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MEDICINE FOR FINALS

MEDICINE FOR FINALS. DR INDER MAINIE MAY 2002. CARDIOVASCULAR. INTRODUCTION MAY I EXAMINE YOU? 45 DEGREES INSPECTION (SOB, SCARS, MALAR FLUSH, ANKLE OEDEMA) ALWAYS LOOK AROUND THE BED, INHALERS, OXYGEN, DIET DRINKS ETC. EXAMINATION. LOOK AT THE HANDS FINGER CLUBBING CYANOSIS

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MEDICINE FOR FINALS

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  1. MEDICINE FOR FINALS DR INDER MAINIE MAY 2002

  2. CARDIOVASCULAR • INTRODUCTION • MAY I EXAMINE YOU? • 45 DEGREES • INSPECTION (SOB, SCARS, MALAR FLUSH, ANKLE OEDEMA) • ALWAYS LOOK AROUND THE BED, INHALERS, OXYGEN, DIET DRINKS ETC

  3. EXAMINATION • LOOK AT THE HANDS • FINGER CLUBBING • CYANOSIS • SPLINTER HAEMORRAGES • PALE

  4. PULSE • RATE • RHYTMN • CHARACTER BRACHIAL/CAROTID • VOLUME • COLLAPSING PULSE

  5. CAUSES OF IRREGULAR IRREGULAR PULSE • ATRIAL FIBRILLATION, VE’S, ATRIAL FLUTTER WITH VAR BLOCK, CHB • CAUSES OF AF • ISCHAMIC HEART DISEASE • RHEUMATIC HEART DISEASE • THYROID • NO CAUSE • CARDIOMYOPATHY • WPW • INFECTION • ASD

  6. COLLAPSING PULSE • AORTIC REGURG LOOK FOR CORRIGAN’S SIGN • PDA • PAGETS • PREGNANCY • RUPTURED ANEURYSM OF AORTIC SINUS • FEVER • ANAEMIA

  7. RADIO-FEMORAL DELAY • COARCTATION OF THE AORTA • ASK WHILE EXAMINING THE PULSE CAN YOU CHECK FOR THIS

  8. BLOOD PRESSURE • ALWAYS REMEMBER TO ASK IF YOU CAN CHECK THE BLOOD PRESSURE

  9. JVP • INTERNAL JUGULAR • BETWEEN THE TWO HEADS • EQUAL TO PRESSURES IN THE RIGHT ATRIUM • a WAVE = ATRAL CONTRACTION • v WAVE= ATRIAL FILLING DURING VENTRICLAR SYSTOLE,TRICUSPID VALVE IS CLOSED

  10. CAUSES OF A RAISED JVP • HEART FAILURE –ELEVATION, SUSTAINED HJR • PE – ELEVATED • PERICARDIAL EFFUSION-ELEVATED, PROMINENT Y DESCENT • CONSTRICTIVE PERICARDITIS-ELEVATED KUSSMAULS, PARADOXICAL RISE ON INSPIRATION • AF NO a WAVES • TRICUSPID STENOSIS- GIANT a WAVES • TRICUSPID REGURG- GIANT v WAVES • COMPLETE HEART BLOCK- CANNON WAVES

  11. APEX BEAT • LOOK FOR STERNOTOMY SCARS • LOOK FOR THORACOTOMY SCARS • POSITION AND CHARACTER • CHECK FOR HEAVES OR THRILLS

  12. HEART SOUNDS • PALPATE THE CAROTID SIMULTANEOUSLY • COMMENT ON I AND II OR ADDITIONAL • MURMURS

  13. MURMURS STENOSIS- APEX LEFT LATERAL USE THE BELL • REMEMBER CHANGES IN BREATHING • INSPIRATION RIGHT HEART MURMURS GET LOUDER • EXPIRATION LEFT SIDE MURMURS GET LOUDER • PANSYSTOLIC MURMUR APEX, AXILLA • EARLY DIASTOLIC AORTIC REGURG 3RD ICS SIT FORWARD ON EXP

  14. GRADING OF MURMURS • 1. FAINT • 2. FAINT BUT EASILY DETECTED • 3. POMINENT BUT NOT LOUD • 4. LOUD THRILL • 5. VERY LOUD • 6. LOUD WITHOUT CONTACT

