Cvs examination


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Cvs examination

  1. 1. CVS Examination Prof Yan-Lynn Myint MBBS,MMedSc (Int.Med.) MRCP(UK) FRCP Edin. YLM 114/03/2006
  2. 2. Why CVS in Dental practise? • Dental practise/ procedures that induce CVS diseases • CVS diseases that can be exacerbated by dental procedures YLM 214/03/2006
  3. 3. History • Name, age, sex, address, occupation • Chief complaints • HOPI • PH • FH/SH • Personal history • O & G history YLM 314/03/2006
  4. 4. Cardinal/common symptoms Symptoms CVS causes Other causes Chest discomfort 1. MI 1. Oesophageal spasm 2. Angina 2. Pneumothorax 3. Pericarditis 3. MS pain 4. Aortic dissection Breathlessness 1. Heart failure 1. Resp disease 2. Angina 2. Anaemia 3. Pul embolism 3. obesity 4. Pul HT Palpitation 1. Anxiety 1. Tachyarrhythmia 2. Hyperthyroidism 2. Ectopic beats 3. drugs Syncope/dizziness 1. Arrhythmias 2. Postural hypertension 1. Simple faints 3. Aortic stenosis 2. epilepsy 4. HOCM 5. Atrial myxoma oedema 1. Heart failure 1. Nephrotic syndrome 2. Constrictive pericarditis 2. Liver disease 3. Venous stasis 3. drugs YLM 414/03/2006
  5. 5. Type of cardiac pain Type Causes Characteristics Angina Coronary stenosis (rarely Ppt by exertion, eased by aortic stenosis, HOCM) rest and/or GTN Characteristic distribution Myocardial Coronary occlusion Similar sites to angina, infarction more severe, persist at rest Pericarditic pain Pericarditis Sharp, raw or stabbing Varies with movement or breathing Aortic pain Dissection of aorta Severe, sudden onset, Radiate to back YLM 514/03/2006
  6. 6. Angina pectoris • Site and radiation • Duration, precipitation and relieving factors Aggravating Relieving •Exertion •Rest •Emotional excitement •GTN •Cold weather •Warm up before exercise •Exercise after meal • Character, severity • Special types 614/03/2006 – Unstable, crescendo, nocturnal, YLM
  7. 7. Differential Diagnosis Angina Oesophageal pain Usu. Ppt by exertion Can be worsened by exertion, but often present at other time Rapidly relieved by rest Not rapidly relieved by rest Retrosternal and radiate to arms Retrosternal or epigastric, and jaw sometimes radiate to arms or back Seldom wakes patient from sleep Often wakes patient from sleep No relation to heartburn (but often Sometimes related to heartburn have wind) Rapidly relieved by nitrates Often relieved by nitrates Typical duration 2-10mins Variable duration YLM 714/03/2006
  8. 8. Differential Diagnosis Angina Myocardial infarction Site: retrosternal, radiate to arm, As for angina epigastrium, neck Ppt by exercise or emotion Often no obvious precipitant Relieved by rest, nitrates Not relieved by rest, nitrates Mild/moderate severity Usually severe (may be silent) Anxiety absent or mild Severe No increased sympathetic activity Increased sympathetic activity No nausea or vomiting Nausea and vomiting are common YLM 814/03/2006
  9. 9. Pericardial pain Site Retrosternal, may radiate to left shoulder or back Prodrome May be preceded by a viral illness Onset No obvious initial precipitating factor;tends to fluctuate in intensity Nature May be stabbing or raw – like sandpaper. Often described as sharp, rarely as tight or heavy Made worse by Changes in posture, respiration Helped by Analgesics, especially NSAIDs Accompanied by Pericardial rub YLM 914/03/2006
  10. 10. Dissection of thoracic aorta Site Often first felt between shoulder blades, and/or behind the sternum Onset Usually sudden Nature Very severe pain, often described as tearing Relieved by No, tend to persist. Patient often restless with pain Accompanied by Hypertension, asymmetric pulses, unexpected bradycardia, early diastolic murmur, syncope, focal neurological symtoms and signs YLM 1014/03/2006
  11. 11. Breathlessness • Awareness of one own breathing – Dyspnoea on exertion – Orthopnoea – Paroxysmal nocturnal dyspnoea YLM 1114/03/2006
  12. 12. Palpitation • Sensation of the heart beating in the chest YLM 1214/03/2006
  13. 13. Syncope and dizziness • Postural hypotension • Arrhythmias • Left ventricular outflow obstruction YLM 1314/03/2006
