Introduction to Clinical Medicine

General approach to a patient

 History taking
 Review of systems
 Physical examination
 Thorough
 Differential diagnosis
 Investigations
 Provisional diagnosis
 Final/confirmatory diagnosis??
 Management/treatment/follow up
CARDIOVASCULAR SYSTEM
Cardiovascular system
Anatomy and physiology

 Surface anatomy

 Cardiac chambers, valves, circulation

 Events in cardiac cycle

 The conduction system

Cardiovascular system
Examination
 JVP and Carotid pulse
JVP Carotid pulse
Rarely palpable Palpable
Soft biphasic undulating A more vigorous thrust with a
quality, usually with two single outward component
elevations and characteristic
inward deflection (descent)
a a
v
c
y

x S1 S2
Cardiovascular system
Examination

JVP
Pulsation eliminated by light
pressure on the vein(s) just
above sternal end of clavicle
Height of pulsation changes
with position, normally
dropping as the patient
becomes more upright
Height of pulsation usually fall
with inspiration
Carotid pulse
Pulsation not eliminated by
pressure on veins at sternal end
of clavicle
Height of pulsation unaffected
with position
Height of pulsation not
affected by inspiration
Cardiovascular system
Examination

 Inspection
 Apical impulse

 Palpation
 Apicalimpulse
 Heaves, thrills

 Percussion
 Not much significance
Cardiovascular system
Examination
 Ausculatation
 Normal heart sounds
◼ S1 and S2

 Abnormal heart sounds

◼ S3,S4
◼ Heart murmurs
◼ Systolic and diastolic
◼ Functional and pathological

 Bruits
Cardiovascular system
Examination
 Levine scale grading of Murmurs
 Grade 1: Very faint, audible only on listening for some time
 Grade 2: Faint, but immediately audible on placing
stethoscope on the chest
 Grade 3: Moderately loud, readily audible but without a
thrill
 Grade 4: Loud, with a palpable thrill

 Grade 5: Very loud, with thrill. May be audible with only

the rim of the stethoscope touching the chest
 Grade 6: Very loud, with thrill. Heard with stethoscope close
to the chest but without touching it
Cardiovascular system
Identify the picture..
Cardiovascular system
The Electrocardiogram (ECG)

 P
 Atrial depolarization

 QRS
 Ventricular depolarization

 T
 Ventricular repolarization