Chandana basnayake (m/98/83)

Cvs medicine
ANALYSIS OF CVS SYMPTOMS

1. Chest pain
2. Difficulty in breathing
3. Palpitation
4. Sybcopal attack/Dizziness
Chest pain
Stable angina Retrosternal pain. Start on exersion.
Unstable angina Rest pain.
MI
Aortic dissection
Pericarditis
GI causes

Oesophagitis
Oesophagial spasms
Hiarus hernia
Peptic ulcer disease.
Pancreatiis.

Pulmonary causes.
Pulmonary embolism.
Pneumonia
Pneumothorax.
Acute asthma.
Pneumothorax.
Other
chest salll muscle pain
Psycogenic chest pain
Costochondritis.
Cervical spondylosis.
CHEST PAIN DUE TO MI
Retro sternal tight/ heavy/ constrictive/ discomfort radiate to neck, jaw, or both
shoulder/arms/(left (common) or right arm)
May present with pain in the referred site. E.g exercise induced jaw pain.

STABLE ANGINA
Predictable symptom pattern.
Angina pain is relieved by rest.
Episods are triggered by exersion on emotional stress.
Glyceryl trinitrate tablets ac______ complete resolution.
Breathlessness may accompany the chest discomfort.

POST PRANDIAL ANGINA

Unstable angina athromatous plaques can fissuring, rupturing, damage - emboli

 Coronary artery spasms.

Serious condition defined clinically
o Onset of chest discomfort of cardiac origin at rest.
o Pain lasting for a long period. 15min/30 min pain developing with minimal
exertion. Severity increased
Patient with past chest pain lasting than more time compare to pre__
o Patient developed it after intervene E.g coronary artery bypass.
o Who has MI now developed pain very frequent.
o Development of abrupt onset ____________ induced angina with marked
limitation of exercise capacity.
o Patient develop chest pain first time of life.- so admit the patient and do full
investigations.
o May have a history of crescendo angina with effort tolerance and increased
frequency and development of chest discomfort arise few days and ______

o
o
o
o

ACUTE MI
Chest pain very severe
Presentation very similar to unstable angina , nausea, vomiting, sweating. Coronary
artery completely obstructed by thrombus.
Unstable angina- patial obstruction.
Atypical presentations
panin in the epigastric site without chest pain
jaw/arm/back pain.

AORTIC DESSECTION
Severe chest pain & sudden onset. Tearing in nature.
May radiate to interscapular region. Atonerve sym+
Depending on extention other symptoms may present.

o
o
o
o
o

PULMONARY EMBOLISM
60% of chest pain
Usually pleuritic type .
Difficulty in breathing usually.
Palpitation, right heart origin.
Syncopal attacks may occur.
ACUTE PERICADITIS

o
o
o
o
o
o

Sharp pain.
Retro sternal or left sided.
May radiate to trapezium
Worse in inspiration and supine position.
May be relived by sitting position.
Coughing and swallowing may aggravate the pain.

BREATHLESSNESS
Cardiac, respiratory, thyrotoxicosis, anaemia.

Almost all types of cardiac illnesses can cause breathlessness.

Few catogories.
i.
pulmonary edema
ii.
reduced cardiac output
iii.
Obstruction of cardiac out put- hiatus stenosis, hypertrophic cardiac
disease.
iv.
Arrythmias
PULMONARY OEDEMA
In acute LVF- Accumulation of fluid in the alveolar spaces results in impaired gas
exchange. When capillary pressure exceeds 20mmHg Pulmonary oedema results.
Stages, Class;
I.
No symptoms during ordinary activity.
II.
Slight limitation during ordinary activity. Eg. Mild occasional o______
dyspnoea.
III.
Marked limitation at normal activity. Without symptoms at rest.
IV.
Unable to undertake physical activity with out symptoms. Symptoms may
present at rest.
Dyspnoea on effert may be only symptom of heart failure.
Causes previous MI , vascular heart disease , cardiopathy
Orthopnoea Dyspnoea on lying flat. Indication of more advance cardiac disease.
hypertension, arrythmias, atrial fibrillation.
Paroxysmal nocturnal dyspnoea.
Dyspnoea at rest.
PND wake the patient during sleep.
Severe LVF
Must be distinguished from acute B.A
PALPITATION
Can get even bradycardia ___________________
May be due to ,
Forceful contraction of heart. Irregularities of heart rhythm
Just HR
Ask.
How often it last.
Paroxysmal palpitation wpw syndrome
Whether other symptoms occur with the palpitation.
Eg. Sypraventricular tachycardia get polyuria
In history The mode of onset, The frequency, _______________
SYNCOPE AND DIZZINESS
Could be due to arrythmias.
Drug related
Left ventricular outflow obstructions.
Cardiovascular disease pretending of non cardiac symptoms .
Stroke Cerebral embolism, Endocarditis, Hypertention.

