cvs - clinical notes

8/9/2019 Cvs - clinical notes

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C ardiovascular S ystemDETAILS OF PRESENTING SYMPTOMS

! C"est #ai$ %c"est discom&ort'(

Ask for

• Site, duration, character, radiation, aggravating & reliving factors

• Any special type of angina (unstable, second wind, nocturnal, pericardial pain, aortic dissection)

Type Location Character Disease

A$)i$a

%myocardialisc"emia'

Retrosternal

pain radiatingto arms, throat, jaw

onstricting pain

Aggr by e!ertion &rapid relief by rest&drugs

A" #

Atherosclerosis,arteritis, congenitalA", embolism

Myocardiali$&arctio$

Same asangina

Same as angina butmore severe & noteasily relived

Acute myocardialinfarction

Pericarditis entral(retrosternal)chest pain

radiate toshoulder $ back

Sharp $ Stabbing$ raw(like sand paper) pain

Aggr by deepinspiration, cough,

postural change

%diopathic,o!sackie infection,complication ofmyocardialinfarction

Pai$ o&aorticdissectio$

Retrosternal $over back ininterscapularregion

Severe tearing pain ofabrupt onset

Aoric dissection

• Grading of Angina (anada heart dissociation)

% Sever e!ertion

%% 'alking uphill $ climbing flight of ordinary stairs

*+


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%%% 'alking on level ground, climbing flight ofordinary stairs

% At rest

*! Dys#$oea

Def: Abnormal awareness of one-s own breathing at rest $ low level of e!ertion

Ask for

At rest$ after e!ertion

.ime of occurrence/ day time$ nocturnal

0nset/ acute$ insidious

"uration

1rading ofdyspnoea/

234A class

I 2o dyspnoea at rest$ moderate e!ertion

II "yspnoea at moderate to severe e!ertion

III "yspnoea at mild e!ertion but minimal at rest

I+ Significant dyspnoea at rest/ often bed bound $

Severe dyspnoea on minimal e!ertion

Associated symptoms like cough, palpitation etc,

Aggravating & relieving factors

2umber of episodes

Cardiac Causes of Dyspnoea

Acute onset Acute pulmonary edema, pulmonary embolism, pneumothora!, pneumonia

Subacute $chronic

hronic 5

*6


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7 85 ("yspnoea is the major symptom)

*7 congenital heart disease

97 ac:uired valvular heart disease

+7 A"67 hypertensive heart disease

;7 cardiomyopathy

I$ additio$ as, &or

• PND

• 0ccurs at night•


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•


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corrects itself

ommon in elderly

< & < resulting in syncoupe

$asovagal syncoupe

!f fre"uent %&malignant vasovagal syndrome'

Stimuli # emotional $painfulstimuli, less commonly cough$micturition

Rapid recovery if pt lies down

(utonomic overactivity provo)ed by

stimuli causes vasodilatation *

inappropriate slowing of pulse causeabnormal fall in < & < resulting insyncoupe

Carotid sinus

syncoupe

+ic) sinus syndrome

Stimulation of carotid sinus bytight shirt collar, Shaving insome elderly pts

-aggerated vagal discharge due toe!ternal stimuli cause refle! vasodil7 &slowing of pulse resulting in fall in < &<

$alvular obstruction

+imilar mechanism in

vasodilator .nitrates,

(C inhibitor/

therapy

?!ertion 0i-ed valvular obstruction in (+, Lt atrialtumor prevents normal rise in C12 during

e-ertion such that physiological asodil70ccurring in e!ercising muscle produceabnormal fall in <

+to)es (dams

syndrome

Self limiting episodes ofasystole $ rapid tachyarrhythmia(including ventr7 5ibrill)

Rapid recovery after normalrhythm is restored asso7 'ithflushing of skin

"ue to the abnormal rhythm there is lossof C121 causing syncoupe & stri)ing pallor

/! 0 1o easy &ati)a2ility

%mportant symptom of heart failure

=ore intense towards end of day

Cause # deconditioning & muscular atrophy, inade:uate 0* delivery to muscle dueto reduced 70

3! Peri#"eral oedema

Ask for # site, duration, progressive$ variable, diurnal variation, associatedweight gain, "rug history (2SA%"S, a channel blockers, Steroids)

*@


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4! 0 1o cya$osis1 cya$otic s#ells

Def # bluish discoloration of skin & mucous mem due to increased amt of red7 4b + gm $ dl

