“Unpleasant Awareness of Breathing”.
• COPD • Restrictive L. Disease
• Br. Asthma • Chest Wall Dis. (kyphossi, scoliosis, pectus excavatum, pectus carinatum.)
• Cardiac – CHF (MS, MR, AS, MI. CM)
• Obesity: - The heart can not pump enough blood to the increasing size of the body. Mechanical causes (elevated diaphragm by the adipose tissue accumulated in the abdomen).
• Psychogenic, especially in young female.
FUNCTIONAL CLASSES OF DYSPNEA: (NYHA Classification)
Class I D.O. extraordinary exertion (or no dyspnea on average exercise).
Class II D.O. moderate exertion
Class III D.O. mild exertion
Class IV D. at rest (PND & Orthopnea)
II. CHEST PAIN OR DISCOMFORT:
- Angina Pectoris
- Unstable Angina.
- Acute Myocardial Infarction
2) Mitral Valve Prolapse (MVP)
3) Pericarditis: retrosternal , continuous, cutting or stretching pain, increased with supine position or inspiration and relieved partially by sitting up.
5) Peptic Ulcer Disease ( PUD )
6) Biliary Disease. Biliary colic may radiate to the chest in addition to its typical radiation to shoulders.
7) Cervical Disc Diseases: for example brachial plexus compression by herniated disc.
8) Teitze's syndrome: non specific costochondritis.
9) Neurocirculatory Asthenia: uncommon cause of chest pain, occur in refined people who have chest pain after minimal exertion. The cause is accumulation of lactic acid that causes pain in those people because they have very low pain threshold.
10) Pleuritic pain: e.g. due to pulmonary infarction or infection.
CORONARY ARTERY DISEASES:
-Chronic stable angina.
- Unstable angina.
- Acute MI.
Acute coronary syndrome includes myocardial infarction and unstable angina.
CHRONIC STABLE ANGINA:
TYPICAL ANGINAL PAIN
deep retrosternal pain radiating to left shoulder and left arm. Sometimes it radiate to mandible, epigastrium, right shoulder and right arm.
Quality of pain:
every few weeks. Severe burning sensation, squeezing, cutting or compressing.
Duration (few minutes):
average 3-5 minutes but it ranges from 1-10 minutes, never for seconds or hours. Infra mammary pin bricking or stabbing pain lasting for seconds is not typical for angina.
to left shoulder and left arm particularly ulnar site up to the little finger. Sometimes it radiate to mandible, epigastrium, right shoulder and right arm.
Provoking factors (Exercise, Emotional excitement and Cold weather especially in early morning (first wind pain.)
Relieving factors: (rest & TNG)
dizziness, moderate sweating, palpitations, nausea and rarely vomiting.
Males > 45 years, females > 55 years.
Dyslipidaemia: high total cholesterol level, high LDL, high TG, low HDL.
Strong family history of coronary artery diseases (e.g. premature CAD or premature cardiac death in parents or sibling.).
The pain last for > 10 minutes and occur at rest or after minimal exertion.
New onset frequent angina. No previous history of angina. Some attacks occur at rest or after very mild exercise.
Crescendo or accelerated angina: previous history of angina attacks but becomes more frequent or occurs at rest for more than 10 minutes. Not Responding well to SL TNG.
Normal response to TNG should be within 5 minutes, if the response takes more than 10 minutes- unstable angina.
Post MI Angina:
The patient come to you and told you that he was discharged from cardiac unit the last week after treating MI and in the previous few days he experinced the same type of the old pain. You have to take it seriously.
Occur at rest. The cause may be vasospasm of coronary arteries.
You should instruct the patients to report to their doctors if they failed to respond to 3 tablets of sublingual TNG
ACUTE MYOCARDIAL INFARCTION PAIN:
Site: start retrosternally but spread like a fire to many sites.
Quality: squeezing, compressing, extremely intolerable severe pain.
Duration: > 30min.
