia.
Balloon dilatation:
May be performed in some patients indicated for valvotomy.
Case study
Questions
A. What did you find in this patient??
Finding suggestive of isolated mitral stenosis in sinus rhythm (or in AF).
B. What is the evidence of severity??
1. Severity of symptoms: dyspnoea (degree) paroxysmal nocturnal hemoptysisedema.
2. Signs of low cardiac output: fatigue cold hands small pulse.
3. Signs of pulmonary hypertension.
4. Duration of middiastolic murmur: the longer, the more severe.
5. Timing of the opening snap: the earlier, the more severe.
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Clinical notes
V.1
By: M. Allam
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Clinical notes
V.1
By: M. Allam
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Clinical notes
V.1
By: M. Allam
pathophysiology
1. During systole:
A part of blood regurgitates from LV to LA leading to:
o Low CO.
o LA dilatation: due to increased blood volume in LA.
2. During diastole:
A large volume of blood LV LV enlargement which may end in LVF.
Clinical picture
Symptoms
1. No symptoms: in early cases.
2. Symptoms of low cardiac output: in late cases.
3. Symptoms of pulmonary congestion: in late cases.
4. PALPITATION.
Palpitation is the most common
symptom
Signs
General:
o No signs: in early cases.
o Signs of low cardiac output: in late cases.
o Signs of pulmonary congestion: in late cases.
Cardiac:
A. Precordial examination:
o Signs of LV enlargement: with hyperdynamic apex.
o Systolic thrill: over the apex.
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Clinical notes
V.1
By: M. Allam
B. Auscultation:
1. First heart sound: weak (muffled) due to failure of proper mitral closure.
2. Third heart sound: present due to excessive flow of blood from LA to LV.
3. Murmur of mitral regurge:
o Timing: pansystolic starting with S1.
o Character: soft or harsh.
o Site: over the apex.
o Propagation:
To the axilla.
To the base of the heart & medially in posterior leaflet disease.
o Position: heard best in the left lateral position.
complications
Same complications of MS, but:
1. Infective endocarditis: is common.
2. Left ventricular failure: occurs.
Investigations
1. Chest X-ray:
o No abnormality: in early cases.
o Enlarged LA & LV: in late cases.
o Pulmonary congestion: in late cases.
o Calcified mitral valve especially: in double mitral lesion.
2. ECG:
o Enlarged LA (P mitrale: broad & bifid).
o Enlarged LV.
3. Echocardiogrpahy:
o Detects the severity of mitral regurgitation.
o Detects chamber enlargement.
o Detects the cause: e.g. MVP .
4. Cardiac catheterization & angiocardiography:
o Detects the severity of mitral regurgitation.
o Detects chamber enlargement.
o Detects the cause: e.g. CAD .
Treatment
1.
o
2.
o
Medical:
Same as that of mitral stenosis.
Surgical:
Valve replacement.
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" " .
Clinical notes
V.1
By: M. Allam
Questions
Q-What did you find in this patient??
A-Findings suggestive of mitral regurgitation: apex shifted, and hyper dynamic systolic thrill at
apex area pan systolic murmur maximal over apex, and propagated to axilla.
Q-What is the differential diagnosis of a pansystolic murmur???
A-1.mitral regurgitation: maximal over louder apex and propagated to axilla, with expiration.
2. Tricuspid regurgitation: maximal over lower end of sternum with inspiration.
3.Ventricular septal defect (VSD): maximal 3rd, 4th left spaces.
Q-What are the common causes of mitral regurgitation???
Rheumatic.
Mitral valve prolapse.
Dilated left ventricle (dilated mitral ring): congestive heart failure cardiomyopathy.
Surgical complications of mitral valvotomy.
Q-What are the complications of mitral regurgitation???
Left heart failure.
Infective endocarditis.
Atrial fibrillation.
Q-What is the treatment of mitral regurgitation???
If severe: surgery: valve replacement usually valve repair in minority.
Prophylaxis against infective endocarditis.
Treatment of heart failure.
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Clinical notes
V.1
By: M. Allam
Pathophysiology
1.
2.
During systole, there is obstruction of blood flow from LV to aorta leading to:
Low cardiac output.
Pressure overload on LV leading to LVH & LVF.
Normally, the aortic valve area is 3 4 cm2. In severe AS, it is less than 0.8 cm2.
