Insider Clincal Internal Medicine Cardiology Sheet 2

Insider Internal Medicine CLINICAL

The following notes are based upon the widely known Jam’ El-Majam’ clinical series, So you will find

nothing new except for organization and

simplification. The aim is to offer it in a more concise way easily to remember and handle. That is

to say it’s the “Skimmed Jam’ El-Majam’”.

Part II Cardiology sheet E x a m - o r i e n t e d

Internal Medicine | Cardiology sheet Internal Medicine | Cardiology sheet

1

Examine the Heart:

I. Inspection AND Palpation:

1. Pericardial bulge:

Congenital HD; Rheumatic HD.

Pericardial effusion; RVH.

2. Apex:

Site:

- Normally in left 5th ICS just inside MCL. Extent:

- Localized → Normally AND LVH.

- Diffuse → RVH.

- Double → MI.

- Bifid → BBB.

Character: Normally no special character.

Thrill : Only low frequency murmurs are palpable.

Relation to systole: Retraction OR Bulge.

3. Pulsations. 4. Thrill. 5. State of the skin:

Dilated vessels (SVC Thrombosis); Pigmentation; Scar.

II. Percussion.

III. Auscultation:

For Heart sounds; Added sounds; Murmurs; Pericardial rub.

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Cause of Abnormal site of the apex:

I. Physiological:

- Long thin person - Children > 2 years - During inspiration - Position

: : : :

6th ICS. 4th ICS. More down. More down in sitting; laterally in left side.

II. Cardiac:

- Dextrocardia. - RVH → Outwards; LVH → Downwards AND outwards.

III. Chest:

I. - PE; Pneumothorax → Push; Fibrosis; Collapse → Pull.

IV. Abdominal:

- ↑ IAP (Ascites; Pregnancy) → Shifted up.

V. Misc.→ Kyphoscoliosis.


Difference () RVH AND LVH:

LVH RVH

Apex:

Site Downwards AND outwards. More outwards.

Extent Localized. Diffuse.

Character 1. Volume overload: Hyperdynamic.

2. Pressure over: Heaving.

Slapping.

Relation to systole

Bulge (Parasternal retraction)

Retraction (Parasternal bulge)

Misc.:

Pulsation

-

1. Epigastric pulsation.

2. Parasternal pulsation: If RVE + LAE:

- Uplift pulsation.

If RVE only: - Heaving pulsation.

Dullness -

1. Lower ⅓ of sternum. 2. Widened bare area.


2

Causes of Absent (Invisible OR Not palpable) Apex:

1. Obesity. (Thick chest wall)

2. Behind a rib.

3. Pleural effusion; Pericardial effusion; Emphysema.

4. Advanced HF. (weak)

5. Dextrocardia.


Causes of Pulsations:

I. Suprasternal pulsation:

- Short obese with short neck and High diaphragm. - Hyperdynamic cir. (AR) - Coarctation of the aorta. - High Aortic Arch. - Aneurysm of aortic arch.

II. Epigastric pulsation:

- RVH. - Hepatic pulsations → TR (Systolic); TR AND TS (Diastolic). - Abdominal Aorta.

III. Pulsation to right of the sternum: (Fingers Tips)

- RAE; Huge LAE. - Aortic Aneurysm. - Internal mammary artery in lactating female.

IV. Parasternal pulsation: (By Paroxysmal part of a palm)

- RVH → Uplift OR Heaving.

V. Pulmonary area pulsation: (Fingers Tips; Left hand ulnar border)

- Pulmonary artery dilation or aneurysm; LAE.

VI. Aortic area pulsation: (Fingers Tips)

- Aortic artery dilation.

Causes of Dullness:

I. Pulmonary area (2nd left ICS):

- Pulmonary artery dilation; LAE. - Aortic artery aneurysm.

II. Aortic area (2nd right ICS):

- Ascending aortic artery dilation.

III. Cardiac waist (3rd left ICS):

- LAE.

IV. Right of the sternum:

- RAE; Huge LAE.

V. Outside the apex:

- Pericardial effusion; Ventricular aneurysm.


Causes of ↓ Bare area:

1. Pneumothorax.

2. Emphysema.


Causes of ↑ Bare area:

1. RVE.

2. Pericardial effusion.

3. Fibrosis; Collapse.


Causes of Huge (Bovine) heart:

1. Multivalvular disease.

2. Pericardial effusion.

3. Dilated cardIomyopathy.

4. Long standing hypertensive HF.


3

Causes of Small heart:

1. COPD.

2. Addison’s disease; Senile cardiac atrophy.


Causes of Accentuated AND Weak S1:

Accentuated S1 Weak S1

MS. Hyperdynamic circulation. Tachycardia. Exercise; Emotion. Children. Thin chest wall.

1. Loss of valvular component: MR. Calcified MS.

2. Loss of Muscular component: Myocarditis. Cardiomyopathy.

3. Misc.: Bradycardia. Absent apex.


Abnormalities of S2:

1. Accentuated splitted S2.

2. Weak splitted S2.

3. Wide and Reversed splitted S2.

4. Single S2.


Causes of Accentuated AND Weak S2:

Accentuated S2 Weak S2

Dilatation and Hypertension of Pulmonary artery and Aorta.

