HISTORY TAKING ANDHISTORY TAKING ANDCLINICAL EXAMINATIONCLINICAL EXAMINATION

OF CARDIAC PATIENTOF CARDIAC PATIENTDR. MOHAMMED FAKHRYDR. MOHAMMED FAKHRY

Ass. Professor of MedicineAss. Professor of MedicineConsultant Internist/CardiologistConsultant Internist/CardiologistDepartment of Internal MedicineDepartment of Internal Medicine

King Fahd Hospital of the UniversityKing Fahd Hospital of the University

A) HISTORYA) HISTORY

IMPORTANCE OF HISTORY:IMPORTANCE OF HISTORY:

The richest source of information.The richest source of information.

It establishes a strong bond between the It establishes a strong bond between the patient and his physician.patient and his physician.

It is the cornerstone of the diagnosis of It is the cornerstone of the diagnosis of some diseases.some diseases.

DyspneaDyspnea

Chest painChest pain

CyanosisCyanosis

SyncopeSyncope

PalpitationPalpitation

EdemaEdema

CoughCough

HemoptysisHemoptysis

FatigueFatigue

Intermittent ClaudicationIntermittent Claudication

CARDINAL SYMPTOMS IN HEART DISEASE:

1)1) DYSPNEA:DYSPNEA: “Unpleasant Awareness of“Unpleasant Awareness of Breathing”. Breathing”.

CAUSES:CAUSES:1)1) PulmonaryPulmonary

• COPDCOPD • • Restrictive L. DiseaseRestrictive L. Disease• Br. AsthmaBr. Asthma • • Ch. W. Dis.Ch. W. Dis.

2)2) Cardiac – CHF (MS, MR, AS, MI. CM)Cardiac – CHF (MS, MR, AS, MI. CM)3)3) AnemiaAnemia4)4) ObesityObesity5)5) Psychogenic.Psychogenic.

FUNCTIONAL CLASSES OF FUNCTIONAL CLASSES OF DYSPNEA: (NYHA classification)DYSPNEA: (NYHA classification)

Class IClass I D.O. extraordinary exertion D.O. extraordinary exertion (no(no

Dyspnea on average exertion)Dyspnea on average exertion)

Class IIClass II D.O. moderate exertionD.O. moderate exertion

Class IIIClass III D.O. mild exertionD.O. mild exertion

Class IVClass IV D. at rest (PND & Orthopnea)D. at rest (PND & Orthopnea)

II. CHEST PAIN OR DISCOMFORT:II. CHEST PAIN OR DISCOMFORT:

Common Causes:Common Causes:1)1) CAD CAD Angina Pectoris, Unstable Angina Angina Pectoris, Unstable Angina

and Acute Myocardial Infarctionand Acute Myocardial Infarction2)2) Mitral Valve ProlapseMitral Valve Prolapse3)3) PericarditisPericarditis4)4) Esoph. Reflux and Esoph. SpasmEsoph. Reflux and Esoph. Spasm5)5) Peptic Ulcer DiseasePeptic Ulcer Disease6)6) Biliary DiseaseBiliary Disease7)7) Cervical Disc DiseasesCervical Disc Diseases

TYPICAL ANGINAL PAIN “in chronicTYPICAL ANGINAL PAIN “in chronic stable angina”: stable angina”:

SiteSite

Quality of painQuality of pain

Duration (few minutes)Duration (few minutes)

RadiationRadiation

Provoking factor (Ex, exit, cold.weather.)Provoking factor (Ex, exit, cold.weather.)

Relieving factors (rest & TNG)Relieving factors (rest & TNG)

Associated symptomsAssociated symptoms

Risk FactorsRisk Factors

UNSTABLE ANGINAUNSTABLE ANGINA

New onset frequent angina.New onset frequent angina.

Crescendo or accelerated angina.Crescendo or accelerated angina.

Post MI Angina.Post MI Angina.

Duration.Duration.

Relation to rest.Relation to rest.

Response to TNG.Response to TNG.

