Introductory Clinical Skills Course Cardiovascular System
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Transcript of Introductory Clinical Skills Course Cardiovascular System
Introductory Clinical Skills Introductory Clinical Skills CourseCourse
Cardiovascular SystemCardiovascular System
Prof.Mohammad Salah Prof.Mohammad Salah AbduljabbarAbduljabbar
““For me, the only things of For me, the only things of interest are those linked interest are those linked
to the heart”to the heart” (Audrey Hepburn)(Audrey Hepburn)
Presenting ComplaintPresenting Complaint
Chest painChest painShortness of breathShortness of breathAnkle swellingAnkle swellingPalpitationsPalpitationsSyncopeSyncope Intermittent claudicationIntermittent claudication
Chest PainChest Pain
Character of painCharacter of pain SeveritySeverity DurationDuration RadiationRadiation At rest or on At rest or on
exertionexertion Previous episodesPrevious episodes
Relieving factorsRelieving factors Worse on taking a Worse on taking a
deep breath deep breath (pleuritic)(pleuritic)
Worse on movementWorse on movement Autonomic symptomsAutonomic symptoms
SweatingSweating NauseaNausea
Causes of Chest PainCauses of Chest Pain CardiovascularCardiovascular
AnginaAngina StableStable UnstableUnstable
Myocardial infarctionMyocardial infarction Aortic dissectionAortic dissection MyocarditisMyocarditis
PleuropericardialPleuropericardial PericarditisPericarditis PleurisyPleurisy PneumothoraxPneumothorax
GastrointestinalGastrointestinal Gastro-oesophageal Gastro-oesophageal
refluxreflux Oesophageal spasmOesophageal spasm
Chest wallChest wall CoughingCoughing Intercostal muscle Intercostal muscle
strain/myositisstrain/myositis Herpes zosterHerpes zoster Viral pleurodyniaViral pleurodynia Thoracic radiculopathyThoracic radiculopathy Rib fractureRib fracture Rib tumourRib tumour CostochondritisCostochondritis
DyspnoeaDyspnoea
Unexpected awareness of breathingUnexpected awareness of breathingAt rest or on exertionAt rest or on exertionQuantify exercise tolerance (yards Quantify exercise tolerance (yards
walked, stairs climbed)walked, stairs climbed)Orthopnoea = shortness of breath on Orthopnoea = shortness of breath on
lying supinelying supineNumber of pillowsNumber of pillowsParoxysmal nocturnal dyspnoeaParoxysmal nocturnal dyspnoea
Causes of DyspnoeaCauses of Dyspnoea Airways diseaseAirways disease
COPDCOPD Chronic bronchitisChronic bronchitis EmphysemaEmphysema
AsthmaAsthma BronchiectasisBronchiectasis Cystic fibrosisCystic fibrosis
Parenchymal diseaseParenchymal disease PneumoniaPneumonia Pulmonary fibrosisPulmonary fibrosis TumourTumour PneumothoraxPneumothorax
Pulmonary vasculaturePulmonary vasculature Pulmonary embolismPulmonary embolism Pulmonary hypertensionPulmonary hypertension
Chest wallChest wall Pleural effusionPleural effusion Rib fractureRib fracture KyphoscoliosisKyphoscoliosis NeuromuscularNeuromuscular
CardiacCardiac Left ventricular failureLeft ventricular failure Mitral valve diseaseMitral valve disease CardiomyopathyCardiomyopathy Pericardial effusionPericardial effusion
OtherOther AnaemiaAnaemia AcidosisAcidosis PsychogenicPsychogenic
Ankle SwellingAnkle Swelling
Unilateral or bilateralUnilateral or bilateral Proximal extent of Proximal extent of
oedemaoedema Pitting/non-pittingPitting/non-pitting CardiacCardiac
Congestive cardiac Congestive cardiac failurefailure
Right ventricular failureRight ventricular failure Cor pulmonaleCor pulmonale Constrictive pericarditisConstrictive pericarditis
DrugsDrugs Calcium channel Calcium channel
blockersblockers OtherOther
Cirrhosis Cirrhosis Nephrotic syndromeNephrotic syndrome Protein-losing Protein-losing
enteropathyenteropathy Deep vein thrombosisDeep vein thrombosis HypothyroidismHypothyroidism LymphoedemaLymphoedema
