Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Symptoms  Signs and Investigations in Cardiovascular Disease Prof:Nooruddin Jaffer Hamdard Medical College Karachi
Importance of the history <ul><li>The richest source of information concerning the patients’ illness </li></ul><ul><li>Est...
Breathlessness(dyspnoea) <ul><li>abnormally uncomfortable awareness of breathing </li></ul><ul><li>regarded as abnormal on...
Breathlessness(dyspnoea) <ul><li>Exertional dyspnoea </li></ul><ul><ul><li>Comes on during exertion and subsides with rest...
Breathlessness(dyspnoea) <ul><li>Paroxysmal Nocturnal dyspnoea </li></ul><ul><ul><li>a variant of orthopnoea </li></ul></u...
Chest Pain or Discomfort <ul><li>history is very important </li></ul><ul><li>although a cardinal manifestation of heart di...
Chest Pain <ul><li>Points to note in the history </li></ul><ul><ul><li>location </li></ul></ul><ul><ul><li>radiation </li>...
Differential diagnosis of chest pain according to location
Oedema <ul><li>Peripheral Oedema </li></ul><ul><ul><li>a feature of chronic heart failure </li></ul></ul><ul><ul><li>due t...
Oedema <ul><li>Causes of peripheral oedema </li></ul><ul><ul><li>cardiac failure </li></ul></ul><ul><ul><li>Chronic venous...
Palpitations <ul><li>definition </li></ul><ul><ul><li>unpleasant awareness of forceful or rapid beating of the heart </li>...
Palpitations <ul><ul><li>associated with drug use </li></ul></ul><ul><ul><ul><li>tobacco, coffee, tea, alcohol epinephrine...
Syncope <ul><li>definition </li></ul><ul><ul><li>sudden temporary loss of consciousness </li></ul></ul><ul><ul><li>associa...
Cough <ul><li>defined as explosive expiration for clearing the tracheobronchial tree of secretions and foreign bodies </li...
Cough <ul><li>the nature of the sputum is often helpful </li></ul><ul><ul><li>pink frothy sputum - pulmonary oedema </li><...
fatigue <ul><li>non-specific </li></ul><ul><li>common in patients with impaired cardiovascular function </li></ul><ul><li>...
Other symptoms <ul><li>Nocturia </li></ul><ul><ul><li>common in early heart failure </li></ul></ul><ul><li>Anorexia </li><...
Physical Examination <ul><li>General examination </li></ul><ul><ul><li>pallor indicate anaemia </li></ul></ul><ul><ul><li>...
Physical Examination <ul><ul><li>facial abnormalities </li></ul></ul><ul><ul><ul><li>ptosis and frontal baldness –dystonia...
CVS examination <ul><li>Pulse </li></ul><ul><ul><li>Rate </li></ul></ul><ul><ul><ul><li>bradycardia </li></ul></ul></ul><u...
Blood pressure <ul><li>use of a sphygmomanometer </li></ul><ul><ul><li>inflatable cuff connected to mercury or aneroid man...
Blood pressure <ul><li>Pitfalls in BP measurement </li></ul><ul><ul><li>apparatus </li></ul></ul><ul><ul><ul><li>small cuf...
Jugular venous pulse <ul><li>observed from the right internal jugular vein </li></ul><ul><li>usually examined with patient...
Praecordium <ul><li>Inspection </li></ul><ul><ul><li>evidence of respiratory difficulty </li></ul></ul><ul><ul><li>visible...
Praecordium: palpation <ul><li>apex beat </li></ul><ul><ul><li>lowermost and outermost point of cardiac impulse </li></ul>...
Praecordium: palpation <ul><li>Right ventricle </li></ul><ul><ul><li>left parasternal heave indicate RVH </li></ul></ul><u...
Cardiac auscultation <ul><li>Areas for auscultation </li></ul><ul><ul><li>cardiac apex </li></ul></ul><ul><ul><li>right an...
Heart sounds <ul><li>4 basic heart sounds </li></ul><ul><li>other sounds i.e.  clicks, prosthetic valve sounds </li></ul><...
Heart sound <ul><li>1 st  heart sound </li></ul><ul><ul><li>two major components </li></ul></ul><ul><ul><li>due to closure...
2nd Heart sound: abnormal splitting <ul><li>single 2 nd  heart sound </li></ul><ul><ul><li>inaudible pulm. component </li>...
2nd Heart sound: abnormal splitting <ul><li>Persistent splitting </li></ul><ul><ul><li>delay in the pulm. component </li><...
2nd Heart sound: abnormal intensity <ul><li>Increased A 2  </li></ul><ul><ul><li>systemic hypertension </li></ul></ul><ul>...
3 rd  heart sound <ul><li>due to sudden limitation of ventricular expansion during early diastolic filling </li></ul><ul><...
4 th  heart sound <ul><li>a low-pitched, presystolic sound produced in the ventricle during ventricular filling </li></ul>...
Murmurs <ul><li>result from vibrations set up  </li></ul><ul><ul><li>in the blood stream  </li></ul></ul><ul><ul><li>and t...
Murmurs <ul><li>for a murmur, determine its </li></ul><ul><ul><li>timing </li></ul></ul><ul><ul><li>intensity </li></ul></...
other cardiac sounds <ul><li>Pericardial rubs </li></ul><ul><ul><li>the hallmark of acute pericarditis </li></ul></ul><ul>...
Other relevant examination <ul><li>lung bases  </li></ul><ul><ul><li>crepitations in left heart failure </li></ul></ul><ul...
Cardiac Investigations and Procedures <ul><li>Electrocardiogram (ECG) </li></ul><ul><li>Chest X-Ray (CXR) </li></ul><ul><l...
Cardiac Investigations and Procedures   <ul><li>Other New Imaging Techniques   </li></ul><ul><li>Cardiac  Catherization </...
Cardiac Investigations and Procedures   <ul><li>Electrophysiological Study of the Heart (EPS) and Radio-frequency Ablation...
 