ACUTE MYOCARDIAL INFARCTON PAIN:ACUTE MYOCARDIAL INFARCTON PAIN:

SiteSite

QualityQuality

DurationDuration

Associated SymptomsAssociated Symptoms

Response to S. L. TNGResponse to S. L. TNG

III. CYANOSIS:III. CYANOSIS: “Bluish Discolorationof Mucous“Bluish Discolorationof Mucous Membranes.” Membranes.”

Peripheral.Peripheral.

Central.Central.

IV. DIZZINESS PRESYNCOPE ANDIV. DIZZINESS PRESYNCOPE AND SYNCOPE. SYNCOPE.

Definition:Definition:

Causes:Causes:1)1) Drugs: Drugs: V. DilatorsV. Dilators2)2) Vasovagal syncopeVasovagal syncope

3)3) Carotid S. Hypersensitivity.Carotid S. Hypersensitivity.

4)4) Cardiac ArrhythmiaCardiac Arrhythmia

5)5) Cardiac Lesions (AS, MS, PS) Cardiac Lesions (AS, MS, PS)

V.V. PALPITATION:PALPITATION: “Unpleasant Awareness of Forceful or “Unpleasant Awareness of Forceful or Rapid Beating of the Heart.”Rapid Beating of the Heart.”

Main Cause:Main Cause: Cardiac Arrhythmias Cardiac ArrhythmiasDescription:Description:

– Fast or slowFast or slow– Regular or irregularRegular or irregular– Onset and offsetOnset and offset– DurationDuration– Associated symptomsAssociated symptoms

VI. EDEMA OF THE LOWER LIMBS.VI. EDEMA OF THE LOWER LIMBS.

CAUSES:CAUSES:

Cardiac.Cardiac.

Renal. Renal.

Hypoalbuminemia (Liver Hypoalbuminemia (Liver cirrhosis).cirrhosis).

Venous Insufficiency.Venous Insufficiency.

VII. COUGH DUE TO CHF:VII. COUGH DUE TO CHF:

It occurs when P.V. P. It occurs when P.V. P. high high

like with exercise in cases oflike with exercise in cases of

CHF.CHF.

VIII. HEMOPTYSIS:VIII. HEMOPTYSIS:

Mild:Mild: P. Congestion (CHF) P. Congestion (CHF) Ruptured P. Ruptured P. Capillaries.Capillaries. It occurs in the course of P. Infarcton.It occurs in the course of P. Infarcton. It occurs in the Eisenmenger Complex.It occurs in the Eisenmenger Complex.

Massive:Massive: Ruptured A-V Fistula.Ruptured A-V Fistula. Ruptured Aortic Aneurysm.Ruptured Aortic Aneurysm.

IX. FATIGUE:IX. FATIGUE:

It is usually due to low C.O.It is usually due to low C.O.

X. INTERMITTENT CLAUDICATION:X. INTERMITTENT CLAUDICATION:

Peripheral Vascular Disease Peripheral Vascular Disease (PVD)(PVD)

B) CLINICAL EXAMINATIONB) CLINICAL EXAMINATION

GENERAL CLINICAL EXAMINATION:GENERAL CLINICAL EXAMINATION:

Patient’s positionPatient’s position : (45º inclination of the : (45º inclination of the head of the bed)head of the bed)

JVPºJVPº

more convenient.more convenient.

Quiet & warm room with good lights.Quiet & warm room with good lights.

General Clinical Examination (cont’d)General Clinical Examination (cont’d)

1)General Look1)General Look– Skin complexion (color)Skin complexion (color)– Pain or respiratory distressPain or respiratory distress– Level of consciousness (place, time & persons)Level of consciousness (place, time & persons)– Body edemaBody edema– Abnormal FaciesAbnormal Facies

Marfan’s SyndromeMarfan’s Syndrome

Down’s SyndromeDown’s Syndrome

– Involuntary Movements Involuntary Movements Rheumatic chorea Rheumatic chorea

2. HAND EXAMINATION:2. HAND EXAMINATION:

1.1. PallorPallor2.2. CyanosisCyanosis3.3. Stigmata of Infective Endocarditis:Stigmata of Infective Endocarditis: 4.4. - Clubbing - Janeway lesion - Clubbing - Janeway lesion 5.5. - Splinter He. - Osler’s Nodules)- Splinter He. - Osler’s Nodules)6.6. Signs of Hyperlipidemia:Signs of Hyperlipidemia:

