Cardiology Sheet PDF - DR. Ahmed Khalifa

# Find Yourself to Be What You Want ## Cardiology ### Symptomatology **What to ask about (12) points** | Point | Question | |---|---| | (1) PVC | - Do you have shortness of breath? With exertion or at rest? <br> - Does it come suddenly and go away on its own by morning? <br> - How many pillows do...

# Find Yourself to Be What You Want ## Cardiology ### Symptomatology **What to ask about (12) points** | Point | Question | |---|---| | (1) PVC | - Do you have shortness of breath? With exertion or at rest? <br> - Does it come suddenly and go away on its own by morning? <br> - How many pillows do you use in bed? <br> - Do you get coughs? With exertion or unrelated? <br> - Did you cough out blood, any time? | | (2) SVC | - Are your legs swollen? <br> - Is your stomach distended? <br> - Do you have pain on the right side of your chest? | | (3) Cyanois | - Do you experience dizziness, blurred vision, or lightheadedness? <br> - Does your chest tighten and you need to rest? <br> - Did your lips or fingertips turn blue before? | | (5) Palpitations | - Do you feel your heart palpitations? | | (6) Chest Pain | - Do you feel a chest tightness like that? <br> - O, G, D, 1st, site, radiation, intensity, association, character | | (7) Pressure Manifest | - Is it hard for you to lay down or to sit up? <br> - Is it hard to speak or do you have a hoarse voice? <br> - Do you have any headaches? | | (8) Blood Pressure | - Is it hard for you to lay down or sit up? <br> - Is it hard to speak or do you have a hoarse voice? <br> - Do you have any headaches? | | (9) Fever | _O_, _C_, _D_, associated, Drug history) | | (10) Thromboembolic | | | (11) PVD | | | (12) Other System Affection | - Any other symptoms? | ## General Examination ### General Observation * **Well/Fair/Ill** * **Body Built:** *Average, under, or over average* * **Mentality:** *Average Mental Function* ### Pallor * **Oedema of Rt. side Heart Failure** ### Cyanois * **Central cyanois in Fallot’s tetrology** * **Peripheral cyanois in & COP** * **Differential cyanois in PDA** ### Jaundice * **Hepatocellulor Jaundice due to Hepatic congestion in patient with Rt. side heart Failure** ### Vital Signs * **Pulse, Bl. pressure, Respiratory rate, and Temperature** ### Special Decubitus * **Orthopenic in Hiside heart leison** ### Special Facies * **Maker Flash in Hitral stenosis (M.S)** ### Head and neck * **Malar Flush** * **Neck veins** * congested pulsating in congestive heart failure * congested non pulsating in pericardial effusion ## Upper Limb * **Nails:** * pale in SBE (subacute bacterial endocarditis) * blue in cyanosis * splinter haemorrhage in SBE * capillary pulsation in aortic regunge * **Oedema** ## Lower Limb * **Hill’s sign:** * Systolic Bl. pressure in L.L) * Bl. pressure in YiL = 60 mmHy (Normally, diff. is about = 10-20 mmity. ## Skin Examination ## Other System Examination * **Abdominal examination:** * **Liver:** enlarged and tender in Pt. Side HF * **Ascites:** in Rt. Side Heart Failure * **Chest examination:** * **Bilateral crepitation:** in Hiside heart failure ## Local Examination of the Heart (Inspection, palpation, percussion and auscultation) ### Patient Position * Expose the patient’s chest up to the umbilicus. * Examine from the patient’s Rt. side * Make sure that the patient is comfortable in this position. ### Inspection * **Shape of chest wall & chest** * **Dilated veins on chest walls** * **SVC obstruction:** * Tongue & peripheral cyanosis ### Scar of Previous Operation * 2 Scars: * **Median Sternotomy:** open heart surgery eg valve replacement * **Lateral thoractomy:** InFlamammary== mitral valvotomy ### Pericardial Pulge * It’s part of the heart muscle (RV) * **RV Enlargment since birth** * Most anterior chamber of the heart (RV) * **Pericardial Effusion** ### Pulsation For Difference Creation * **Mainly apical pulsation** * **Apex:** * **Definition:** outermost, lowermost palpable visible pulsation * **Site:** 5th intercostal space (MCL) * **Tips of Fingers while the patient in H. lateral position** ### Palpation * **Pulsation** * **Thrill** * **Palpable sounds** ### Area of Pulsation * **Suprasternal pulsation:** * cause: