Clinmed - CVS PDF

CLINICAL MEDICINE Lecturer: Dr. Paul Lucas Batch 2025...

CLINICAL MEDICINE Lecturer: Dr. Paul Lucas Batch 2025 CVS ANATOMY Angina Pectoris - Exertional chest pain with radiation to PRECORDIUM the left side of the neck and down the left arm Aortic Dissection - sharp pain radiating into the back or The anterior surface of the chest overlying the heart and into the neck great vessels Pericarditis - Chest pain that improves when leaning Extends vertically from 2nd-5th ICS and transversely from forward the right border of sternum to the left midclavicular line o Base: corresponds to the right and left 2nd ICS close PALPITATION to the sternum An unpleasant awareness of the heartbeat o Apex: 5th L ICS at or within 1-2 cm medial to MCL or Described as skipping, racing, fluttering, pounding, or 7-9 cm lateral to MSL stopping of the heart BORDERS OF THE HEART Clues in the history include: RIGHT BORDER o Premature Contractions - Transient skips and o Extends from the upper border of 3rd costal cartilage flipflops o Paroxysmal Supraventricular Tachycardia - rapid 2cm lateral to its junction with the sternum to the 6th R regular beating of sudden onset and offset costochondral junction o Sinus Tachycardia - a rapid regular rate of less than Formed by the RIGHT ATRIUM 120 beats per minute, especially if starting and INFERIOR BORDER stopping more gradually o From the 6th Right costochondral junction to the 5th L ICS 1-2 cm medial to MCL SHORTNESS OF BREATH Formed by the RIGHT VENTRICLE May be reported as dyspnea, orthopnea, or paroxysmal LEFT BORDER nocturnal dyspnea o Extends from the apex to the 2nd left costal cartilage o Dyspnea - Uncomfortable awareness of breathing that 1-2cm to the left of its articulation with the sternum is inappropriate to a given level of exertion Formed by the LEFT VENTRICLE and o Orthopnea - Dyspnea that occurs when the patient is superiorly by the LEFT ATRIUM lying down and improves when the patient sits up § Quantified according to the number of pillows the patient CLINICAL VALVULAR AREAS uses for sleeping 2nd ICS right PSL - AORTIC § Suggests left ventricular heart failure or mitral stenosis 2nd ICS left PSL – PULMONIC o Paroxysmal Nocturnal Dyspnea - Describes as 4th-5th ICS left lower sternal border (left xiphisterna episodes of sudden dyspnea and orthopnea that junction) – TRICUSPID awaken the patient from sleep, usually 1 or 2 hours 5th left ICS 1-2cm medial to MCL - MITRAL after going to bed, prompting the patient to sit up, stand o Atrioventricular valves - Mitral, Tricuspid up, or go to a window for air o Semilunar valves - Aortic, Pulmonic Suggests left ventricular heart failure or mitral HEART SOUNDS stenosis and may be mimicked by nocturnal S1 - Closure of atrioventricular valves (M1, T1) asthma attacks S2 - Closure of semilunar valves (A2, P2) EDEMA S3 - Ventricular filling / gallop Accumulation of excessive fluid in the interstitial tissue S4 - Atrial filling spaces and appears as swelling COMMON OR CONCERNING SYMPTOMS Cause: congestive heart failure Chest Pain o others: nutritional (hypoalbuminemia), renal and liver Palpitations disease or maybe positional Shortness of breath, orthopnea, or paroxysmal dyspnea THE GENERAL PHYSICAL EXAMINATION Swelling or edema General appearance CHEST PAIN Age Posture Think through the range of possible cardiac, pulmonary, and extra thoracic etiologies Demeanor Overall health status Possible sources of chest pain o Myocardium Is the patient in pain or resting quietly, o Pericardium Dyspneic or diaphoretic? o Aorta o Trachea Does the patient choose to avoid certain o large bronchi Body positions to reduce or eliminate pain? o parietal pleura In case of o Esophagus pericarditis, o chest wall leaning o Other extra thoracic structures such as the neck, forward gallbladder, and stomach improve CV causes: symptoms o Angina Pectoris o Myocardial Infarction, Pericarditis o Dissecting Aortic Aneurysm OP CUTIE 1  TRANS: CVS shunting at the great vessel level (reversal of