Xanthoma PalmarisXanthoma PalmarisTendon XanthomatosisTendon Xanthomatosis

7.7. Signs of severe AR:Signs of severe AR:Quincke’s SignsQuincke’s Signs

8.8. Signs of Thyrotoxicosis:Signs of Thyrotoxicosis:Fine TremorsFine Tremors

3. RADIAL PULSE:3. RADIAL PULSE:

1.1. RhythmRhythm2.2. RateRate3.3. Volume Volume

– NormalNormal– High High

LowLow4.4. Character:Character:

– Collapsing PulseCollapsing Pulse– Slow rising pulse (pulsus parvus et tardus or Anacrotic Slow rising pulse (pulsus parvus et tardus or Anacrotic

Pulse)Pulse)– Pulsus alteransPulsus alterans– Pulsus paradoxicusPulsus paradoxicus– Pulsus bigeminusPulsus bigeminus– Pulsus bisferiousPulsus bisferious

5.5. Vessel WallsVessel Walls6.6. Radio-radial and Radio-femoralRadio-radial and Radio-femoral Equality and Synchronization Equality and Synchronization

4. BLOOD PRESSURE MEASUREMENT:4. BLOOD PRESSURE MEASUREMENT:

11. The Cuff. The Cuff22. Position of the patient. Position of the patient3.3. Home measurement Home measurement44. Ambulatory 24 Hours BP Monitoring.. Ambulatory 24 Hours BP Monitoring.

TechniqueTechnique– KOROTKOFFKOROTKOFF Sounds Sounds

Syst BP Syst BP Korotkoff 1 Korotkoff 1Diast BP Diast BP Korotkoff 5 Korotkoff 5

Optimal BPOptimal BP<120 Systolic<120 Systolic<80 Diastolic<80 Diastolic

Prehypertensive StagePrehypertensive Stage120-139 systolic120-139 systolic80-89 diastolic80-89 diastolic

Stage 1 HPTStage 1 HPT140-159 systolic140-159 systolic90-99 diastolic90-99 diastolic

Stage 2 HPTStage 2 HPT160 systolic160 systolic100 diastolic100 diastolic

Blood Pressure Measurement (cont’d)Blood Pressure Measurement (cont’d)

Abnormal FaciesAbnormal Facies::Down’s SyndromeDown’s SyndromeMarfan’s SyndromeMarfan’s SyndromeMolar RashMolar RashPlethoric FacePlethoric Face

Pallor:Pallor:ConjunctivaConjunctivaMucous Membranes of the MouthMucous Membranes of the Mouth

5. RESPIRATORY RATE AND TEMPERATURE.5. RESPIRATORY RATE AND TEMPERATURE.

6. FACE EXAMINATION:6. FACE EXAMINATION:

JaundiceJaundice ScleraSclera Mucous Membranes of the MouthMucous Membranes of the Mouth

Arcus CornialisArcus CornialisXanthelasmaXanthelasmaCyanosisCyanosisSigns of HyperthyroidisSigns of Hyperthyroidis ExophthalmosExophthalmos Lid LagLid Lag Lid RetractionLid Retraction

Mouth HygieneMouth Hygiene

6. FACE EXAMINATION (cont’d)6. FACE EXAMINATION (cont’d)

Position of the patient Position of the patient 45º 45ºRt. Internal JVRt. Internal JVAnatomical CourseAnatomical CourseWavesWavesNormal JVP = Normal JVP = 8 cm water. 8 cm water.Causes of Prominent Causes of Prominent AA wave wave PHPH PSPS TSTS T. Atresia T. Atresia (Giant A wave)(Giant A wave)