PalpitationsPalpitations
= Unexpected = Unexpected awareness of awareness of heartbeatheartbeat
Ask patient to tap Ask patient to tap palpitations on chestpalpitations on chest
Slow or fastSlow or fast Regular or irregularRegular or irregular DurationDuration Speed of onset or Speed of onset or
offsetoffset Relieving manoeuvresRelieving manoeuvres
Sinus tachycardiaSinus tachycardia Ventricular Ventricular
extrasystolesextrasystoles Atrial fibrillationAtrial fibrillation Atrial flutterAtrial flutter Supraventricular Supraventricular
tachycardiatachycardia Ventricular Ventricular
tachycardiatachycardia
SyncopeSyncope
= Transient loss of consciousness due to = Transient loss of consciousness due to cerebral hypoperfusioncerebral hypoperfusion
What was the patient doing at the time?What was the patient doing at the time? Standing for prolonged periodStanding for prolonged period Standing up suddenly (postural Standing up suddenly (postural
hypotension)hypotension) CoughingCoughing Prodromal symptomsProdromal symptoms Abnormal movements (epilepsy)Abnormal movements (epilepsy) Sensation of room spinning (vertigo)Sensation of room spinning (vertigo)
Intermittent ClaudicationIntermittent Claudication
Pain in one or both calves, thighs or Pain in one or both calves, thighs or buttocksbuttocks
Brought on by walking a certain Brought on by walking a certain distance (claudication distance)distance (claudication distance)
Worse on walking uphillWorse on walking uphillRelieved by restRelieved by restSuggests peripheral vascular diseaseSuggests peripheral vascular disease
Risk factors for Ischaemic Heart Risk factors for Ischaemic Heart DiseaseDisease
1.1. HyperlipidaemiaHyperlipidaemia
2.2. Diabetes mellitusDiabetes mellitus
3.3. SmokingSmoking
4.4. HypertensionHypertension
5.5. ObesityObesity
6.6. Family historyFamily history
Past Medical HistoryPast Medical History
Rheumatic feverRheumatic feverPrevious cardiac investigationsPrevious cardiac investigationsPrevious myocardial infarctionPrevious myocardial infarctionCoronary angioplasty + stent Coronary angioplasty + stent
insertioninsertionCoronary artery bypass graftingCoronary artery bypass graftingPacemaker insertionPacemaker insertion
MedicationsMedications
Anti-anginal agentsAnti-anginal agents Use of sublingual nitrate sprayUse of sublingual nitrate spray
Antihypertensive agentsAntihypertensive agents Anti-arrhythmicsAnti-arrhythmics StatinsStatins Platelet inhibitors, e.g., AspirinPlatelet inhibitors, e.g., Aspirin Anticoagulants, e.g., WarfarinAnticoagulants, e.g., Warfarin
Allergies Allergies NB Document in front of chart and inform NB Document in front of chart and inform
nursesnurses
Social HistorySocial History
OccupationOccupatione.g., train driver, long distance truck e.g., train driver, long distance truck
driverdriverSmokingSmoking
Number of pack yearsNumber of pack yearsAlcohol intakeAlcohol intakeStairs at homeStairs at home
Family HistoryFamily History
Ischaemic heart diseaseIschaemic heart diseaseAnginaAnginaMIMICABGCABG
Hypertrophic obstructive Hypertrophic obstructive cardiomyopathycardiomyopathy
Dilated cardiomyopathyDilated cardiomyopathy
Physical ExaminationPhysical Examination
GeneralGeneral HandsHands PulsePulse Blood pressureBlood pressure FaceFace NeckNeck Jugular venous Jugular venous
pressurepressure
PrecordiumPrecordium InspectionInspection PalpationPalpation PercussionPercussion AuscultationAuscultation
BackBack AbdomenAbdomen Lower limbsLower limbs OtherOther
Examination - GeneralExamination - General
Position patient at 45 degreesPosition patient at 45 degreesRespiratory rateRespiratory rateCachexiaCachexiaMarfan’s syndromeMarfan’s syndromeDown’s syndromeDown’s syndrome
Did Abraham Lincoln have Marfan’s Did Abraham Lincoln have Marfan’s Syndrome?Syndrome?