0R 9B of total 4b &


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•


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*7 Goints involved

97 5leeting (migrating) $ addictive

+7 Associated fever, rashes

67 Recovery;7 Any residual deformity

;7 4oarseness of voice $ hemiparesis

PAST 0ISTORY

• Specific en:uiry about the past history of conditions that may be associatedwith cardiac diseases # "=, A", A12, A5, Amyloidosis, ardiomyopathy

7 similar complaints before # pedal edema, "yspnoea, infective endocarditis,stroke

*7 4 $o recurrent respiratory tract infections

97 (nte natal history in mother / 1erman measles, drug intake, lupus (congenitalcomplete heart block)

+7 !ntranatal history # mode of delivery, cry, congenital cyanosis

67 post natal history # feeding difficulties, failure to thrive, delayed milestones,retarded growth, recurrent respiratory tract infections, cyanotic & s:uattingepisodes

;7 3 8o rheumatic fever .rheumatic age: 7# 67 years/ # throat pain, fever, joint pain( pattern of joint involvement & recovery), involuntary movements &subcutaneous nodules

>7 4 $o 4., "=,


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*7 Alcohol (A5, 4., ardiomyopathy)

97 Smoking

+7 ?!cessive coffee (palpitation)

67 %77 drug abuse, Recreational drugs like cocaine (chest pain)

OCC;PATIONAL 0ISTORY

! =ature of employment / to know about limitation of activities

*! =edico/legal conse:uences/ pilots, drivers of heavy commercial vehicles

DR;G 0ISTORY

7 8ist of drugs used

*7 4 $o 0. drugs (2SA%"S), Alternative medicines, 4erbal remedies (theymay contain ingredients with a cardiovascular action)

Drug history is important as

• "rugs may cause$ aggravate cardiac symptoms

• =ay give a clue for the presence of chronic diseases ("=, Rheumatoid arthritis,Skin diseases)

FAMILY 0ISTORY

7 onsanguineous parents # degree

*7 =other-s Age at delivery

97 Similar complaints in family / ardiac diseases with genetic component

5irst degree rothers and sister

Second degree 5isrt generation relative uncle

.hird degree Second generation

9*


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+7


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v7


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7 with low hair line/ turner-s (coartation)I

*7 with low set ears/ 2oonan-s (


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%n ". as failure worsens (due to activation of R A A)

4! 8au$dice

• ongestive hepatomegaly•

=icroanglopathic hemolytic anemia # prosthetic valves• !Muscular s,eletal system7 high arch palate, arachnodactyly, pes cavus # marfan-s syndrome*7 absence of radius,97 absence of thumb # (4oltram syndrome) /AS"+7 syndactyly, polydactyly, Hyphoscoliosis,

eripheral +igns of !nfective ndocarditis

7 5ever, anemia,

*7 Clubbing # usually three weeks after onset of endocarditis97 Sub/conjunctival hemorrhage

+7 s nodes # tender erythematous patches over pulp of fingers and toes

>7 ?aneway>s lesions # nontender erythematous patches over palms and soles

@7 Absence of any peripheral pulse

F7+plenomegaly

# usually three weeks after onset of endocarditis7 =icroscopic hematuria

7 Arthralgia

9;


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+ital data "#amination of pulses

• DefinitionN wave form transmitted along the arterial tree in a peripheral direction muchAhead of the actual column of blood as a result of cardiac systole7

• Arteries e#amined

7 superficial temporal*7 brachial97 carotids+7 radial67 femoral;7 popliteal>7 dorsalis pedis@7 posterior tibial

• All pulses have to be compared on both sides simultaneously e!cepts carotids

• 5ollowing points have to be noted! rate

@radycardia C 6 perminute

Tachycardia * $ minute*! r"yt"m

•

Rhythm may be regular or irregular7

• .he irregularity may be regularly irregular or irregularly irregular 7

Regularly irregular • Atrial tachyarrhythmias with fi!ed block• entricular bigemini, bid gemeni• Sinus arrhythmia

!rregularly irregular

• ?ctppics # atrial$ ventricular • Atrial fibrillation• Atrial tachyarrhythmias with varying blocks

9>


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-! volumei7 small volume pulse (4ypokinetic pulse)

• Small weak pulse/ small volume and narrow pulse pressure

• Causes

o ardiac failureo Shocko 8ow cardiac output due too alvular heart disease # =itral $ aortic stenosiso =yocardial diseaseo


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True colla#si$) #ulse Pseudo colla#si$) #ilse 0eature "iastolic < C