Clinical picture
Symptoms
1. No symptoms: in mild cases.
2. Symptoms of low CO: in severe cases.
3. Symptoms of pulmonary congestion: due to LVF.
4. SYNCOPE: especially exertional due to low fixed CO.
5. ANGINA: due to
Reduced coronary blood flow: due to low CO & shortened diastole.
Left ventricular hypertrophy: increases the myocardial O2 demands.
Associated coronary atherosclerosis: especially in calcific AS.
Signs
General:
1. Pulse:
Pulsus parvus et tardus (plateau pulse): rises slowly, of small volume, returns slowly.
Pulsus bisferiens: bifid pulse occuring in double aortic lesion.
2. BP: low SBP in severe cases.
3. Systolic thrill: over the carotid arteries.
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Clinical notes
V.1
By: M. Allam
Cardiac:
A. Precordial examination:
1. Signs of LVH: with a heaving apex.
2. Systolic thrill: over second right space apex & carotid arteries.
B. Auscultation:
Over the aortic area:
1. Second heart sound: weak.
2. Systolic ejection click: due to opening of the rigid cusps.
3. Systolic ejection murmur:
Midsystolic, harsh.
Maximum over second right space apex & carotid arteries.
Over the pulmonary area:
Reversed splitting of the second heart sound.
Over the mitral areas:
1. S4.
2. Propagated murmur of AS.
complications
1.
2.
3.
4.
5.
LVF.
Infective endocarditis.
Sudden death: usually due to VF.
Heart block: in calcific AS due to extension of calcification to AV bundle.
Rheumatic activity: in rheumatic AS.
Investigations
1. Chest X-ray:
No abnormality: in mild cases.
LV: LVH.
Lungs: pulmonary congestion when LVF occurs.
Aorta:
o Small aortic knuckle or post-stenotic dilatation.
o Aortic valve calcification may be seen.
2. ECG:
LVH.
3. Echocardiopraphy:
Detects the severity of stenosis by:
o Measurement of valve area.
o Measurement of pressure gradient across the valve.
Detects the type of stenosis.
Detects LVH.
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Clinical notes
V.1
By: M. Allam
Calcific
Old
Absent
Valvular
Atherosclerosis
Treatment
1. Medical:
Same as that of mitral stenosis.
Anginal attacks: may be relieved by SL nitrates.
2. Surgical: (Aortic valve replacement) indications:
a. Presence of severe symptoms.
b. Pressure gradient more than 50 mmHg.
c. Valve area less than 0.8 cm2.
3. Balloon dilatation: indications:
a. Children: with congenital AS as an alternative to surgery.
b. Elderly: with severe calcific AS who are too till to undergo surgery.
Questions
Q-What did you find in this patient???
Finding suggestive of aortic stenosis.
Heaving apex.
Systolic thrill at the base.
Harsh ejection systolic murmur propagated to right side of the neck.
Small prolonged plateau pulse.
Q- How to differentiate between aortic stenosis and pulmonary stenosis???
The murmur is similar (harsh ejection systolic murmur), but differences are obvious:
The murmur of the pulmonary stenosis is maximal over the left upper parasternal area.
P2 is diminished or absent.
Right ventricular hypertrophy (versus LV hypertrophy in AS).
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Clinical notes
V.1
By: M. Allam
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101
" " .
Clinical notes
V.1
By: M. Allam
Etiology
1.
2.
3.
4.
Pathophysiology
Regurgitation of blood from the aorta to the LV in diastole leads to:
1. Increased LV stroke volume, this results in:
a. Increased SBP.
b. Peripheral VD which (together with regurigitation) will decrease the DBP.
c. SBP & DBP wide pulse pressure causing peripheral signs of AR.
2. Volume overload on the LV leading to LV dilatation & later on LVF.
Clinical picture
Symptoms
1. Generalized body throbbing: due to increased arterial pulsation.
2. Palpitation: due to forcible LV contraction.
3. Symptoms of pulmonary congestion: when LVF occurs.
4. Angina pectoris: "two types of angina occur in aortic regurge"
Classic angina of effort :
Decreased DBP: reduces coronary filling.
Angina of Lewis:
Nocturnal & associated with autonomic disturbance e.g. sweating & tachycardia.
Signs
General: "Peripheral signs of aortic regurge"
4 head and neck, 3 upper limb and 3 lower limb
4 head and neck
1. De-Musset sign: nodding of the head.
2. Corrigan's sign: prominent carotid pulsations.
3. Systolic thrill: over the carotid arteries.
4. Arteriolar pulsation: seen by fundus examination
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Clinical notes
1.
