Indoor Rotations

for the Undergraduate

Cardiology

Prof. M. Shamim Anwar

MRCP (UK); FRCP (Edin)
 Taking history of a Cardiac patient

Dyspnoea Chest Pain

Enquiring about various types of Differentiating cardiac chest pain
cardiac dyspnoeas and from pain of pleurisy, oesophageal
differentating from respiratory pain and musculoskeletal pain.
dyspnoeas.

Orthopnoea
Paroxysmal nocturnal dyspnoea
General principle
Predominantly dyspnoea (especially on lying down) with occasional or mild cough is
cardiac. Predominantly cough with mild to moderate dyspnoea is more likely to be
respiratory.

Some exceptions of respiratory disease presenting with dyspnoea with almost no cough
Fibrosing alveolitis
True emphysema without bronchitis
Tension pneumothorax

Are you a diabetic?

Are you a patient of high BP and taking any treatment for it?

Past history
History of chest pain or admissions with chest pain?
History of rheumatic fever (High grade fever & joint pains) in chlidhood?
Family history
Sudden deaths in the family?
Myocardial infarction in parents and siblings at yuong age?
Hx of Hypertension or diabetes in the family?
 Prof. M. Shamim Anwar
FRCP (Edin)

CARDIOVASCULAR SYSTEM
(Outline of examination technique)
Position the patient
Have a little chat with him … for example
“I am Dr. Salman” ...... and "May I examine you Sir"

General appearance at a glance

The Patient (Build and weight)
Posture … Supine/Propped up

Look at the face

Puffiness. Mitral flush. Corpulmonale look.
Hypothyroidism. Acromegaly. Thyrotoxicosis.

The drug trolley

Digoxin, Frusemide, Captopril etc.

The sputum pit

The hand
Clubbing . Splinter haemorrhages . Prominent veins . Sweating .
The Pulse
Rate . Rhythm . Character . Volume .
Blood vessel wall.
Synchronicity of the two radials.
Radio-femoral delay.
Pulse deficit ( in suspected atrial fibrillation ).

The blood pressure.

Face and neck

Anaemia . Cyanosis .
Carotids. Thyroid.

The neck veins

Praecordium
Inspection and palpation
"Is the heart enlarged?"
Which chamber? ...Type of cardiac impulse.
Any palpable sounds or murmurs (thrills)

Auscultation
Auscultate the precordium
Auscultate the carotids
Auscultate the lung bases.

Fluid retention
Check sacral oedema. Check ankle oedema.
Examine the abdomen ..... Hepatomegaly and Ascites.

Bring the patient to a normal status (clothes etc.)

"Thank you very much for your cooperation".
 Pulse
Rate. Rhythm. Character. Volume. Blood vessel wall.
Synchronicity of the two radial pulses. Radio-femoral delay.
Regularly irregular
(Ectopics)
Rhythm
Iregularly irregular
(Atrial fibs or
multifocal ectopics)

Height

Normal
Based on variations of volume & duration of pulse

Duration

Height
Collapse
Aortic regurgitation Collapsing
Waterhammer
Duration

Aortic stenosis Height Plateau

Anacrotic
Duration

Mixed aortic stenosis

Character

and regurgitation Height

Bisfiriens
Duration

Left ventricular
failure (LVF) Pulsus alternans
One high and one low volume regular pulse

Pericardial effusion
Asthma
Pulsus paradoxus
Expiration--high volume pulse Inspiration--low volume pulse
The systolic blood pressure difference in inspiration vs expiration
will be more than 10 mm of Hg
JVP
ŸThe normal upper limit of height of the
JVP is 3cm vertically above the sternal
angle.
Ÿ
ŸThe right atrium lies approximately 5cm
below the sternum. So this figure of a
maximum height of 3cm corresponds to a
right atrial pressure (RAP) of 8cm water.
Ÿ
ŸTextbooks may give right atrial pressure
in mmHg and cause you some confusion.
In order to convert cm of water to mmHg
multiply by 0.75.
8cm water x 0.75 = 6mmHg

