CARDINAL SIGN OF CARDIAC DISEASE

DYSPNOEA CHEST PAIN PALPITATION SYNCOPE

CAUSES
CARDIAC RESPIRATORY
- LSHF - MS
- pericardial
effusion
- pulm eodema
- COPD
- interstitial pulm fibroris
- atelectasis
- pneumonia
TYPES
1. Exertional dyspnea on effort
2. Orthopnea
- on lying flat
- relieved by sitting
- mech:
i) VR from LL pulm
congestion
ii) elevation of diaphragm
interfere respiratory
movement
causes:
- LSHF
- MS
- bronchial asthma
- COPD
3. PND
- attack at night
- awake patient
- 3-4 hrs after sleep
- LV failure
- MS

*earlier than orthopnea

4. Cardiac asthma 5. Bronchial
asthma
family hx -ve +ve
dyspnea inspiratory expiratory
onset 2 hrs after sleep early in morning/
late at night
expect-
ration
frothy during attack
*blood tinged =
pulmonary edema
thick pellet at the
end of attack
pul edema - basal crepitations
- murmurs

auscultation wheezy chest dt bronchospasm
BP normal
pulse rapid normal
ECG abnormal normal
Rx morphine
* adrenaline is C/I!
adrenaline
*morphine is C/I!

GRADING OF EXERTIONAL DYSPNEA
G1 > daily effort
G2 On daily effort
G3 < daily effort
G4 At rest


CAUSES, maybe;

ORGANIC PSYCHOGENIC
CARDIAC NON CARDIAC
- MI
- stable angina
- pericarditis
- aortic
dissection
- pleurisy
- chondritis
- myositis


Comment on:
i) Site
Retrosternal (fist sign) Precordial
1. Ischaemic
- angina - MI
*post-MI + epigastric pain
2. Vascular
- dissecting aortic aneurysm
- pulmonary embolism
- pericarditis
- pericardial effusion
ii) Radiation

iii) Onset

iv) Duration

v) Character
constricting, squeezing,
compressing
angina
stabbing MI
dull aching pulmonary embolism
tearing dissecting aortic aneurysm
stitching pericarditis, pleurisy

vi) Precipitating factor
- bed ridden DVT pulmonary embolism
- stress, cold wheather ischaemia

vii) Relieving factor
- rest, SL nitroglycerine : angina (not MI-occur at rest)
- lying on one side : pleurisy of same side

viii) Associated symptoms
- palpitation, sweating, vertigo IHD
- fever pericarditis, etc

= awareness of heart beat

CAUSES
i) physiological : with exercise
ii) psychogenic : stress, in women
iii) pathological
1. associated with
arrhythmia
2. NOT associated
with arrhythmia
i) Premature beats
(extrasystole) *most
common cause

ii) Tachycardia
iii) Bradycardia
- AR - AS
- ASD - VSD
- PDA


Extra systole Tachycardia Bradycardia
- Acute MI
- Myocarditis
- Adrenaline
- Digitalis
i) Sinus
tachycardia
- hyperdynamic
circulation
(anaemia,
hemorrhage,
thyrotoxicosis)
- adrenaline
ii) Paroxysmal
tachycardia
- SVT ( AF)
- Venticular
( vent fibrillatn)
- Heart
block
- Digitalis

Comment on;
- on rest/effort
- onset (gradual- sinus T / sudden paroxysmal T )
- how it terminates (resp/rest/massage/spontaneous
in SVT)
- rapid (tachycardia) / slow (bradycardia)
- regular/irregular rhythm

= sudden transient loss of
consciousness dt transient cerebral
ischaemia, followed by spontaneous
recovery

CAUSES
1. Vasovagal attack *MCC!
- commonly induced by strong
emotions or trauma to
epigastrium/genitalia

2. Cardiac syncope
- COP
- arrhythmia
- Fallot tetralogy

3. Postural HTN
- after prolonged standing
- potent hypotensive drug
- diabetes

4. Cerebral
- transient ischaemic attack
- stroke

5. Hypersensitive carotid sinus reflex

INSPECTION, PALPATION AUSCULTATION HEAD & NECK PULSE
1. PRECORDIAL BULGE
- in congenital HD
*tangentially

2. PULSATION
Precordial Extra-precordial
- apex
- aortic
- pulmonary
- lower left parasternal
- suprasternal
(hyperdynamic)
- epigastric
(hepatic/aortic/ RV)
* tangent & feel

i) localized +ve thrust/ diffuse
ii) rhythm
iii) rate
iv) force
v) duration

3. THRILL = palpable murmur

present =
- ORGANIC murmur , NOT functional murmur (no
thrills)
- murmur of HIGH INTENSITY (grade 4,5,6)