Dizziness because of hypotension.
Nausea and vomiting
Generally, it does not respond to SL TNG.
“Bluish Discoloration of the Skin and Mucous Membranes.”
Central: the blood is not well saturated with oxygen.
COPD: e.g. severe cases of asthma, restrictive lung disease.
Congenital cyanotic heart diseases e.g tetralogy of Fallots.
Some of the congenital heart diseases (e.g ASD, VSD, PDA, coarctation af aorta) that start non cyanotic then becomes cyanotic. This is called Eisenmenger's syndrome.
Central cyanosis is seen any where in the body particularly and most importantly in oral mucosa (sublingual mucosa and hard palate). It can be also seen in skin and hands, which becomes warm (because carbon dioxide is a vasodilator).
Poor circulation in the peripheral parts of the body.
Cold (VC of arteries).
Connective tissue diseases e.g SLE, RA ,Raynaud's phenomena: VC of arteries due to vasculitis induced by cold.
The hands in peripheral cyanosis are cold.
Increase intensity of cyanosis particularly upon exercising. The patient may even have convulsions due to severe brain hypoxemia.
In congenital cyanotic heart diseases there is shunting of blood from right to left ventricle withut oxygenation which lead to cyanosis. Squatting Increase peripheral resistance and decrease the intracardiac shunts- decreased cyanotic blood.
IV. DIZZINESS, PRESYNCOPE AND SYNCOPE.
Presyncope: the patient feel that he is going to lose his conscious but have limited consciousness to support himself on a chair or anything else to prevent falling down. ( يحس المريض كأنه في نفق مظلم )
Syncope: The patients fall down. Sudden Loss of consciousness for a while (not more than 30 minutes).
• Drugs: V. Dilators. E.g. when you start treating hypertension the drugs will cause VD of arteries and may induce hypotension this is known as First Dose Phenomena so it is better to start therapy with small doses then titer it until you reach the desired effect. You can give the first dose in your office and ask the patient to wait in the hospital for 2-3 hours or let the patient sleep in the hospital that night and in this way you can interfere early if any side effect occur.
• Vasovagal syncope: cause bradycardia and hypotension.
Bad news especially in females: sympathetic reaction followed by parasympathetic reaction.
Pain e.g. severe intestinal colic or disc prolapse.
Hot weather, heat exhaustion
Watching some tragedy.
• Carotid S. Hypersensitivity: rare
• Cardiac Arrhythmia: the most common cause.
Severe tachycardia > 200 beat/minutes ,limit the filling time,decrease the blood volume, decrease the stroke volume , decrease the cardiac output.
Complete heart block ,sever bradycardia.
• Cardiac Lesions especially stenotic lesions (AS, MS, PS) limit the stroke volume, cardiac output,compromised cerebral perfusion.
“Unpleasant Awareness of Forceful or Rapid Heart Breathing.”
– Fast or slow.
– Regular or irregular.
– Onset and offset:
Sudden onset and offset in paroxysmal supraventricular tachycardia or paroxysmal atrial fibrillation.
– Associated symptoms: dizziness, presyncope and syncope, chest pain, dyspnea, polyuria, pallor.
VI. EDEMA OF THE LOWER LIMBS.
In general, the most common cause of limb edema is venous insufficiency.
Cardiac: the most common cardiac cause is CHF
Renal. Acute or chronic (nephrotic syndrome ).
Hypoalbuminemia (Liver cirrhosis).
Venous Insufficiency: damaging of valves, extravasation, mainly in female (multipara, physical inactivity).
In general, the most common cause of limb edema is venous insufficiency.
1+ Around ankle Joint.
2+ Below knee joint.
3+ Above knee joint.
4+ Scrotal edema: hydrocele, and edema of the ant. abdominal wall.
Sacral edema can occur with 2nd,3rd, 4th degree if the patient is confined to bed.