shunting) Malar telangiectasias Scleroderma with pulmonary hypertension Mitral stenosis Hemochromatosis Hereditary iron overload A common cause of restrictive cardiomyopathy Chronically ill-appearing emaciated patient Jaundice Causes: With advanced right heart failure and congestive o Long-standing heart failure or hepatomegaly or late-term "cardiac cirrhosis." another systemic disorder such as a Cutaneous ecchymoses malignancy Seen in patients taking vitamin K antagonists or antiplatelet Various genetic syndromes often with cardiovascular involvement Holt-Oram Syndrome Marfan Syndrome LIPID DISORDERS ASSOCIATED WITH CVS DISEASES Trisomy 21 (Down) Syndrome Xanthelasma – yellow growths on or near the eyelids Height and Weight o When deposits of cholesterol build up under the skin Height and weight should be measured Subcutaneous Xanthomas - particularly along the tendon BMI should be calculated sheaths or over the extensor surfaces of the extremities. Measure waist circumference and the waist to hip ratio Palmar Crease Xanthomas - specific for type III hyperlipoproteinemia Pseudoxanthoma Elasticum - a disease associated with premature atherosclerosis o Axilla and neck creases HEAD AND NECK SKIN CONDITIONS ASSOCIATED WITH CVS DISEASE Dentition and oral hygiene should be assessed in every Central cyanosis patient both as a source of potential infection and as an Significant right-to-left shunting at the level of the heart or index of general health lungs High-arched palate is a feature of Marfan syndrome and Peripheral cyanosis or acrocyanosis other connective tissue disease syndromes Bifid uvula - Loeys-Dietz syndrome Reduced extremity blood flow due to small vessel EVIDENCE OF CONGENITAL HEART DISEASE constriction Hypertelorism o Severe Heart Failure Low-set ears o Shock Micrognathia o Peripheral Vascular Blue sclerae - feature of osteogenesis imperfecta Disease FUNDUSCOPIC EXAMINATION Assess the microvasculature Atherosclerosis Hypertension Diabetes mellitus Suspected endocarditis Differential cyanosis CHEST isolated cyanosis affecting the lower but not the upper Midline sternotomy, left posterolateral thoracotomy, or extremities infraclavicular scars at the site of pacemaker/defibrillator o patient with a large patent ductus arteriosus (PDA) generator implantation secondary pulmonary hypertension with right-to-left to Prominent venous collateral pattern o Suggest subclavian or vena caval obstruction. OP CUTIE 2  TRANS: CVS Thoracic cage abnormalities - connective tissue disease § The finding of an elevated JVP implies a cardiovascular syndromes like Marfan Syndrome etiology o Pectus carinatum – “pigeon chest” o Pectus excavatum – “funnel chest” Arterial Bruit The presence of an arterial bruit over the abdomen suggests high-grade atherosclerotic disease, though precise localization is difficult. EXTREMITIES Clubbing Presence of central right-to-left shunting EVIDENCE OF OBSTRUCTIVE LUNG DISEASE Patients with endocarditis Barrel chest deformity - ↑ AP diameter Appearance can range from cyanosis and softening of the Tachypnea root of the nail bed, to the classic loss of the normal angle Pursed - lip breathing between the base of the nail and the skin Use of accessory muscles Loss of diamond-shaped window ANKYLOSING SPONDYLITIS Severe kyphosis and compensatory lumbar, pelvic, and knee flexion Should prompt careful auscultation for a murmur of aortic regurgitation (AR) Dilatation of aortic ring with valvular insufficiency Holt-Oram syndrome STRAIGHT BACK SYNDROME Unopposable, "fingerized" thumb Loss of the normal kyphosis of the thoracic spine Frequently associated with atrial septal defect Seen in MVP and its variants. Pulmonary artery may be compressed against the sternum → gradient across pulmonary outflow tract → ejection murmur Respiratory rate and pattern should be noted during spontaneous breathing o Depth o Audible wheezing o Stridor Lung examination can reveal adventitious sounds indicative of pulmonary edema, pneumonia, or pleuritis ABDOMEN