By Thomas Scott,2014-06-26 20:33
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Lecture ...

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    ? 45 degrees

    ? Distress dyspnoea (RR 12-15/min)

    ? Anaemia

    ? Cyanosis (desaturated Hb >5g/dL)

    ? Jaundice (bilirubin 2-3x normal

    ? Other pathologies

    o Marfans

    o Ankylosing spondylitis hang dog posture (head thrust lower) assoc w/ aortic valve


    o Myoedema

    ? Sallow, milky complexion

    ? Fullness of cheeks

    ? Bradycardiac

    ? ? thyroid hormone


    ? Nails

    o Splinter haemorrhages bacterial endocarditis

    o Clubbing

    ? Digits

    o Cyanosis

    o Arachnodactyly marfans

    o Oslers nodes endocarditis

    ? Black, painful nodule (probably embolic)

    ? Tendon xanthomas (familial hypercholesterolaemia)

    o Especially Achilles tendons and extensor tendons of the hands

    o Tendons feel nodular and lumpy

    ? Palms


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    o Pallor

    o Striae yellowish discolouration of palmar creases (type III hyperlipoproteinaemia)

    due to deposition of foam cell macrophages

    o Eythema

    o Janeway lesions

Causes of clubbing

    ? Above diaphragm

    o cardiac

    ? Cyanotic congenital diseases

    ? Endocarditis

    o Respiratory

    ? Chronic infections especially in cystic fibrosis (bronchiectasis, lung

    abcess, empyema)

    ? Pulmonary fibrosis

    ? Lung cancer

    ? Mesothelioma

    ? TB

    o Hyperthyroidism

    ? Below diaphragm

    o Cirrhosis

    o Inflammatory bowel disease eg chron’s disease, ulcerative colitis

    o Coelic disease


    ? Rate (60-100 bpm)

    ? Rhythm

    o Regularly irregular

    o Irregularly irregular atrial fibrillation ? Character and volume (use the carotid)

    o Collapsing (use the radial pulse hold the wrist in the air) C:\convert\temp\61486741.doc

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    ? Condition of the arterial wall

    o Eg calcified, atherosclerotic ? Radiofemoral and radio-radial delay

    o If present, then could be coarctation of the aorta


    ? Xanthomas

    ? Scars of brachial catheterization (for cardiac catheter) not done routinely anymore

    ? Blood pressure always an OSCE station

Blood pressure

    ? Lying/sitting and standing

    ? Cuff should cover 2/3 or upper arm

    ? Determine BP by palpation to avoid auscultatory gap

    ? Defate cuff for one minute then determine BP by ausculatation (deflate 3-4 mmHg/s)

    ? Redetermine BP after 5 min

    Korotkoff sounds ? I first sound heard = SPB

    ? II sounds increase in intensity

    ? III sounds decrease in intensity

    ? IV sounds muffled

    ? V sounds disappear = DBP

    o In aortic regurgitation/systemic stenosis, this may never occur (?use IV and take


? Normal 120/80mmHg

    ? Hypertension = 140/90 at 3 visits

    ? WHO/ISH guidelines suggest 130/85 as cufoff for hypertension

    ? Significant 10mmHh C:\convert\temp\61486741.doc

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    o Postural drop

    o Arm asymmetry

    o Pulsus paradoxus

    ? Asthma

    ? Pericarditis

    ? BP in legs 10 mmHg higher than arms


    ? General

    o Myxoedema

    o Mitral facies mitral stenosis

    ? ? in elderly, migrants

    ? Flush over cheek bones

    ? Cyanosis

    ? Eyes

    o Arcus senilis - hypercholesterolaemia

    ? White rim around cornea due to cholesterol deposition

    o Xanthelasma dyslipidaemia

    ? Yellowish deposition of foam cells around eyelid rim

    o Jaundice

    o Conjunctival pallor

    o Fundoscopy

    ? Mouth

    o Dentition endocarditis

    o Cyanosis lift tongue to the roof of the mouth

    o High arched palate remove dental plate

Neck JVP

    ? Two jugular vv EJV and IJV

    ? Zero position is the manubriosternal angle, which is level with the base of the neck, with

    opatient at 45


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    ? The height is measured in cm above the manubriosternal angle

    ? The JVP has a complex waveform w/ three positive (a, c, v) and two negative (x, y) waves

    ? In congestive cardiac failure

    o Peripheral oedema

    o ? JVP

    o Malaise

    ? See diagram of JVP waveforms

    o A wave atrial contraction

    o C wave artifact related to tricuspid closure

    o X atrial relaxation

    o V atrial filling and tricuspid bulging

    o Y

    ? Characteristics of the JVP

    o Corresponds to the anatomical location of the JVP (IF btwn heads of sternomastoid

    up to the angle of jaw)

    o Wave form

    o Impalpable

    o Moves w/ respiration (? on insp / abdo pressure hepatojugular reflux)

    o Can be obliterated w/ gentle pressure and fills from above

    ? Cuases of raised JVP (>3cm)

    o RH failure

    o Tricuspid incompetence diagnosed by JVP

    o Pericardial effusion or constriction

    o SVC obstruction (nonpulsatile)

    o Fluid overload

    o EJV kinked in platysma in normal people ?look for IJV (runs in carotid sheath)