VII. COUGH DUE TO CHF:
It occurs when pulmonary vascular pressure ,with exercise or even at rest in patients with CHF , transudation of fluid into alveolar spaces , Cough, and sometimes Hemoptysis.
Dyspnea on exertion and cough on exertion occur in CHF.
P. Congestion (CHF) , Ruptured P. Capillaries.
It occurs in:
- P. Infarction.
- Eisenmenger Complex.
- severe aortic stenosis.
-Ruptured A-V Fistula.
-Ruptured Aortic Aneurysm into bronchotracheal tree.
It is usually due to low C.O.
CHF, AS, MS, PHT, MI, CM.
The patient is pale, effort-intolerant.
Severe femoral or popliteal artery stenosis.
Ischemic pain in one leg on walking, depend on the other leg , claudication.
Correlate claudication to distances:
Mild- 500 m
Moderate – sever – 100-200
Very severe – few meters
At rest , the patient is at risk of gangrene.
B) CLINICAL EXAMINATION
GENERAL CLINICAL EXAMINATION:
Patient’s position : (45º inclination of the head of the bed)
JVP, more convenient,Quiet & warm room with good lights.
1) General Look
– Skin complexion (color).
– Pain or respiratory distress.
– Level of consciousness ( Orientation to place, time & persons).
– Body edema: anasarca.
2. HAND EXAMINATION:
Stigmata of Infective Endocarditis:
Janeway lesion : erythamatous rash including thenar and hypothenar muscles.
Osler’s Nodules: palp of phalanges show violet tender nodules.
Signs of Hyperlipidemia:
Signs of Thyrotoxicosis:
Cause of thyrotoxic heart disease, HF and severe tachcardia.
Fine Tremors, warms, wet hands
Signs of clubbing:
1+obliteration of the angle
2+ curvature obliteration
3+ transverse drum stick
4+ involvement of the rest ( pulmonary osteoarthopathy.)
3. RADIAL PULSE:
the arm should be vertical ( not supine nor prone)
• Collapsing Pulse. Impress hand with very strong bound then disappear suddenly. AR
• Slow rising pulse (pulsus parvus et tardus or Anacrotic Pulse).AS : take long time to increase to the normal. Appearance of anacrotic notch.
• Pulsus alterans.one impulse is normal and the other is weak. The distance between the 2 pulse are equal.
• Pulsus paradoxicus. In cases of severe asthma, constrictive pericarditis,pericardial effusion.
• Pulsus bigeminus.one impulse is strong and normal followed immediately by weak.Premature atrial or ventricular beat.
• Pulsus bisferious.
Thickened (generalized atherosclerosis, cord like artery, check it in large arteries: brachial or carotid).
Radio-radial : if both radial arteries are asynchronized large arteries occlusion ( aneurysm or atherosclerosis)
Radio-femoral Equality and Synchronization. if femoral artery pulse is delayed and weak coarctation of aorta.
4. BLOOD PRESSURE MEASUREMENT:
1. The Cuff
2. Position of the patient
– There are 5 KOROTKOFF’s Sounds:
Syst BP -Korotkoff 1
Increase intensity -Korotkoff 2
Full intensity - Korotkoff 3
Murmush - Korotkoff 4
Diast BP -Korotkoff 5
<120 style="color: rgb(153, 51, 153);">Prehypertensive Stage:
Stage 1 HPT:
Stage 2 HPT:
5. RESPIRATORY RATE AND TEMPERATURE.
The oral temperature is normally lower than the rectal temperature by 0.5
Axillary temperature is lower than the oral reading by 0.5.
Normal respiratory rate is <>6. FACE EXAMINATION:
Down’s Syndrome: small simple ears, flat nasal bridge, norrow high arched palate,…etc. They have congenital heart disease, especially endocardial cushion defects.
Marfan’s Syndrome: tall stature, thoracic kyphosis, pectus excavatum, arachnodactyly (spider fingers) long limb,and high arched palate. Commonly have AR, intraseptal defects, MVP
Malar Rash: MS, connective tissue disease like SLEAR.
