recent apdates in tip and tricks of sheet.pptx

recent apdates in tip and tricks of sheet

1. قَالُواْ سُبْحَٰنَكَ لَا عِلْمَ لَنَآ إِلَّا مَا عَلَّمتَنَآ ۖ إِنَّكَ أَنتَ ٱلْعَلِيمُ ٱلْحَكِيمُ (البقرة - 32)

2. Tips and tricks in clinical sheet

3. Items included in clinical sheet: History (personal history, complaint, present history, past and family history). General examination: general condition, vitals, colors, examination for head, neck, limbs, abdomen, chest, neurological. Local examination to the heart. Collect important data. Provisional diagnosis Differential diagnosis Investigations Treatment of provisional diagnosis.

4. Complaint Present history Past-history There is symptom free interval between it and present history with no relation to clinical picture of the presenting disease. ? Rheumatic fever and prosthetic valve. Events in sequential & chronological manner with analysis of each symptom (severity, progression and related symptoms). Leading questions for non-mentioned cardinal cardiac symptoms. Symptoms related to other system affection. At the end of present history. It is the cause of seeking the presenting medical advice. In the patient own word. Onset and course. 1. History

5. Cardiac symptoms Pulmonary congestive symptoms : dyspnoea , cough , haemoptesis. Systemic congestive symptoms : dependant edema , right hypochondrial pain , indigestion . Symptoms suggesting low COP Chest pain Syncope Palpitation Symptoms of thrombo-embolism Pressure symptoms

6. Types of dyspnea

7. Causes of chest pain Non-cardiac causes: Gastrointestinal: Esophageal, cholecystic pains. spasm Respiratory: PE, pleuritic pain Neuro-musculoskeletal: Herpes zoster, Cervical spondylitis, trauma, Costochondritis (Tietze’s syndrome) Psychogenic: Cardiac neurosis (commonest cause)

8. 2. General examination General appearance including posture, built, abnormal motion, distress Basic intellectual function : orientation and co-ordination Colors and Vitals Face: Facial expression, complexion, special faces Neck: JV examination, lymph nodes, carotid Limbs: cutaneous manifestations, deformities, locomotor function, signs of peripheral arterial dysfunction, signs of venous diseases (edema, varices, DVT) Chest examination Abdominal examination Neurological examination

9. 2. General examination Do not forget peripheral pulsations and radio-femoral delay in pulse examination. Do not forget peripheral manifestations of infective endocarditis (particularly with fever or acute deterioration of valvular HD where they should be mentioned in detail). Do not forget peripheral manifestations of aortic regurgitation (particularly Hill’s sign) when there is big pulse pressure or early diastolic murmur (should be mentioned in detail). Do not forget manifestations of DVT (hotness, redness and tender cuff muscle) with LL examination.

10. 3. Local examination Should be done and reported in systematic manner: Inspection and palpation, then percussion and lastly auscultation. Inspection and palpation : deformity, skin, , the palpable sounds and murmurs (thrills). Auscultation: For each area examine normal heart sound (first HS for intensity in M & T areas and S2 (in the Ao & P areas for intensity and splitting), then abnormal heart sound (filling sounds (S3 & S4) and others), then murmurs . Murmurs : Site, area and propagation Timing, intensity (for systolic murmurs), duration, and character Changes with maneuvers (particularly respiration and positional changes).

11. 4. Important findings Dominant symptoms. Loaded chambers and types of loads. Heart sound (especially S2). Murmurs. Signs of pulmonary or systemic congestion (basal crepitation or edema, high JVP). If suggested: Peripheral signs of high COP (big pulse pressure/signs of AR) Peripheral signs of endocarditis (fever with murmurs). Signs of congenital syndromes (young age, valvular regurgitation, or cyanosis).

12. 5. Provisional diagnosis (most probable diagnosis) Should include these components: Etiological diagnosis : rheumatic, congenital, degenerative…..etc. Anatomical diagnosis : valvular, myocardial or pericardial diseases. Functional diagnosis : severity of affection and cardiac function. Complications: AF, pulmonary hypertension, endocarditis…..etc.

13. 6. Differential diagnosis (other probable diagnosis) Other diseases (valvular, congenital, myocardial, pericardial diseases) can produce chief manifestations (main symptom and murmur). Take care that: Each cardiac symptom has DD including cardiac and non-cardiac causes. Murmurs may be related to cardiac lesion as murmurs complicating condition (as AR associated with VSD, systolic and early diastolic murmurs of PR), or as flow murmurs (mid-diastolic murmur with AR, AV regurgitations, or shunts, ejection systolic murmur with AR). Examples : Dyspnea and apical systolic murmur may be produced by rheumatic MVD or dilated cardiomyopathy or VSD (systolic murmur propagated from left parasternal border).

14. Continue differential diagnosis Pulmonary and systemic congestion with systolic, mid-diastolic and early diastolic murmur may be produced with rheumatic multi-valvular diseases, VSD (produce systolic murmur, complicated by aortic regurgitation and associated with MV flow diastolic murmur). Dominant systemic congestive symptoms may be produced by right sided disease (valvular or myocardial diseases particularly restrictive CM), pulmonary hypertension (may be primary or secondary to Lt sided cardiac diseases, Lt-Rt shunts, pulmonary diseases or CTEPT), constrictive pericarditis. Other etiology of provisional diagnosis : congenital or degenerative etiologies of valvular HD, VTE, cardiac and pulmonary causes of PHT, alcoholic or ischemic etiology of dilated CM.