    ? Wave form abnormalities

    o Dominant V wave tricuspid incompetence (sail-like appearance of pulse


    o Dominant A wave

    ? Pulmonary H/T


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    ? Pulmonary stenosis

    ? Tricuspid stenosis

    o Cannon a wave atrial contraction w/ closed TV

    ? Heart block

    ? AV dissociation

    o Abnormalities of descent

    ? X descent

    ? Absent in AF

    ? Exaggerated in acute tamponade and constricative pericarditis

    ? Y descent

    ? Rapid in constrictive pericarditis and TR

    ? Slow in tricuspid stenosis

Carotid impulse

    ? Find the thyroid cartilage and run fingers laterally to find carotid

    ? Don’t fel both carotids simultaneously ? Best site to assess pulse character

    o Anacrotic slow upstroke/low volume

    o Plateau “” = aortic stenosis

    o Collapsing (waterhammer) aortic regurgitation, PDA, AV fisulat, normal elderly,

    hyperdynamic circulation

    o Bisferiense anacrotic and collapsing as/ar

    o Alternans alternating strong and weak LV failure

    o Jerky double pulsation



    ? Pacemakers unde clavicles

    ? Kyphoscoliosis, pectus excavatum

    ? Impulses apex beat, rt strenal lift (lower part of sternum lifting up_

    ? Scars


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    o Median sternotomy

    o Lt thoracotomy scar in submammary cease mitral valve surgery


    ? Apex beat

    o 5LICS, MLC

    o Role on side, and count down ICSs

    o Character tapping , forceful, dyskinetic

    ? Parasternal lift flat of hand over lower sternum, slightly to left ? Thrills at base of heart etc


    ? Track the murmur

    o Where is it loudest

    o Where does it radiate to

    o Base of heart = aortic and pulmonary area

    ? Listen first at the paex with the diaphragm, then with the bell

    ? Move across tot eh sternum gradulally

    ? Move up the sternum to the base of the heart

    ? IF you hear a murmur try to work out wher it is loudest and where it radiates to (axilla, neck)

    ? Roll the patient 45 degrees to the left, and localize apex beat and lifsten w/ bell in expiration for


    ? Sit the patient fowrad and listen at the lower left sternal edge in exp for AR

    ? Lifsten to all the components of the cardiac cylce in turn

    o The HS

    o Systeole

    o Diastole

    o Prostehitic sounds

    o Extara heart sounds…..

    ? Grading of murmurs

    o 1 very soft C:\convert\temp\61486741.doc

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    o 2 soft but audible

    o 3 clearly audible

    o loud w/ a thrill…….

    ? A systolic ejection murmur is usually aortic stenosis

    ? Pansystolic murmur is usually mitrl regurgitation……

Complete the examination

    ? Back

    o Sacral oedema

    o Pleural effusion basal crackels

    ? Abdo

    o Hepatomegaly

    o Asceitis

    o Splenoegaly

    ? Legs

    o Pulses

    o Trophic changes

    o Ulcers

    o Peripheral oedema

    o Xanthomas

    ? Causes of oedema

    o Bilateral pitting

    ? Heart filaure

    ? Hepatic failure

    ? Nephritic sydrome

    ? Protein losing enteropathy

    o Unilateral pitting

    o Non pitting


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    Heart failure The situation when the heart is incapable of maintaining a cardiac output adequate to

    accommodate metabolic requirements and venous return

    ? 300 000 australians

    ? 30000 new cases /yr

    ? 90000 annual admissions


    ? Coronary a disease

    ? Vavluar heart disease

    ? Hypertenisons

    ? Alcohol

    ? Endocarditis

    ? Acute MI

     ventricular pump function

    ? Symptoms

    o Dyspnoea

    o Fatigue ? Signs

    o Oedema

    o Ascites

    o JVP

New york heart assoc classification

    1. no limitation

    2. slight limitation

    3. marked limitation

    4. bedridden

? Can’t increase contractility, ?dilate to increase fibre stretch


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Neurohumoral activation

    ? ?CNS SNS outflow

    o ?cardiac SNS activity ?arrhythmias

    o activation of Renin-angiotensin system?fluid retention, v/c

Physical examination in CCF

    ? Appearance

    o Distress

    o Tachypneoae

    o Cyanosis

    o Cheyne0stokes breathing ? Pulse

    o Weak

    o Teachycardia

    o Atrial fibrillation

    o Pulsus alternans ? BP low

    ? Face

    o Cyanosis ? JVP

    o ? ? Carotids - ? volume ? Prechordium

    o Apex beat displaced ? Ausculation

    o 3

    ? Legs - oae


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