Modified.Cardiovascular .Exam.pptx

Modified.Cardiovascular .Exam.pptx

1. Lecture v/s Teaching v/s Coaching Lecture It is a monologue It conveys information Lecturer is active - learner is passive Teaching It is a dialogue It conveys understanding Teacher and learner are both active Coaching Unlocking learner’s potential to maximize the performance during examination

2. To shift from passive clinical examination to a focused, inferential examination Coach you to perform three parallel tasks while doing physical examination Search for physical signs Understand how physical signs evolve Generate diagnostic hypothesis

3. Cardio Vascular Examination How to examine meaningfully Step I – History - Narrative - Interrogative Step II – Technical Necessities

4. Well or unwell Thriving well or not Dysmorphic features Resp. Distress + Harrison’s sulcus Cyanosis Scars of previous operations Down’s Turner’s Noonan’s Marfan’s Rubella Sy . Step III – Observe from bed end

5. Take both hands and look for clubbing, cyanosis, pallor Splinter hemorrhages Osler’s nodes Palmer creases Conjunctiva – pallor Ask to open mouth Tongue – central cyanosis Teeth – Dental health Step IV

6. What pulse denotes? Quickly feel both radials move swiftly to both brachials Lift Rt. Arm upwards while feeling pulse - look for collapsing pulse move to both femorals and dorsalis pedis Place index and middle finger in suprasternal notch for carotid pulsations and thrill Rate Rhythm Character Step V: Pulse examination

7. Inspection - Fullness, excessively prominent indicates long term cardiomegaly Visualise apex if visible Palpation place both palms on each side of chest to know apex position Dextrocardia , masocardia With Rt. hand on precordium look for area of MCI? Parastersal ? I ndicates Ventricular predominance Step VI: Look at precordium

8. Define apex accurately using sternal angle as guide (2 nd ICS) Normal – 5 th LICS on MCI → Rt. V. E. ͞ ↓ L.V.E. Heaving – pressure overload Hyperkinetic – Volume overload Appreciation of palpable H.S. Appreciation of palpable murmur (Thrill)

9. Take a pause and think of options Ask question – 1) Cong. or Acquired? Congenital 2) Cyanotic or Acyanotic ? 3) Shunt or no shunt? 4) Rt or Lt Ven -Dominance? 5) Cardiomegaly? Rheumatic 1) pulse ? Low Volume ? High Volume ? Collapsing 2) ?Palpable 1 st H.S. ? Palpable 2 nd H.S. 3) ? Thrill.

10. Step VIII - Auscultation Fix the sequence of auscultation of precordial area. Bell of stethoscope – low pitched sounds Diaphragm of stethoscope – High pitched sounds 1 st H.S. at apex 2 nd H.S. - pulmonary area Good at picking up Systolic murmurs but nervous about diastolic murmurs Characterise the murmur completely - Timing , site of maximum intensity, radiation intensity (Gr 1 to 6 Systolic, 1 to 4 for Diastolic), character - harsh / soft / rumbling / blowing

11. 3rd & 4th H. S. Clicks, Snaps, Rubs B. P. Abdomen- Hepatomegaly Pitting edema over shins Continuous Murmurs PDA, AV anastomosis, Collaterals Venous Hum

12. Systolic murmurs

13. Diastolic murmurs Do not get nervous Decrescendo early diastolic murmur: AR Mid diastolic flow murmur Large VSD Mid diastolic rumble at apex –AR (A-F) Diastolic with presystolic accentuation at apex – M.S.