7. JUGULAR VENOUS PRESSURE (JVP7. JUGULAR VENOUS PRESSURE (JVP))

Cause of absent Cause of absent A A wave wave A. Fib A. FibCause of Prominent Cause of Prominent VV wave wave TR TRCauses of Cannon A waveCauses of Cannon A waveKussmaul’s SignKussmaul’s Sign JVP during Inspiration > ExpirationJVP during Inspiration > ExpirationCauses:Causes:1.1. Constrictive PericarditisConstrictive Pericarditis2.2. Cardiac tamponadeCardiac tamponade3.3. Severe RV failureSevere RV failure

7. JUGULAR VENOUS PRESSURE (JVP) (cont’d)7. JUGULAR VENOUS PRESSURE (JVP) (cont’d)

Surface AnatomySurface AnatomyInspectionInspection

NormalNormal Corrigan’s SignCorrigan’s Sign

PalpationPalpation Location:Location:

Lt thumb for Rt carotid ALt thumb for Rt carotid A Rt thumb for Lt carotid ARt thumb for Lt carotid A

VolumeVolume CharacterCharacter Thrill Thrill Carotid shadder Carotid shadder Vessel wallsVessel walls

Auscultation:Auscultation: Systolic MurmurSystolic Murmur Systolic BruitSystolic Bruit

8. CAROTID PULSE:8. CAROTID PULSE:

InspectionInspectionPalpationPalpationPercussionPercussionAuscultationAuscultation

9. THYROID GLAND:9. THYROID GLAND:

A) Inspection: A) Inspection: Shape of the chestShape of the chest

– Pectus excavatumPectus excavatum– Rectus CraniatumRectus Craniatum– Kyphosis & ScoliosisKyphosis & Scoliosis

Precordial BulgePrecordial BulgeScar of previous cardiac surgeryScar of previous cardiac surgery

– Mid-sternotomy scarMid-sternotomy scar

10. EXAMINATION OF10. EXAMINATION OF THE PRECORDIUM: THE PRECORDIUM:

A) InspectionA) Inspection (cont’d (cont’d))

Apex Beat: Apex Beat: Causes of absent apical impulseCauses of absent apical impulse::

EmphysemaEmphysemaObesityObesityDextrocardiaDextrocardiaLt. pleural effusion or pneumothoraxLt. pleural effusion or pneumothoraxSevere pericardial effusion. Severe pericardial effusion.

Other cardiac ImpulsesOther cardiac Impulses::

Lt. parasternalLt. parasternalP. areaP. areaAortic areaAortic areaEpigastrium Epigastrium

B) PALPATIONB) PALPATION

1.1. Apical ImpulseApical ImpulseSiteSite

CharacterCharacter NormalNormal HyperdynamicHyperdynamic SustainedSustained

TappingTapping Localized or diffuseLocalized or diffuse

ThrillThrill

2) Other Pulsation:2) Other Pulsation:

Left Parasternal HeaveLeft Parasternal Heave

CausesCauses R.V. enlargementR.V. enlargement Severe LA dilatationSevere LA dilatation

Pulmonary areaPulmonary areaDilated Pulm. ArteryDilated Pulm. Artery

Causes:Causes: PHPH IdiopathicIdiopathic Post-stenoticPost-stenotic

Aortic AreaAortic Area Aortic aneurysm Aortic aneurysm

Epigastric pulsation:Epigastric pulsation:

Causes:Causes: RV enlargementRV enlargement Pulsatile hepatomegalyPulsatile hepatomegalyRS HFRS HF Palpable Abd. AortaPalpable Abd. Aorta

C) PALPABLE HEART SOUNDS AND CLICKSC) PALPABLE HEART SOUNDS AND CLICKS

1.1. Palpable S1Palpable S1 Tapping apical impulse Tapping apical impulse

2.2. Palpable P2 Palpable P2 PH PH

3.3. Palpable S3 Palpable S3 CHF CHF

4.4. Palpable S4 Palpable S4 HOCM HOCM

5.5. Palpable Clicks Palpable Clicks Metalic clicksMetalic clicks prosthetic valves prosthetic valves

D) THRILLS:D) THRILLS:

1.1. Diastolic ThrillsDiastolic Thrills MS & TSMS & TS Rarely ARRarely AR

2.2. Systolic ThrillSystolic Thrill MR at the M. areaMR at the M. area AS AS aortic area aortic area PS PS p. area p. area VSD VSD 3 3rdrd & 4 & 4thth Lt. ICS Lt. ICS