  15. REMEMBER • LUNG BASES • SACRAL OEDEMA • HEPATOSPLENOMEGALY FAILURE • PERIPHERAL PULSES

  16. MITRAL STENOSIS • MALAR FLUSH • PULSE- IRREGULR IRREGULAR • RAISED JVP • TAPPING APEX NOT DISPLACED • LEFT PARASTERNAL HEAVE(RIGHT VENTRICULAR ENLARGEMENT) • LOUD 1ST HS • OPENING SNAP

  17. MITRAL STENOSIS • CAUSES- RHD • TAPPING APEX BEAT -DUE TO ACCENTUATED 1ST HS • OPENING SNAP OPENING OF A STENOSED VALVE – PLIABLE, ABSENT IN DIFFUSELY CALCIFIED VALVE • LOUD 1ST – VALVES ARE MOBILE • PRESYSTOLIC ACCENTUATION- SINUS RHYTMN DUE TO THE ATRIAL SYSTOLE WHICH INCREASES FLOW ACROSS A STENOTIC VALVE

  18. COMLICATIONS • LEFT ATRIAL ENLARGEMENT • AF • PULMONARY HTN • TR • RHF

  19. SEVERITY • NARROWER DISTANCE BETWEEN 2ND HS AND OS • LONGER THE DIASTOLIC MURMUR

  20. MITRAL REGURG • PERIPHERAL PULSES- NORMAL JERKY DUE TO REDUCED SYSTOLIC EJECTION TIME SECONDARY TO A LARGE VOLUME OF BLOOD REGURG INTO LEFT ATRIUM • APEX BEAT- DISPLACED • 1ST HS SOFT • 3RD HS • PSM -> AXILLA LOUDER ON EXP

  21. CAUSES OF MR • MITRAL VALVE PROLAPSE • RHD • LEFT VENTRICLAR DILATATION • CORONARY DISEASE • ANNULAR CALCIFICATION • ENDOCARDITIS • PAPILLARY MUSCLE RUPTURE • CARDIOMYOPATHY • CONNECTIVE TISSUE DISORDER • TRAUMA • MYXOMATOUS DEGENERATION

  22. CAUSES OF PSM • MR • TR • VSD • HOCM

  23. AORTIC REGURG • PULSE- LARGE VOLUME, COLLAPSING • CORRIGAN’S • APEX DISPLACED OUTWARDS, FORCEFUL • EDM- LSE SIT FORWARD EXPIRATION

  24. Aortic Regurgitation • WIDE PULSE PRESSURE • FEMORALS- PISTOL SHOTS(TRAUBE’S) • TO AND FRO MURMUR (DUROZIEZ’S) • CORRIGANS – CAROTID PULSATION • QUINCKE’S • UVULA PULSATIONS (MULLER’S) • ARGYLL ROBERTSON PUPIL • MARFANS • ANK SPOND, RA

  25. Causes Of Aortic Regurgitation • RF • HTN • ATHEROSCLEROSIS • ENDOCARDITIS • SYPHILIS • MARFANS • RA • ANK SPOND • TRAUMA • AORTIC DISSECTION

  26. SEVERITY • WIDE PULSE PRESSURE • SOFT 2ND HS • 3RD HS • AUSTIN FLINT MURMUR • LVF • LONGER + LOUDER

  27. AORTIC STENOSIS • LOW VOLUME SLOW RISING • APEX- HEAVING, NOT DISPLACED • SOFT 2ND • EJECTION CLICK • S4 MAY BE HEARD • ESM • NARROW PULSE PRESSURE • REVERSE SPLITTING

