Introductory Clinical Skills Course Cardiovascular System

1. Introductory Clinical Skills CourseCardiovascular System Prof.Mohammad Salah Abduljabbar

2. “For me, the only things of interest are those linked to the heart”(Audrey Hepburn)

3. Presenting Complaint • Chest pain • Shortness of breath • Ankle swelling • Palpitations • Syncope • Intermittent claudication

4. Character of pain Severity Duration Radiation At rest or on exertion Previous episodes Relieving factors Worse on taking a deep breath (pleuritic) Worse on movement Autonomic symptoms Sweating Nausea Chest Pain

5. Cardiovascular Angina Stable Unstable Myocardial infarction Aortic dissection Myocarditis Pleuropericardial Pericarditis Pleurisy Pneumothorax Gastrointestinal Gastro-oesophageal reflux Oesophageal spasm Chest wall Coughing Intercostal muscle strain/myositis Herpes zoster Viral pleurodynia Thoracic radiculopathy Rib fracture Rib tumour Costochondritis Causes of Chest Pain

7. Acute Anteroseptal MI

8. Dyspnoea • Unexpected awareness of breathing • At rest or on exertion • Quantify exercise tolerance (yards walked, stairs climbed) • Orthopnoea = shortness of breath on lying supine • Number of pillows • Paroxysmal nocturnal dyspnoea

9. Airways disease COPD Chronic bronchitis Emphysema Asthma Bronchiectasis Cystic fibrosis Parenchymal disease Pneumonia Pulmonary fibrosis Tumour Pneumothorax Pulmonary vasculature Pulmonary embolism Pulmonary hypertension Chest wall Pleural effusion Rib fracture Kyphoscoliosis Neuromuscular Cardiac Left ventricular failure Mitral valve disease Cardiomyopathy Pericardial effusion Other Anaemia Acidosis Psychogenic Causes of Dyspnoea

10. Pulmonary Oedema Normal Chest Radiograph Pulmonary Oedema

11. Unilateral or bilateral Proximal extent of oedema Pitting/non-pitting Cardiac Congestive cardiac failure Right ventricular failure Cor pulmonale Constrictive pericarditis Drugs Calcium channel blockers Other Cirrhosis Nephrotic syndrome Protein-losing enteropathy Deep vein thrombosis Hypothyroidism Lymphoedema Ankle Swelling

12. = Unexpected awareness of heartbeat Ask patient to tap palpitations on chest Slow or fast Regular or irregular Duration Speed of onset or offset Relieving manoeuvres Sinus tachycardia Ventricular extrasystoles Atrial fibrillation Atrial flutter Supraventricular tachycardia Ventricular tachycardia Palpitations

14. Syncope • = Transient loss of consciousness due to cerebral hypoperfusion • What was the patient doing at the time? • Standing for prolonged period • Standing up suddenly (postural hypotension) • Coughing • Prodromal symptoms • Abnormal movements (epilepsy) • Sensation of room spinning (vertigo)

15. Intermittent Claudication • Pain in one or both calves, thighs or buttocks • Brought on by walking a certain distance (claudication distance) • Worse on walking uphill • Relieved by rest • Suggests peripheral vascular disease

16. Risk factors for Ischaemic Heart Disease • Hyperlipidaemia • Diabetes mellitus • Smoking • Hypertension • Obesity • Family history

17. Past Medical History • Rheumatic fever • Previous cardiac investigations • Previous myocardial infarction • Coronary angioplasty + stent insertion • Coronary artery bypass grafting • Pacemaker insertion

18. Medications • Anti-anginal agents • Use of sublingual nitrate spray • Antihypertensive agents • Anti-arrhythmics • Statins • Platelet inhibitors, e.g., Aspirin • Anticoagulants, e.g., Warfarin • Allergies • NB Document in front of chart and inform nurses

19. Social History • Occupation • e.g., train driver, long distance truck driver • Smoking • Number of pack years • Alcohol intake • Stairs at home

20. Family History • Ischaemic heart disease • Angina • MI • CABG • Hypertrophic obstructive cardiomyopathy • Dilated cardiomyopathy

21. General Hands Pulse Blood pressure Face Neck Jugular venous pressure Precordium Inspection Palpation Percussion Auscultation Back Abdomen Lower limbs Other Physical Examination

22. Examination - General • Position patient at 45 degrees • Respiratory rate • Cachexia • Marfan’s syndrome • Down’s syndrome

23. Did Abraham Lincoln have Marfan’s Syndrome? High arched palate

24. Examination - Hands • Clubbing • Splinter haemorrhages (infective endocarditis) • Osler’s nodes (tender) • Janeway lesions (non-tender) • Xanthomata (Hyperlipidaemia)