Plethoric Face: sign of polycythemia, but in Scandinavian who have white skin and drink alcohol (that cause VD), plethoric face is a normal finding.
Mucous Membranes of the Mouth: look for pallor, cyanosis and jaundice.
Mucous Membranes of the Mouth
Arcus Cornialis: lipid deposition around the cornea occuring in middle aged (around 40 years), incomplete ring (crescent-like shape) which indicate hyperlipidaemia. If this ring occur in old aged (80 years) it is called Arcus Senilis.
Xanthelasma: intracutaneous yellow cholestrol deposit around the eyes, may be normal or indicate type II or III hyperlipidaemia.
Signs of Hyperthyroidis
Mouth Hygiene: some times cardiac infection may result from poor oral hygiene.
7. JUGULAR VENOUS PRESSURE (JVP)
Position of the patient -45º
Rt. Internal JV is used because it has direct continuation with the right atrium unlike left internal JV which makes sveral turns before entering the heart. (left internal JV unites with the left subclavian vein behinde the medial end of clavicle to form left brachiocephalic vein which then passes obliquely to the right side and join right brachiocephalic vein to form SVC).
Upper third: medial to sternocleidomastoid.
Middle third: lateral to sternocleidomastoid
Lower third: between the 2 heads of sternocleidomastoid
Normal JVP =8 cm water.
A wave-caused by atrial contraction (late diastolic, presystolic event.)
C wave - tricuspid valve closure.
V wave- venous return to the heart ( atrial filling, end systolis.)
We have 2 large positive waves (A+ v) and one small positive wave (c wave)
Y wave- diastolic, the most prominent negative wave caused by tricuspid valve opening.
X1 and X2 waves - systolic negative waves:
X1 between A and C waves
X2 between C and V waves
Causes of Prominent A wave:
- PH - TS
Cause of absent A wave A. Fib
Cause of Prominent V wave TR
- during Inspiration > Expiration.
Normally the venous return to the heart increases during inspiration so JVP decrease( blood is shifted to the heart) but the situation is opposite to that in kussmaul's sign which occur in conditions where you have impaired right ventricular filling so during inspiration more blood is accumulated in the veins elevated JVP.
Cause of prominent A and V waves, RSHF
Normally we DO NOT see JVP.
If you find the top of the pressure wave,measure the vertical distance between the top of the column and angle of Louis and add 5 cm to it ( the rough vertical distant from the angle to the right atrium with the patient lying at 45 degree), the sum is an estimate of the central venous pressure.
8. CAROTID PULSE:
Normally not seen.
Corrigan’s Sign: prominent carotid pulsation caused by:
- Hyperdynamic circulation, thyrotoxicosis.
- Aortic atherosclerosis, aneurysm.
Lt thumb for Rt carotid A
Rt thumb for Lt carotid A
-Thrill - Carotid shadder transmitted from severe AS
Auscultation: done for aged patients, do it for youngs if you suspect AS or carotid atherosclerosis which is serious conditions with high risk for stroke (carotid arteries provide much of the blood supply to the brain.)
9. THYROID GLAND:
Inspection: enlarged or normal
Percussion: percuss the maniburum from downward upward.
Auscultation: auscultate for thyroid bruit which is a sign of increased blood supply that may occur in hyperthyrodism. If the sound is heard in one lobe only, it is usually due to malignancy.
10. EXAMINATION OF THE PRECORDIUM:
Shape of the chest
– Pectus excavatum
– Rectus Craniatum
– Kyphosis & Scoliosis
Precordial Bulge: long standing heart diseases e.g. AR, CM., left or right ventricular dilatation specially in children and adolescence.
Scar of previous cardiac surgery
– Mid-sternotomy scar: previous open heart surgery.
Apex Beat: is it visible or not??
Causes of absent apical impulse: (they are also the causes of impalpable apical impulse)
Lt. pleural effusion or pneumothorax
Severe pericardial effusion.