14. What are prototypes of CRHD in exam? 1] A 9 yr old child, admitted with dyspnea on exertion for 6 months, suddenly develops resting dyspnea. Had vague pain in left knee followed by right ankle 2 weeks prior 2] patient – asymptomatic/ exertional dyspnea/ CHF/ palpitation/ high grade fever, admitted, but recovered with Rx 3] 12 year old child attending cardiac clinic regularly/ insidious onset of CHF/ cardiac symptoms of chest pain/ palpitation

15. What are anatomical categories of Rheumatic Valvular Heart Disease? Isolated MV disease - MS/MR Combined MV disease- MS + MR Combined Mitral and Aortic valve disease-MR+AR, MS+AR MS + Functional TR

16. What are structural alterations in chronic Mitral valve disease? Mitral Valve MS MR Valve leaflets, commissures Fused Not fused Chordae tendinae Thickened fused Retractile fibrosis of chordae Mitral annulus Normal Dilated

17. What are symptoms of CRVD? SYMPTOMS PATHOPHYSIOLOGY LESION Dyspnea -Pulmonary venous hypertension Interstitial edema Decreased lung compliance -Chronic MS -Acute MR - MS+ MR Orthopnea/PND -Supine position, sudden rise of pulmonary edema -Severe MS MR with LV failure Severe resting dyspnea - Pulmonary hypertension -Severe MS - MS with recurrence of ARF, CHF, pulmonary infection, AF PULMONARY SYMPTOMS:

18. CARDIAC SYMPTOMS: Fatigue Decreased cardiac output -AR -MR Palpitation Increased vigor of LV contractions in supine position -Arrhythmia -AR -MS with AF Anginal chest pain - Decreased aortic diastolic pressure causing decreased coronary filling AR AS Dizziness, syncope Fixed aortic output -AS -severe AR

19. Symptoms CHF Dyspnea + Fatigue LVF MR AR+AS Dyspnea+ edema, ascites RVF MS MR+ PH Symptoms due to infection Fever -Recurrence of ARF -IE -Pulmonary infection -Increased ASO,ESR MR, AR, AS (blood culture, ECHO) MS MR ( x-ray chest)

20. What signs to look for on general examination ? What to examine Findings Interpretation State of health Well looking Ill looking with poor weight Mild heart problem Severe heart disease Growt h parameters Grossly underweight Severe heart disease Dysmorphic features Webbing of neck Marfanoid features Upward slant of eyes Turner’s – Coarctation Marfan’s – MVP Down’s - A-V canal defect Nails Pallor, Cyanosis Clubbing Splinter hemorrhages Oster’s nodes I.E. Lower extremities Pedal edema CHF

21. What are the S/S I.E. one should look for Infection – Fever with rigors Arthralgia Splenomegaly Anemia Clubbing Embolism – RBC in urine Icterus Stroke Immunological – Splinter hemorrhage Petechiae Oster’s nodes Heart – S/O CHD or AHD with CHF What are vegetations ? An amorphous clot harbouring microorganisms without inflammatory cells, protected from host defenses, so need long courses of antibiotics Which lesions need I.E.P. ? Any condition with abnormal flow from high pressure area to low pressure area – MR, AS, VSD, PDA. Minimum risk Moderate risk Severe risk

22. What are CVS physical signs to look for ? MS MR AR Pulse Normal or volume Hyperkinetic but normal volume High volume Collapsing + P.S. of aortic run off. B.P. Normal or Normal Systolic Diastolic Hill’s sign UE : LE > 20 mmHg JVP Normal or in RVF, PAH Normal in CHF Normal HJR in CHF Normal Normal

23. MS MR AR Precordium Inspection Apex Normal Left parasternal pulsations RV enlargement Apex out Precordial Prominance suggests Cardiomegaly Precordium LV enlargement Apex out & down Palpation Apex Tapping Forceful, diffuse hyperkinetic Forceful heaving Area of MCI Parasternally MCI MCI Thrill Diastolic at apex Systolic apical thrill Absent Left Parasternal Heave + if severe MS Therefore, LA filling + LV LA Absent

24. Take a pause before going over to Auscultation Low pulse volume Tapping apex MCI parasternally Diastolic thrill at apex MS Low volume Heaving apex MCI – MCL Systolic thrill in aortic arc AS Hyperkinetic but normal volume pulse Systolic thrill at apex MCI – MCL MR Collapsing pulse Wide pulse pressure Hill’s sign + Heaving apex Peripheral S/O of AR AR

