Cvs - clinical notes

C

C

ardiovascular

ardiovascular

SS

ystem

ystem

DETAILS OF PRESENTING SYMPTOMS DETAILS OF PRESENTING SYMPTOMS

!

! C"eC"est #aist #ai$ %c"e$ %c"est disst discomcom&or&ort'(t'( Ask for 

Ask for 

•

• Site, duration, character, radiation, aggravating & Site, duration, character, radiation, aggravating & reliving factorsreliving factors •

• Any special type of Any special type of angina (unstable, second wind, nocturnal, pericardialangina (unstable, second wind, nocturnal, pericardial

 pain, aortic dissec  pain, aortic dissection)tion)

T

Tyyppee LLooccaattiioon n CChhaarraacctteer r DDiisseeaassee

A$)i$a A$)i$a %myocardial %myocardial isc"emia' isc"emia' Retrosternal Retrosternal  pain radiating  pain radiating to arms, throat, to arms, throat,  jaw  jaw onstricting pain onstricting pain Aggr by e!ertion & Aggr by e!ertion & rapid relief by rest rapid relief by rest &drugs &drugs A" # A" # Atherosclerosis, Atherosclerosis, arteritis, congenital arteritis, congenital A", embolism A", embolism Myocardial Myocardial i$&arctio$

i$&arctio$ Same asSame asanginaangina Same as angina butmore severe & notSame as angina butmore severe & not easily relived easily relived Acute myocardial Acute myocardial infarction infarction Pericarditis

Pericarditis entralentral

(retrosternal) (retrosternal) chest pain chest pain radiate to radiate to shoulder $ back shoulder $ back

Sharp $ Stabbing$ raw Sharp $ Stabbing$ raw (like sand paper) pain (like sand paper) pain Aggr by deep Aggr by deep inspiration, cough, inspiration, cough,  postural change  postural change %diopathic, %diopathic, o!sackie  o!sackie  infection, infection, complication of complication of myocardial myocardial infarction infarction Pai$ o& Pai$ o& aortic aortic dissectio$ dissectio$ Retrosternal $ Retrosternal $ over back in over back in interscapular interscapular region region

Severe tearing pain of Severe tearing pain of abrupt onset

abrupt onset Aoric dissectionAoric dissection

•

• Grading Grading  of Angina (anada heart dissociation) of Angina (anada heart dissociation)

%% SSeevveer r ee!!eerrttiioonn

%%%%%% ''aallkkiinng og on ln leevveel gl grroouunndd, c, clliimmbbiinng  g  fflliigghht ot off ordinary stairs

ordinary stairs %% AAt t rreesstt

*!

*! DDysys##$$oeoeaa

 Def:

 Def: Abnormal awareness of one-s own breathing at rest  Abnormal awareness of one-s own breathing at rest $ low level of $ low level of e!ertione!ertion

Ask for Ask for

At rest$ after e!ertion At rest$ after e!ertion

.ime of occurrence/ day time$ nocturnal .ime of occurrence/ day time$ nocturnal 0nset/ acute$ insidious

0nset/ acute$ insidious

"uration "uration 1rading of 1rading of dyspnoea/ dyspnoea/  234A  234A classclass

II  2o dyspnoea at rest$ moderate e!ertion 2o dyspnoea at rest$ moderate e!ertion II

II "yspnoea at moderate to severe e!ertion"yspnoea at moderate to severe e!ertion III

III "yspnoea at mild e!ertion but minimal at rest"yspnoea at mild e!ertion but minimal at rest I+

I+ Significant dyspnoea at rest/ often bed bound Significant dyspnoea at rest/ often bed bound $$ Severe dyspnoea on minimal e!ertion

Severe dyspnoea on minimal e!ertion

Associated symptoms like cough, palpitation etc, Associated symptoms like cough, palpitation etc, Aggravating & relieving factors

Aggravating & relieving factors  2umber of episo

 2umber of episodesdes

Card

Cardiac Causes iac Causes of Dyspnoeaof Dyspnoea

Ac

Acutute oe onsnsetet AcAcutute pe pululmomonanary ry ededemema,a,  pulmonary em

 pulmonary embolism,bolism,  pneumotho

 pneumothora!, pneumoniara!, pneumonia Subacute $

Subacute $ chronic

7

7 885 5 ("y("yspnspnoea oea is is the the majmajor or symsymptomptom)) *7

*7 cocongengeninitatal hel hearart dit diseseasasee 97

97 ac:ac:uiruired ved valvalvulaular her heart art disdiseaseasee ++77 AA""

67

67 hyhyperpertetensnsivive heae heart dirt diseseasasee ;7

;7 cacardrdioiomymyopopatathyhy

I$ additio$ as, &or I$ additio$ as, &or

•

•  PND PND •

• 0ccurs at night0ccurs at night •

• <atient awakens with a feeling of <atient awakens with a feeling of suffocasuffocation and grasps for tion and grasps for breathbreath •

•  2eeds longer tim 2eeds longer time in sitting position e in sitting position for relief for relief  •

•  Mechanism Mechanism # not e!actly known, # not e!actly known,  slow reabsorpti

 slow reabsorption of interstitial fluid fron of interstitial fluid from dependent positionom dependent position of the body and of the body and

resultant e!pansion of intrathoracic blood volume resultant e!pansion of intrathoracic blood volume

 sudden elevation of thoracic blood volume and diaphragm

 sudden elevation of thoracic blood volume and diaphragm which occurs which occurs

immediately after recumbency as in case of o

immediately after recumbency as in case of orthopnoearthopnoea

 Reduced adrenergic s

 Reduced adrenergic support upport  of left ventricular function during sleep of left ventricular function during sleep

normal

normalnocturnal depnocturnal depressiressionon of the of therespiratrespiratory ory center center 

<osterior of thora! does not take part

<osterior of thora! does not take part in respiration when patient lies downin respiration when patient lies down

•

• Clinical causesClinical causes /ischemic heart disease, aortic  /ischemic heart disease, aortic valve disease, 4.,valve disease, 4.,

ardiomyopathy, Atrial fibrillation (A5) ardiomyopathy, Atrial fibrillation (A5)