 
 
 
 
 
 
 
 
 
 
 
 
Upcoming SlideShare
Loading in …5
×

Symptoms Signs & Investigations in Cardiovascular Diseases

2,060 views

Published on

  • Be the first to comment

Symptoms Signs & Investigations in Cardiovascular Diseases

  1. 1. Symptoms Signs and Investigations in Cardiovascular Disease Prof:Nooruddin Jaffer Hamdard Medical College Karachi
  2. 2. Importance of the history <ul><li>The richest source of information concerning the patients’ illness </li></ul><ul><li>Establishes a bond with the patient & improves his co-operation </li></ul><ul><li>Allows evaluation of the impact of the disease </li></ul>
  3. 3. Breathlessness(dyspnoea) <ul><li>abnormally uncomfortable awareness of breathing </li></ul><ul><li>regarded as abnormal only when it occurs </li></ul><ul><ul><li>at rest or </li></ul></ul><ul><ul><li>at level of physical activity not expected to cause it </li></ul></ul><ul><li>associated with diseases of </li></ul><ul><ul><li>heart </li></ul></ul><ul><ul><li>lungs </li></ul></ul><ul><ul><li>chest wall </li></ul></ul><ul><ul><li>respiratory muscles </li></ul></ul><ul><li>also associated with anxiety </li></ul>
  4. 4. Breathlessness(dyspnoea) <ul><li>Exertional dyspnoea </li></ul><ul><ul><li>Comes on during exertion and subsides with rest </li></ul></ul><ul><ul><li>Commonly due to HF or lung disease </li></ul></ul><ul><li>Orthopnoea </li></ul><ul><ul><li>breathlessness on lying flat </li></ul></ul><ul><ul><li>A symptom of left ventricular failure </li></ul></ul><ul><ul><li>due to redistribution of fluid from the lower extremities to the lungs </li></ul></ul>
  5. 5. Breathlessness(dyspnoea) <ul><li>Paroxysmal Nocturnal dyspnoea </li></ul><ul><ul><li>a variant of orthopnoea </li></ul></ul><ul><ul><li>patient awakes from sleep </li></ul></ul><ul><ul><ul><li>severely breathless </li></ul></ul></ul><ul><ul><ul><li>persistent cough, may have white frothy sputum </li></ul></ul></ul><ul><ul><li>a manifestation of left ventricular failure </li></ul></ul>
  6. 6. Chest Pain or Discomfort <ul><li>history is very important </li></ul><ul><li>although a cardinal manifestation of heart disease, also originates from </li></ul><ul><ul><li>Non-cardiac intrathoracic structures </li></ul></ul><ul><ul><ul><li>aorta, pulmonary artery, bronchopulmonary tree, pleura, mediastinum, oesophagus and diaphragm </li></ul></ul></ul><ul><ul><li>tissues of the neck and thoracic wall </li></ul></ul><ul><ul><ul><li>skin, thoracic muscles, cervicodorsal spine, costochondral junctions, breasts, sensory nerves and spinal cord </li></ul></ul></ul><ul><ul><li>subdiaphragmatic organs </li></ul></ul><ul><ul><ul><li>stomach, duodenum, pancreas and gallbladder </li></ul></ul></ul><ul><ul><li>Functional or factitious </li></ul></ul>
  7. 7. Chest Pain <ul><li>Points to note in the history </li></ul><ul><ul><li>location </li></ul></ul><ul><ul><li>radiation </li></ul></ul><ul><ul><li>character </li></ul></ul><ul><ul><li>aggravating factors </li></ul></ul><ul><ul><li>relieving factors </li></ul></ul><ul><ul><li>time relationships </li></ul></ul><ul><ul><ul><li>duration, frequency and pattern of occurrence </li></ul></ul></ul><ul><ul><li>setting in which it occurs </li></ul></ul><ul><ul><li>associated factors </li></ul></ul>
  8. 8. Differential diagnosis of chest pain according to location