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d! Pulsus alter$a$s• Def N %t is the alteration of the strength of the pulse sensed by palpation inthe absence of arrhythmia or of a significant variation in interval between

beats7 Rhythm is regular • est felt in radial or femoral artery• Causes / severe 85, beat following premature ventricular beat

e! Pulsus 2i)emi$us• %t is an irregular rhythm, a normal beat is followed by a premature beat and a

compensatory pause, resulting in alternation of the strength of the pulse7• %t is the sign of digitalis to-icity

&! Pulsus #arado


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• in aortic regurgitation the phase four (muffling phase) of koratoff sounds

shd be taken as diastolic pressure even though koratoff sounds are heard

till

• in aortic regurgitation with significant associated aortic stenosis, there will be systolic decapitation ie systolic pressure will not be very high

o thus when systolic < is > mm4g in a patient with AR

associated significant AS is unlikely

o similarly "iastolic < + mm4g rules out significant aortic

stenosis

o eg in pure (R the @ will be 49989 mm hg and in AR associatedwith significant (+ the @ will be 679 8 A9 mm 8 hg

"#amination of neck veins

• Right internal jugular vein is used to assess pressure & wave forms as it is

in line with right atrium

•

%nspect the jugular veins in between the two heads of sternomastoid•


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!ll sustained pulsations Shunt lesions/ AS", S"

+ustained pulsations


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Aortic ejection click ongenital valvular AS, aorticroot dilatation

Pulmo$aryarea


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Mitral area

"iastolic thrillQ77 Systolic thrillQQ

=itral stenosis=itral regurgitation

ulmonary area

ontinuous thrillQ Systolic thrillQQ


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97 second aortic$ erb-s area (9rd left %S close to sternum)+7 pulmonary (*nd 8eft %S close to sternum)67 aortic area (*nd Right %S close to sternum)

41 Concentrate

7 5irst on heart sounds esp to loudness=uch attention to S* # loudness, split (physiological $ pathological) in pulmonary & aortic area

*7 then on added sounds like opening snaps97 lastly for murmurs

1 auscultate for murmurs over peripheral arteries #esp femoral & carotids

@etter heard withbell +, +A, Mid# diastolic murmur, venous hum

=etter "eard :it"dia#"ra)m

S, S*, licks, 0pening snap, Systolic murmur,early diastolic murmur, pericardial rub

! 0eart sou$ds%n diseased state following abnormalities can occur

a1 Differing intensity/ increased $ decreasedb1 (bnormal split is heardc1 8ow fre:uency sound in diastole/ +, +A may be heard d1 (dditional high pitched sounds may be heard

5eatures of heart sounds

S S* S- S.

Cause losure ofmitral andtricuspid

valve

losure ofsemilunar valve

%nitial passive filling of ventricles hysiological/ healthy

young adults, atheletes, pregnancy athological / 85,=R, AS", S",


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bell of steth

osition incardiac cycle

%mmediately precedes A%%mmediately precedescarotid pulsewave

5ollows A%

5ollows carotid pulse wave

oincide with onset of period of rapidventricular filling

'hen bolus of bloodis delivered toventricle bycontraction of theatrium (atrial systole)

2ther

characteristic

features

ElubO in Elub/dupO

EdubO in lub/dupOnormally split/A*


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Seco$d "eart sou$doncentrate on split & intensity of the * components

• S* in aortic valve disease

Aortic ste$osis !ncreased intensity =on calcified congenital AS

=ormal intensity 4ypertrophic cardiomyopathy, sub valvular stenosis

Decreased intensity Calcified bicuspid aortic valve disease, rheumaticstenosis, aortic valve sclerosis in old age

*! Aortic re)ur)itatio$ ( varies depending on etiology, 8 function, asso7 8esions,

L2;D Syphilis, marfan-s , rheumatoid arthritis,annuloaortic ectasia,(conditions producing aortic root dilatation)

+20T Rheumatic etiology, asso7 Aortic stenosis,infective endocarditis

•

(bnormalities of split

hysiology of split +4

• =ormally +4 is split into 4 components during inspiration & is single in e!piration

?!piration %nspiration

T S S* S A*


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tetrology of fallot, tricuspid atresia, tricuspid arteriosus,transposition of great arteries

severe calcified ASsevere


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• ombination of tachycardia and loud S9 gives a characteristic cadence tothe heart sounds described as gallop rhythm $ triple rhythm

• %n any clinical setting presence of S9 indicates abnormal 8 filling withhigh end diastolic pressure

ii! S. (refer table above)

iii! O#e$i$) s$a#• 3igh pitched sound • 4eard all over precordium• est heard with diaphragm Bust Medial to the (pe-• ?asily mistaken for split S*• Accentuated by e!ercise & 'idens on standing•


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cusps becomes softer on inspirationbut loud * sharp on e-piration

pulmonary artery due toidiopathic nature $ pulmonary 4.