•

• Ort"o#$oeaOrt"o#$oea

o

o  "yspnoea in recumbent position, within minutes of  "yspnoea in recumbent position, within minutes of recumbencyrecumbency o

o 0ccurs in awake patient0ccurs in awake patient o

o Relived by sitting up $ elevation of head with pillowsRelived by sitting up $ elevation of head with pillows o

o  Mechanism Mechanismis believed to be due is believed to be due to redistribution of fluid in to theto redistribution of fluid in to the

intravascular compartment on lying down with resultant increased venou intravascular compartment on lying down with resultant increased venouss return

return

o

o Clinical causesClinical causes / Acute 85, e!treme degree of 5 / Acute 85, e!treme degree of 5

*; *;

• <latypnoea

o "yspnoea only in upright position

o  thrombus$ tumors of left atrium, <ulmonary A fistula

•  .repopnoea

o "yspnoea only in left $ rt lat7 "ecubitus position o <ts with heart disease

•  heyne stokes breathing

-! Pal#itatio$ Ask for #

=ode of onset, fre:uency, duration, occurring at rest$ e!ertion, aggravating & relieving factors persistent$ paro!ysmal

Rapid & regular of

abrupt onset Atrial, junctional, ventriculartachyarrhythmia Rapid, irregular A5

.! Sy$co#e

Ask for # onset, duration, causative factors (drug related, arrhythmia related, e!ertion related), associated neurological deficit

Clinical disorders

Aortic stenosis , Atrial my!omas, hypertrophic cardiomyopathy, acute =%,

<rimary <ulmonary 4., severe pulmonary stenosis, .etrology of fallot

Arrhythmias/ sick sinus syndrome, ventricular tachycardia,

Supraventricular tachycardia, complete heart block Features o& certai$ ty#es o& sy$co#e

 Disorder Description of stimuli, recovery Cause of cerebral hypoperfusion (CP)

 ostural hypotension Syncoupe on standing, pt falls to

corrects itself  ommon in elderly

< & < resulting in syncoupe

$asovagal syncoupe  !f fre"uent %

&malignant vasovagal   syndrome'

Stimuli # emotional $painful stimuli, less commonly cough$ micturition

Rapid recovery if pt lies down

 (utonomic overactivity provo)ed by  stimuli causes vasodilatation *

inappropriate slowing of pulse cause

abnormal fall in < & < resulting in syncoupe

Carotid sinus  syncoupe

+ic) sinus syndrome

Stimulation of carotid sinus by tight shirt collar, Shaving in some elderly pts

 -aggerated vagal discharge due to

e!ternal stimuli cause refle! vasodil7 & slowing of pulse resulting in fall in < & < $alvular obstruction +imilar mechanism in vasodilator .nitrates,  (C inhibitor/ therapy

?!ertion  0i-ed valvular obstruction in (+, Lt atrial tumor prevents normal rise in C12 during e-ertionsuch that physiological asodil7

0ccurring in e!ercising muscle produce abnormal fall in <

+to)es (dams  syndrome

Self limiting episodes of

asystole $ rapid tachyarrhythmia (including ventr7 5ibrill)

Rapid recovery after normal rhythm is restored asso7 'ith flushing of skin

"ue to the abnormal rhythmthere is loss of C121 causing syncoupe & stri)ing  pallor 

/! 0 1o easy &ati)a2ility

%mportant symptom of heart failure

=ore intense towards end of day

Cause # deconditioning & muscular atrophy, inade:uate 0* delivery to muscle due

to reduced 70

3! Peri#"eral oedema

Ask for # site, duration, progressive$ variable, diurnal variation, associated weight gain, "rug history (2SA%"S, a channel blockers, Steroids)

4! 0 1o cya$osis1 cya$otic s#ells

 Def # bluish discoloration of skin & mucous mem due to increased amt of red7 4b  + gm $ dl

0R  9B of total 4b & <a 0* C @6B 0R due to presence of abnormal 4b pigments in  perfused areas

Ty#es Causes

Central Decreased art! O* saturat$7

7 Decresed atm presr#high altitude

*7 !mpaired pul1 0ntn # alveolar hypoventilation, ventilation

 perfusion =ismatch, impaired 0* diffusion

97 (natomical shunt # congenital cyanotic heart diseaseD,

<ulmonary A fistula

+7 3b with low affinity for 24

02 a2$ormalities 7 Met 3b 5 617 g8dl 

  4ereditary

Ac:uired # drugs (nitrate, nitrite, sulphonamide) *7 sulph 3b 5 917 g8dl

1 C2# 3b  (smokers)

 eripheral  Reduced ardiac 0utput, cold e!posure, redistribution of blood

flow from e!tremities, obstruction of arter y $ vein

 Differentia l

7 2nly in LL # <"A with pulmonary 4. with rt to lt shunt

*7 2nly in ;L/ E E & transposition of 1rt vsls

97 LL < left ;L .rarest ) # when <"A opens pro!imal to origin of 8t

subclavian artery 5Co$)e$ital Cya$otic "eart diseases6

7 .etrology of fallot

*7 .ransposition of great vessels 97 .runcus arteriosus

+7 .otal anomalous pulmonary venous connection 67 .ricuspid atresia

• yanotic congenital heart disease with cyanosis seen on the &irst day o& 2irt"

7 .otal anomalous pulmonary venous connection *7 .ricuspid atresia

97  <ulmonary atresia

•  !n Tetrology of 0allot, cyanosis occurs3 to 6 months after birth due to following

reasons

• <resence of fetal haemoglobin

• 'ith growth of child, severity of pulmonary stenosis increases • 0!ygen demand increases with growth of the child

77 0emo#tysis

7 =itral stenosis

Rupture of bronchopulmonary collateral (bronchopulmonary apople!y)

<ulmonary edema <ulmonary infarction 'inter bronchitis *7 Acute pulmonary edema

97 <ulmonary embolism & infartion

 Also ask history about folloin!

