cardiac vascular mediastinal Causes airway chest pain wall determine Character Dyspnoea palpitation

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1 Written by: Mohammad Al Marhoon Reference: Clinical Examination (Talley) Major Symptoms chest pain Causes determine Character cardiac vascular mediastinal ischemia MI Pleuropericardial airway aortic dissection aortic aneurysm tracheitis intubation esophageal spasm esophagitis mediastinitis lymphoma pericarditis pleurisy pneumonia pneumothorax mesothelioma tumor central bronchial carcinoma gastroesophageal reflux wall duration location quality persistent cough nerve compression rib fracture agg/reliv factors angina pleuritic pain chest wall pain crushing, heaviness, central, radiate to jaw or arms pleurisy or pericarditis worse by inspiration relieved by sitting up or leaning forward sharp & localized dissecting aneurysm massive pul. embolism tearing, sever, radiate to back sudden, dyspnoea, cyanosis, collapse pneumothorax sharp, localized, severe dyspnoea Dyspnoea palpitation syncope ankle swelling cardiac dyspnoea is chronic & occur with exertion orthopnoea PND postural micturition tussive vasovagal Rt ventricular/biventricular failure 2ndary to lung dis. progression legs/thigh/genitalia more suggestive of cardiac failure intermittent claudication dizziness Fatigue pain in calves/thighs/buttocks after walking a distance peripheral vascular dis. with poor blood supply Risk factors for coronary artery dis. previous ischemic heart dis. Hypercholesterolemia smoking Hypertension family DM Optimal lipids levels LDL <100 HDL Total <200 Triglycerides <200 Past History previous angina or MI rheumatic fever

2 Written by: Mohammad Al Marhoon Reference: Clinical Examination (Talley) Guide to physical examination (Bates) Medial to sternomastoid stenosis or insufficiency of aortic valve never palpate both small weak pulse >>cardiogenic shock bounding pulse >>aortic insufficiency pulse character reflects right atrial pressure Internal JV is medial to sternocleidomastoid raise head 30 degrees & turn it to other side use tangential light to find vein between sternal & clavicular head of sternomastoid identify highest oscillation point measure vertical distance from sternal angle visible but not palpable pulse twice decrease with inspiration in applying pressure at base of neck, obliterated then filled from above atrial contraction S1 Carotid pulse Tricuspid valve closure atrial relaxation reduced or absent pulse atrial filling enlarged tender liver pulsatile liver <<tricuspid regurgitation ascites <<Rt heart failure splenomegaly <<infective endocarditis Rt ventricular failure volume overload a wave c point x descent v wave palpate femoral a., popliteal, pos. tibial, dorsalis pedis percussion & auscultation of lung bases pitting edema of sacrum inspiratory crackles pleural effusion normal 2 3 cm normal JVP Measurement difference from arterial pulse >3 cm edema Achilles tendon xanthomata without finger clubbing >>Patent ductus arteriosus femoral systolic bruits pallor changes in vessel wall change in blood flow change in constitution of blood cyanosis clubbing peripheral vascular dis. calf pain or tenderness prolonged immobilization thrombus in heart 2ndary to: 1 MI 2 atrial fibrillation 3 infective endocarditis cardiac failure trauma DIC Contraceptive pills inspect long & short saphenous veins hard >>thrombosis tender >>thrombophlebitis fluid thrill after pt. cough if saphenofemoral valve is incompetent mechanism causes Height Character DVT acute arterial occlusion Palpation cough impulse test Trendelenburg test Perthes' test leg ulcer due to venous stasis Varicose veins Carotid a. JVP 45 degrees Clubbing ill or well respiration Cachectic Splinter hemorrhage Osler's node Janeway lesion infective endocarditis vasculitis in rheumatoid arthritis polyarteritis nodosa infective endocarditis on pulps of finger or thenar or hypothenar eminence tender Tendon xanthomata Palmar xanthomata infective endocarditis on pulps of finger or palms non tender Tuboeruptive xanthomata Rate Rhythm Volume Bradycardia <60 Tachycardia > 100 regular irregular Radiofemoral delay Radio radial delay Character Vessel wall jaundice in sclera xanthelasma mouth hand & arm Type 2 hyperlipidemia Type 3 hyperlipidemia elbows & knees Type 3 hyperlipidemia Coarctation of aorta atherosclerosis aneurysm assessed by brachial or carotid collapsing pulse pulsus alternans Pulsus paradoxus pulsus bigeminus pulsus bisferiens Normal systolic <140 Normal diastolic <90 Korotkoff sounds systolic BP vary by 10 mmhg Inspiration >>BP decrease Pulsus paradoxus Postural hypotension congestive cardiac failure hepatic congestion aortic regurgitation Lt ventricular failure Cardiac tamponade, pericardial constriction premature ectopic beat exaggerated decrease in BP in inspiration fall in BP with paradoxical rise in pulse rate constrictive Pericarditis pericardial effusion severe asthma in standing: fall of systolic >15 fall of diastolic >10 prosthetic heart valve induced hemolysis of RBC cholesterol deposits around eyes type 2 or 3 hyperlipidemia high arched palate teeth hygiene cyanosis Marfan's synd. infective endocarditis rapid ventricular filling (atrial emptying) test for Rt ventricular failure y descent Hepatojugular reflux