&id

systolic

click

arise from haltingof mitral leaflet as

it prolapses intothe left atriumduring systole

• 8oud clicks occurring in midsystole in association with

=<• =imics S9 but differentiated

by its high fre:uency (S9 isof low fre:uency)

• 8ate systolic murmur(sometimes absent)

=itral valve prolapse(=


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• 1rading of S3S.08% murmurs (8ance & 5reeman-s grading) ! ery soft (heard in a :uiet room) !! Soft !!! =oderate

!$ 8oud with thrill$ ery loud$! ery loud (heard even when

stethoscope is away from chest wall)

• 1rading of "%AS.08% murmurs (8ance & 5reeman-s grading) ! ery soft !! Soft !!! 8oud !$

8oud with .hrillo


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Differential dia!nosis of &D&

7 Austin flint murmur

*7 5low murmur in AS",S",


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co$ditio$s61 Tricuspid

regurgitation

8eft lower strnal edge%ncreases with inspiration

Severe pulmonary4., pulsatile liver

41 $+D .Loud*

harsh/

8eft 9rd & +th %S .hrill

Dia!nosis of eection systolic murmur

• Aortic stenosisRough crescendo # decrescendo well heard in sitting position with breath

held in e!piration conduction to carotids

Differential dia!nosis of eection systolic murmur

i7 4ypertrophic cardiomyopathyii7 Stenosis/ Sub/valvular aortic, Supra/valvular aortic,


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onditions resulting in AR murmur best heard on right side of sternumi7 Aortic aneurysm # cystic medial necrosis, Syphilis, %diopathic,

=arfan-sii7 Sinus of alsalva aneurysm,

iii7 Aortic dissectionCom#ariso$ o& AORTIC 9 P;LMONARY i$com#ete$ce

eripheral

signs


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Anomalous origin of 8eft oronary Artery from


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*7 A* # 0S interval NSevere =S 76 # 7> sec=ild =S 7 # 7* sec

97 %ntensity doesn-t correlate with Severity

+7 alve Area 2ormal 6 s:7 cmAsymptomatic *76 s:7 cm=ild 76 # *76 s:7 cm=oderate # 76Severe C s:7 cm

*! MITRAL REG;RGITATION• ulse / 2ormal $ large volume pulse with $ without A5• 4yperdynamic (! # thrill rarely made out• 8eft arasternal lift ,• Soft S• Audible S9,• ?vidence of pulmonary 4.•


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S9 # heard all over aortic areaS+ may be heardRough, crescendo/ decrescendo eBection systolic murmur

est heard in sitting position

reath held in e!pirationonducted to the carotids (ssessment of severity

7 according to alve area

*7 according to S*

A* followed by 6 s:7 cm +evereC 76 s:7 cm Critical

6@


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7duroJeiJ sign / systolic murmur heard over femeral artery with pro!imal

compression and diastolic murmer with distell compression

7 hill signs # popliteal cuff systolic < e!ceeds brachial cuff pressure by *

mm4g

C * mm4g =ormal

* to + mm4g Mild (R

+ to ; mm4g Moderate (R

; mm4g +evere (R

*7osenbach sign # pulsatile liver 971rehadt sign/ pulsatile spleen+7ecker sign # retinal arteriolar pulsation

• Cardiovascular findings

• 8arge volume pulse• 4igh Systolic < with very 8ow "iastolic <• 4yperdynamic Apical %mpulse• 4eart sounds # Soft S L presence of S9• ?"=

o high pitched, blowing, decrescendo, early diastolic murmur o well heard in aortic area & ?rb-s areao patient sitting & leaning forwardo breath held in e!piration

• (ssessment of severity

7 =arked peripheral signs*7 isferians pulse97 4ill-s sign ; mmhg+7 "uration of =urmur # occupying *$9 rd of the "iastole67 Austin flint murmur

Assessment of dominant lesion in presence of combined AS & ARPositive si)$s For AR 9 For AS

6F


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infections s:uatting episodes,41 !mpulse 8eft parasternal 4yperkinetic 8 apical

impulse/

1 +6 2ormal $ accentuated Accentuated 2ormalA1 +4 'ide & 5i!ed split

with

cvs - clinical notes

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