  9. 9. Oedema <ul><li>Peripheral Oedema </li></ul><ul><ul><li>a feature of chronic heart failure </li></ul></ul><ul><ul><li>due to excessive salt and water retention </li></ul></ul><ul><ul><li>In ambulant patients </li></ul></ul><ul><ul><ul><li>found in the ankles, legs, thighs and lower abdomen </li></ul></ul></ul><ul><ul><li>In patients who are recumbent </li></ul></ul><ul><ul><ul><li>over the sacrum </li></ul></ul></ul><ul><ul><li>associated with other features of heart failure </li></ul></ul><ul><ul><li>Usually pitting except if it has been long standing </li></ul></ul>
  10. 10. Oedema <ul><li>Causes of peripheral oedema </li></ul><ul><ul><li>cardiac failure </li></ul></ul><ul><ul><li>Chronic venous insufficiency </li></ul></ul><ul><ul><li>Hypoalbuminaemia – nephrotic syndrome, liver disease, protein losing enteropathy </li></ul></ul><ul><ul><li>Drugs </li></ul></ul><ul><ul><ul><li>retaining sodium (fludrocortisone, NSAID) </li></ul></ul></ul><ul><ul><ul><li>increasing capillary permeability (nifedipine) </li></ul></ul></ul>
  11. 11. Palpitations <ul><li>definition </li></ul><ul><ul><li>unpleasant awareness of forceful or rapid beating of the heart </li></ul></ul><ul><ul><li>caused by disorders of cardiac rhythm and rate </li></ul></ul><ul><li>history in palpitation </li></ul><ul><ul><li>isolated jump or skips </li></ul></ul><ul><ul><ul><li>extrasystoles </li></ul></ul></ul><ul><ul><li>attacks with abrupt beginning, rapid heart rate with regular or irregular rhythm </li></ul></ul><ul><ul><ul><li>paroxysmal tachycardias </li></ul></ul></ul><ul><ul><li>independent of exercise or excitement to account for the symptom </li></ul></ul><ul><ul><ul><li>atrial fibrillation, atrial flutter, thyrotoxicosis, anaemia, anxiety states </li></ul></ul></ul>
  12. 12. Palpitations <ul><ul><li>associated with drug use </li></ul></ul><ul><ul><ul><li>tobacco, coffee, tea, alcohol epinephrine, aminophylline, MAOI </li></ul></ul></ul><ul><ul><li>on standing </li></ul></ul><ul><ul><ul><li>postural hypotension </li></ul></ul></ul><ul><ul><li>middle aged women, associated flushes and sweats </li></ul></ul><ul><ul><ul><li>menopausal syndrome </li></ul></ul></ul><ul><ul><li>associated with normal rate and rhythm </li></ul></ul><ul><ul><ul><li>anxiety state </li></ul></ul></ul>
  13. 13. Syncope <ul><li>definition </li></ul><ul><ul><li>sudden temporary loss of consciousness </li></ul></ul><ul><ul><li>associated with loss of postural tone </li></ul></ul><ul><ul><li>with spontaneous recovery </li></ul></ul><ul><ul><li>not requiring electrical or chemical cardioversion </li></ul></ul><ul><li>due to sudden vasodilation or sudden fall in cardiac output or both simultaneously </li></ul>
  14. 14. Cough <ul><li>defined as explosive expiration for clearing the tracheobronchial tree of secretions and foreign bodies </li></ul><ul><li>cardiovascular causes include those that lead to </li></ul><ul><ul><li>pulmonary venous hypertension </li></ul></ul><ul><ul><li>interstitial and alveolar oedema </li></ul></ul><ul><ul><li>pulmonary infarction </li></ul></ul><ul><ul><li>compression of the tracheobronchial tree </li></ul></ul>
  15. 15. Cough <ul><li>the nature of the sputum is often helpful </li></ul><ul><ul><li>pink frothy sputum - pulmonary oedema </li></ul></ul><ul><ul><li>clear white mucoid sputum –viral infection or longstanding bronchial irritation </li></ul></ul><ul><ul><li>thick, yellowish sputum – infection </li></ul></ul><ul><ul><li>rusty sputum – pneumococcal pneumonia </li></ul></ul><ul><ul><li>blood streaked sputum – tuberculosis, bronchiectasis, Ca lung or pulmonary infarction </li></ul></ul>