3 gap before S2 Aortic or Pulmonary stenosis children Innocent Ejection systolic (Midsystolic) Supine Lt lateral decubitus sitting & leaning forward anemia, pregnancy, fever Physiologic scars median sternotomy in valve surgery or open heart surgery Mitral or Tricuspid regurgitation VSD Pansystolic (Holosystolic) systolic pectus excavatum kyphoscoliosis apical impulse 5th Lt intercostal space 1cm medial to midclavicular line use finger pads not felt >>Lt lateral decubitus Location displaced in cardiomegaly Mitral prolapse Late systolic Diameter (normal <2.5 cm) preceded by systolic clicks Amplitude Aortic or Pulmonary regurgitation Mitral or Tricuspid stenosis Mitral or Tricuspid stenosis pericarditis louder in sitting & leaning forward Lt 3rd interspace above medial 1/3 of clavicle radiate to 1st & 2nd interspace air in mediastinum post surgical aspiration of pericardial effusion pneumothorax causes Lt 2nd interspace radiate to Lt clavicle Early diastolic Mid diastolic Late diastolic (pre systolic) pericardial friction rub Venous hum PDA mediastinal crunch (Hamman's sign) diastolic continuous Timing apical impulse Duration Character parasternal impulse (heave) Thrills Apical thrills Base of heart 2/3 of systole assess with pt. on Lt lateral decubitus pressure loaded Dyskinetic double impulse tapping impalpable forceful & sustained aortic stenosis or HTN felt over large area Lt ventricular dysfunction hypertrophic cardiomyopathy when S1 is palpable (abnormal) mitral stenosis obesity thick chest wall emphysema pericardial effusion shock dextocardia using heel of hand on parasternal edge Rt ventricular enlargement severe Lt atrial enlargement pt. rolled over Lt side Normal sitting up leaning forward with full expiration Loud murmur of aortic stenosis radiate to neck very faint, heard after concentrating Quiet, heard immediately early systolic in aortic or pulmonary area congenital aortic or pulmonary stenosis systolic in mitral area mitral valve prolapse, ASD systolic ejection click non ejection systolic click diastolic in lower Lt sternal edge sudden open of mitral valve mitral stenosis louder at apex & on expiration Lt vent. failure & dilatation aortic & mitral regurgitation VSD PDA louder at Lt sternal edge & in inspiration Rt vent. failure constrictive pericarditis Aortic stenosis acute mitral regurgitation systemic hypertension ischemic heart disease Pulmonary hypertension pulmonary stenosis inaudible S3 & S4 combine to produce audible sound mid diastolic, low pitched cause gallop rhythm opening snap Lt vent. S3 Rt vent. S3 late diastolic, low pitch cause gallop rhythm due to poor vent. compliance occur if rate >120 S3 & S4 are present severe vent. dysfunction cessation of vent. filling due to constrictive pericardial dis. Area of maximal intensity Crescendo Decrescendo Crescendo Decrescendo loud with thrills very loud with thrills thrills heard without stethoscope Plateau grade 1 grade 2 grade 3 grade 4 grade 5 grade 6 low, medium, high blowing, harsh, rumbling, musical Radiation Shape Intensity Pitch Quality Lt vent. S4 Rt vent. S4 S3 S4 Summation gallop quadruple rhythm diastolic pericardial knock prosthetic heart valve sound Praecordium S1 S2 Areas intensity Murmurs Systolic or diastolic mitral & tricuspid valve closure (mitral 1st) beginning of vent. systole aortic & pulmonary valve closure (aortic 1st) beginning of diastole shorter & higher pitch splitting is audible in pulmonary area & Lt sternal border splitting is wider in inspiration mitral area Tricuspid area Pulmonary area Aortic area loud S1 soft S1 loud S2 Soft A2 timing with bell then diaphragm mitral & tricuspid stenosis reduced diastolic filling time (tachycardia) prolonged diastolic filling time (heart block, mitral regurgitation) loud A2 >>systemic hypertension loud P2 >>pulmonary hypertension aortic valve calcification aortic regurgitation area of maximal intensity radiation Intensity Lt lateral decubitus sit & lean forward Aortic regurge Splitting of S2 squatting standing use bell on mitral area for mitral stenosis, S3, S4 Exhale & hold use diaphragm on apex & Lt sternal border normally accentuated on inspiration increased fixed reversed Valsalva manoeuver Isometric exercise ASD Delayed closure of pulmonic valve Rt bundle branch block pulmonary stenosis Delayed closure of aortic valve Lt bundle branch block murmur of mitral prolapse outflow obstruction (hypertrophic cardiomyopathy) murmur of aortic stenosis opposite to squatting Written by: Mohammad Al Marhoon Dr.Marhoon@gmail.com Reference: Clinical Examination (Talley) Guide to physical examination (Bates) straining has effect of standing release has effect of squatting sustained hand grip for 30 seconds

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