Other Cardiac pulsations:
Site: usually fourth or fifth left intercostal space at the mid-clavicular line.
It can be displaced away from its normal position, e.g. in left ventricular dilatation, chest wall deformity, pleural or pulmonary diseases.
If displaced downward: mention the space it reach e.g. sixth, seventh intercostal space.
If displaced laterally: mention how many cm does it displaced lateral to mid-clavicular line.
It can be displaced downward and laterally: e.g. sixth intercostal space at the anterior axillary line.
• Normal: felt over an area about the size of a coin.
• Tapping (palpable S1)
• Localized (you can localize it with the tip of your index finger) or diffuse (if the diameter is more than 2 cm or found in 2 intercostal spaces). Diffuse apical impulse associated with left ventricular dilatation e.g. AR,
Thrill= vibration, more easily felt with the patient rolled over to the left side (left lateral position).It can be systolic (e.g. MR) od diastolic (e.g. MS).
Triple apical impulse: HOCM (take this shape because maximum obstruction occure during maximum contraction)
2) Other Pulsation:
Left Parasternal Heave: palpate it with the palm, borders or heel of hand.
Severe LA dilatation
Pulmonary area, Dilated Pulm. Artery,PH
Aortic Area , Aortic aneurysm
Pulsatile hepatomegalyRS HF
Palpable Abd. Aorta (e.g. aneurysm).
Pulsation below the xiphoid process( subcostal area) Left atrium enlargement.
C) PALPABLE HEART SOUNDS AND CLICKS
Palpable S1- Tapping apical impulse
Palpable P2- PH
Palpable A2 at right second intercostal space- systemic hypertension.
Palpable S4 - HOCM
MS & TS
MR at the M. area
AS -A. area
PS - P. area
VSD - 3rd & 4th Lt. ICS
Continuous Thrill - PDA in left sub-clavicular area.
Low frequency sounds -S3, S4
Mid-diastolic murmur - MS & TS.
High frequency sounds -S1, S2, E. clicks, non-ejection click and clicks due to prosthetic valves.
Early diastolic murmur -AR
Continuous murmur- PDA
C) CARDIAC AUSCULTATION:
Quiet and warm room.
S1 at mitral area (diaphragm)- [ both component of S1 (T and M) will be heard here]
S2 at pulmonary area (diaphragm)
S3 & S4 at M. area & T. area (Bell)
Inching auscultation: start auscultation at mitral area then move to tricuspid area ( left fourth or fifth intercostal space). Next inch up the left sternal edge to the pulmonary (second left intercostal space) and aortic (second right intercostal space).
-Mitral Area - Apex beat area (5th LICS).
-Tricuspid Area - 4th, 5th LICS at sternal edge.
-2nd Aortic Area - 3rd LICS at sternal edge.
-Pulmonary Area - 2nd LICS at sternal edge.
-1st Aortic Area -2nd RICS at sternal edge.
The HR should be counted from the M. area if the radial pulse was totally irregular - Pulsus deficit.
When there is irregularity e.g. fibrillation, some of the contractions will be weak and can not cause vibration of arteries walls so there is no generation of peripheral pulse -pulsus deficit ( radial pulse rate is less than the heart rate).
S1 : M. area (mitral & tricuspid components)
S2- P. area (aortic & pulm. components)
physiological splitting of S2
Mitral & T. Areas for S3 and S4.
S3 - usually physiological in children and adolescents due to rapid filling of the LV.
S3 - CHF & Volume overload AR, MR.
S4 - HOCM, ACS( acute cardiac syndrome), HPT.
Timing in Cardiac Auscultation:
Carotid Impulse - systolic event.
Apical Impulse -systolic event.
The heart sound which correlates with the beginning of Carotid Impulse or Apical Impulse - S1.
The heart sounds which correlates with the end of carotid or apical impulse - S2.