  16. 16. fatigue <ul><li>non-specific </li></ul><ul><li>common in patients with impaired cardiovascular function </li></ul><ul><li>consequent to a reduced cardiac output </li></ul><ul><li>associated with muscular weakness </li></ul><ul><li>may be caused by drugs e.g. β -blockers </li></ul><ul><li>may also result for excessive blood pressure reduction in patients with hypertension or heart failure </li></ul><ul><li>caused by excessive diuresis or diuretic induced hypokalaemia </li></ul>
  17. 17. Other symptoms <ul><li>Nocturia </li></ul><ul><ul><li>common in early heart failure </li></ul></ul><ul><li>Anorexia </li></ul><ul><li>Abdominal fullness </li></ul><ul><li>right upper quadrant abdominal discomfort </li></ul><ul><li>weight loss </li></ul><ul><li>cachexia </li></ul>
  18. 18. Physical Examination <ul><li>General examination </li></ul><ul><ul><li>pallor indicate anaemia </li></ul></ul><ul><ul><li>cyanosis: bluish discolouration of the mucous mucosa and skin due to arterial hypoxaemia </li></ul></ul><ul><ul><ul><li>central cyanosis </li></ul></ul></ul><ul><ul><ul><ul><li>poor gaseous exchange in the lungs– pulmonary disease or pulmonary oedema </li></ul></ul></ul></ul><ul><ul><ul><ul><li>right to left shunt in congenital heart disease </li></ul></ul></ul></ul><ul><ul><ul><li>peripheral cyanosis </li></ul></ul></ul><ul><ul><li>obesity </li></ul></ul><ul><ul><ul><li>associated with hyperlipidaemia and diabetes </li></ul></ul></ul><ul><ul><li>features of hyperlipidaemia </li></ul></ul><ul><ul><ul><li>corneal arcus </li></ul></ul></ul><ul><ul><ul><li>xanthelasma </li></ul></ul></ul>
  19. 19. Physical Examination <ul><ul><li>facial abnormalities </li></ul></ul><ul><ul><ul><li>ptosis and frontal baldness –dystonia myotonica(cardiomyopathy and conduction defects) </li></ul></ul></ul><ul><ul><ul><li>high arched palate and ocular lens abnormalities – Marfan’s syndrome(Aortic aneurysm) </li></ul></ul></ul><ul><ul><ul><li>unusual facial features(congenital heart diseases) </li></ul></ul></ul><ul><ul><li>finger clubbing </li></ul></ul><ul><ul><ul><li>cyanotic congenital heart diseases </li></ul></ul></ul><ul><ul><ul><li>infective endocarditis(advanced) </li></ul></ul></ul><ul><ul><li>Splinter haemorrhages </li></ul></ul><ul><ul><ul><li>trauma </li></ul></ul></ul><ul><ul><ul><li>infective endocarditis </li></ul></ul></ul><ul><ul><li>Moist palms </li></ul></ul><ul><ul><ul><li>cold – anxiety </li></ul></ul></ul><ul><ul><ul><li>warm – thyrotoxicosis </li></ul></ul></ul>
  20. 20. CVS examination <ul><li>Pulse </li></ul><ul><ul><li>Rate </li></ul></ul><ul><ul><ul><li>bradycardia </li></ul></ul></ul><ul><ul><ul><li>tachycardia </li></ul></ul></ul><ul><ul><li>Rhythm </li></ul></ul><ul><ul><ul><li>regular </li></ul></ul></ul><ul><ul><ul><li>irregular </li></ul></ul></ul><ul><ul><ul><ul><li>regular with dropped beats </li></ul></ul></ul></ul><ul><ul><ul><ul><li>completely irregular </li></ul></ul></ul></ul><ul><ul><ul><ul><li>sinus arrhythmia (speeds up in inspiration and slows with expiration) </li></ul></ul></ul></ul><ul><ul><li>Volume </li></ul></ul><ul><ul><ul><li>depend on the cardiac stroke volume and the compliance of the arterial system </li></ul></ul></ul><ul><ul><li>State of the arterial wall </li></ul></ul><ul><ul><li>Synchronicity </li></ul></ul><ul><ul><ul><li>radio-femoral delay </li></ul></ul></ul><ul><ul><li>Other pulses </li></ul></ul><ul><ul><ul><li>brachial, carotid, femoral, popliteal, posterior tibial and dorsalis pedis </li></ul></ul></ul>