The liver is frequently enlarged and tender in patients with chronic heart failure. Systolic pulsations over the liver signify severe tricuspid regurgitation (TR) Splenomegaly may be a feature of infective endocarditis Spleen is palpable 2 cm below left costal margin on deep Marfan syndrome inspiration Arachnodactyly “spider fingers” - abnormally long and Ascites slender fingers o Positive "wrist" sign (overlapping of the thumb and fifth o Advanced Chronic Right Heart Failure finger around the wrist) o Constrictive Pericarditis o Positive "thumb" sign (protrusion of the thumb beyond o Hepatic Cirrhosis the ulnar aspect of the hand when the fingers are o Intraperitoneal Malignancy clenched over the thumb in a fist) sign. OP CUTIE 3  TRANS: CVS o Marfan syndrome are usually associated with MVP Has been used to discriminate between high and low and aortic aneurysm central venous pressure (CVP) o Mnemonic: (MARfan – Mvp, AneuRysm) ENDOCARDITIS LESIONS Venous pressure Janeway lesions The vertical distance between the top of the jugular venous pulsation and the sternal inflection point (angle of Louis) Nontender, slightly raised hemorrhages on the palms and soles A distance >4.5 cm at 30°elevation is considered abnormal. Osler's nodes Tender, raised nodules on the pads of the fingers or toes Splinter hemorrhages Linear petechiae in the mid position of the nail bed o MNEMONICS: JANEWAY – PAIN AWAY OSLER – “OUCH”LER AN ELEVATED JVP Presacral edema in the setting of an elevated JVP Prognostic significance in patients with both symptomatic Volume overload and may be a feature of chronic heart heart failure and asymptomatic left ventricular systolic failure or constrictive pericarditis. dysfunction. Lower extremity edema in the absence of jugular venous Associated with a higher risk of subsequent hospitalization hypertension for heart failure, death from heart failure, or both. Lymphatic or venous obstruction A distance >4.5 cm at 30°elevation is considered abnormal. Venous insufficiency THE JUGULAR VENOUS PULSE WAVES Pitting edema can also be seen in patients who use dihydropyridine calcium channel blockers. Muscular atrophy or the absence of hair along an extremity Severe arterial insufficiency or a primary neuromuscular disorder. CARDIOVASCULAR EXAMINATION JUGULAR VENOUS PRESSURE AND WAVE FORM Jugular venous pressure The single most important bedside measurement from which to estimate the volume status Internal jugular vein Preferred because the external jugular vein is valved and not directly in line with the superior vena cava and right atrium. External jugular vein OP CUTIE 4  TRANS: CVS o A - Atrial contraction (RA) Associated with o C - Closure of tricuspid valve (bulging of tricuspid valve o Constrictive Pericarditis with ventricular contraction) o Restrictive Cardiomyopathy o X- atrial relaXation o Massive Pulmonary Embolism o V – Villing (filling) of RA (blood from Vena cava) o Right Ventricular Infarction o Y – atrial emptYing with opening of tricuspid valve o Advanced Left Ventricular Systolic Heart Failure. A WAVE Normally, the venous pressure should fall by at least 3 Prominent a wave - Seen in reduced right ventricular mmHg with inspiration compliance Y DESCENT o Cannon a wave occurs with atrioventricular (AV) Follows the peak of the v wave dissociation and right atrial contraction against a Can become prolonged or blunted with obstruction to closed tricuspid valve. right ventricular inflow, as may occur with tricuspid o Seen also in wide ventricular tachycardia stenosis (TS) or pericardial tamponade. Not present with atrial fibrillation Pulsation X DESCENT Defines the fall in right atrial pressure after inscription of the a wave After atrial contraction there will be release of blood to the right ventricle, so when there is relaxation of the atrium there will now backflow of blood from the jugular vein going back to right atrium There will be now decrease in pressure and at the same time, blood flows in the right ventricle C WAVE Interrupts