High arched palate
Examination - HandsExamination - Hands
Clubbing Clubbing Splinter haemorrhages (infective Splinter haemorrhages (infective
endocarditis)endocarditis)Osler’s nodes (tender)Osler’s nodes (tender) Janeway lesions (non-tender)Janeway lesions (non-tender)Xanthomata (Hyperlipidaemia)Xanthomata (Hyperlipidaemia)
Examination - PulseExamination - Pulse
Radial arteryRadial artery Rate (normal = 60-Rate (normal = 60-
100)100) Bradycardia (<60)Bradycardia (<60) Tachycardia (>100)Tachycardia (>100)
RhythmRhythm RegularRegular IrregularIrregular
Radiofemoral delay Radiofemoral delay (coarctation of the (coarctation of the aorta)aorta)
Character and volume Character and volume assessed from carotid assessed from carotid arteryartery
Collapsing pulse (aortic Collapsing pulse (aortic regurgitation)regurgitation)
Pulsus alternans (left Pulsus alternans (left ventricular failure)ventricular failure)
Pulse deficit (atrial Pulse deficit (atrial fibrillation)fibrillation)
Examination - Blood PressureExamination - Blood Pressure
SphygmomanometerSphygmomanometer Systolic/diastolic Systolic/diastolic
pressurepressure Normal <140/90 Normal <140/90
mmHg (lower in mmHg (lower in diabetes)diabetes)
Korotkoff soundsKorotkoff sounds Use larger cuff width Use larger cuff width
for large armsfor large arms
Deflate at 4 mmHg/sDeflate at 4 mmHg/s Difference between Difference between
arms of <10 mmHgarms of <10 mmHg Pulsus paradoxus = Pulsus paradoxus =
exaggerated exaggerated reduction in BP with reduction in BP with inspiration (>10 inspiration (>10 mmHg)mmHg)
Postural hypotensionPostural hypotension
Examination – Face and NeckExamination – Face and Neck
JaundiceJaundice XanthelasmataXanthelasmata Corneal arcusCorneal arcus Malar flush (mitral Malar flush (mitral
stenosis)stenosis) High arched palate High arched palate
(Marfan’s syndrome)(Marfan’s syndrome) Dental caries Dental caries
(infective (infective endocarditis)endocarditis)
Central cyanosis Central cyanosis Carotid pulse Carotid pulse
charactercharacter Slow rising (AS)Slow rising (AS) Bisferiens (AS + AR)Bisferiens (AS + AR) Collapsing (AR)Collapsing (AR) Alternans (LVF)Alternans (LVF) Jerky (HOCM)Jerky (HOCM)
Carotid bruitCarotid bruit
Jugular Venous PressureJugular Venous Pressure
Patient at 45 degreesPatient at 45 degrees Good lightingGood lighting Internal jugular veinInternal jugular vein Reflects right atrial Reflects right atrial
pressurepressure Zero point = sternal Zero point = sternal
angleangle Visible but not palpableVisible but not palpable Complex wave form (a, Complex wave form (a,
c, v waves) c, v waves) Decreases on inspirationDecreases on inspiration
Fills from aboveFills from above Hepatojugular refluxHepatojugular reflux Abnormal if >3 cm above Abnormal if >3 cm above
zero point:zero point: RV failureRV failure RV infarctRV infarct Tricuspid stenosisTricuspid stenosis Tricuspid regurgitationTricuspid regurgitation Pericardial effusionPericardial effusion SVC obstructionSVC obstruction Fluid overloadFluid overload
Precordium - InspectionPrecordium - Inspection
ScarsScars Median sternotomyMedian sternotomy
CABGCABGValve replacementValve replacement
Lateral thoracotomyLateral thoracotomy Infraclavicular Infraclavicular
(pacemaker)(pacemaker) Pectus excavatumPectus excavatum Pacemaker boxPacemaker box Apex beatApex beat
Sternotomy scar
Pectus excavatum
Precordium - PalpationPrecordium - Palpation Apex beatApex beat
LocationLocation CharacterCharacter
HeavingHeaving ThrustingThrusting DoubleDouble TappingTapping ParadoxicalParadoxical
Left parasternal heaveLeft parasternal heave Thrills (palpable murmurs)Thrills (palpable murmurs)
SystolicSystolic DiastolicDiastolic
Palpable P2 (pulmonary Palpable P2 (pulmonary hypertension)hypertension)