  21. 21. Blood pressure <ul><li>use of a sphygmomanometer </li></ul><ul><ul><li>inflatable cuff connected to mercury or aneroid manometer </li></ul></ul><ul><ul><li>stethoscope over the branchial artery </li></ul></ul><ul><ul><li>inflate cuff above the POP </li></ul></ul><ul><ul><li>reduce the pressure in the cuff slowly </li></ul></ul><ul><ul><li>reappearance of Korotkov sound – systolic pressure </li></ul></ul><ul><ul><li>disappearance of Korotkov sounds – diastolic pressure </li></ul></ul>
  22. 22. Blood pressure <ul><li>Pitfalls in BP measurement </li></ul><ul><ul><li>apparatus </li></ul></ul><ul><ul><ul><li>small cuff – overestimation of the BP by 20 - 30 mmHg </li></ul></ul></ul><ul><ul><ul><li>large cuff – underestimation of the blood pressure </li></ul></ul></ul><ul><ul><ul><li>calibration of the sphygmomanometer </li></ul></ul></ul><ul><ul><li>Patient </li></ul></ul><ul><ul><ul><li>emotional state of the patient </li></ul></ul></ul><ul><ul><ul><li>anxiety(white coat hypertension) </li></ul></ul></ul><ul><ul><ul><li>posture and the position of the sphyg </li></ul></ul></ul><ul><ul><li>observer </li></ul></ul><ul><ul><ul><li>auscultatory gap </li></ul></ul></ul>
  23. 23. Jugular venous pulse <ul><li>observed from the right internal jugular vein </li></ul><ul><li>usually examined with patient at 45 ° </li></ul><ul><li>2 major pulsations can be observed – ‘a’ and ‘v’ waves </li></ul><ul><li>measurement of the JVP </li></ul><ul><ul><li>height above the sternal angle – usually < 4cm </li></ul></ul><ul><li>Abdomino-jugular reflux </li></ul><ul><ul><li>seen in right heart failure </li></ul></ul><ul><li>Causes of raised JVP </li></ul><ul><ul><li>Rt heart failure </li></ul></ul><ul><ul><li>Tricuspid incompetence </li></ul></ul><ul><ul><li>Pericardial effusion </li></ul></ul><ul><ul><li>SVC obstruction </li></ul></ul><ul><ul><li>Constrictive pericarditis </li></ul></ul><ul><ul><li>Tricuspid stenosis </li></ul></ul>
  24. 24. Praecordium <ul><li>Inspection </li></ul><ul><ul><li>evidence of respiratory difficulty </li></ul></ul><ul><ul><li>visible veins – obstruction of SVC </li></ul></ul><ul><ul><li>praecordial bulge or prominence – long standing cardiac enlargement before puberty </li></ul></ul><ul><ul><li>abnormalities of the chest wall </li></ul></ul><ul><ul><li>Praecordial hyperactivity – suggests severe valvular abnormality </li></ul></ul><ul><ul><li>Apex beat </li></ul></ul>
  25. 25. Praecordium: palpation <ul><li>apex beat </li></ul><ul><ul><li>lowermost and outermost point of cardiac impulse </li></ul></ul><ul><ul><li>normally in the 5LICS at the mid-clavicular line </li></ul></ul><ul><ul><li>when displaced suggests cardiac enlargement </li></ul></ul><ul><ul><li>heaving apex – LVH </li></ul></ul><ul><ul><li>tapping apex beat (palpable 1 st heart sound) – mitral stenosis </li></ul></ul>
  26. 26. Praecordium: palpation <ul><li>Right ventricle </li></ul><ul><ul><li>left parasternal heave indicate RVH </li></ul></ul><ul><li>Palpable sounds </li></ul><ul><ul><li>Palpable 2 nd heart sound –loud P2 or A2 </li></ul></ul><ul><li>Thrills </li></ul><ul><ul><li>palpable murmurs with low frequency components </li></ul></ul>