Comment on;
i) Site of maximal intensity
ii) Timing of thrills

4. DIASTOLIC SHOCK
= palpable accentuated S2 in pulmonary area dt
PHTN

* sitting pt, leaning forward
* ulnar border of hand over pulm area (2
nd
left
interspace parasternal line)
* deep inspiration full expiration hold breath
1. HEART SOUND
S1 S2
Best site Apex/ lower left
parasternal
Pulmonary/aortic
@apex Weak/accentuated
/normal
Heard or not
@pulm/
aortic
Heard/not Weak/accentuated
/normal

2. MURMUR

3. ADDITIONAL HS
Comment on:
- timing (in relation to apical & carotid pulse! not to HS )
S3, S4 is heard only at mitral area

4. PERICARDIAL RUB
1. TRACHEA

2. THYROID EXAM

3. SUBMANDIBULAR LYMPH NODES

4. CAROTID PULSATION

Carotid IJV
Medial to sternomastoid Lateral to sternomastoid
Felt & seen Better seen than felt
No relation with
respiration
Empty with respiration


5. NECK VEIN (IJV)
* lying 45 , avoid straining
Comment on;
i) pressure
ii) level of congestion
iii) pulsation
iv) relation of respiration
v) relation to cardiac cycle
vi) abdomino-jugular reflux

6. MOVEMENT OF NECK
1. RATE N= 60-100 beat/min

2. RHTYHM
Irregular
irregular
Regular
irregular
Interval X - Bigemini
- Trigemini

Force X
Volume X

Irregular
AF Extra systole
Effect of exercise Remain
irregular
Abolished
Pulse deficit
(radial & apical
pulse difference)
>10 <10

3. FORCE= amount of external force to occlude the vessel

Volume overload
- AR
COP
- anaemia
- dehydration
- MS

4. VOLUME= amount of rise of finger

Volume overload
Hyperdynamic
circulation


5. VESSEL WALL
- AS, dyslipidaemia

6. EQUALITY ON BOTH SIDE
- in aortic dissection/thrombosis

7. SPECIAL CHARACTER

8. OTHER PULSATION
Dorsalispedis 1
st
i/osseous space
Posterior tibial Behind lateral malleolus
Popliteal Midway in popliteal fossa
Femoral Midway btwn ASIS &symphysis
pubis




INSPECTION & PALPATION
Item with normal condition/value Abnormality
1. PRECORDIAL BULGE N = not present
(precordium = part of ant chest wall covering the heart)
*look tangentially from side of chest/feet
present in congenital HD/long standing cardiomegaly since childhood

2. PULSATION
Precordial Extra-precordial
- apex
- aortic
- pulmonary
- lower left parasternal
- suprasternal (hyperdynamic)
- epigastric (hepatic/aortic/ RV)


APEX PULSATION

comment :
i) Visibility + type
Localized apex : LV apex
Diffuse apex : RV apex

ii) Location : left 5
th
intercostal space just inside the MCL
* palm on precordium localize by index finger the outermost
lowermost most evident +ve thrust (left lateral position if not found)

iii) Rate : N=60-90 beats/min

iv) Rhythm N=regular

v) Force N=average

vi) Duration N=not sustained

vii) Character (FORCE + DURATION)








i) Invisible apex:
- under the rib dextrocardia pleural effusion - weak myocardium

ii) Shifted (abnormal location)
upwards outwards out + downwards
- SOL in abdomen
- ascites
RVH LVH

iii) Pulse deficit = HR > pulse rate (in AF)

iv) Force
Strong apex Weak apex
- exercise
- pressure overload (LVH dt AS,
long standing systemic HTN)
- volume overload (AR, MR,
hyperdynamic circulation)
- MS
- pleural, pericardial effusion
- weak myocardium
- emphysema

v) Duration
Sustained Not sustained
Pressure overload (LVH) Volume overload (AR, MR)

vi) Character
Heaving apex
(strong, sustained)
Hyperdynamic apex
(strong, not sustained)
Tapping apex
(weak, not sustained)
Pressure overload
(LVH)
Volume overload
(MR, AR)
RVH (MS)

OTHER PULSATION
Left parasternal Aortic Pulmonary Suprasternal Epigastric
left 3
rd
, 4
th
i/costal space right 2
nd
i/costal space
parasternal line
left 2
nd
i/costal space
parasternal line
suprasternal notch - aortic aneurysm
- RVH
- Enlarged pulsating liver
(tricuspid regurge)
- aortic aneurysm
- aortic dilatation
pulmonary artery
dilatation
- hyperdynamic circulation
- high arched aorta

3. THRILL = palpable murmur

Comment on;
i) Site of maximal intensity
ii) Timing of thrills
iii) Grading
G1
G2
G3
G4
G5
G6


present =
- ORGANIC murmur , NOT functional murmur (no thrills)
- murmur of HIGH INTENSITY (grade 4,5,6)