F7 4 $o s:uatting episodes

7 4 $o convulsions, loss of consciousness

7 Respiratory symptoms / ough, hemoptysis, epista!is

*! G! I! sym#toms

 nausea and vomiting (digitalis to!icity)

 upper abdominal pain (hepatomegaly due to 5)  right hypochondrial pain

 abdominal distension # ascites due to 5, constrictive pericarditis  loss of appetite (anore!ia) $ weight

Anore!ia / git congestion in 5 -! uri$ary sym#toms

2liguria # poor renal perfusion due to 5, Renal artery embolism  =octuria/ increased renal perfusion in 5 in recumbent position  3ematuria # a manifestation of infective ?ndocarditis

+7 Fever/ duration & pattern 6! 8oi$t #ai$ 9 s:elli$)

7 Acute$ chronic

*7 Goints involved

97 5leeting (migrating) $ addictive +7 Associated fever, rashes

67 Recovery

;7 Any residual deformity ;7 4oarseness of voice $ hemiparesis

PAST 0ISTORY

• Specific en:uiry about the past history of conditions that may be associated

with cardiac diseases # "=, A", A12, A5, Amyloidosis, ardiomyopathy

7  similar complaints before # pedal edema, "yspnoea, infective endocarditis,

stroke

*7 4 $o recurrent respiratory tract infections

97  (nte natal history in mother / 1erman measles, drug intake, lupus (congenital

complete heart block)

+7  !ntranatal history # mode of delivery, cry, congenital cyanosis

67  post natal history # feeding difficulties, failure to thrive, delayed milestones,

retarded growth, recurrent respiratory tract infections, cyanotic & s:uatting episodes

;7  3 8o rheumatic fever .rheumatic age: 7# 67 years/ # throat pain, fever, joint

 pain( pattern of joint involvement & recovery), involuntary movements & subcutaneous nodules

>7 4 $o 4., "=, <.

@7 Recurrent dental works $ other potential cause of bactremia (for endocarditis)

PERSONAL 0ISTORY 7 "iet

*7 Alcohol (A5, 4., ardiomyopathy) 97 Smoking

+7 ?!cessive coffee (palpitation)

67 %77 drug abuse, Recreational drugs like cocaine (chest pain)

OCC;PATIONAL 0ISTORY

!  =ature of employment / to know about limitation of activities

*! =edico/legal conse:uences/ pilots, drivers of heavy commercial vehicles

DR;G 0ISTORY

7 8ist of drugs used

*7 4 $o 0. drugs (2SA%"S), Alternative medicines, 4erbal remedies (they may contain ingredients with a cardiovascular action)

 Drug history is important as

• "rugs may cause$ aggravate cardiac symptoms

• =ay give a clue for the presence of chronic diseases ("=, Rheumatoid arthritis,

Skin diseases)

FAMILY 0ISTORY

7 onsanguineous parents # degree

*7=other-s Age at delivery

97Similar complaints in family / ardiac diseases with genetic component 5irst degree rothers and sister  

Second degree 5isrt generation relative uncle .hird degree Second generation

+7 <remature A" in st _{degree relative}

67Sudden une!plained death at younger age (cardiomyopathy $ inherited

arrhythmia) in st _{degree relative}

P"ysical E<ami$atio$

Co$ditio$ Features Cardiac lesio$

 Marfan>s  syndrome

"islocation of lens (upward & outward), %rododonesis, 4igh arch palate, Hyphoscoliosis, Arachnodactyly, .humb sign, 'rist sign (=urdoch sign)

Aortic regurgitation, "issection of arota7 =<, =R 

-! =uilt 9 $ouris"me$t / thin, obese, normal .! #yre<ia

i7 infective endocarditis # low grade$ swinging (if  paravascular abscess develops)

ii7 myocardial infarction # first 9 days after =%

iii7 Recurrent respiratory tract infection in shint lesions, pulmonary congestion

iv7 Acute pericarditis

Co$ditio$ Features Cardiac lesio$

 Down  syndrome

=ental retardation, epicanthic folds, low set ears, mongoloid face, depressed nasal

 bridge, 4ypotonia, macroglossia

?ndocardial cushion defect

Turner  syndrome

'ebbed neck, se!ual infantilism wide set nipples, low hair line, small chin, wide carrying angle oarctation of aorta, bicuspid aortic valve  =oonan  syndrome

Same as above but phenotypically male <ulmonary valve stenosis

v7 <ulmonary embolism

vi7 2S infection in cyanotic heart diseases /!  pallor # shock, 3! lymphadenopathy 4! a$emia • %nfective endocarditis • As a result of hemoptysis •  2utritional anemia

• Anemia may e!acerbate angina & 4eart failure

7! #olycyt"emia

%nfective endocarditis, or pulmonate, ?isenmenger syndrome >! Eyes

7 proptosis, *7 lid retraction,

97 sub conjunctival hemorrhage, +7 !anthalesma (A")

67 corneal arcus (A")

;7 brush field spots, coloboma,

>7 irododonesis (shimmering iris) , dislocation of lens# marfan-s syndrome, @7 cataract ?! $ec, 7 venous pulse *7 goiter  97 webbing of neck 9+

7 with low hair line/ turner-s (coartation)I

*7 with low set ears/ 2oonan-s (<S, 40=)

!Cya$osis # (details given in presenting complaints) *!clu22i$) / ask for onset, duration

i7 congenital cyanotic disease/ absent at birth, develops during infancy & become marked

ii7 infective endocarditis # only other cardiac cause of clubbing

-!&i$)ers 9 $ails

Signs of infective endocarditis

i7 splinter hemorrhages in nail/bed

ii7 tender erythematous nodules in pulp of finger  iii7 janeway lesions # painless erythematous lesions on

 palms .!warm hands # high output states /!cold$ess o& e<tremities

%mportant sign of reduced 707 in pts hospitaliJed with severe heart failure (=easuring skin temp/ useful to monitor 70 in %K)

3!Pedal edema

• Sub/cutaneous, pitting edema # ardinal feature of 45

• <ressure applied over bony prominence # tibia, lat7 =alleoli, sacrum • Cause # retention of salt & water by kidney by following mechanisms

o Reduced 2a delivery to 2ephron

 Symp activtn L A. %% M preglomerular arterioles constrictedMreduced

15R M reduced 2a delivered

o %ncreased 2a reabsorption from 2ephron  %n <. during early phase

 %n ". as failure worsens (due to activation of R A A)

4! 8au$dice

• ongestive hepatomegaly

• =icroanglopathic hemolytic anemia # prosthetic valves • <ulmonary infarction

• Anticoagulant drug # 'arfarin

7!S,i$

"ry, coarse =y!oedema

old and clammy <eripheral vascular collapse 'arm and sweating .hyroto!icosis

>!Muscular s,eletal system

7 high arch palate, arachnodactyly, pes cavus # marfan-s syndrome *7 absence of radius,