this x descent and is followed by a further descent. It happens when there is closure of the tricuspid valve ABDOMINOJUGULAR REFLEX and start of right ventricular contraction, so when right Elicited with firm and consistent pressure over the upper ventricular contracts there will now be an increase in the portion of the abdomen preferably over the right upper pressure and pushes the tricuspid valve to the right atrium quadrant, for at least 10 s. It creates pressure going now to the jugular vein Positive response: sustained rise of more than 3 cm in JVP V WAVE for at least 15 s after release of the hand. Useful in predicting a pulmonary artery wedge pressure in Represents atrial filling (atrial diastole) excess of 15 mmHg in patients with heart failure. Occurs during ventricular systole. ASSESSMENT OF BLOOD PRESSURE The height of the v wave is determined by o Right atrial compliance Accurate measurement depends on o Volume of blood returning to the right atrium either o Body position antegrade from the cava or retrograde through an o Arm size incompetent tricuspid valve o Time of measurement o Place of measurement In Tricuspid Regurgitation o Device The v wave is accentuated o Device size The subsequent fall in pressure (y descent) is rapid o Technique With progressive degrees of TR, the v wave merges with o Examiner the c wave (cv wave) Blood pressure is best measured The right atrial and jugular vein waveforms become o In the seated position "ventricularized.“ o With the arm at the level of the heart o Using an appropriately sized cuff o After 5–10 min of relaxation When it is measured in the supine position, the arm should be raised to bring it to the level of the mid-right atrium. The length and width of the blood pressure cuff bladder should be 80% and 40% of the arm's circumference, respectively. Common source of error in practice KUSSMAUL SIGN Using an inappropriately small cuff resulting in marked Defined by either a rise or a lack of fall of the JVP with Overestimation of true blood pressure inspiration OP CUTIE 5  TRANS: CVS Inappropriately Large cuff, resulting in Underestimation of BP MEASUREMENT true blood pressure Blood pressure should be measured in both arms, and the § Solution: use appropriately sized BP cuff difference should be less than 10 mmHg. § MNEMONICS: SOLUtion: Small – Overestimate Large – A blood pressure differential that exceeds this threshold Underestimate may be associated with o Atherosclerotic Or Inflammatory o Subclavian Artery Disease o Supravalvular Aortic Stenosis § Higher BP on right due to streaming of jet straight up along ascending aorta towards brachiocephalic artery o Aortic Coarctation o Aortic Dissection Systolic leg pressures are usually as much as 20 mmHg higher than systolic arm pressures. The cuff should be inflated to 30mmHg above the expected systolic pressure and the pressure released at a rate of 2–3 mmHg/s. Systolic and diastolic pressures are defined by the first and fifth Korotkoff sounds, respectively. Greater leg–arm pressure differences o Chronic severe AR extensive and calcified lower extremity peripheral arterial disease. The ankle-brachial index o Lower pressure in the dorsalis pedis or posterior tibial artery divided by the higher of the two brachial artery pressures o Powerful predictor of long-term cardiovascular mortality The blood pressure measured in an office or hospital setting may not accurately reflect the pressure in other venues. “WHITE COAT HYPERTENSION" At least 3 separate clinic-based & at least 2 non-clinic- based measurements 20 mmhg or in diastolic pressure >10 mmhg in response to assumption of the upright posture from a supine position within 3 min. Common cause of postural lightheadedness/syncope Exacerbated by advanced age, dehydration, certain meds, food, deconditioning, and ambient temperature ARTERIAL PULSE The carotid artery pulse occurs just after the ascending aortic pulse. Character and contour of the arterial pulse depend on the: o Stroke Volume o Ejection