Heart Sounds Pattern on Cardiac Auscultation:
Lub( first sound) ---- Dub( second sound) ---- Lub ---- Dub
Occurs due to presence of S3,S4 or a summation of S3 & S4 in tachycardic patients.
ST( short cardiac cycle).
Soft S1 - Long PR
Variable S1-Non-rheumatic A. Fibrillation
Muffled S1 - MR
Accentuated A2 : Systemic Hypertension.
Accentuated P2 : P. Hypertension.
Soft A2 - AR.
Wide Splitting of S2 during inspiration -when there is delay in right ventricular emptying e.g. RBBB( right bundle branch block)
Fixed and Wide Splitting of S2 - ASD
Paradoxical Splitting of S2- AS ( P component becomes first) - LBBB( left bundle branch block)
Opening Snap - MS
Prosthetic mitral and aortic valve opening.
Prosthetic Mitral valve closure (as a replacement of S1)
Prosthetic AV closure (as a replacement of A2).
ESM (crescendo decrescendo murmur, diamond shape)
A) Functional - Hyperdynamic circulation.
Innocent in childhood and adolescence.
PSM (Pansystolic murmur)
Muffled S1, soft because of incompetent valves.
VSD ( third to fourh left intercostal space)
Early Murmur: acute MI
Late systolic: MVP
Early Diastolic murmur:
Continuous Murmur– PDA.(machinery murmer).
Late diastolic with pre-systolic accentuations: MS
Description of a murmur:
Quality: systolic or diastolic.
Intensity – Scale of 6 grades.
- Grade 1: very soft, even cardiologists face difficlties detecting it.
- Grade2: murmur easily heard by cardiologist but difficult for medical students.
- Grade 3: easily heard by anybody.
- Grade 4: very easily heard, very loud associated with thrills.
- Grade 5: you can hear the murmur by putting your ear on the chest.
- Grade 6: very loud. Can be heard even without placing ears or stethescope on the chest wall.
Site of maximum intensity.
- MR- axilla
- AS-neck arteries ( carotid A)
- AR- radiates downward to apex.
Maneuvers which increases or decreases its intensity:
In general any murmur on the right side is increased by inspiration (increase venous return and therefore increase blood flow to the right side of the heart) and any murmur on the left side is increased with expiration.
Examination of Other Parts of the Body:
Fine bilateral basal crepitation
Liver- Pulsatile & tender hepatomegaly.
Sometimes Ascitis & splenomegaly.
Examination of Other Parts of the Body:
A) Cardiac Edema:– Bilateral & Pitting.
1+ Around ankle Joint..
2+ Below knee joint.
3+ Above knee joint.
4+ Scrotal edema: hydrocele, and edema of the ant. abdominal wall.
B) Peripheral Circulation:
– Inspection & Palpation:
Pale and cold.
Loss of sensation.
Signs of Gangrene
Total arterial occlusion.
Weak or absent pulsations:
if you find normal dorsalis pedis pulse, there is no need to palpate other periphral pulses in the lower limb.
– Dorsalis pedis.
– Tibialis posterior.
– Medial popliteal.
– Femoral artery.
– Poor capillary filling.
C) Varicose Veins:
Dilated tortous superfacial veins.
– Long saphenous vein: medial aspect of legs.
– Short saphenous vein: lateral aspect of legs.
– Superfacial varicosity is an indicator of deep varicosity which is a risk factor for thrombosis.
D) Deep Venous Thrombosis (DVT):
– Unilateral Pitting edema.
– Darker skin than the other limbs.
– surface temperature.
– Tense and painful calf.
– Superfacial varicosity.
– below knee joint -medial popliteal vein
– above knee joint -long saphenous vein or femoriliac venous thrombosis.
Leg circumference is usually - 2.5cm than the other leg (anatomical reference - tibial tuberosity
Thigh circumference - 5cm than the other thigh. (Anatomical land mark medial or lateral epicondyle of the femor bone).