AS; PS. Hypertension. Shock. Absent apex.

Difference () Wide and Reversed splitted S2:

Wide splitted S2 Reversed splitted S2

Haemodynamics Delayed closure of Pulmonary valve.

Delayed closure of Aortic valve.

Causes ASD. PS. RBBB.

PDA. AS. LBBB.

Effect of deep inspiration

↑ Disappear


Causes of Single S2:

1. TOF; Pulmonary atresia.

2. Truncus arteriosus; Very large VSD.


Causes of S3 (Protodiastolic sound):

Rap

id V

entr

icu

lar

filli

ng 1. MR.

2. TR. 3. ASD. 4. VSD. 5. PDA. 6. Hyperdynamic circulation.

7. HF; Cardiomyopathy. (Flabby myocardium)


Causes of S4 (Presystolic sound): (↑ ventricular pressure)

↑ a

tria

l co

nt.

1. AS; PS. 2. Hypertension (Pulmonary; Systemic). 3. Pulmonary embolism. 4. Coarctation of Aorta.


4

5. Rapid and early atrial contraction. (Against resistance)

6. MI. (↓ Compliance).


Added heart sounds:

1. Opening snap. (MS; TS)

2. Ejection click. (AS; PS)

3. Pericardial knock. (Constrictive pericarditis)

4. Gallop:

- S3 Gallop - S4 Gallop - Summation Gallop

→ → →

S3 + Tachycardia. S4 + Tachycardia. S3 + S4 + Tachycardia.

5. Mid-systolic click. (Mitral valve prolapse)

6. Tumor plops. (Left atrial myxoma)


Value of hearing opening snap:

1. Absence of calcification; NO MR; NO AF.

2. The nearer the opening snap to S2, The more severity of MS.

3. Differentiate () Rh. MS AND Left atrial myxoma (Absent).


Enumerate Systolic murmurs:

Over the base Over the apex

AS; PS.

Aortic OR Pulmonary aneurysm.

Coarctation of the aorta.

ASD.

VSD; PDA.

Venous hum. Still’s murmur.

1. Mitral valve: MR (Organic; functional). Mitral valve prolapse.

2. Propagated murmurs: TR. AS; PS. VSD; PDA.

Enumerate Diastolic murmurs:

Over the base Over the apex

AR; PR. Coarctation of the aorta.

PDA. Venous hum.

1. Mitral valve: MS (Organic; functional). Carey Coomb’s murmur. Austin Flint murmur. Left atrial myxoma. Cor triatriatum.

2. Propagated murmurs: AR.


Enumerate Continuous murmurs:

1. PDA.

2. Coarctation of the aorta.

3. Venous hum.

4. Systemic (Pulmonary; Coronary) fistula.

5. Bronchial collaterals.

6. Broncho-pulmonary stenosis.

7. Rupture aneurysm of Valsalva (Aortic) sinus into Rt. side of the Ht.


Difference () Continuous AND To-Fro murmurs:

Continuous murmur To-Fro murmurs

Gap () the 2 phases (Systole AND Diastole)

NO Gap Gap

Flow direction One direction Opposite direction

Causes PDA

Coarctation of aorta

Venous hum.

(See before...)

Severe AR + AS


5

Types of murmurs:

Time and duration

Character

Mu

rmu

r w

hic

h is

Site

Wit

h p

rop

agat

ion

to

Propagation Misc.

MR

Pansystolic Soft Blowing

Max. AT Apex

Axilla

OR The heart base [in Pt. leaflet regurge] ↑

in le

ft

late

ral p

osi

tio

n

Left

sid

e m

urm

urs

↑ w

ith

exp

irat

ion

MS Mid- Diastolic

Rumbling Localized TO Apex

-

AR

Early Diastolic

Soft Blowing

Max. OVER A1

OR Max. OVER A2 [in Rh. AR]

Apex

Neck

↑ w

ith

lean

ing

forw

ard

AS Ejection Systolic

Harsh Max. OVER A1

Apex

Neck

TR Pansystolic

Soft Blowing

Mu

rmu

r w

hic

h is

Max. OVER T Area

Wit

h p

rop

agat

ion

to

Apex

-

Rig

ht

sid

e m

urm

urs

↑ w

ith

insp

irat

ion

[C

arva

llo s

ign

]

TS Mid- Diastolic

Rumbling Max. OVER T Area

-

PR Early Diastolic

Soft Blowing

Max. OVER P Area

-

-

PS Ejection Systolic

Harsh Max. OVER P Area

Apex

Neck

NB:

- Severity of the lesion depends on the duration (which is determined by pressure gradient) NOT the intensity of the murmur.

VSD:

- Pansystolic harsh murmur which is maximum at 3rd

and 4th

ICS with propagation all over the pericardium.

PDA:

- Continuous machinery murmur which is maximum at left infraclavicular area with propagation to apex AND neck.

Innocent murmurs:

- Early systolic soft murmurs.

- Best heard over P area AND Left sternal edge.

- ↑ with standing and respiration.

- Causes: Hyperdynamic circulation; Minimal organic lesions; Chest deformities.


The End

Part II: Cardiology sheet

Clinical sheets of Internal medicine

Exam-oriented

First edition 2009

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Insider Clincal Internal Medicine Cardiology Sheet 2