  27. 27. Cardiac auscultation <ul><li>Areas for auscultation </li></ul><ul><ul><li>cardiac apex </li></ul></ul><ul><ul><li>right and left sternal borders interspace by interspace </li></ul></ul>
  28. 28. Heart sounds <ul><li>4 basic heart sounds </li></ul><ul><li>other sounds i.e. clicks, prosthetic valve sounds </li></ul><ul><li>time the sounds with palpation of the carotid artery </li></ul>
  29. 29. Heart sound <ul><li>1 st heart sound </li></ul><ul><ul><li>two major components </li></ul></ul><ul><ul><li>due to closure of the atrio-ventricular valves </li></ul></ul><ul><ul><li>loud in </li></ul></ul><ul><ul><ul><li>tachycardia </li></ul></ul></ul><ul><ul><ul><li>short PR interval </li></ul></ul></ul><ul><ul><ul><li>short circle lengths in AF </li></ul></ul></ul><ul><ul><ul><li>mitral stenosis with a pliable leaflet </li></ul></ul></ul><ul><li>2 nd heart sound </li></ul><ul><ul><li>due to closure of the semi-lunar valves </li></ul></ul><ul><ul><li>normally two components A 2 and P 2 </li></ul></ul><ul><ul><li>splitting of the 2 nd heart sound in inspiration </li></ul></ul>
  30. 30. 2nd Heart sound: abnormal splitting <ul><li>single 2 nd heart sound </li></ul><ul><ul><li>inaudible pulm. component </li></ul></ul><ul><ul><ul><li>pulmonary atresia </li></ul></ul></ul><ul><ul><ul><li>due to emphysema </li></ul></ul></ul><ul><ul><ul><li>severe pulm. stenosis </li></ul></ul></ul><ul><ul><li>inaudible aortic component </li></ul></ul><ul><ul><ul><li>severe calcific aortic stenosis </li></ul></ul></ul><ul><ul><ul><li>aortic atresia </li></ul></ul></ul><ul><ul><li>persistent synchrony of the two components </li></ul></ul><ul><ul><ul><li>Eisenmenger’s complex </li></ul></ul></ul>
  31. 31. 2nd Heart sound: abnormal splitting <ul><li>Persistent splitting </li></ul><ul><ul><li>delay in the pulm. component </li></ul></ul><ul><ul><ul><li>complete RBBB </li></ul></ul></ul><ul><ul><li>early timing of the first component </li></ul></ul><ul><ul><ul><li>mitral regurgitation </li></ul></ul></ul><ul><li>Fixed splitting </li></ul><ul><ul><li>ostium secundum atrial septal defect </li></ul></ul><ul><li>Paradoxical splitting </li></ul><ul><ul><li>complete LBBB </li></ul></ul><ul><ul><li>right ventricular pacemaker </li></ul></ul><ul><ul><li>severe aortic outflow obstruction </li></ul></ul><ul><ul><li>a large aorta-to-pulmonary artery shunt </li></ul></ul>
  32. 32. 2nd Heart sound: abnormal intensity <ul><li>Increased A 2 </li></ul><ul><ul><li>systemic hypertension </li></ul></ul><ul><li>increased P 2 </li></ul><ul><ul><li>pulmonary hypertension </li></ul></ul>
  33. 33. 3 rd heart sound <ul><li>due to sudden limitation of ventricular expansion during early diastolic filling </li></ul><ul><ul><li>heard normally in children </li></ul></ul><ul><ul><li>and in patients with high cardiac output </li></ul></ul><ul><ul><li>in patients over 40 years old </li></ul></ul><ul><ul><ul><li>an S3 usually indicates </li></ul></ul></ul><ul><ul><ul><ul><li>impairment of ventricular function </li></ul></ul></ul></ul><ul><ul><ul><ul><li>AV valve regurgitation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>other conditions that increase the rate or volume of ventricular filling </li></ul></ul></ul></ul>