15. Common clinical cases Murmurs: valvular HD, congenital HD, degenerative, myocardial HD. Systemic congestion : core pulmonale, restrictive CM, pericardial compression diseases (tamponade, constriction), secondary to left sided disease. Prosthetic valve : normal functioning, mal-functioning valve or associated valvular HD. Congenital cyanotic HD : Fallot pathophysiology, Eisenmenger pathophysiology, TGA, common mixing pathology or mixed pathophysiology.

16. 7. Investigations Should be systematic : lab., ECG, CXR, echocardiography, CT or radio-nuclear scanning if they add value and lastly invasive assessment (catheterization or biopsy) Should be linked with differential diagnosis (with each disease what are the suspected findings gained by investigation? Example: Dominant systemic congestive symptoms may be produced by primary, complicating left to right shunt, or secondary pulmonary hypertension (may be core pulmonale or left heart disease), constrictive pericarditis, restrictive CM. ECG : findings of PHT (RBBB, RVH, RAE), findings of LHD (chamber enlargement, ischemia), findings of constrictive pericarditis (ST-T changes). CXR : cardiomegaly, findings related to PHT (pruning), calcific pericardium in CP, chest diseases in PHT secondary to chest diseases.

17. Continue investigation CT : pericardial thickening, chest diseases. CMR : if there is possible myocardial diseases. Echocardiography : findings of PHT (TRV, dilated RV, RA, and IVC, changes in PA), LHD, finding of CP (pericardial thickening, septal bounce and prominent respiratory phasic changes). Catheterization : differentiation between CP and RC. Biopsy: may be useful for RCM. The echocardiography is the main diagnostic tool for structural HD, which is the case in examination, so detailed findings should be mentioned i.e., findings for diagnosis and evaluation for severity and eligibility for intervention.

18. 8. Therapy: Therapy for provisional diagnosis. Must be systematic i.e., medical, interventional, surgical or device therapy. You must mention indication of intervention (in this case) and what are the types of interventions?

19. Prosthetic valve dysfunction: Manifestations: Symptoms of abnormal loads, loaded chambers, muffled closure sound, abnormal murmurs. All valves produce stenotic murmur except ball and cage valve in mitral position (high profile) No regurgitant murmurs and be heard exept : In aortic position for single disc valve . In mitral valve for heterograft bio-prosthetic valve (systolic murmur with ball and cage valve is due to LVOT obstruction) All produce mainly closure sound except ball and cage valve produce closure and opening sound .

20. Common pathophysiologies of cyanotic heart diseases Decrease pulmonary blood flow (PBF) without PHT : TOF/Fallot physiology and variants (VSD with obstruction to RVOT), Ebstein, severe PS with ASD. Decrease pulmonary blood flow (PBF) with PHT Eisenmenger physiology (reversed shunt due to PHT). Increase pulmonary blood flow (PBF) with PHT Common mixing physiology (TAPVD, common atrium/ventricle, TA (mixing of systemic and pulmonary flows in single chamber). Normal PBF : TGA with intact septum or restricted VSD (parallel circulations – may be of Fallot physiology or common mixing physiology (big VSD)). Pulmonary venous hypertension : hypoplastic left heart syndrome (HLHS), or obstructed TAPVD.

21. Important findings in cases have cyanotic heart diseases Onset of Cyanosis Early neonatal period (0-7 days) – duct dependent: Pulmonary atresia with intact ventricular septum/restricting VSD Hypoplastic left heart syndrome Severe Ebstein anomaly D-TGA without VSD / PDA Obstructive TAPVC Late neonatal (8-28 days) Non-obstructive TAPVC D-TGA with VSD Tetralogy of Fallot (TOF)

22. Onset of Cyanosis Infancy • TOF and TOF physiologies • D-TGA with VSD • Truncus arteriosus Childhood • TOF and TOF physiologies (CC-TGA with VSD with PS, Single ventricle with PS) • Eisenmenger syndrome Adulthood • Ebstein anomaly • Eisenmenger syndrome

23. Loaded chamber: Hyperkinetic dilated chambers in common mixing or TGA with big shunts, Sustained RV pulsation in TOF and Eisenmenger disease, Quite heart in Ebstien’s anomaly, Left ventricular apex in: Tricuspid atresia (with or without PS) Pulmonary atresia with intact ventricular septum Single ventricle (LV type) with or without PS Unbalanced AV canal defect (LV type) with PS Ebstein anomaly

24. Continue findings in cyanotic HD Second heart sound: Fixed, wide: TAPVC, ASD with shunt reversal. Normal/narrow/single: PDA with shunt reversal. Single loud S2 (A2): Any entity in Tetralogy physiology with severe PS, malposed great arteries. Single loud S2 (P2): VSD with shunt reversal. A preserved P2, excludes truncus arteriosus, pulmonary atresia and TOF with absent pulmonary valve. Characteristic murmurs: Commonly there is left para-sternal systolic murmur. Diastolic Murmur may be heard in Truncal regurgitation, TOF with absent pulmonary valve or Graham Steell murmur in Eisenmenger disease.