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

Acute Anteroseptal MIAcute Anteroseptal MI

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

Pulmonary OedemaPulmonary Oedema

Normal Chest Radiograph

Pulmonary Oedema

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)

Clubbing

Splinter Haemorrhages

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

Eye signs in HyperlipidaemiaEye signs in Hyperlipidaemia

CORNEAL ARCUS

XANTHELASMATA

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)

Dorsalis pedis pulse

Posterior tibial pulse

Peripheral PulsesPeripheral Pulses

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

THE ENDTHE END