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Cardiovascular Examination

Cardiovascular Examination. Part 1. Clinical History. Common Presenting Complaint Previous Medical History Medication Psychosocial Aspect. Presenting Complaints. Chest Discomfort Breathlessness Dizziness Palpitations Blackouts. Chest Discomfort. Classic

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Cardiovascular Examination

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  1. Cardiovascular Examination Part 1

  2. Clinical History • Common Presenting Complaint • Previous Medical History • Medication • Psychosocial Aspect

  3. Presenting Complaints • Chest Discomfort • Breathlessness • Dizziness • Palpitations • Blackouts

  4. Chest Discomfort Classic • Constricting chest pain radiating to the left arm or neck

  5. Angina • No pain at all • Back pain • Discomfort • Epigastric • Shoulder • Isolated arm • Jaw

  6. Atypical Symptoms • Precipitating Factors • Relieving Factors • Associated Symptoms • Supporting Evidence

  7. Precipitating Factors • Effort • Emotion

  8. Relieving Factors • Rest • Sublingual nitrates

  9. Associated Symptoms • Breathlessness • Autonomic Features • Sweating • Nausea • Vomiting • Pallor

  10. Supporting Evidence • EKG • Cardiac Enzymes

  11. Breathlessness Cardiac • Arrhythmia • Chronic low cardiac output • Ischemic LV dysfunction • Pulmonary Edema

  12. Breathlessness Non Cardiac • Pulmonary Edema • Systemic Acidosis • B-blockade • Pulmonary Embolism • Pneumonia

  13. Differentiate • Precipitating Factors • Effort • Lying flat • Relieving Factors • Rest • GTN • Sitting Up • Associated Symptoms • Chest Pain • Palpitation

  14. Palpitation • Onset • Gradual • Rapid • Rate of Rhythm • Slow • Fast • Regular versus Irregular • Precipitants • Effort • Anginal episode • alcohol

  15. Grading Symptoms - NYHA • Fatigue • Dyspnea • Angina

  16. Grading Symptoms - NYHA

  17. Dizziness Causes • Cardiac • Low CO • Arrhythmia • Drugs • Antianginal • Diuretics

  18. Dizziness Causes • Vasovagal Syndrome • Vascular • Carotid • Vertebrobasilar • Cerebrovascular

  19. Dizziness Associated Symptoms • Flushing • Palpitation • Syncope

  20. Blackouts • Cardiac • Exertional Syncope • Aortic Stenosis • Outflow Obstruction • Exercise-induced arrhythmia • Vasovagal • Prolonged Standing • Emotion • Noxious Stimuli • Cough • Micturition

  21. Previous Medical History • Previous MI • Angina • History of • Rheumatic Fever • Scarlet Fever • Cardiac Surgery • CABG • Valve replacement

  22. Previous Medical History • Coronary Risk Factor • Hypercholesterolemia • Smoking • Diabetes Mellitus • Family History • Hypertension • Medication

  23. Psychosocial History • Work • Home • Alcohol • Psychological problems

  24. Cardiovascular Examination • General Inspection • Demeanor • Color • Pallor • Central cyanosis • Peripheral cyanosis • Jaundice • Plethora • Malar flush

  25. Cardiovascular Examination • Build • Obesity • Cachexia • Marfanoid • Dysmorphic • Hypertelorism – PS • Elfin facies – Supravalvular AS • Down Syndrome – Endocardial cushion defect.

  26. Hands and Face • Temperature • Sweating • Digital clubbing • Cutaneous features of endocarditis • Petechiae • Splinter haemorrhages • Osler’s modes • Janeway lesions

  27. Hands and Face • Xanthomata • Tendon xanthomata • Palmar xanthomata • xanthelesma • Teeth • Eyes • Corneal arcus • Hypertensive retinopathy • Diabetic retinopathy • Roth spots

  28. Arterial System Pulses • Rate • Rhythm • Volume • Low volume • High volume • Character • Pulsus alternans • Pulsus paradoxus • Pulsus biferiens • Collapsing pulse • Slow rising • Jerky pulses

  29. Arterial System Peripheral Pulses • Femoral • Volume • Radio-femoral delay • Duroziez’s Sign • Popliteal • Dorsalis Pedis • Posterior tibial

  30. Arterial System Blood Pressure • Check BP in both arm • Supine upper and lower limbs • Pulsus Paradoxus

  31. Pulsus Paradoxus • A decrease in systolic BP of greater than 10 mmHg or weakening of the pulse during inspiration. • It occurs commonly in cardiac tamponade; • Occurs occasionally in constrictive pericarditis, severe asthma, or COPD; • Occurs rarely in restrictive cardiomyopathy, severe pulmonary embolism, or hypovolemic shock.

  32. Jugular Venous Pressure Systole Diastole a a c c v y x

  33. Jugular Venous Pressure • a-wave • Rise in JVP due to atrial contraction • c-wave • Transmitted carotid pulse at onset of systole • v-wave • Rise in RA due to filling against a closed tricuspid valve

  34. Jugular Venous Pressure • x descent • RA relaxation followed by descent of TV in systole • y descent • Pressure drop as TV opens at start of diastole

  35. Jugular Venous Pressure • Gives and index of RAP • Elevated • Recline patient at 45 degree incline • Timed with carotid pulse

  36. Jugular Venous Pressure Abnormal JVP • Large a-wave • RVH • TS • Cannon waves • Atrial contraction against a closed valve • Junctional rhythm • Complete heart block • Large v-wave • TR

  37. Jugular Venous Pressure • Rapid y descent • Myocardial dysfunction and increased CVP • ASD • Constrictive pericarditis • Kussmaul’s sign • Rise of JVP on inspiration • Onstirctive pericarditis • Tamponade • Fixed, raised JVP • SVC Obstruction

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