2.
3.
1.
2.
3.
V.1
By: M. Allam
3 upper limb
Water hammer pulse: Raises rapidly, of big volume, collapses rapidly.
Blood pressure
a. Wide pulse pressure: exaggerated differences between systolic and diastolic blood
pressure.
Capillary pulsations: detected in nail bed, lips or ear lobule.
3 lower limb
Pistol shots: loud booming sounds heard with each pulse beat over the arteries (especially
femoral) due to sudden distension of collapsed arteries.
Duroziez's sign:
It consists of systolic & diastolic murmurs over the femoral artery if it is slightly
compressed with the stethoscope bell.
The systolic murmur is due to the rapid flow of blood to periphery, while the diastolic
murmur is due to rapid regurge of blood to the heart.
Hill's sign:
Exaggerated difference between SBP in LLs & ULs: more than 50 mmHg.
Normally, SBP in LLs is higher than in ULs: by about 10 20 mmHg.
Cardiac
A. Precordial examination:
Signs of LV enlargement: with hyperdynamic apex.
No thrill over the aortic area: in isolated AR.
B. Auscultation:
Over the arotic area:
a. Normal second heart sound.
b. Murmur of AR:
o Timing: early diastolic.
o Character: soft blowing, decrescendo.
o Site: maximum over the third space.
o Propagation: to the apex.
o Position: best heard with the diaphragm of the stethoscope, the patient is:
Sitting up.
Leaning forward.
Holding his breath in forced expiration.
c. Soft ejection systolic murmur:
o Due to blood flow across the aortic valve (relative AS).
Over the mitral area:
a. S3.
b. Propagated murmur: of AR.
c. Pan systolic murmur: of functional MR.
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Clinical notes
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By: M. Allam
Complications
1. Rheumatic activity.
2. Infective endocarditis.
3. LVF.
Investigations
1. Chest X-ray: "Aortic configuration (Boot-shaped heart)"
LV enlargement & dilated aorta.
2. ECG:
LV enlargement.
3. Echocardiography:
Detects the severity of the lesion.
Detects chamber enlargement.
4. Cardiac catheterization & angiocardiography:
Detects the severity of the lesion.
Detects chamber enlargement.
Treatment
1. Medical:
Same as that of mitral stenosis.
Syphilis: anti-syphilitic treatment.
2. Surgical: (aortic valve replacement) indications:
a. Presence of severe symptoms.
b. Progressive cardiomegaly.
c. Declining LV functions.
Questions
Q-What did you find in this patient???
Findings suggestive of aortic regurgitation:
Shifted hyperdynamic apex.
Early blowing diastolic murmur.
Corrigan's sign waterhammer pulse.
Very low diastolic pressure.
Q-What is the cause of pallor in this patient???
Vasoconstriction: compensatory in severe aortic valve disease.
The patient is not anemic: color of tongue is normal.
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Clinical notes
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By: M. Allam
Q-How can you differentiate aortic regurgitation (AR) from pulmonary regurgitation (PR)??
The early diastolic murmur is identical in both conditions.
Distinction is made by noting:
Peripheral arterial phenomena: confirm AR.
Manifestations of pulmonary hypertension: confirm PR.
Q-What are the causes of aortic regurgitation???
Rheumatic.
Marfan's syndrome.
Infective endocarditis.
Syphilitic aortitis.
Q-What is Marfan's syndrome???
Genetic disorder:
Tall thin built.
Long extremities.
Arachnodactyly (long thin fingers with pads in between).
High arched palate.
Q-how do you assess severity of aortic regurgitation??
1. Apex beat: noting the extent of displacement and degree of hyperkinetic pulsation.
2. Peripheral phenomena.
3. B.P.: how wide is the pulse pressure.
Q-What are the complication of AR???
Heart failure.
Infective endocarditis.
Q-What is the treatment??
Prophylactic antibiotics.
Valve replacement: severe cases.
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Clinical notes
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By: M. Allam
Pathophysiology
During systole, blood regurgitates from RV to RA causing:
Low CO.
RA enlargement.
RV enlargement.
RVF (systemic congestion).
Clinical picture
Symptoms
1. Systemic congestion.
2. Low CO.
Signs
General:
1. Systemic congestion including:
Congested pulsating neck veins: with systolic expansion.
Enlarged tender pulsating liver.
Ascites before oedema of LLs (Ascites precox).