97 absence of thumb # (4oltram syndrome) /AS" +7 syndactyly, polydactyly, Hyphoscoliosis,

 eripheral +igns of !nfective ndocarditis

7 5ever, anemia,

*7 Clubbing  # usually three weeks after onset of endocarditis

97 Sub/conjunctival hemorrhage +7 <etechial rashes

67 Splinter hemorrhage under finger and toe nails

;7 2sler>s nodes # tender erythematous patches over pulp of fingers and toes

>7  ?aneway>s lesions # nontender erythematous patches over palms and soles

@7 Absence of any peripheral pulse

F7 +plenomegaly # usually three weeks after onset of endocarditis

7 =icroscopic hematuria 7 Arthralgia

+ital data

 "#amination of pulses

•  DefinitionN wave form transmitted along the arterial tree in a peripheral direction much

Ahead of the actual column of blood as a result of cardiac systole7

•  Arteries e#amined 7 superficial temporal *7 brachial 97 carotids +7 radial 67 femoral ;7 popliteal >7 dorsalis pedis @7 posterior tibial

• All pulses have to be compared on both sides simultaneously e!cepts carotids • 5ollowing points have to be noted

! rate

 @radycardia C 6 per

minute

Tachycardia  * $ minute

*! r"yt"m

• Rhythm may be regular or irregular7

• .he irregularity may be regularly irregular  or irregularly irregular 7

 Regularly irregular 

• Atrial tachyarrhythmias with fi!ed block • entricular bigemini, bid gemeni

• Sinus arrhythmia  !rregularly irregular

• ?ctppics # atrial$ ventricular  • Atrial fibrillation

-! volume

i7  small volume pulse (4ypokinetic pulse)

• Small weak pulse/ small volume and narrow pulse pressure • Causes

o ardiac failure o Shock

o 8ow cardiac output due to

o alvular heart disease # =itral $ aortic stenosis o =yocardial disease

o <ericardial disease

ii7 large volume pulse (hyperkinetic pulse)

• A high volume pulse with rapid rise # large volume and wide

 pulse pressure

• Causes

o 4igh output states/ pregnancyI fever, anemia,

thyroto!icosis, beri beri, paget-s disease

o =itral regurgitation o entricular septal defect o Systolic hypertension o Aortic regurgitation o <"A

.! c"aracter

a7 Colla#si$) #ulse (water hammer pulse, orrigan-s pulse)

• 8arge volume pulse with rapid upstro)e* a rapid down stro)e7

• est felt in radial or brachial 

 Rapid upstro)e

4igh systolic pressure and increased stroke volume

 Rapid down  stro)e

"ue to very low diastolic pressure and rapid run off to periphery7

True colla#si$) #ulse Pseudo colla#si$) #ilse

 0eature "iastolic < C <ulse prsr "iastolic <  <ulse prsr  Condition

 s

Aortic regurgitation, <"A, A fistula, aorto/pulmonary window, rupture of sinus of valsalva

Severe =R & large S"

2! Pulsus 2is&eria$s ( bis # * ferire # to beat )

• %t is double peaking pulse both pea)s in systole • est felt in carotid

• Causes / pure aortic regurgitation, aortic stenous and regurgitation,

hypertrophic cardio myopathy

•  -planation

• st peak represent force of left ventricular contraction transmitted via aortic

valve & *nd _{peak is due to actual ejection of blood}

• st peak is due to sudden ejection of large volume of blood & *nd peak due to

elastic recoil of aorta

• At the peak rate of flow there is a ernoulli ?ffect on the valves on the

ascending aorta causing a sudden fall in pressure on the inner side of aortic wall

• %n 40= initially there is no obstruction outflow, obstruction appears late

in systole as mitral valve begins to appro!imate the hypertrophied septal area7 .here is a sharp drop in pressure followed by sudden rise to overcome the obstruction

c! Dicrotic #ulse

• "ouble peaking pulse but one pea) in systole * other pea) in diastole7 • est felt in carotids

• auses #85, typhoid, dilated cardiomyopathy, cardiac tamponade • ?!planation

A combination of very low stroke volume and decrease peripheral assistance  produces this type of pulse

d! Pulsus alter$a$s

•  Def N %t is the alteration of the strength of the pulse sensed by palpation in

the absence of arrhythmia or of a significant variation in interval between  beats7 Rhythm is regular 

• est felt in radial or femoral artery

• Causes / severe 85, beat following premature ventricular beat

e! Pulsus 2i)emi$us

• %t is an irregular rhythm, a normal beat is followed by a premature beat and a

compensatory pause, resulting in alternation of the strength of the pulse7

• %t is the sign of digitalis to-icity

&! Pulsus #arado<us

•  Def N %t is an e!aggeration of normal physiological reduction in strength in

arterial pulse during inspiration

 =ormal fall in less than  mm $ hg during

:uite inspiration

 ulsus  parado-us

=ore than 

• Causes / cardiac tamponade, constrictive pericarditis, acute severe asthma

67 whether all peripheral pulses are felt

;7 Radio/ 5emoral delay/ Lve in oarctation of Aorta

 $lood pressure

• < shd be recorded in right upper limb$ all four limbs if indicated

• if atrial fibrillation is present < shd be recorded 9 times & average taken

• in aortic regurgitation the phase four (muffling phase) of koratoff sounds

shd be taken as diastolic pressure even though koratoff sounds are heard till 

• in aortic regurgitation with significant associated aortic stenosis, there will

 be systolic decapitation ie systolic pressure will not be very high

o thus when systolic < is > mm4g in a patient with AR

associated significant AS is unlikely

o similarly "iastolic <  + mm4g rules out significant aortic

stenosis

o eg in pure (R the @ will be 49989 mm hg  and in AR associated

with significant (+ the @ will be 679 8 A9 mm 8 hg 

 "#amination of neck veins

• Right internal jugular vein is used to assess pressure & wave forms as it is

in line with right atrium

• %nspect the jugular veins in between the two heads of sternomastoid • <atient shd b inclined at +6 degree to the ground