4. DIASTOLIC SHOCK
= palpable accentuated S2 in pulmonary area dt PHTN

* sitting pt, leaning forward
* ulnar border of hand over pulm area (2
nd
left interspace parasternal
line)
* deep inspiration full expiration hold breath

in Pulmonary HTN

Other signs of PHTN =
1. pulsation (palpation) & dullness (percussion) on pulmonary area
2. diastolic shock
3. accentuated S2 (auscultation)

AUSCULTATION
Item with normal condition/value Abnormality
1. HEART SOUND
S1 S2
duration 0.3 sec 0.5 sec
timing systolic diastolic
cause closure of AV valve (mitral
tricuspid)
closure of semi-lunar valve (aortic
pulmonary)
best site mitral area pulmonary area
comment;
i)
accentuated
- MS (slapping apex)
- hyperdynamic circulation
A2:
aortic aneurysm
systemic HTN

P2: PHTN,
ii) muffled MR (RHD) weak: - PS - AS
splitting N=no splitting physiological in inspiration ( VR
delay pulm closure)


Splitting S1
- RBBB
- ASD

S2
Wide fixed split ASD
Wide split RBBB
PS
Absent splitting severe PS/AS
Reversed/
Paradoxical
splitting
P A
LBBB
AS


2. ADDITIONAL HS

S3 S4 Systolic click Opening snap Mid-systolic snap Pericardial friction rub
low-pitched high pitched rough scratchy sound
heard in healthy young
individual
NEVER heard in healthy
young individual
at base at apex
timing rapid filling pre-systolic early in systole diastolic systole & diastole
cause rapid descent of
blood from A V
very strong atrial systole opening of
semilunar valve
opening of AV valve mitral valve
prolapsed into LA

volume overload

pressure overload AS, SHTN
PS, PHTN
mitral stenosis mitral valve
prolapse
acute pericarditis



3. MURMUR
= abnormal sound dt turbulence of blood flow in the heart / great vessels.
i) Type
Functional murmur (hemic Organic murmur
short, soft, no thrills + thrills
hyperdynamic circulation (thyroxicosis,
anemia
valvular lesion

comment on;
- timing
- character
- site of max intensity
- propagation
- grading






4. PERICARDIAL RUB


acute pericarditis



SYSTOLIC MURMUR
VSD MITRAL REGURGE TRICUSPID REGURGE AORTIC STENOSIS PULMONARY STENOSIS
S1 muffled weak heard/not
S2 heard/not weak
Add. HS
Murmur
- Character Harsh Harsh Harsh
- Timing Pansystolic Pansystolic Pansystolic Ejection Systolic Ejection Systolic
- Site of max intensity Left parasternal Mitral area Tricuspid area 1
st
aortic area Pulmonary area
- Radiation Whole precordium To left axilla not propagated Neck, carotid artery
- Grading
- Relation w inspiration - - with inspiration with respiration
- Relation w posture - in left lateral position - with leaning forward
- Special character - - muffled S1 - hepatic pulsation
(systolic)

- Rx




- nitroprusside/
nitroglycerine
- surgery (MV
repair/replacement)
Rheumatic TVD
1. Valve repair with
annuloplasty (if not
severe)
2. Valve replacement
(severe)
1. Antibiotic
2. AF digitalis,
BB/CCB
3. Anticoagulant
4. Diuretics
5. Surgical replacement

- Indication for surgery



1. Symptomatic + severe
1ry MR
2. Asymptomatic +
severe 1ry MR + LV
dysfx
- LV-ESD > 4cm
- LV-Ef < 60%
- PHTN
- Development of AF

*MV REPAIR is
procedure of choice in
MR caused by:
- degenerative valve
disease
- infective endocarditis
- IHD
Surgical replacement
1. Symptomatic
2.

- Complication



- LV dilatation
- PHTN
- CHF
- sudden cardiac death
- HF
- conduction defects
- IE
- calcific embolization




































DIASTOLIC MURMUR
MITRAL STENOSIS TRICUSPID STENOSIS AORTIC REGURGE PULMONARY REGURGE
S1 accentuated heard/not
S2 heard//not
Add. HS
Murmur
- Character Rumbling Rumbling Soft blowing Graham-steel
- Timing Mid-diastolic Mid-diastolic Early diastolic Early diasolic
- Site of max intensity Mitral area Tricuspid area 2
nd
aortic area Pulmonary area
- Radiation not propagated not propagated apex
- Grading
- Relation w inspiration - with inspiration
- Relation w posture in left lateral position - with leaning forward
- Special character - accentuated S1 - hepatic pulsation
(presystolic)

