Circulatory System(I)

Zhu Que,Ph.D.

The Second Affiliated Hospital of Chongqing Medical University

A. Information of the patient

• Name

• Age

• Sex

• Religion

• Occupation

• Address

• Date of admission

• Date of examination
B. The history proper:

• Chief or presenting complaints

• History of present illness (HOPI)

• Past history

• Personal history

• Family history

• Treatment history

• Psychological history

• Menstrual and obstetric history in females

C. Physical examination:

• I. General survey or examination:

• Level of consciousness; alert, oriented and cooperative

• Any acute distress present or not

• Decubitus (position of the patient in bed)

• Build (skeletal framework): average/dwarf/tall stature

• Nutrition (nourishment of the body): average/ undernutrition/ obese

• Height and weight

• Facial appearance (facies)

• Pallor or anemia

• Cyanosis (central or peripheral)

• Jaundice
• Neck vein distension
• Lymph nodes (all over the body)
• Clubbing
• Koilonychia
• Thyroid gland
• Oedema
• Dehydration
• Skin, hairs and nails
• Any obvious deformity (of skull, spine, limbs or swelling of abdomen)
• II. Vital signs:

• Pulse: rate, rhythm, volume, character, all peripheral pulses

• Respiration: rate, rhythm, type, depth

• Temperature: oral or axillary

• Blood pressure: supine and standing or sitting

• III. Systemic examination:

• Cardiovascular system (CVS)

• Respiratory system

• GI system

• Nervous system

• Genitourinary system
D. Summary of the case

• About two paragraphs, with history and brief examination points

E. Provisional diagnosis: Points in favor of diagnosis

F. Differential diagnosis

G. Relevant investigations

H. Final diagnosis
Anatomy
•T h e c i r c u l a t o r y s y s t e m c o n s i s t s o f t h e h e a r t 、 v e s s e l s a n d
neurohumoral adjustable devices of blood circulation.
•The heart
•a four-chambered pump. Its pumping action creates the pressure
needed to push blood in the vessels to the lungs as well as to the rest
of the body cells.
•Location of the heart
•T h e h e a r t l i e s o b l i q u e l y i n t h e m e d i a s t i n u m , b e t w e e n t h e l u n g s ,
inside the thoracic cavity. About 2/3 of the heart is located to the left
of the midline.
•Shape of the heart
•T h e h e a r t i s a h o l l o w, f o u r c h a m b e re d m u s c u l a r o r g a n , w h i c h i s
approximately the size and shape of a clenched fist and weighs about
250-350g in adults.
•General description of the heart
The heart looks like flattened and rounded pyramid
that has an apex, a base,two surfaces and three
borders(margins).
•Cardiac apex
The cardiac apex is a free, cone-shaped end, which is
made up only by the left ventricle.The cardiac apex is
located at the level of the left 5thintercostal space and
0.5-1cm medial to the midclavicular line. This location
is an important one for clinical purposes；for
auscultation as well as for palpation.
• Cardiac base
The cardiac base is primarily made up by the left
atrium with a lesser contribution of the right atrium.
l Grooves
There are three grooves on the surface of heart:the
coronary sulcus, the anterior interventricular groove, the
posterior interventricular groove.
•Chambers of the heart
• The heart is a four-chambered,double
pump,consisting of the right and left atria above
and the right and left ventricles below.
•R i g h t a t r i u m F r o m t h e r i g h t m a rg i n o f t h e
heart. Receives b l ood f r om t he s u pe r i o r ve na
cava, inferior vena cava and coronary sinus.
•R i g h t v e n t r i c l e B l o o d f r o m t h e r i g h t a t r i u m
passes thought the tricuspid valve to fill the
right ventricle.
•Left atrium located on the posterior aspect of
the heart，receives blood from the pulmonary
vein
•Left ventricle The left ventricle receives the
blood from the left atrium. These two chambers
are separated by the bicuspid (mitral) valve.
 Structure of the heart

•Structure of the heart wall

•endocardi um l oc a t e d i n t h e i n t e r i a l s u r f a c e h e a r t
atrium and ventricle wall.consist of every valve of the
heart. The place is easily invased by Rheumatic diseases.
•myocardium the majority of the heart wall,contains
myocardioventricle and myocardiatrium .the former is
t h i c k e r t h a n t h e l a t t e r, e s p e c i a l l y l e f t
myocardioventricle.they don't continue each other.
•p e r i c a r d i u m f i b r o u s p e r i c a r d i u m a n d s e r o u s
pericardium
Conduction system of the heart