25. Auscultation MS MR AR S 1 Loud S 1 1 st Finding of MS Merged with Holosystolic murmur Soft due elevated LVEDP > PR interval S 2 (A 2 – P 2) P 2 – Normal Loud PH Normal P 2 ↑ PH Normal split S 3 Never heard Since rapid filling of LV prevented +, related to volume of MR at apex in expiration + LXF pathological 3 rd HS Opening snap Classic finding of MS 0.03 to 0.1 second after 2 nd HS medial to apex Triple cadense S1 – S 2 - OS Absent Absent

26. MS MR AR Murmur 1) A rumbling mid diastolic low pitched best heard with bell lightly applied Best heard between apex & LLSB Severe stenosis – Presystolic accentuation 1) Holosystolic , high pitched, blowing murmur, includes S 1 & S 2 conducted to axilla with expiratory accentuation 1) Soft, high pitched blowing diastolic decrescendo murmur - 3 rd LI space - Best heard with Diaphragm - Patient sitting up & leaning forward position 2) Systolic murmur of TR if PH Inspiratory accentuation 2) Mid diastolic flow murmur due to increased blood through MV or if associated with MS (loud S 1 ) 2) Systolic ejection murmur Due to increased LV stroke volume

27. Differential diagnosis MS D/D of Apical MDM Organic MS TS located at LSB Diastolic murmur in MR, no pre-systolic accentuation, normal S1 Diastolic murmur of AR Austin Flint murmur MR D/D of apical PSM MVP DCM GSD ASD (primum) AR PR (no peri . s/ oA . run-off) Bicuspid Aortic valve IE

28. How will you investigate? MS MR AR ECG LAE (P mitrale ) RAD + RVH qR in V1- functional TR LAE- broad bifid P - negative terminal deflection of P in V1 LAE, LAD LVVO with ST-T changes. LVS – overload q wave + depressed T XRC LAE, earliest causing straightening of left heart border Redistribution of PBF to upper lobe Inc PA, RV-PH LAE – size reflects severeity LVE- reflects severity If PH PA dil and Rt vent enlargement Cardiomegaly LAE ECHO M-mode 2 D Doppler Dec E-F slope of MV Dec diastolic excursion of mitral leaflet Dec MV area-relates gradient To exclude MR To confirm MR To assess regurg volume To exclude other causes of MR- MVP, DCM, ruptured chordae E-F slope Fluttering of AML Aortic V annulus Severity of AR

29. Cardiology for clinical Examination Rule of Three 3D’s - VSD, ASD, PDA 3C’s - TOF, TGA with VSD with PS, TAPVC 3B’S - AS, PS, coarctation of aorta 3I’s – Dextrocardia ( malpositions ) Cong. Complete H. B. Innocent murmur. 3R’s – Acute Rh Fever, IE, CHF Single valve –MS, AR Mixed valve – MS with MR or AR

30. 3 ECG – Bradycardia (Long lead2) - Tachycardia P.S.V.T. or WPW - Torsades de pontes - Electrolyte – ↑k+ ↓k+ ↑ cal 3 images - Peri or myocarditis or endocarditis - Kawasaki – ECHO 3 Shapes - Fig of 8 and fig. of 3 - Box Heart - Egg Shaped heart 3 Scars – Rt. Thoracotomy - Lt. Thoracotomy - mid sternotomy 3 Theory Q - CHF / or Intractable CHF - Cardiomyopathy or cardiomegalyD.D . - Hypertension.

31. Take home message Physical examination cannot be learnt by reading books. Practice – Practice – Practice To recognise abnormal one must first know what is normal Your clinical findings have to make sense More than memorization, understanding is necessary Come to diagnostic framework before putting stethoscope on chest wall Think before putting your mouth in gear

32. THANK YOU