- Rx 1. Pulmonary congestion
diuretics
2. AF digitalis, BB
3. Recent AF DC
cardioversion
4. Anticoagulant (warfarin)
5. Antibiotic (penicillin)
6. Surgery
Rheumatic TVD
1. Valve repair with
annuloplasty (if not severe)
2. Valve replacement (severe)
1.
Acute AR:
- BB & vasodilators in aortic dissection

Chronic AR:
- antibiotic prophylaxis
- vasodilator (nifedipine, ACEI)

2. Surgery (replacement)

- Indication for surgery Percutaneous Mitral Balloon
Valvotomy (PMBV)
1. Symptomatic +
moderate/severe MS
2. Asymptomatic +
moderate/severe MS + PHTN

Open Mitral Commisurotomy
- Presence of LA thrombus
- Significant MR if valve
anatomy is suitable
- Pt with other concomitant
valvular disease
- Pt with coronary artery
disease that require surgery

MV Replacement
- MV area < 1cm
- MR
- Thrombus formation
- Echo score 10/16
1. Symptomatic regardless the LV fx
2. Asymptomatic + LV dysfx by
- EF <50%
- LV ESD >5.5cm

- Complication - LA dilatation
- AF
- PHTN
- sudden death
- HF

Peripheral signs of AR
Mussets
sign
head bobbing with
each beat
Mullers
sign
systolic pulsatn of
uvula
Hills sign LL >40mmHg above
UL
Water
Hammer/
Corrigan
pulse
rapid distension &
collapse of arterial
pulse
Quinkes
pulse
capillary pulsation in
the nail bed
Duroziezs
sign
to & fro murmur
over compressed
femoral artery
Pistol shot
sound
prominent syst &
diastolic sound over
brachial/femoral






PULSE
1. RATE N= 60-100 beat/min




Tachycardia >100/min Bradycardia <60/min
i- physiological (exercise)
ii- psychological
iii- pathological
Sinus T Paroxysmal T
- hyperdynamic
circulation
(anaemia, fever,
thyrotoxicosis)
- AF
- VF

i-physiological ( athlete, old
age)
ii) pathological
- heart block
- digitalis
- myxoedema


2. RHTYHM
regularity = interval in between pulse wave

Irregular rhythm
Regular irregular Irregular irregular
Interval X
Force x X
Volume x X
Eg - Extra systole (premature beat)
- Pulsus Bigemini
- PulsusTrigemini
- AF
- multiple
extrasystole

Irregular irregular pulse AF Extra systole
Effect of exercise Remain irregular Abolished
Pulse deficiet
(radial & apical pulse difference)
>10 <10

3. FORCE
= amount of external force to occlude the vessel
- synchronous with systolic BP


Volume overload
- AR
COP
- anaemia - dehydration - MS

4. VOLUME
= amount of rise of finger



- Hyperdynamic circulation (fever,
anaemia, thyrotoxicosis)
- Atherosclerosis
- Aortic incompetence
- AS (plateau pulse)
- CHF, AMI (thready)


5. VESSEL WALL
- N=not felt

- atherosclerosis (cord-like)
- dyslipidaemia

6. EQUALITY ON BOTH SIDE
- normally equal in force & volume

- in aortic dissection/thrombosis
7. SPECIAL CHARACTER
pulse def causes
1. BOUNDING pulse
(hyperkinetic)
pulse of big amplitude
( wide PP : systolic but normal diastolic)
- atherosclerosis
- hyperkinetic state
2. WATER HAMMER/
COLLAPSING pulse
pulse of big amplitude with rapid ascend & rapid descent
(wide PP : systolic, diastolic)
- AR
3. THREADY pulse
(hypokinetic)
pulse of narrow amplitude
(narrow PP)
- CHF
- MI
4. PLATEAU pulse pulse of small amplitude with slow ascend & slow descend - AS
5. PULSUS BISFERIENS pulse with 2 peaks occurring during systole - double aortic lesion (AS + AR)
- HOCM
6. PULSUS ALTERNANS alternate beats (weak & strong) with regular rhythm - LV failure
- MI
- myocarditis
7. PULSUS
PARADOXUS
exaggeration of normal fall of systolic BP (N= less than 10 mmHg) during
inspiration more than 10mmHg
- cardiac tamponade
- constrictive pericarditis
- COPD, severe asthma

8. OTHER PULSATION *bilateral!
Dorsalis pedis 1
st
i/osseous space
Posterior tibial Behind lateral malleolus
Popliteal Midway in popliteal fossa
Femoral Midway btwn ASIS &symphysis
pubis

Weak LL pulse
- coarctation of aorta
- advanced atherosclerosis

Absent pulsation
- DM
- arterial obstruction