  34. 34. 4 th heart sound <ul><li>a low-pitched, presystolic sound produced in the ventricle during ventricular filling </li></ul><ul><li>it is associated with an effective atrial contraction and is best heard with the bell piece of the stethoscope </li></ul><ul><li>absent atrial fibrillation </li></ul><ul><li>occurs when diminished ventricular compliance increases the resistance to ventricular filling </li></ul><ul><li>seen in </li></ul><ul><ul><li>patients with systemic hypertension </li></ul></ul><ul><ul><li>aortic stenosis </li></ul></ul><ul><ul><li>hypertrophic cardiomyopathy </li></ul></ul><ul><ul><li>ischemic heart disease </li></ul></ul><ul><ul><li>acute mitral regurgitation </li></ul></ul>
  35. 35. Murmurs <ul><li>result from vibrations set up </li></ul><ul><ul><li>in the blood stream </li></ul></ul><ul><ul><li>and the surrounding heart and great vessels </li></ul></ul><ul><ul><li>as a result of </li></ul></ul><ul><ul><ul><li>turbulent blood flow, </li></ul></ul></ul><ul><ul><ul><li>formation of eddies, </li></ul></ul></ul><ul><ul><ul><li>cavitation (bubble formation as a result of sudden decrease in pressure) </li></ul></ul></ul><ul><li>graded I – VI </li></ul><ul><ul><li>grade I faint, heard only with special effort </li></ul></ul><ul><ul><li>grade II soft </li></ul></ul><ul><ul><li>grade III loud </li></ul></ul><ul><ul><li>grade IV loud with thrill </li></ul></ul><ul><ul><li>grade V audible with stethoscope barely touching the chest </li></ul></ul><ul><ul><li>grade VI murmur is audible with the stethoscope removed from contact with the chest </li></ul></ul>
  36. 36. Murmurs <ul><li>for a murmur, determine its </li></ul><ul><ul><li>timing </li></ul></ul><ul><ul><li>intensity </li></ul></ul><ul><ul><li>pitch </li></ul></ul><ul><ul><li>site of maximal intensity </li></ul></ul><ul><ul><li>radiation </li></ul></ul><ul><ul><li>configuration </li></ul></ul><ul><ul><li>relationship with posture and respiration </li></ul></ul><ul><li>three major categories of murmurs </li></ul><ul><ul><li>systolic, diastolic and continuous </li></ul></ul>
  37. 37. other cardiac sounds <ul><li>Pericardial rubs </li></ul><ul><ul><li>the hallmark of acute pericarditis </li></ul></ul><ul><ul><li>generated by the parietal and visceral pleura rubbing against each other </li></ul></ul>
  38. 38. Other relevant examination <ul><li>lung bases </li></ul><ul><ul><li>crepitations in left heart failure </li></ul></ul><ul><li>abdomen </li></ul><ul><ul><li>hepatomegaly in right heart failure </li></ul></ul>
  39. 39. Cardiac Investigations and Procedures <ul><li>Electrocardiogram (ECG) </li></ul><ul><li>Chest X-Ray (CXR) </li></ul><ul><li>Echocardiography </li></ul><ul><li>Trans- oesophagealEchocardiography (TEE) </li></ul><ul><li>Treadmill Testing </li></ul><ul><li>Tilt Table Test </li></ul>t
  40. 40. Cardiac Investigations and Procedures <ul><li>Other New Imaging Techniques </li></ul><ul><li>Cardiac Catherization </li></ul><ul><li> Percutanous Transluminal Coronary Angioplasty (PTCA) </li></ul><ul><li>Stenting (PTCS), </li></ul><ul><li>drug eluting stents </li></ul><ul><li> Brachytherapy (radiation) </li></ul>
  41. 41. Cardiac Investigations and Procedures <ul><li>Electrophysiological Study of the Heart (EPS) and Radio-frequency Ablation (RF) </li></ul><ul><li>Permanent Pacemaker Implantation (PPM) </li></ul><ul><li>Automatic Implantable Cardiovertor -Defibrillator (AICD) </li></ul><ul><li>Automated External Defibrillators ( AEDs ) </li></ul>

×