1. How will you measure the JVP?

2. How will you differentiate JVP from the carotid pulse?
3. How will you differentiate raised JVP of cardiac failure
from raised JVP of SVC obstruction?
4. What is Kussmauls sign?
 Inspection & Palpation of the Precordium
“Purpose Oriented Examination”
Purpose 1
“The heart is not enlarged because the
Is the heart enlarged?
trachea is central and the apex beat is in
Carry out two tasks the 5th intercostal space”.
1. Palpate the Trachea
2. Localize the Apex beat “The heart is enlarged because the trachea
is central and the apex beat is deviated to
the 7th intercostal space”.

Purpose 2
Which chamber is enlarged or hypertrophied?
Elicit the cardaic impulse. Heaving cardiac impulse = LV hypertrophy.
Thrusting cardiac impulse (para-sternal lift) =
RV hypertrophy
Tapping cardiac impulse does not tell us about
any chamber enlargemnet . It indicates that the
first heart sound is so loud that it is palpable.
Purpose 3
Are there any palpable sounds or murmurs?
The 1st heart sound may be palpable in tachycardia and mitral stenosis
and ASD.
The 2nd heart sound may be palpable in hypertension (loud A2) and in
pulmoary hypertension (loud P2)
The 3rd or 4th heart sounds may be palpable when present.
Murmurs may be palpable. Palpable murmurs are called thrills. A thrill may
be systolic or diastolic.

Why is the trachea important in deciding whether the heart is enlarged or

not?
What is apex beat?
Is mitral area and apex beat the same thing?

A left basal lung collapse may result in deviation of the apex to the lower and lateral
position even when the heart is not enlarged. A right pulmonary collapse may keep the
apex beat within the 5th space even when cardiomegaly is present.

Apex beat is the lowermost and outermost part of the cardiac impulse.

No. Mitral area is a fixed anatomical area i.e the 5th intercostal space in the mid-
clavicular line. Apex beat is a mobile area and may be in the 5th space in a normal
person and in the 6th or 7th space in cardiomegaly.
 Cardiac Auscultation
Technique & Manoures
Start from the mitral area with the diaphragm.
Time the first heart sound – Technique?

Concentrate on the heart sounds - Loudness ... Split.

Concentrate on 3rd or 4th sound.
Concentrate on murmurs.

If a systolic murmur is audible “inch” the stehoscope towards the axilla

(to see if the murmur radiates to the axilla or not).

Now change to the bell of the stehoscope.

On the mitral area concentrate on the 3rd heart sound and on the diastolic murmur of mitral
stenosis.
While the stethoscope is on the mitral area now tilt the patient to the left lateral position.
(murmur of mitral stenosis may become audible or become louder and clearer during this
procedure.
Tilt the patient back to the supine 45 degree position.

While the bell is still on ... Auscultate the left lower sternal edge (tricuspid area) for the 4th
heart sound.

Now shift to the diaphragm.

Auscultate while inching up along the left sternal edge towards the base of the heart ...
auscultating the Aortic area-2, Pulmonary area and the Aortic area-1.

At the Pulmonic and Aortic areas concentrate on the intensity of the 2nd heart sound and
any murmurs.

Now make the patient sit up and lean forward. Aucultate on the 2nd aortic area with the
diaphragm while the patient is holding breath in expiration.

Remember

Bell is used for Click is a sound resembling the 3rd

S3 S4 heart sound but is a systolic heart
Murmurs of mitral stenosis & tricuspid stenosis
Bruis sound.

Loud S1 ... Tachycardia. Mitral stenosis.

ASD.
Loud S2 ... Hypertension. Pulmonary I II S3 S4
I II
Tachycardia +S3 or S4
Split S2 or both = “gallop rhythm”
In inspiration in normal people.
Wide & fixed splitting in ASD
Auscultation