Abdominal pain Liver congestion , Unexplained right hypochondriac pain , jaundice.

ANKLE SWELLING
Manifestation
-

of of cardiac disease.
Congestive cardiac failure cardiomyopathies etc.
Hypoalbuminaemia
Nephrotic syndrome / Renal disease/ poor nutrition.
Venous insufficiency varicose veins.
Lymphatic obstruction.
Venous obstruction in perineum / abdomen
Eg pregnancy, tumors.
o DVT
o Idiopathic edema of women

EXAMINATION OF CVS
Examination of CVS
First impression.
Marfans syndrome
Aortic regurgitation, Atypical fibrosis.
Thyrotoxicosis.
Ankylosing spondylitis- Aortic regurgitation, Apical fibrosis
1. GENERAL EXAMINATION:Breathlessness ,
in pain
febile
pallor
xanthesma
cleft ear lobes associated with coronary artery disease.
Central cyanosis
Dental care
Thyroid enlargement
Clubbing
Stage I
:- Increased fluctuation of nail bed
Stage II
:- Loss of angle
Stage III
:- Increased curvature
StageIV
:- Dunstic appearance.- Bronchial
carcinoma
Ineffective endocarditis
Cyanotic heart disease.- peo use vibraters
Oslers nodes
Janeways lesions infective endocarditis, ankle edema.
2. PULSE
Presence / abscense.
Low volume irregular Multiple v. ectopies.
Low volume law volume LVF AS, AR :- Thats why ask to examine pulse.

Collapsing PDA, mitral regurgitation

Absent pulse Takayase disease

Rate Sinus tachycardia/ bradycardia.

Rhythm
Character
Bruits+
3. BLOOD PRESSURE
4. JVP. Level more than 5cm. elevated. 3 5 normal(a, c, v, x, y read)
5. INSPECTION.
Shape of the chest
Pectus corinatus long standing cardias disease
Sugical scars In re mitral stenosis . raise the brease and
see.
Visible pulsation over pulmonary artery In pulmonary
hypertension
Location of apex beat.
6. PALPATION
o Apex beat
double apex beat- LV aneurysm , HOCM
o Tapping MS
o Dyskinatic / diffuse after MI
o Parasternal heaving RVH
o Palpable HS over the clavicle- PDA.
o Palpable murmurs- thrill- systolic/diastolic. If cant palpate turn
patient to the left.
o Inability of detection of apex beat COPD, dextrocardia, Obesity ,
Pericardial effusion.
7. AUSCULTATION
Heart sounds first and second heart sounds clearly separating in N.
intensity
Level increase
P first MS
P second PHT
P2 soft AS
P1 soft MR
Varing intensity
- incomplete heart block
Heart murmurs
Other sounds- abnormal HS. Pericaridial rubs. Opening and
closing snaps. Clicks m. valve prolapse
Heart sounds 1, 2,3(heart failure) ,4
Spliting P2 is normal
MURMURS
I. Systolic
- Pansystolic -- MR , VSD , TR
- Mid systolic AS, PS
- Late systolic Mitral valve prolapse

II. Diastolic
- Mid MS/TS
- EarlyAortic regurgitation, PR,
- CO_______- PDA
AS Systolic
Mid /ejection systolic murmur
o Best heard at the upper right sternal edge. Heard over the carotid
arteries.
AR
Early diastolic
Left sternal edge.

mid diastolic murmur in mitral area, not diagnostic of MS

OtherARasking L. rheumatic heart disease.
Acute rheumatic carditis due to mitral valve edema
o VSDflow murmur
o PDAflow murmur
o Atrial myxoma

VSD
Pansystolic at lerft sternal edge.
Other
CV___
Opening snaps
N ncas_____
Prosthetic valve _______
Mitral valve murmurs
Auscultate with bell. Give proper instruction to take deep well breath an exhale.
Turning the patient to the left in expiration
AR murmurs
Left sternal edge lower down. Get patient sit forward. Get diaphragm in
expiration
MS
Mid diastolic , R_________, cardiac apex, Low pitched , best heard with the bell,
Left side in expiration. May or may not be with opening snap
Tapping apex
MR
Parasystolic except ____________________ with mitral valve prolapse in late.
Best heard at apex.
Conducted/ radiate to the axilla.