Velocity OP CUTIE 6  TRANS: CVS o Vascular Compliance Described in patients with hypertrophic obstructive o Systemic Vascular Resistance. cardiomyopathy (HOCM) Best appreciated at the carotid level o HOCM: bifid pulse with Normal: predominantly monophasic two systolic peaks. The second peak (tidal wave has lower amplitude than the initial percussion wave) Easily appreciated in patients on Abnormalities of pulses: intra-aortic balloon counter o A weak and delayed pulse (pulsus parvus et tardus) pulsation (IABP), in whom defines severe aortic stenosis (AS). the second pulse is diastolic in timing o IABP or Sepsis: bifid pulse with systolic a and diastolic peak PULSUS PARADOXUS A fall in systolic pressure >10 mmHg with inspiration AORTIC PULSE Seen in patients with: Best appreciated in the epigastrium o pericardial tamponade Just above the level of the umbilicus o massive pulmonary embolism PERIPHERAL ARTERIAL PULSES o hemorrhagic shock Subclavian, brachial, radial, ulnar, femoral, popliteal, o severe obstructive lung disease dorsalis pedis, and posterior tibial o tension pneumothorax o In patients in whom the diagnosis of either temporal First Korotkoff sound heard only at expiration + First arteritis or polymyalgia rheumatica is suspected, the Korotkoff sound heard both on expiration and inspiration temporal arteries also should be examined. (118-92 = 26mmHg) o Although one of the two pedal pulses may not be PULSUS ALTERNANS palpable in up to 10% of normal subjects, the pair Defined by beat-to-beat variability of pulse amplitude. should be symmetric. Present only when every other phase i korotkoff sound is The pulses should be examined for their: audible as the cuff pressure is lowered slowly o Symmetry Typically, in a patient with a regular heart rhythm o Volume Independent of the respiratory cycle. o Timing Seen in severe left ventricular systolic heart failure o Contour AUSCULTATION o Amplitude Auscultation for carotid, subclavian, abdominal aortic, and o Duration femoral artery bruits should be routine. Simultaneous auscultation of the heart can help identify a Cervical bruit = weak indicator of the degree of carotid delay in the arrival of an arterial pulse artery stenosis; The carotid upstrokes should never be examined o The absence of a bruit does not exclude the presence simultaneously or before listening for a bruit. of significant luminal obstruction Light pressure should always be used to avoid precipitation The likelihood of significant lower extremity peripheral of carotid hypersensitivity syndrome and syncope in a arterial disease increases with presence of: susceptible elderly individual. o Claudication PULSE IN AORTIC REGURGITATION o Cool skin With chronic severe AR, the carotid upstroke has a sharp o Abnormalities on pulse examination rise and rapid fall-off (Corrigan's or water-hammer pulse). o Presence of a vascular bruit Some patients with advanced ABNORMAL PULSE OXIMETRY AR may have a bifid or A >2% difference between finger and toe oxygen bisferiens pulse, in which two saturation) systolic peaks can be Used to detect lower extremity peripheral arterial disease appreciated. Comparable in its performance characteristics to the ankle brachial index. INSPECTION AND PALPATION OF THE HEART BIFID PULSE OP CUTIE 7  TRANS: CVS o Pressure overload of the left ventricle (e.g., aortic stenosis) o Volume overload of the left ventricle (e.g., mitral regurgitation). Sustained, high-amplitude impulse (normally located): left ventricular hypertrophy from pressure overload (ex. hypertension) Sustained high amplitude impulse displaced laterally: volume overload Sustained low-amplitude (hypokinetic) impulse: dilated cardiomyopathy. Palpable presystolic impulse (S4) Corresponds to the fourth heart sound (S4) The left ventricular apex beat may be visible in the Indicative of reduced left ventricular compliance and the midclavicular line at the fifth intercostal space in thin- forceful contribution of atrial contraction to ventricular filling. chested