Corrigan pulse of AR * **Visible vigorous pulsation in carotid arteritis** ### Epigastric Pulsation * **RVE:** * by deep inspiration * **Hepatic:** * Liver is enlarged and tender * **Aorta:** * pulsation down to umbilicus * pulsation ### Aortic Area Pulsation * **Site:** Rt. 2nd ICs porasternal Line * **Cause:** Aortic aneurysm, hypertension ### Pulmonary Area Pulsation * **Site:** H. and ICS parasternal line * **Cause:** Pulmonary aneurysm, pulmonary HTN ### H. parasternal Area * **Cause:** Rt. Vent. Enlargement ### Apex * **Inspect:** palpate H. lateral position * **Commont:** * Site: 5th Ics Hcl It.) * Area: Normally, it’s localized = less one inch, one space * **Diffuse apex:** RVE * **Localized apex:** LVE * **Character:** * **Hyperdynamic: AR** * **Having sustained: ** AS * **Slapping apex:** MS * **Forsible apex:** * except hyperdynamic ### Thrill and Palpable Heart Sounds * **Diastolic Thrill:** MS * **Systolic Thrill:** HR ### 1st Heart Sound: MS ### Rate & Rhythm * **Normally:** regular and equal to radial pulse * **Irregular:** pulsus deficit er AF, c-out extrasystole ### Thrill * Flaps metacarpal bones ### H. parasternal Area * Base of Heart * **Systolic:** AS TPS * **Diastolic:** MS, AR ### Apex * **Systolic:** * outwards and lateral * Thrill & grade * Diastole: thrill is present * **Diastolic:** * Thrill is present * Systolic is absent ## Heart Heavy (Percussion) * **Heavy percussion (4-5cm depth), except bare area** * **Hepatic dullness:** * **Starts from 2nd & Et ICS by heavy percussion.** * **When reach the hepatic dullness, ask the patient to breath.** * **Upper border of the liver is normally in Rt. 5th ICS MCI** * **R border (Rt. 3rd ICS):** * percuss parallel to Rt. border of sternum * Normally, no dullness. * Dullness: RA enlargement or pericardial effusion * **Aortic Area:** * percuss and Rt. space from lateral to medial * Normally, it’s resonant * Dullness: Aortic aneurysm, syst. HTN * **Pulmonary Area:** * percuss and It. Space lateral to medial * Dullness: pulmonary HTN * **Wiast:** * percuss 3rd space It. * Dullness: LA enlargement * **Bare area of the area:** Retrosternal * Percuss lower 1/3 sternum by direct * Dullness: RVE ## Auscultation * **Heart Sounds:** S1, S2, S3, S4 * **Added** * Murmurs * Pericardial rubs ### Diaphragm * **Cone:** Rembling murmur, S3, S4 * 10 - 51, 52 (you will hear the heart valves) * 2 - put the phonendoscope in these four locations: Aortic, pulmonary, tricuspid and mitral ## Heart Sounds * **1st HS** * cause: valvular comp: closure of mitral and tricuspid valve * muscular comp: contraction of ventricle * **Accentuated S1** * MS, TS * **Systemic HTN** * due to muscular comp of filling * **Tachycardia** * diastolic time → ↓ * muscular comp of filling * closure of valves ## Weak S1 * **MR, TR** * **Myocardial diseases (due to muscular complication)** * **Bradycardia** * ↑ Diastolic time → better filling → closure from high position * **Calcified MS** * calcified MS = (Okik MS & Calcified double mitral disease (MS+MR) ## 2nd HS (Base of Heart) * **Cause:** Closure of Aortic and pulmonary valve * **S2** * Systemic HTN * Pulmonary HTN * Hyperdynamic circulat * **S2** * A2: AS, AR * P2: AS, PR * Hypopotension ### During Systole * Hiventricule Contract * opening of aortic valve ### During Diastole * Toward corta, aortic preasure increases * Closure of aortic valves ## Splitting of S2 * **When ventricle ejection phase continues until the pressure of pulmonary & aorta are decreased.** * S2 is bied in ventricle * **When aortic and pulm. valves close** * **Systole S1: Hiventricle:** 120mmtly * **Systole S2: Rt. ventricle:** 25 monthg * **Which valve closes first?