Mild jaundice & peripheral cyanosis (cyano-icteric face).
2. Low CO.
Cardiac:
A. Precordial examination:
RA & RV enlargement.
Rarely: systolic thrill over tricuspid area.
B. Auscultation:"over tricuspid area"
a. Weak muffled S1.
b. S3.
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Clinical notes
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By: M. Allam
Investigations
1. Chest X-ray:
RA & RV enlargement.
2. ECG:
RA & RV enlargement.
3. Echocardiography:
Diagnostic.
4. Cardiac catherization & angiocardiography:
Diagnostic.
Treatment
1. Medical:
Treatment of right sided heart failure.
2. Surgical:
Valve replacement.
Questions
Q-What did you find in this patient???
Findings suggestive of tricuspid regurgitation:
Increased JVP with marked systolic expansion (V wave).
Parasternal hyperdynamic pulsations (marked dilatation of right ventricle).
Pansystolic murmur at lower end of sternum, increased with inspiration.
Enlarged pulsating liver.
Q- What is the etiology of tricuspid regurgitation???
Most cases are functional: dilated ring due to congestive heart failure.
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Clinical notes
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By: M. Allam
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Clinical notes
Valve
lesion
MS
V.1
Most
important
cause
Rheumatic
Most
important
symptom
Pulmonary
congestion
esp.
dyspnea
MR
Rheumatic
Palpitation
AS
Rheumatic
Calcified
Congenital
Low CO esp.
Angina &
syncope
AR
Rheumatic
Syphilitic
Throbbing
palpitation
TS
Rheumatic
Systemic
congestion
TR
Functional
Systemic
congestion
Accentuated S1.
Mid- diastolic
rumbling M
over apex.
Pulmonary
hypertension.
Pan systolic M
& thrill over the
apex
propagated to
axilla
Heaving apex.
Harsh ejection
systolic M &
thrill "over the
second right
space
carotid"
Peripheral signs.
Hyper dynamic
apex.
Early diastolic
soft blowing M
"over the third
left space"
Giant a-wave.
Mid-diastolic
rumbling M
over tricuspid
" with
inspiration "
Systolic
expansion in
neck vein.
Pansystolic M
over tricuspid
" with
inspiration"
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By: M. Allam
Chest X-ray
ECG
Mitralizati
on.
Pulmonary
congestion
.
P-mitrale.
P-
LAE.
LVE.
LAE.
LVE.
LVE.
Small
aortic
knunkle or
Poststenotic
dilatation.
Boot
shaped
heart.
LVE.
RAE.
RAE.
RAE.
RVE.
RAE.
RVE.
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pulmonale.
AF.
LVE.
Clinical notes
V.1
By: M. Allam
B. General examination
1. Patient with an average general condition.
2. Mentality: patient is fully conscious, oriented by time, place and persons, with good mood
and memory; he is co-operative with an average inelegancy.
3. Average built.
4. Patient lies comfortable in bed.
5. Face:
Body temperature = 37.1 C.
No pallor, jaundice or cyanosis.
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6. Neck:
Not congested neck veins.
Normal carotid pulsation.
Central trachea.
No thyroid or lymph node enlargement.
7. Upper limbs:
Pulse: 85 beats / min., irregular, variable volume, equal in both sides, pulse deficit >
10 / min., condition of blood vessels are normal with palpable doraslis pedis.
Blood pressure = 110 / 70.
No hand clubbing.
8. Lower limbs:
No lower limb edema.
Intact peripheral pulsations.
c. Local examination
Inspection:
No precordial bulge.
No scars.
No dilated vein or pigmentations.
Visible apical pulsation.
Palpation:
Apex
Site: left 5th I.C. / M.C.L.
Area: localized.
Character: hyper dynamic.
Thrill: systolic thrill.
Percussion:
Hepatic dullness in 5th I.C. space.
No dullness outside right border of the heart.
No dullness on base of the heart.
No dullness outside the apex.
No sternal dullness.
Auscultation:
Apex
Variable S1.
Murmur:
o Pansystolic.
o Soft.
o On apex.
o Propagated to axilla.
o by exercise.
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Clinical notes
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By: M. Allam
Tricuspid
Variable S1.
No murmur.
Base
Normal S2.
No murmur.
No additional sounds or crepitation.
Diagnosis
A case of rheumatic valvular heart disease, most probably M.S. & M.R.
Patient is compensated but complicated by A.F.
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