33. . Continuous ThrillContinuous Thrill PDA PDA44. . Carotid ShadderCarotid Shadder AS AS

C)CARDIAC AUSCULTATIONC)CARDIAC AUSCULTATION

STETHOSCOPE:STETHOSCOPE:a)a) BellBell Low frequency sounds Low frequency sounds S3, S4S3, S4

Mid-diastolic murmur Mid-diastolic murmur MS MS

b)b) Diaphragm Diaphragm High frequency sounds High frequency sounds S1, S2, S1, S2, E. click, non-ejection click, clicks due to prosthetic E. click, non-ejection click, clicks due to prosthetic valves.valves.

Systolic murmurs.Systolic murmurs.

Early diastolic murmurEarly diastolic murmur ARAR

Continuous murmur Continuous murmur PDAPDA

C) CARDIAC AUSCULTATION:C) CARDIAC AUSCULTATION:

CircumstancesCircumstancesQuiet and warm room.Quiet and warm room.The physician should be well trained and with The physician should be well trained and with clear mind.clear mind.Good stethoscope.Good stethoscope.Systematic approach:Systematic approach: S1 at mitral area S1 at mitral area (diaphragm)(diaphragm) S2S2 at pulmonary area at pulmonary area (diaphragm)(diaphragm)

S2 at aortic area for comparisonS2 at aortic area for comparison S3 & S4 at M. area & T. area S3 & S4 at M. area & T. area (Bell)(Bell) Clicks Clicks DiaphragmDiaphragm Inching auscultationInching auscultation

C) CARDIAC AUSCULTATION:C) CARDIAC AUSCULTATION:

Ausculatory Areas:Ausculatory Areas:

Mitral AreaMitral Area Apex beat area (5 Apex beat area (5thth LICS). LICS). Tricuspid AreaTricuspid Area 4 4thth LICS at sternal LICS at sternal

edge.edge. 22ndnd Aortic Area Aortic Area 3 3rdrd LICS at sternal LICS at sternal

edge.edge. Pulmonary AreaPulmonary Area 2 2ndnd LICS at sternal LICS at sternal

edge.edge. 11stst Aortic Area Aortic Area 2 2ndnd RICS at sternal edge. RICS at sternal edge.

C) CARDIAC AUSCULTATION:C) CARDIAC AUSCULTATION:

Ausculatory Areas (cont’d)Ausculatory Areas (cont’d)The HR should be counted from the M. area if it The HR should be counted from the M. area if it was totally irregular on radial pulse examination was totally irregular on radial pulse examination pulsus deficit.pulsus deficit.

S1 S1 M. area (mitral & tricuspid components) M. area (mitral & tricuspid components)

S2 S2 P. area (aortic & pulm. components)P. area (aortic & pulm. components)

physiological splitting of S2physiological splitting of S2

C) CARDIAC AUSCULTATION:C) CARDIAC AUSCULTATION:

Ausculatory Areas (cont’d)Ausculatory Areas (cont’d)

Mitral & T. Areas for Mitral & T. Areas for S3S3 and and S4S4..

S3S3 usually physiological in children and usually physiological in children and adolescents due to rapid filling of the LV.adolescents due to rapid filling of the LV.

S3 S3 CHF & volume overload. CHF & volume overload.

S4S4 HOCM, ACS, HPT. HOCM, ACS, HPT.

All ausculatory areas should be screened All ausculatory areas should be screened for systolic and diastolic murmurs for systolic and diastolic murmurs (inching(inching method).method).

C) CARDIAC AUSCULTATIONC) CARDIAC AUSCULTATION

Timing in Cardiac Auscultation:Timing in Cardiac Auscultation:Carotid Impulse Carotid Impulse systolic event. systolic event.

Apical Impulse Apical Impulse systolic event. systolic event.

The heart sound which correlates with the The heart sound which correlates with the beginning of Carotid Impulse or Apical beginning of Carotid Impulse or Apical Impulse Impulse S1. S1.

The heart sounds which correlates with the The heart sounds which correlates with the end of carotid or apical impulse end of carotid or apical impulse S2. S2.