  14. 14. Peripheral oedema Unilateral •Deep vein thrombosis •Soft tissue infection •Trauma •Immobility, e.g. hemiplegia Bilateral •Heart failure •Chronic venous insufficiency •Hypoproteinemia, e.g. nephrotic syndrome, kwashiorkor, cirrhosis •Lymphatic obstruction, e.g. pelvic tumor, filariasis •Drugs, e.g. NSAIDs, Nifedipine, amlodipine, fludrocortisone •IVC obstruction •Thiamine deficiency (Wet Beri Beri) •Milroy’s disease •immobility YLM 1414/03/2006
  15. 15. CVS disease presenting with non-cardiac symptoms System Symptom Causes •Cerebral embolism CNS Stroke •Endocarditis •Hypertension Jaundice •Liver congestion GI •2˚to heart failure Abdominal pain Mesenteric embolism Renal Oliguria Heart failure YLM 1514/03/2006
  16. 16. Presenting complaint • Recent onset • Slowly progressive • Functional assessment YLM 1614/03/2006
  17. 17. Past history • Rheumatic fever • Diabetes mellitus • Hypertension • Thyroid disease • Recent dental works YLM 1714/03/2006
  18. 18. Drug history Exacerbation of heart failure by β-blockers, some Dyspnoea CCB, NSAIDs Dizziness Vasodilators, e.g. nitrates, alpha-blockers, ACEI Aggravated by thyroxine, drug-induced anaemia, e.g. Angina aspirin, NSAIDs •Fluid retention from steroids, NSAIDs Oedema •Oedema from CCB (nifedipine, amlodipine) •Tachycardia and/or arrhythmia from thyroxine, beta-2 stimulant (salbutamol), Palpitation •digoxin toxicity, •hypokalemia from diuretics, tricyclic antidepressants YLM 1814/03/2006
  19. 19. Family history • IHD, HT • Sudden death at young age YLM 1914/03/2006
  20. 20. Social history • Smoking – CHD, PVD • Alcohol – AF, HT • Caffeine – palpitation YLM 2014/03/2006
  21. 21. Occupational history Occupational exposure associated with CVD Organic solvents Arrhythmias, cardiomyopathy Vibrating machine tools Raynaud’s phenomenon Publicans Alcoholic cardiomyopathy Occupational exposure exacerbating pre-existing cardiac conditions Cold exposure Angina, Raynaud’s disease Deep-sea diving Embolism through foramen ovale Occupational requirements for high standards of CVS fitness Pilots, public transport, HGV drivers, armed forces, police YLM 2114/03/2006
  22. 22. Physical examination • General examination – face • Dyspnoeic or not • Pallor • Cyanosis • Xanthoma, xanthelesma, arcus – hands • Signs of infective endocarditis – Splinter haemorrhage, clubbing, Osler’s nodes, Janeway’s lesion – Feet/sacral area • Oedema, petichial haemorrhage, YLM 2214/03/2006
  23. 23. Pulses Fast heart rate (tachycardia, >100/min) Sinus tachycardia Arrhythmia •Exercise •Atrial fibrillation •Pain •Atrial flutter •Excitement/anxiety •Supraventricular tachycardia •Fever •Ventricular tachycardia •Hyperthyroidism •Medications: –Sympathomimetics –vasodilators YLM 2314/03/2006
  24. 24. Pulses Slow heart rate (bradycardia, < 60/min) Sinus bradycardia Arrhythmia •Sleep •Carotid sinus hypersensitivity •Athletic training •Sick sinus syndrome •Hypothyroidism •Second-degree heart block •Medications: •Complete heart block –Beta-blockers –Digoxin –Verapamil, diltiazam YLM 2414/03/2006
  25. 25. Causes of irregular pulse •Sinus arrhythmia •Atrial extrasystoles •Ventricular extrasystoles •Atrial fibrillation •Atrial flutter with variable response •Second-degree heart block with variable response Common causes of atrial fibrillation •Hypertension •Cardiac failure •Myocardial infarction •Thyrotoxicosis •Alcohol-related heart disease •Mitral valve disease •Infection, e.g. respiratory, urinary tract •Following surgery, especially cardiothoracic surgery YLM 2514/03/2006
  26. 26. Blood pressure • Rest • Sitting for ambulant • Support the arm at about heart level • Apply the cuff • Inflate the cuff • Deflate the cuff • Systolic • diastolic YLM 2614/03/2006
  27. 27. Differences between carotid and jugular pulsation Carotid Jugular Rapid outward movement Rapid inward movement One peak per heartbeat Two peaks per heartbeat palpable Impalpable Pulsation unaffected by Pulsation diminished by pressure at the root of neck pressure at the root of neck Independent of respiration Height of pulsation varies with respiration Independent of position Varies with position of patient Independent of abdominal Rises with abdominal pressure pressure YLM 2714/03/2006