• =easure the upper level of jugular pulsation from the sternal angle using *

scales

 %u!ular pulse Carotid pulse

 Laterally placed =edially placed

 @etter visible etter felt

aries with posture & respiration 2o variation * waves in each cardiac cycle  wave

<redominantly inward

movement <redominately outwardmovement =ade more prominent with

abdominal compression

 2o effect

0bscured by pressure over root

of neck  2o obscure

E<ami$atio$ o& Cardiovascular System INSPECTION

7 hest wall symmetry *7 "eformities of chest wall

o +ternum # pectus e!cavatum, pectus carinatum o Costal cartilages #costochondritis

o +pine # kyphosis, scoliosis, ankylosing spondylitis, straight back

syndrome

97 <osition of trachea & A%

+7 <recordial bulge M presence of rt ventricular hypertrophy since childhood 67  ulsations over precordium/

look for pulsations over

i7 mitral area (apical impulse)

ii7  suprasternal area / Aortic regurgitation, aortic arch aneurysm,

coarctation of aorta, high output states/ pregnancy, fever, thyroto!icosis, anemia

iii7aortic / hronic aortic regurgitation, Ascending aorta aneurysm

iv7 pulmonary / <ulmonary artery dilatation, <ulmonary hypertension,

%ncreased pulmonary blood flow/ AS", S", <"A, 4igh output states

v7 left parasternal  (parasternal heave)

%t can be due to right ventricular hypertrophy$ left atrial enlargement (Also refer Eparasternal heaveO under palpitation)

 !ll sustained pulsations Shunt lesions/ AS", S"

+ustained pulsations <ulmonary 4. of any cause, <S

vi7 ?pigastric/ Right ventricular hypertrophy, Aortic aneurysm,

8iver pulsations/ tricuspid regurgitation, tricuspid stenosis, aortic regurgitation

vii7 back/ inter & infra scapular pulsations # oarctation of aorta PALPATION

7 onfirm inspectory findings *! A#ical im#ulse

o "efN lower most outermost point of definite cardiac impulse with a ma!imum thrust to

the palpating finger 

o  2ormally felt in 6th left intercostal space P O medial to midclavicular line o inspection in sitting position

o Character has to be assessed in 8eft 8ateral position

o Causes # de!trocardia (present in right 6th %S), thick chest wall,

<ericardial effusion behind the ribs,

?mphysematous chest, left sides <leural effusion Ty#es o& AI descri#tio$ disorders

Tapping <alpable S =itral stenosis

 3eaving %ncrease in amplitude &

duration of the lift <ressure overload conditionslike systemic hypertension, aortic stenosis

 3yperdynamic "uration of lift increased

amplitude is normal7 <ulsations in  %S

olume overload of left ventricle/ mitral& aortic regurgitation, S", <"A

97 S"oc,s (palpable e:ivalentsof heart sounds)

<alpate for any sound in aortic, <ulmonary, Apical (mitral) area

+ite +hoc) Cause

Aortic ejection click ongenital valvular AS, aortic root dilatation

Pulmo$ary

area <* Q<ulmonary ejection click <ulmonary 4.<ulmonary valve stenosis &  pulmonary artery dilatation A#ical area SQQQQQ 0pening snap Q S9 QQ S+ QQ7 =S =S "= 40= .! Paraster$al "eave

o ase of hand is used to feel heaves

o 1rading of parasternal impulse (A%%=S grading)

% isible but not palpable

%% isible ,palpable, obliterated by  pressure

%%% isible ,palpable, not obliterated by  pressure

Causes

i7  Right ventricular enlargement  / due to pressure overload $ volume overload

C"aracter Cli$ical co$ditio$

$olume overload 5ast, ill / sustained 8eft to right shunts # AS", S"  ressure overload  Slow, sustained <S

ii1 Left atrial enlargement

=itral stenosis

=itral regurgitation/ in sever cases aneurismal dilatation of left atrium is seen

/! T"rills

o <alpate for any thrill over precordium & carotids o ase of fingers are used to feel thrills

 Mitral area

"iastolic thrillQ77

Systolic thrillQQ =itral stenosis=itral regurgitation

 ulmonary area

ontinuous thrillQ

Systolic thrillQQ <"A, Rupture of sinus of alsalva<ulmonary stenosis, S", <"A

 (ortic area

"iastolic thrillQ77 Systolic thrillQ77

Acute severe AR due to eversion $ infection $ perforation of the valve Aortic stenosis

Carotid thrill

Systolic thrill (carotid Shrudder)

Aortic stenosis

 Left lower parasternal area .rd  _{* A}th _!C+/

S"

PERC;SSION

• ;seful to detect

o dilatation of aorta / aneurysm of aorta

o dilatation of pulmonary artery # idiopathic, pulmonary 4.

o  position & enlargement of heart / <ericardial effusion, ardiomyopathy

 ercuss for

o Right cardiac border o 8eft cardiac border 

A;SC;LTATION

61 (ll areas systematically in following order

7 mitral (cardiac ape!)

97 second aortic$ erb-s area (9rd _{left %S close to sternum)}

+7 pulmonary (*nd _{8eft %S close to sternum)}

67 aortic area (*nd _{Right %S close to sternum)}

41 Concentrate

7 5irst on heart sounds esp to loudness

=uch attention to S* # loudness, split (physiological $ pathological) in  pulmonary & aortic area

*7 then on added sounds like opening snaps 97 lastly for murmurs

1 auscultate for murmurs over peripheral arteries #esp femoral & carotids

 @etter heard with bell 

+, +A, Mid# diastolic murmur, venous hum

=etter "eard :it"

dia#"ra)m S, S*, licks, 0pening snap, Systolic murmur,early diastolic murmur, pericardial rub

! 0eart sou$ds

%n diseased state following abnormalities can occur  a1 Differing intensity/ increased $ decreased b1 (bnormal split  is heard

c1 8ow fre:uency sound in diastole/ +, +A may be heard  d1 (dditional high pitched sounds may be heard

5eatures of heart sounds

S S* S- S. Cause losure of mitral and tricuspid valve losure of

semilunar valve %nitial passive filling of ventricles

 hysiological/ healthy

young adults, atheletes,  pregnancy  athological / 85, =R, AS", S", <"A Rapid emptying of  blood into noncompliant ventricle / ischemic heart disease, systemic 4.