Pacemaker boxPacemaker box
Precordium – AuscultationPrecordium – AuscultationHeart SoundsHeart Sounds
Bell – low pitched Bell – low pitched soundssounds
Diaphragm – high Diaphragm – high pitched soundspitched sounds
Mitral Mitral Tricuspid Tricuspid Pulmonary Pulmonary Aortic Aortic areasareas
S1 (first heart sound)S1 (first heart sound) S2 – Splitting (A2, S2 – Splitting (A2,
P2)P2)
Abnormalities of Heart Abnormalities of Heart SoundsSounds
Loud S1 Loud S1 Soft S1Soft S1 Loud A2Loud A2 Loud P2Loud P2 Soft A2Soft A2 Splitting of S1Splitting of S1 Increased splitting of Increased splitting of
S2S2 Fixed splitting of S2Fixed splitting of S2 Reversed splitting of Reversed splitting of
S2S2
S3 (third heart sound)S3 (third heart sound) S4 (fourth heart S4 (fourth heart
sound)sound) Summation gallop Summation gallop Opening snapOpening snap Systolic ejection clickSystolic ejection click Mid-systolic clickMid-systolic click Tumour plopTumour plop Pericardial knockPericardial knock Metallic clickMetallic click
Precordium – AuscultationPrecordium – AuscultationMurmursMurmurs
Timing of murmurTiming of murmur SystolicSystolic DiastolicDiastolic ContinuousContinuous
Site of maximal Site of maximal intensityintensity
LoudnessLoudness Grades I-VIGrades I-VI ThrillThrill
PitchPitch RadiationRadiation Dynamic Dynamic
manoeuvresmanoeuvres RespirationRespiration
Left-sided Left-sided on exp. on exp.Right-sided Right-sided on insp. on insp.
ValsalvaValsalva SquattingSquatting
Heart MurmursHeart Murmurs
SystolicSystolic PansystolicPansystolic
Mitral regurgitationMitral regurgitation Tricuspid regurgitationTricuspid regurgitation Ventricular septal defectVentricular septal defect
Ejection systolicEjection systolic Aortic stenosisAortic stenosis Pulmonary stenosisPulmonary stenosis HOCMHOCM Atrial septal defectAtrial septal defect
Late systolicLate systolic Mitral valve prolapseMitral valve prolapse
DiastolicDiastolic Early diastolicEarly diastolic
Aortic regurgitationAortic regurgitation Pulmonary regurgitationPulmonary regurgitation
Mid-diastolicMid-diastolic Mitral stenosisMitral stenosis Tricuspid stenosisTricuspid stenosis Atrial myxomaAtrial myxoma
ContinuousContinuous Patent ductus arteriosusPatent ductus arteriosus Arteriovenous fistulaArteriovenous fistula
Pericardial friction Pericardial friction rubrub
Examination – BackExamination – Back
Percuss and auscultate lung basesPercuss and auscultate lung basesLeft ventricular failureLeft ventricular failurePleural effusionPleural effusion
Sacral pitting oedemaSacral pitting oedemaRight heart failureRight heart failure
Examination - AbdomenExamination - Abdomen
Patient lying with one pillow (if Patient lying with one pillow (if tolerated)tolerated)
Tender hepatomegalyTender hepatomegalyPulsatile liver (tricuspid Pulsatile liver (tricuspid
regurgitation)regurgitation)AscitesAscitesSplenomegalySplenomegalyAbdominal aortic aneurysmAbdominal aortic aneurysm
Examination – Lower LimbsExamination – Lower Limbs
Peripheral oedemaPeripheral oedema Pitting/non-pittingPitting/non-pitting Upper levelUpper level
Achilles tendon Achilles tendon xanthomataxanthomata
Capillary returnCapillary return Trophic skin changesTrophic skin changes
Palpate arteriesPalpate arteries FemoralFemoral PoplitealPopliteal Posterior tibialPosterior tibial Dorsalis pedisDorsalis pedis Buerger’s test Buerger’s test
(peripheral vascular (peripheral vascular disease)disease)
Examination - OtherExamination - Other
Urinalysis Urinalysis Haematuria (infective Haematuria (infective
endocarditis)endocarditis) FundiFundi
Hypertensive Hypertensive retinopathyretinopathy
Roth spots (infective Roth spots (infective endocarditis)endocarditis)
Temperature chartTemperature chart Infective endocarditisInfective endocarditis