  28. CAUSES OF AORTIC STENOSIS • RHEUMATIC • DEGENERATIVE CALCIFICATION OF A BICUSPID VALVE

  29. OTHER CAUSES OF ESM • PULM STENOSIS • HOCM • SUPRAVALVULAR STENOSIS

  30. SYMPTOMS • FATIGUE • ANGINA • DYSPNOEA • SYNCOPE • DEATH

  31. INVESTIGATIONS • ECG • CXR • ECHO • CATH • EST BE CAREFUL IF SYMPTOMATIC

  32. TRICUSPID REGURGITATION • CAUSES • FUNCTIONAL • PULMONARY HTN • CCF • RHD • ENDOCARDITIS – DRUG ADDICTS

  33. VSD • PSM AT LSE • LOUD P2 OF PULM HTN • MAY HAVE CCF • LOUDNESS DOES NOT MEAN SEVERE

  34. CAUSES OF VSD • CONGENITAL • RUPTURE AFTER MI • 50% MAY CLOSE SPONTANEOUSLY • COMPLICATIONS ARE • CCF • AORTIC REGURG • SBE • PULM HTN

  35. INFECTIVE ENDOCARDITIS • ANAEMIA • CLUBBING • SPLINTER HAEMORRAGES- EMBOLISM • OSLER NODES- INFLAMMATION OF EMBOLI • JANEWAY LESIONS • PETECHIAE • ROTH SPOTS • SPLENOMEGALY • HAEMATURIA • DENTAL • FBP- NORMOCYTIC NORMOCHROMIC • ESR • BLOOD CULTURES • ECHO/ TOE

  36. COMLICATIONS OF SBE • CARDIAC FAILURE • RENAL PAIN • CEREBRAL ANEURYSMS • MYCOTIC ANEURYSMS • VALVE ABSCESS

  37. HOCM • PULSE JERKY • DOUBLE APICAL- LEFT VENTRICULAR HEAVE WITH PROM PRESYSTOLIC PULSE • PSM- SOFTER ON SQUATTING • 4TH HS • FAMILY HISTORY

  38. RESPIRATORY • INTRO • SITTING POSITION • SPUTUM CUP • BREATHLESS • WASTING • ASYMMETRICAL BREATHING • COUNT RESP

  39. HANDS • CLUBBING • CYANOSIS • TAR • BOUNDING PULSE • ASTERIXIS • TONGUE – CYANOSIS • EYES- PALLOR, HORNERS

  40. EXAMINATION • LOOK FOR NECK VEINS • CERVICAL LYMPH • TRACHEA DEVIATION tug • PALPATE • MOVEMENTS OF BOTH SIDES • VOCAL FREMITUS • PERCUSSION • AUSCULTATION

  41. PLEURAL EFFUSION • LOOK FOR DECREASED MOVEMENT • TRACHEAL DEVIATION • ASPIRATION MARKS • STONY DULL • DECREASED VOCAL RESONANCE • FIND THE UPPER LEVEL • BRONCIAL BREATHING • SIGNS OF RA, TAR, LYMPH NODES, RADIATION BURNS, MASTECTOMY

  42. CAUSES OF DULLNESS • PLEURAL EFFUSION • PLEURAL THICKENING • CONSOLODATION • COLLAPSE • RAISED HEMIDIAPHRAGM

  43. INVESTIGATIONS • CXR • TAP • SEND FOR PROTEIN, LDH, GLUCOSE, BACTERIOLOGY, CYTOLOGY • PH IF EMPYEMA • AMYLASE IN NG, PANCREATITIS, OESOPHAGEAL RUPTURE • RHEUMATOID FACTOR

  44. TRANSUDATE • NEPHROTIC SYNDROME • CARDIAC FAILURE • LIVER FAILURE • HYPOTHYROID • CONSTRICTIVE PERICARDITIS • MEIGS

  45. EXUDATE • CA • SECONDARIES • PNEUMONIA • PE • TB • RA • SLE • LYMPHOMA • MESOTHELIOMA

  46. PROGNOSIS • POOR IN NG PEURAL FLUID • LOW GLUCOSE • LOW pH

  47. HAEMORRAGIC FLUID • PE • NG • TB

  48. REMEMBER OCCUPATION EG SHIP BUILDING

  49. BRONCHIECTASIS • LOOK FOR SPUTUM CUP • FINGER CLUBBING • BILATERAL COARSE CREPS • LATE INSP CREPS

  50. BRONCHIECTASIS • DEF - CHRONIC NECROTIZING INFECTION OF THE BRONCHI AND BRONCHIOLES LEADING TO ABNORMAL, PERMANENT DILATATION OF THE AIRWAYS

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