 3eard best at  Ape! ase =itral area in left

lateral position with in left lateral positionwith bell of steth +;

 bell of steth  osition in cardiac cycle %mmediately  precedes A% %mmediately  precedes carotid pulse wave 5ollows A% 5ollows carotid  pulse wave

oincide with onset of  period of rapid

ventricular filling

'hen bolus of blood is delivered to

ventricle by

contraction of the atrium (atrial systole)

2ther

characteristic  features

ElubO in Elub/

dupO EdubO in lub/dupOnormally split/ A* <* (9 ms)

8ow pitched sound 8ow pitched sound 4eard only in  presence of sinus

rhythm

.hird heart sound

 

 

S S* S9 S 5ourth heart sound

@ 

@ 

S S* S+ S

Alteratio$s i$ "eart sou$ds

First "eart sou$d

 !ntensity of +6

 Loud +6 ?!ercise, hyperdynamic circulation, sinus tachycardia, =S, AS" +oft +6 Acute =%, myocarditis, Sinus bradycardia, =R 

+6in mitral stenosis

Causes o& loud S I$ MS

o 0pen mitral valve till end of

diastole

o "elayed mitral valve closure o =itral valve closure at higher

 pressure of the atrium

o .hickened but mobile mitral valve

So&t S i$ MS

o Calcified M$ 

o Severe sub valvalular 

fusion

o Asso7 =R  o Asso7AR 

Seco$d "eart sou$d

oncentrate on split & intensity of the * components

• S* in aortic valve disease

Aortic ste$osis

 !ncreased intensity =on calcified  congenital AS

 =ormal intensity 4ypertrophic cardiomyopathy, sub valvular stenosis  Decreased intensity Calcified bicuspid aortic valve disease, rheumatic

stenosis, aortic valve sclerosis in old age

*! Aortic re)ur)itatio$ ( varies depending on etiology, 8 function, asso7 8esions,

 L2;D Syphilis, marfan-s , rheumatoid arthritis,annuloaortic ectasia,

(conditions producing aortic root dilatation)

+20T  Rheumatic etiology, asso7 Aortic stenosis,infective endocarditis

•  (bnormalities of split   hysiology of split +4

•  =ormally +4 is split into 4 components during inspiration & is single in e!piration

?!piration %nspiration

 





T

S S* S A* <*

•  ostponing of 4: During inspiration, due to #ve intrathoracic pressure the venous return

to heart increases which increases rt ventricular stroke volume prolonging R ejection7This  postpones 4 of +4

• <reponing of AN At same time venous return to 8 is reduced7 .he reduced 8 stroke

volume shortens 8 ejection7This prepones (4

 (bnormalities

Si$)le S*

tetrology of fallot, tricuspid atresia, tricuspid arteriosus, transposition of great arteries

severe calcified AS severe <S

elsenmenger S" :ide 9 &i<ed S*

AS"

<artial anomalous pulmonary venous connection, right ventricular diseases,

massive acute pulmonary embolism

 @asis for wide * fi-ed split in (+D

• .he increase in R stroke volume (due to 8eft to Right shunt at Atrial level) causes

wide split +41

• .he right & left ventricular stroke volumes vary in the same way during the respiratory

cycle (because the right and left atria are in free communication) resulting in fi-ed split 

?!piration %nspiration









S A* <* S A* <*

reversed s#lit S*

hypertrophic obstructive cardiomyopathy, left bundle branch block,

severe systemic 4., large <"A, severe AR  ?!piration %nspiration





 



Added sou$ds

S-• ombination of tachycardia and loud S9 gives a characteristic cadence to

the heart sounds described as gallop rhythm $ triple rhythm

• %n any clinical setting presence of S9 indicates abnormal 8 filling with

high end diastolic pressure ii! S. (refer table above)

iii! O#e$i$) s$a#

•  3igh pitched sound 

• 4eard all over precordium

• est heard with diaphragm Bust Medial to the (pe-• ?asily mistaken for split S*

• Accentuated by e!ercise & 'idens on standing

• <ersists despite atrial fibrillation & even after mitral valvulotomy

• 0ccurs in MS when the stenosed valve moves forward towards the left

ventricle at the beginning of systole

• Absent in =S in the following conditions

o mild =S

o  alcified $ markedly 5ibrosed valve o Associated significant =R

 Mechanism:

.he sound is due to sudden $ sharp tensing of the cusps of the mitral valve as it tries to open during early diastole, when the left Atrial pressure  left ventricle pressure

iv! EBectio$ clic,s

• 4igh pitched sounds closely following +6 • "ue to opening of semilunar valves

• =imic the split S • .ypes

*7 aortic ejection click (?) 97 pulmonary ?

+7 mid systolic click

Cause Character Clinical conditions

 Aortic "C  Abnormality of

aortic valve cusps  best heard at ape!'ell heard thru out precordium, ongenital AS # bicuspidaortic valve

 Pulmonar   y "C

Abnormality of

 pulmonary valve 4eard at pulmonary area2nly right sided event that

ommonly invalvular + 

Also in dilatation of

cusps becomes softer on inspiration but loud * sharp on e-piration

 pulmonary artery due to

idiopathic nature $  pulmonary 4.

 &id systolic click

arise from halting of mitral leaflet as it prolapses into the left atrium during systole

• 8oud clicks occurring in mid

systole in association with =<

• =imics S9 but differentiated

 by its high fre:uency (S9 is of low fre:uency)

• 8ate systolic murmur

(sometimes absent)

=itral valve prolapse (=<)

Also in .ricuspid vale  prolapse, aneurysm of

interatrial $ interventricular septum, Severe AR 

v7 Pericardial ru2

• haracter / Scratching $ grating $ creaking

• .riphasic (mid systolic, mid diastolic & presystollic) • ?vanescent, vary with time & posture

• est heard # along left sternal edge in 9rd & +th spaces • 4eard in

7 pericarditis # viral $ pyogenic $ tuberculous *7 acute =%

97 acute rheumatic fever & rheumatoid arthritis

• =echanismN <roduced due to sliding of the * inflamed layers of

 pericardium vi! Pericardial ,$oc,

• 8oud, 4igh fre:uency diastolic sound • 4eard in constrictive pericarditis

• <roduced due to abrupt halt of early diastolic filling

Murmurs

•  Def N relatively prolonged series of auditory vibrations of variable intensity, Uuality,