adults. Palpable third sound (S3) Visible pulsations anywhere other than this expected Indicative of a rapid early filling wave in patients with heart location are abnormal. failure The left anterior chest wall may heave in patients with an May be present even when the gallop itself is not audible. enlarged or hyperdynamic left or right ventricle. RIGHT VENTRICLE A visible right upper parasternal pulsation may be suggestive of Marked increase in amplitude with little or no change in ascending aortic aneurysm duration: chronic volume overload of the right ventricle disease. (atrial septal defect) o Thrill: palpable heart Impulse with increased amplitude and duration: pressure murmur felt as a 'shudder' overload of the right ventricle (pulmonic stenosis or under the hand pulmonary hypertension) Best felt with distal Left 2nd Interspace—Pulmonic Area. palm Prominent pulsation accompanies dilatation or increased o Heave: thrusting sensation flow in the pulmonary artery often used to describe A palpable s2 suggests increased pressure in the large area and amplitude pulmonary artery (pulmonary hypertension) with sustained movement Right 2nd Interspace—Aortic Area PALPATION OF HEART Palpable S2 suggests systemic hypertension Pulsation suggests a dilated or aneurysmal aorta Thrills may accompany loud, harsh, or rumbling murmurs as in: o Aortic Stenosis o Patent Ductus Arteriosus o Ventricular Septal Defect o Mitral Stenosis LV IMPULSE Thrills are palpated more easily in patient positions that Less than 2 cm in diameter and moves quickly away from accentuate the murmur the fingers HEART SOUNDS Better appreciated at end expiration, with the heart closer Ventricular systole is defined by the interval between the to the anterior chest wall. first (S1) and second (S2) heart sounds Enlargement of the lv cavity is manifested by a leftward and The first heart sound (S1) includes mitral and tricuspid valve downward displacement of an enlarged apex beat. closure. APEX BEAT/ POINT OF MAXIMAL IMPULSE The apical impulse may be displaced upward and to the left by pregnancy or a high left diaphragm. Lateral displacement may be due to: o Cardiac enlargement in congestive heart failure o Cardiomyopathy o Ischemic heart disease o Displacement in deformities of the thorax o Mediastinal shift Dextrocardia—a heart situated on the right side The apical impulse is on the right. Situs inversus – the heart, stomach and liver are on the opposite side from normal. A right-sided heart with a normally placed liver and stomach is usually associated with congenital heart disease. NORMAL SOUNDS In the left lateral decubitus position, a diameter greater than S1 – Closure of MV and TV; loudest at apex 3 cm indicates left ventricular enlargement. S2 – Closure of AV and PV; loudest at base Increased amplitude may also reflect FIRST HEART SOUND (S1) o Hyperthyroidism The intensity of S1 is determined by o Severe anemia OP CUTIE 8  TRANS: CVS o The distance over which the anterior leaflet of the mitral valve must travel to return to its annular plane o Leaflet mobility, o Left ventricular contractility o PR interval SPLIT S1 Young patients Right bundle branch block Tricuspid valve closure is relatively delayed REVERSED OR PARADOXICAL SPLITTING Pathologic delay in aortic valve closure o Left bundle branch block o Right ventricular apical pacing o Severe AS o HOCM o Acute Myocardial Ischemia With reversed or paradoxical splitting, the individual components of S2 are audible at end expiration, and their interval narrows with inspiration THIRD HEART SOUND (S3) Occurs during the rapid filling phase of ventricular LOUD S1 diastole Early phases of rheumatic mitral stenosis Can be a normal finding in children, adolescents, and young Hyperkinetic circulatory states adults Short PR intervals In older patients, it signifies heart failure o PR interval: from the beginning of P wave until the A left-sided S3 is a low-pitched sound best heard over the beginning of QRS left ventricular (LV) apex. o