It consists of special myocardial fibers, forms a

knot or bundle, locates in the heart wall.
The system has the character of generating
excitement, conducting impulse and maintaining
normal rhythm of the heart beat.
sino-atrial node locates in the epicardial deep surface
between superior vena cava and right auricle, normal heart
pacemaker.
atrioventricular node locates in the endocardial deep
surface between coronary sinus and right atrioventricular
orifice,conducts impulse from sino-atrial node into His
bundles.
atrioventricular bundle the only important way of linking
the heart atrium with ventricle.
•Heart Vessels
•Arteries and Veins
•Ascending aorta Source, left ventricle of the heart;
branches:left and right coronary artery, continues as
aortic arch;.
•L e f t c o r o n a r y a r t e r y Source, ascending aorta;
branches：anterior interventricular branches and
circumflex branches.
•R i g h t c o ro n a r y a r t e r y S o u rc e , a s c e n d i n g a o r t a ；
branches：sinoatrial nodal branches, right marginal
branches, posterior interventricular branches,
atrioventricular nodal branches.
Pathway of blood circulation

•systemic circulation left ventricle contract and eject arterial

blood into aorta,pass away its branches into capillaries,exchange
with substances and gases by production of different tissues or
cells, then transform into vein blood and return the right atrium.
•p u l m o n a r y c i rc u l a t i o n right ventricle contract and eject
phelbial blood into pulmonary artery,pass away its branches into
c a p i l l a r i e s , e x c h a n g e w i t h o x y g e n f ro m l u n g a l v e o l u s e s , t h e n
transform into arterial blood and return the left atrium.
Risk factors or causes for heart disease

•Smoking/intemperance
•High cholesterol /hyperlipidemia
•Diabetes
•Obesity/mal-nutrition
•Lack of exercise
•Family history
•Hypertension/hypotention
•Congenital malformation
•Peripheral artery disease
•virus or bacterial infection
•poisoning
•Age/sex
•Physiological degeneration
Chronic symptoms

•cardic symptoms
• chest distress
• palpitation
• angina pectoris
•pulmonary circulation
• cough
• expectoration
• Hemoptysis
• cyanosis
• dyspnea
systemic circulation
Ø faintness
Ø abdominal distension and pain
Ø vomiting
Ø oliguria
Ø edama
Ø headache
Ø dizziness
Ø twitching
In the present era of
technological advances,
particularly in the various
imaging modalities, physical
examination of the heart
still provides useful
information.

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n It is simple, convenient, cheap as premier assessment of the
severity and an etiology of the lesions and also serves as an
clue to use advanced techniques for the diagnosis of CVD.

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Patient’s exposure and position
(sitting or lying down) , with enough
light and appropriate temperature
Four parts: inspection, palpation,
percussion, and auscultation

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Part one
Inspection

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 Precordium is the
region of the anterior
surface of the body
covering the heart and
lower thorax.
n Thoracic cage deformity
n Apical impulse
n Abnormal pulsations in precordium
n Inspect the obverse
side.

n Then inspect the

patient’s lateral
surface
Asymmetry of the
thoracic cage due to a
convex bulging of the
precordium suggests the
presence of heart
disease since childhood.

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Such as congenital heart disease
and rheumatic heart disease, with
skeletal molding to accommodate
cardiac enlargement.

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 （ inspection）

n A p i c a l i m p u l s e m a i n l y re s u l t s f ro m t h e l e f t
ventricular contraction, when LV contracts, the
apical knocks at the correspondent position of
anterior chest wall, resulting in intercostal
impulse outward movement.

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 （ inspection）
Normal apical impulse
Position:
left border of sternum, fifth intercostal space,
inside the midclavicular line 0.5~1.0cm
Range: 2~2.5cm in diameter

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 （ inspection）
n Apical impulse displacement
n Changes of intensity and area of
apical impulse
n Inward impulse

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 （ inspection）

Apical impulse displacement

(1). non-cardiovascular factors
(2). cardiac enlargement
(3). body posture

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 Displacement
Other factors:
Obesity, pregnancy, etc. could cause
elevation of diaphragm, apical
impulse shifts to outward and
upward, at left the 4th intercostal
space outside midclavicular line.

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 Displacement
non-cardiovascular
factors:
Abdominal disease:
abdominal tumor, a large
number of ascites, etc.
elevation of diaphragm,
apical impulse shifts to
outward and upward
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 Displacement
non-cardiovascular factors:
Leptosome; severely
pulmonary emphysema.
Then apical impulse shifts
to inward and downward,
reaches at the 6th
intercostal space.

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 Displacement
non-cardiovascular factors:
Single side pleural thickening,
or adhesion, or atelectasis
result in mediastinum and
heart shifting to the sick
side, and the apical
impulse shifts to the sick
side , too.
LV
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 Apical Impulse
Displacement
heart shifts to the healthy side

to the health side

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Normal Effussion in the right
 Displacement
Cardiac enlargement
Right ventricle enlargement. Apical impulse
shifts to the left but not downward.

Left ventricle enlargement. Apical impulse shifts

to the left and downward at the same time.

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Left Ventricle Enlargement

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Normal LV enlargement
Both Ventricles Enlargement

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 Displacement
Body posture
Dorsal decubitus. Apical impulse moves a little
upward, if left lateral decubitus the apical
impulse shifts to the left 2~3cm.