5re:uency due to turbulence arising when blood velocity increases due to increased flow via a constricted $ irregular orifice

•  =ote the following features

o Area over precordium where best heard, conduction o Systolic $ diastolic

o .iming & character, o %ntensity (grading)

• 1rading of S3S.08% murmurs (8ance & 5reeman-s grading)

 !  ery soft (heard in a :uiet room)

 !!  Soft

 !!!  =oderate

 !$  8oud with thrill

$  ery loud

$!  ery loud (heard even when

stethoscope is away from chest wall)

• 1rading of "%AS.08% murmurs (8ance & 5reeman-s grading)

 !  ery soft

 !!  Soft

 !!!  8oud

 !$  8oud with .hrill

o <itch

o etter heard with bell $ diaphragm

o ariation with respiration, posture, dynamic auscultation

Classification of murmurs

 Dia!nosis of the &D& (mid diastolic murmur)

•  Mitral stenosis (low pitched, rough, rumbling, 8ong drawn ="= with

 presystolic Accentuation ending in loud S with $ without 0pening snap, heard in left lateral position, @ell of the stethoscope reath held in  -piration/ Ty#e Causes +ystolic . from S to S*) 7 ?arly systolic Q7 *7 =id systolic Q777 97 8ate systolicQQ +7 <an systolicQQ7

S", acute severe .R, acute severe =R 

AS, <S, hypertrophic cardiomyopathy(40=) =itral alve <rolapse (=<), .<

=R, .R, S"  Diastolic 7 ?arly QQQQ7 *7 =id QQQQ777 97 8ate QQQQ77   (presystolic) AR, <R 

=S, .S (other rare causes given below)

=S, .S, Atrial my!omas, complete heart block

Continuous Refer below

 Differential dia!nosis of &D& 

7 Austin flint murmur 

*7 5low murmur in AS",S", <"A,

97 arey # oombs murmur ( soft, low# pitched MDM in (cute rheumatic mitral valvulitis usually Transient )

+7 8eft Atrial =y!omas 67 all valve thrombus

;7 .ricuspid stenosis (best heard in left sternal edge !ncreases in  !nspiration e-aggerated &a' wave in ?$ )

Comparison of  &itral 'tenosis *  Austin lint &urmur 

2pening snap <resent Absent

+ 8oud 2ormal

+ Absent <resent

 Left $entricular lift Absent ommon

 Right ventricular heave <resent Absent

 Rhthym Atrial 5ibrillation Sinus rhythm

 alpitation ommon Kncommon

 3emoptysis ommon Kncommon

Thrill ommon Kncommon

 eripheral signs of (R Absent <resent

 Dia!nosis of pan systolic murmur 

• =itral regurgitation

%t is a high pitched, Soft, an systolic murmur , well heard in the mitral area, in

left lateral position with diaphragm, breath held in e!piration conducted to a!illa & back7

o .he conduction of the murmur depends on the leaflet involved

 (nterior leaflet A!illa & back  osterior leaflet ase

 Differential dia!nosis of pan systolic murmur 

co$ditio$s

61 Tricuspid regurgitation

8eft lower strnal edge

%ncreases with inspiration Severe pulmonary4., pulsatile liver

41 $+D .Loud* harsh/

8eft 9rd _{& +}th _{%S .hrill}

 Dia!nosis of eection systolic murmur

• Aortic stenosis

Rough crescendo # decrescendo well heard in sitting position with breath held in e!piration conduction to carotids

 Differential dia!nosis of eection systolic murmur 

i7 4ypertrophic cardiomyopathy

ii7 Stenosis/ Sub/valvular aortic, Supra/valvular aortic, <ulmonary iii7 AS"

iv7 <ulmonary arterial hypertension v7 .hyroto!icosis

vi7  hysiological 

7 %nnocent systolic murmur, *7 Anemia,

97 <regnancy,

+7 chest wall deformity (pectus e!cavatum)

 Dia!nosis of "D& 

• A0R.% regurgitation/

 high pitched, blowing, decrescendo, early diastolic murmur, well heard in aortic area & ?rb-s area, patient sitting & leaning forward, breath held in

e!piration

Etiolo)y o& AR EDM %2est "eard' Rheumatic etiology 8eft *nd _%S

Aortic root dilatation Right *nd _%S

 Differential dia!nosis of early diastolic murmur 

 <ulmonary regurgitation (1raham # Steell murmur)

 !n case of a murmur better heard along rt side of sternum search for non# rheumatic etiology

onditions resulting in AR murmur best heard on right side of sternum i7 Aortic aneurysm # cystic medial necrosis, Syphilis, %diopathic,

=arfan-s

ii7 Sinus of alsalva aneurysm, iii7 Aortic dissection

Com#ariso$ o& AORTIC 9 P;LMONARY i$com#ete$ce

 eripheral  signs

<resent Absent

Chamber enlargement 

8eft ventricle Right ventricle

 (pical impulse

4yperdynamic 2ormal

 Murmur Right *nd %S &

?rbs area 8eft * nd _%S  Relation of respiration 0n e!piration 0n inspiration CONTIN;O;S murmur

• egins in systole, overlaps the S* & spills over to diastole for a variable period

generated by flow of blood from Jone of high resistance to a Jone of low resistance without interruption during both systole & diastole

•  Differentiated from +ystolico E diastolic murmurs and To * fro murmurs by

 prominent +41

Systolico( diastolic murmur To 9 Fro murmur

 Definition 0ccupies both systole & diastole but

the murmur occurs thru different channels and doesn-t peak around S*

0ccupies both systole and diastole but both

components originate across a single channel

+een in S" with AR/ systolic murmur

originates across S" & diastolic murmur across aortic valve

AS with ARI <S with <RI =S with =R 

 Differential dia!nosis of continuous murmur /

<"A, Aorto/ pulmonary window, Rupture of sinus of alsalva, Artereio venous (A) fistula, oronary A fistula,

Anomalous origin of 8eft oronary Artery from <ulmonary Artery (A8A<A), enous hum,