25. Splinter Haemorrhages Clubbing

26. Radial artery Rate (normal = 60-100) Bradycardia (<60) Tachycardia (>100) Rhythm Regular Irregular Radiofemoral delay (coarctation of the aorta) Character and volume assessed from carotid artery Collapsing pulse (aortic regurgitation) Pulsus alternans (left ventricular failure) Pulse deficit (atrial fibrillation) Examination - Pulse

27. Sphygmomanometer Systolic/diastolic pressure Normal <140/90 mmHg (lower in diabetes) Korotkoff sounds Use larger cuff width for large arms Deflate at 4 mmHg/s Difference between arms of <10 mmHg Pulsus paradoxus = exaggerated reduction in BP with inspiration (>10 mmHg) Postural hypotension Examination - Blood Pressure

29. Jaundice Xanthelasmata Corneal arcus Malar flush (mitral stenosis) High arched palate (Marfan’s syndrome) Dental caries (infective endocarditis) Central cyanosis Carotid pulse character Slow rising (AS) Bisferiens (AS + AR) Collapsing (AR) Alternans (LVF) Jerky (HOCM) Carotid bruit Examination – Face and Neck

30. Eye signs in Hyperlipidaemia CORNEAL ARCUS XANTHELASMATA

34. Patient at 45 degrees Good lighting Internal jugular vein Reflects right atrial pressure Zero point = sternal angle Visible but not palpable Complex wave form (a, c, v waves) Decreases on inspiration Fills from above Hepatojugular reflux Abnormal if >3 cm above zero point: RV failure RV infarct Tricuspid stenosis Tricuspid regurgitation Pericardial effusion SVC obstruction Fluid overload Jugular Venous Pressure

35. Precordium - Inspection • Scars • Median sternotomy • CABG • Valve replacement • Lateral thoracotomy • Infraclavicular (pacemaker) • Pectus excavatum • Pacemaker box • Apex beat Sternotomy scar Pectus excavatum

36. Precordium - Palpation • Apex beat • Location • Character • Heaving • Thrusting • Double • Tapping • Paradoxical • Left parasternal heave • Thrills (palpable murmurs) • Systolic • Diastolic • Palpable P2 (pulmonary hypertension) • Pacemaker box

37. Precordium – AuscultationHeart Sounds • Bell – low pitched sounds • Diaphragm – high pitched sounds • Mitral  Tricuspid  Pulmonary  Aortic areas • S1 (first heart sound) • S2 – Splitting (A2, P2)

40. Loud S1 Soft S1 Loud A2 Loud P2 Soft A2 Splitting of S1 Increased splitting of S2 Fixed splitting of S2 Reversed splitting of S2 S3 (third heart sound) S4 (fourth heart sound) Summation gallop Opening snap Systolic ejection click Mid-systolic click Tumour plop Pericardial knock Metallic click Abnormalities of Heart Sounds

41. Timing of murmur Systolic Diastolic Continuous Site of maximal intensity Loudness Grades I-VI Thrill Pitch Radiation Dynamic manoeuvres Respiration Left-sided  on exp. Right-sided  on insp. Valsalva Squatting Precordium – AuscultationMurmurs

43. Systolic Pansystolic Mitral regurgitation Tricuspid regurgitation Ventricular septal defect Ejection systolic Aortic stenosis Pulmonary stenosis HOCM Atrial septal defect Late systolic Mitral valve prolapse Diastolic Early diastolic Aortic regurgitation Pulmonary regurgitation Mid-diastolic Mitral stenosis Tricuspid stenosis Atrial myxoma Continuous Patent ductus arteriosus Arteriovenous fistula Pericardial friction rub Heart Murmurs

44. Examination – Back • Percuss and auscultate lung bases • Left ventricular failure • Pleural effusion • Sacral pitting oedema • Right heart failure

45. Examination - Abdomen • Patient lying with one pillow (if tolerated) • Tender hepatomegaly • Pulsatile liver (tricuspid regurgitation) • Ascites • Splenomegaly • Abdominal aortic aneurysm

46. Peripheral oedema Pitting/non-pitting Upper level Achilles tendon xanthomata Capillary return Trophic skin changes Palpate arteries Femoral Popliteal Posterior tibial Dorsalis pedis Buerger’s test (peripheral vascular disease) Examination – Lower Limbs

47. Peripheral Pulses Dorsalis pedis pulse Posterior tibial pulse

48. Examination - Other • Urinalysis • Haematuria (infective endocarditis) • Fundi • Hypertensive retinopathy • Roth spots (infective endocarditis) • Temperature chart • Infective endocarditis

49. THE END