Introductory Clinical Skills Course Cardiovascular System

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Introductory Clinical Skills CourseCardiovascular
System

• Dr. Gerard Flaherty
• Lecturer in Medicine
• NUI, Galway

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For me, the only things of interest are those
linked to the heart (Audrey Hepburn)
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Presenting Complaint

• Chest pain
• Shortness of breath
• Ankle swelling
• Palpitations
• Syncope
• Intermittent claudication

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Chest Pain

• 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

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Causes of Chest Pain

• 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

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Acute Anteroseptal MI
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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

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Causes of Dyspnoea

• 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

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Pulmonary Oedema
Normal Chest Radiograph
Pulmonary Oedema
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Ankle Swelling

• 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

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Palpitations

• 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

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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)

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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

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Risk factors for Ischaemic Heart Disease

• Hyperlipidaemia
• Diabetes mellitus
• Smoking
• Hypertension
• Obesity
• Family history

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Past Medical History

• Rheumatic fever
• Previous cardiac investigations
• Previous myocardial infarction
• Coronary angioplasty stent insertion
• Coronary artery bypass grafting
• Pacemaker insertion

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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

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Social History

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

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Family History

• Ischaemic heart disease
• Angina
• MI
• CABG
• Hypertrophic obstructive cardiomyopathy
• Dilated cardiomyopathy

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HOCM
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Physical Examination

• General
• Hands
• Pulse
• Blood pressure
• Face
• Neck
• Jugular venous pressure

• Precordium
• Inspection
• Palpation
• Percussion
• Auscultation
• Back
• Abdomen
• Lower limbs
• Other

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Examination - General

• Position patient at 45 degrees
• Respiratory rate
• Cachexia
• Marfans syndrome
• Downs syndrome

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Did Abraham Lincoln have Marfans Syndrome?
High arched palate
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Examination - Hands

• Clubbing
• Splinter haemorrhages (infective endocarditis)
• Oslers nodes (tender)
• Janeway lesions (non-tender)
• Xanthomata (Hyperlipidaemia)

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Splinter Haemorrhages
Clubbing
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Examination - Pulse

• Radial artery
• Rate (normal 60-100)
• Bradycardia (lt60)
• Tachycardia (gt100)
• 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)

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Examination - Blood Pressure

• Sphygmomanometer
• Systolic/diastolic pressure
• Normal lt140/90 mmHg (lower in diabetes)
• Korotkoff sounds
• Use larger cuff width for large arms

• Deflate at 4 mmHg/s
• Difference between arms of lt10 mmHg
• Pulsus paradoxus exaggerated reduction in BP
  with inspiration (gt10 mmHg)
• Postural hypotension

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Examination Face and Neck

• Jaundice
• Xanthelasmata
• Corneal arcus
• Malar flush (mitral stenosis)
• High arched palate (Marfans syndrome)
• Dental caries (infective endocarditis)

• Central cyanosis
• Carotid pulse character
• Slow rising (AS)
• Bisferiens (AS AR)
• Collapsing (AR)
• Alternans (LVF)
• Jerky (HOCM)
• Carotid bruit

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Eye signs in Hyperlipidaemia
CORNEAL ARCUS
XANTHELASMATA
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Jugular Venous Pressure

• 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 gt3 cm above zero point
• RV failure
• RV infarct
• Tricuspid stenosis
• Tricuspid regurgitation
• Pericardial effusion
• SVC obstruction
• Fluid overload

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Precordium - Inspection

• Scars
• Median sternotomy
• CABG
• Valve replacement
• Lateral thoracotomy
• Infraclavicular (pacemaker)
• Pectus excavatum
• Pacemaker box
• Apex beat

Sternotomy scar
Pectus excavatum
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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

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Precordium AuscultationHeart Sounds

• Bell low pitched sounds
• Diaphragm high pitched sounds
• Mitral ? Tricuspid ? Pulmonary ? Aortic areas
• S1 (first heart sound)
• S2 Splitting (A2, P2)

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Abnormalities of Heart Sounds

• 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

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Precordium AuscultationMurmurs

• 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

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Heart Murmurs

• 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

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Examination Back

• Percuss and auscultate lung bases
• Left ventricular failure
• Pleural effusion
• Sacral pitting oedema
• Right heart failure

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Examination - Abdomen

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

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Examination Lower Limbs

• Peripheral oedema
• Pitting/non-pitting
• Upper level
• Achilles tendon xanthomata
• Capillary return
• Trophic skin changes

• Palpate arteries
• Femoral
• Popliteal
• Posterior tibial
• Dorsalis pedis
• Buergers test (peripheral vascular disease)

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Peripheral Pulses
Dorsalis pedis pulse
Posterior tibial pulse
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Examination - Other

• Urinalysis
• Haematuria (infective endocarditis)
• Fundi
• Hypertensive retinopathy
• Roth spots (infective endocarditis)
• Temperature chart
• Infective endocarditis

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THE END