Right lateral decubitus. The apical impulse

shifts to the right 1~2.5cm.

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 （ inspection）
Changes of intensity and area of apical impulse
(1). Physical conditions
(2). Pathological conditions

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Physical conditions
Ø Thickness of the chest wall
Ø Emotion excited
Ø Strong physical activity

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Pathological conditions Pathological conditions
Enhanced Weakened
apical impulse : apical impulse :
left v e n t r i c u l a r dilated myocardiopathy,
enlargement hydropericardium,
hyperthyroidism left pleural effusion,
fever, anemia pulmonary emphysema
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 Inward impulse. The apex depresses far from
the chest instead of striking the chest during
s y s t o l e . B ro a d b e n t ’s s i g n i s o f v a l u e i n t h e
diagnosis of adherent pericardium. It is also
seen in RVH.

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n Right vertricular n Pulmonary
hypertophy (RVH). emphysema with
The impulse is clearly RVH, usually the
seen in left third pulsation can be
fourth intercostal found inferior the
space. xiphoid process

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n In ascending or arch Pulmonary
aortic aneurysm, one hypertension with
may detects dilatation the
abnormal pulsations pulsation in systole
in aortic area, with may be detected in
bulging or pulsation left second
in systole. intercostal space to
the edge of sternum.
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n Marked pulsation at the base of the heart
is seen in aortic insufficiency, in a dilated
aorta or a saccular aneurysm.

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3.palpation

Touch at the apex beat , record whether the enhanc e d and

weakened apex beat , with or without tremor , pericardial
friction sensitivity .Touch the radial artery , record pulse rate ,
judgement if the arterial pulsation is powerful or not, including
the rhythm is or not in the low ,and comparing both sides are
symmetrical ,Determine whether there is pul sus par adoxus ,
alternating pulse or sign of capillary pulsation,etc.
4、Percussion
Draw the relative cardiac dullness by the percussion of
chest ,in order to determine whether the increase or decrease
of heart.
5、auscultation

Listen to the heart by the

stethoscope to determine if the
rhythm is neat or not and the
abnormal cardiechema.
some important signs

1.Cardiac enlargement
2.Abnormal heart sounds and pulse beat
3.Arrhythmia
4.abnormal breath sounds
5.Pulmonary rales
6.hepatomegaly
7.Jugular vein distention
8.lower extremity edema
Laboratory tests

• The doctors use physical , chemical and biological laboratory technology to test
patients' blood,fluid,secretion and tissue ,so as to obtain data and assist
diagnosis and treatment.

• Routine conventional tests

blood,urine,faece routine examination

• Special tests

1.microbial culture: infectious heart disease

2.ASO/ESR/CRP: rheumatic heart disease

3.lipids tests : coronary atherosclerotic heart disease

4.CK/CK-MB/cTnT/cTnI : myocardial infarction and angina pectoris

Equipment inspection

Electrocardiogram
put the electrode onto the special regions of body
surface,record out continuous curve about electricardia
charges with the machine.
mainly diagnose : Arrhythmia and Myocardial infarction
24-hour Holter
24-hour ambulatory blood pressure
•Echocardiography
•move the prode onto
the heart surface
re g i o n s , o b s e r v e t h e
c a r d i o g r a p h y
charges of computer.
•m a i n l y d i a g n o s e
cardiovalvularopath
y.
•angiocardiogram胸片

•Selective coronary angiography

•------gold standard
 Classfication of the heart

Etiology
• Congenital
• Acquired
• 1.Atherosclerosis
• 2.Rheumatic
• 3.primary hypertention
• 4.pulmonary
• 5.inflectious
• 6.endocrinopathic
• 7.hematopathic
• 8.Nutritional and metabolic
• 9.Cardiac neurosis
Pathological anatomy

•1.Endocardium disease(endocarditis )
•2.Myocardosis (myocardial ischemia )
•Arrhythmia(tachycardia )
•3.pericardial disease (hydropericardium )
•4.Macrovascular disease (aortic stenosis )
•5.congenital malformation(Congenital heart
disease)
Pathophysiology

•1.heart failure
•2.shock
•3.dysfunction of coronary circulation
•4.dysfunction of Papillary muscle
•5.Hyperdynamic circulation
•6.Cardiac tamponade
Diagnosis

• Etiology

• Pathological anatomy

• Pathophysiology

• eg:Rheumatic valvular heart disease

• 1.Rheumatic heart disease

• 2.bicuspid valve stenosis or incompetence

• 3.heart failure

• 4.atrial fibrillation
 Prevention

•1.stop smoking
•2.proper rest
•3.more movement
•4.lose weight
•5.decompression
•6.controll diets
•7.health education
•8.steady emotion
Treatment

•1.release symptoms
•(1)deal with the emergency conditions
• acute myocardial infarction, acute left heart failure
• (2)keep a balance of life sign
• (3)relieve pain
• (4)swelling
•
Thanks