=ammary soufflV +ENO;S 0;M

• ontinuous ruit heard over neck veins due to increased velocity of flow 0R

diminished viscosity

• <atient # sitting position

• ell of steth used lightly etween the * heads of Sternomastoid • "isappears with compression of root of neck

• 0ccurs in Anemia, .hyroto!icosis, %ntracranial A fistula

E<ami$atio$ o& ot"er systems

 *'+ look for bilateral basal crackles

<leural effusion, 5, ronchiectasis, commonly on left side in =S

 Abdomen/ look for hepatosplenomegsaly, free fluid,in abdomen, 5, infective

endocarditis,

CN'+ look for any focal neurological deficit due to emboli in the form of stroke

Clinical dia!nosis of common cardiovascular diseases

! MITRAL STENOSIS

•  ulse 8ow volume with regular $ irregular rhythm, tapping in character  •  @  is normal

• <alpable <* with variable <arasternal heave • "iastolic thrill

• loud Swith $ without opening snap • mid diastolic murmur

o low pitched, rough, rumbling, 8ong drawn o  presystolic accentuation

o 4eard in left lateral position o ell of the stethoscope

o reath held in ?!piration

•  (ssessment of severity:

7 "uration of murmur N shorter the duration, less severe the stenosis

*7 A* # 0S interval N

Severe =S 76 # 7> sec =ild =S 7 # 7* sec 97 %ntensity doesn-t correlate with Severity +7 alve Area  2ormal 6 s:7 cm Asymptomatic *76 s:7 cm =ild 76 # *76 s:7 cm =oderate  # 76 Severe C  s:7 cm *! MITRAL REG;RGITATION

•  ulse / 2ormal $ large volume pulse with $ without A5 • 4yperdynamic (! # thrill rarely made out

• 8eft arasternal lift , • Soft S

• Audible S9,

• ?vidence of pulmonary 4. • <an systolic murmur

o 4igh pitched soft

o well heard in mitral area o in left lateral position o with diaphragm

o  breath held in e!piration o conducted to a!illa & back

• Assessment of dominant lesion in combined =S & =R 

 ositive signs  &itral 'tenosis &itral re!ur!itation

+6 8oud Soft

Thrill "iastolic Systolic

 (pical !mpulse .apping 4yperdynamic

+ Absent <resent

-! AORTIC STENOSIS Slow Rising pulse arotid thrill

S9 # heard all over aortic area S+ may be heard

Rough, crescendo/ decrescendo eBection systolic murmur 

est heard in sitting position reath held in e!piration onducted to the carotids

 (ssessment of severity

7 according to alve area

*7 according to S*

A* followed by <*  Mild

Single S*  Moderate

Reversed Split S* +evere

97 long drawn murmur with 8ate <eaking Msevere +7 presence of S+ & absence of A* M severe

.! AORTIC REG;RGITATION

•  eripheral signs of (ortic Regurgitation

7 lighthouse sign # alternate flushing & blanching of forehead

*7 landolfi-s sign # change in papillary siJe inaccordance to cardiac cycle and not related to light

97 de musset sign # head nodding with each heart beat +7 mullers sign # pulsatin uvula

67 :uinke sign # capillary pulsation ;7 orrigan sign # dancing carotids

>7 water hammer pulse # collapsing pulse

@7 pulsus bisferians # double peaking pulse, both peaks in systole F7 traube sign # pistol shot sound over femoral artery

+ s:7 cm  =ormal 

C 7>6 s:7 cm +evere

C 76 s:7 cm Critical 

7duroJeiJ sign / systolic murmur heard over femeral artery with pro!imal compression and diastolic murmer with distell compression

7 hill signs # popliteal cuff systolic < e!ceeds brachial cuff pressure by * mm4g

C * mm4g  =ormal 

* to + mm4g  Mild (R

+ to ; mm4g  Moderate (R

 ; mm4g +evere (R

*7osenbach sign # pulsatile liver  971rehadt sign/ pulsatile spleen

+7ecker sign # retinal arteriolar pulsation

• Cardiovascular findings • 8arge volume pulse

• 4igh Systolic < with very 8ow "iastolic < • 4yperdynamic Apical %mpulse

• 4eart sounds # Soft S L presence of S9 • ?"=

o high pitched, blowing, decrescendo, early diastolic murmur  o well heard in aortic area & ?rb-s area

o  patient sitting & leaning forward o  breath held in e!piration

•  (ssessment of severity

7 =arked peripheral signs *7 isferians pulse

97 4ill-s sign ; mmhg

+7 "uration of =urmur # occupying  *$9 rd of the "iastole 67 Austin flint murmur 

Assessment of dominant lesion in presence of combined AS & AR

 eripheral signs 8  slow rising pulse

<eripheral signs Slow rising pulse

 ulse pressure 'ide 2arrow +ystolic thrill in

 (ortic area

Absent <resent

 @ 4igh systolic < & low

diastolic < Systolic "ecapitation

/! +e$tricular Se#tal De&ect %+SD)

• <alpitation, "yspnoea on e!ertion, 5re:uent respiratory infections •  2ormal $ wide pulse pressure

• 4yperdynamic precordium with systolic thrill in left 9rd & +th %S • S & S* masked by murmur at the left sternal border

• 'ide split S* with variable attenuation of <* • S may be heard at the ape!

• <S= over left <ara sternal area, not conducted to a!illa • 5low ="= may be heard over ape!

Com#ariso$ o& murmurs o& MR TR 9 +SD

Features MR TR +SD

 @est heard Ape! .ricuspid area 8eft para/asternal area

Thrill Rare Absent ommon

Conduction A!ial and back 2ot conducted Absent

Character Soft blowing Soft blowing Rough harsh

 Relation to respiration

?!piration in lying

 position %nspiration in sitting Knrelated

 (ssociated  features 8 hypertrophy Soft S 8ow volume S9 R hypertrophy Signs of <ulmonary 4. ?levated G< # EvO iventricular hypertrophy Apical ="=

Sym#toms 9 si)$s o& 

ASD PDA Tetrolo)y o& Fallot

61 +ymptoms 1enerally

asymptomatic Symptomatic sincechildhood <alpitation, ?ffort

intolerance, 5re:uent chest

Symptomatic since

childhood, Ano!ic spells, "yspnoea on e!ertion, ?!ercise intolerance,