** * Aortic valve (A2) * Pulmonary valve (P2) * **Side of hearing:** pulmonary arte area * **Inspiration:** venous return ↑ to Rt. side * **Course:** * pulmonary valve closes later * inspiration without splitting ## Closure of Pul Valve * 3 cases: * **Pulmonary stenosis (PS)** * Right BBB bundle branch block * VSD `ventricular septal defects` * **Wide splitting of S2:** * during systole * **Closure of Aortic valva:** * 3 cases * Aortic stenosis * R. BBB * PDA * **Paradox splitting** ## S3 * **Ventricle: to atrium** * **Normal velocity** * **Normal myocardium** * **What happened if:** * **Excess blood flow across normal or diseased valve** → S3 * **Normal blood flow on diseased myocardium →** S3 ### Causes * **ASD** * **VSD** * S3 on tricusp. area * S3 on mitral area ## S4 * **Def.: late diastolic sound heard just before S1** * **Mechanism:** * forceful atrial contraction against ventricular end diastolic pressure * **Causes:** * Tension overload leading ventricular hypertrophy * LV: systemic HTN, AS * RV: pulmonary HTN, PSilily * **Reduced compliance of ventricles:** MI, HOCM * **Added sounds** * Pericardial knock * Pericardial rub * Tumor plob * Metallic clicks * Valve prolapse clicks ## O.S * **All valves when they open don’t generate sound, and when they close, they generate sound.** * **mitral, tricusp:** → 1st HS * **Aortic, pulmonary, and Hs:** → opening of mitral valve * **In MS** → opening of mitral valve occurs sound called opening snap * **What does O.S indicate?** * **Mitral valve:** it indicates stenosis of mitral valve * **Is it still viable?** * Yes * If you hear this sound, it means the valve is still viable * **Where can you hear this sound?** * Isovolemetric Relax * M.S: you can hear this sound during auscultation * **Xiphisternums apex:** listen to the cone * **Importance of O.S:** * Valve is still viable = not calcified * Severity of MS ## EC (Ejection Click) * **Ejection click: sound when the valve opens.** * pulmonary valve, aortic * It should not be a sound when the valve closes. * **How to recognize EC?** * **EC sound occurs before S2.** * **When the sound is present and sounds like a split S2.** * ** What the EC sound indicates?** * **Organic.** * **PS or AS (aortic stenosis)** * **How to differentiate between S2 and EC?** * **Fallot’s tetetr.:** EC sound is present but S2 is absent. * **Why are EC sounds present in subvulvular PS?** * because PS causes obstruction before the valve closes. * **What are some other causes of EC?** * **Systemic and pul. HTN:** * the pulmonary valve is closed * pulmonary preassure ↑ * pul. HTN acts like a block * **Sclerosis:** ## Pericardial Knock * **Why is a Pericardial Knock present in S3?** * The blood flows from ventricles to atrium very quickly. * It is relaxed = comfortable * **In constrictive pericarditis:** the pericardium becomes fibrous tissue, making a catching effect on the ventricle. * **Relaxed No Diastole:** * ventricle * S3 is heard because of the speed of blood flow * It is the pericardial knock (Knock Logan) ### Pericardial Rub * **2 layers**: the scratch you hear is a sound from the 2 layers of pericardial * **Where is the sound heard**: anywhere on the heart * **Which sounds are heard**: monophasic, biphasic or triphasic ## Murmurs * ** Definition:** musical sound due to the passage of blood through stenotic or regurgitant valve ### Common Murmurs * **Timing**: * **Character**: * Soft: all regurgitant Murmur * Harsh: AS * Rembling murmur: MS * **Site and propagation**: * **Relation to position and respiration**: * **Associated thrill**: * **gradest**: * **Site of maximal intensity**: * Aortic stenosis: 1st nordia area * Aortic regurge: 2nd aortic area * **MS** * **Tricuspid stenosis & TR:** Tricuspid area * **MR:** mitral area * **AS:** aortic area * **Relation to Position:** * Mitral vulvopathy: H. kateral position * Aortic vulvopathy: lean forward * Tricuspid vulvopathy: respiration * **Associated with thrill**: * Stenotic murmur: harsh + marked thrill * regurge murmur -> soft + minimel thrill * **Grade**: * **Very faint** * **Faint** * **Moderate intensity e’out thrill ** * **Loud e’out thrill ** * **Very loud** * **Extremely loud** ## Diagnosis * **Aetological:** * **Rheumatic** * multivalvular + History of RF * **Congenital:** * since birth + other anomalies * **Ischaemic:** * **Degenerative:** * **Anatomical:** * **valve leison** → HF * **myocardium** → HF * **Pathological:** * **stenotic or regurgitant or double ** * **Functional:** * **Compansated** * no manifestation of HF * **Decompensated** * manifestations of HF * **Complicated by** * AF, arrhythmig * embolic manifestations eg hemiplegia, chest infection. e.g. Rheumatic HD, Double Mitral, It. side heart Failure complicated by AF.