C) CARDIAC AUSCULTATION:C) CARDIAC AUSCULTATION:

E) Heart Sounds Pattern on Cardiac E) Heart Sounds Pattern on Cardiac Auscultation:Auscultation:

Lub ---- Dub ---- Lub ---- DubLub ---- Dub ---- Lub ---- Dub

F) Gallop Rhythm:F) Gallop Rhythm:

Occurs due to presence of S3 or a summation of Occurs due to presence of S3 or a summation of S3S3 & & S4S4 in tachycardic patients. in tachycardic patients.

Accentuated S1:Accentuated S1:

MSMS

TSTS

STST

Short PR intervalShort PR interval

Hyperdynamic circulation (anemia, Hyperdynamic circulation (anemia, thyrotoxicosis & pregnancy)thyrotoxicosis & pregnancy)

Prosthetic MVProsthetic MV

Soft S1:Soft S1:Long PR intervalLong PR intervalMRMRCHFCHFLBBBLBBBHypothyroidismHypothyroidism

Variable S1:Variable S1:Non-rheumatic A. FibrillationNon-rheumatic A. Fibrillation33ºº AVB AVB

Muffled S1 Muffled S1 MR MR

Accentuated A2:Accentuated A2:Systemic Hypertension.Systemic Hypertension.

Congenital AS.Congenital AS.

Accentuated P2:Accentuated P2:P. Hypertension.P. Hypertension.

Soft A2:Soft A2:AR.AR.

Aortic Valve Calcification.Aortic Valve Calcification.

Wide Splitting of S2 during Wide Splitting of S2 during inspiration:inspiration:RBBBRBBBPSPS

Fixed and Wide Splitting of S2:Fixed and Wide Splitting of S2:ASDASDRV FailureRV Failure

Paradoxical Splitting of S2:Paradoxical Splitting of S2:ASASLBBBLBBBSevere LV FailureSevere LV Failure

Opening Snap Opening Snap MS MS

Ejection Clicks:Ejection Clicks:PS.PS.

AS.AS.

Prosthetic AVR (Opening Click of Prosth.AV)Prosthetic AVR (Opening Click of Prosth.AV)

Closing ClickClosing ClickProsthetic Mitral valve closure (as a Prosthetic Mitral valve closure (as a replacement of S1)replacement of S1)

Prosthetic AV closure (as a replacement of Prosthetic AV closure (as a replacement of A2).A2).

CARDIAC MURMURS:CARDIAC MURMURS:

Systolic MurmursSystolic Murmurs ESMESM (crescendo decrescendo murmur) (crescendo decrescendo murmur)

A) FunctionalA) Functional Hyperdynamic circulation. Hyperdynamic circulation.

Anemia.Anemia.

Pregnancy.Pregnancy.

Thyrotoxicosis.Thyrotoxicosis.

A-V shunts.A-V shunts.

Innocent in childhood and adolescence.Innocent in childhood and adolescence.

Systolic Murmurs (cont’d)Systolic Murmurs (cont’d) B) OrganicB) Organic::

ASAS

- - SupravalvularSupravalvular - Valvular- Valvular - Subvalvular (HOCM-Subaortic descrete- Subvalvular (HOCM-Subaortic descrete membrane)membrane)

Coarctation of the aortaCoarctation of the aorta PSPS

– ValvularValvular– InfundibularInfundibular– P. Artery stenosisP. Artery stenosis

Pansystolic MurmurPansystolic Murmur MRMR TRTR VSDVSD

Diastolic Murmurs:Diastolic Murmurs:– Early Diastolic murmur:Early Diastolic murmur:

ARAR PRPR

– Mid-diastolic murmur:Mid-diastolic murmur: MSMS TSTS VSD & ASDVSD & ASDM.areaM.area

Continuous MurmurContinuous Murmur– PDA.PDA.– Arteriovenous shunt.Arteriovenous shunt.– Arteriovenous malformation.Arteriovenous malformation.

Description of a murmur:Description of a murmur:Quality and timing.Quality and timing.Intensity – Scale of 6 grades.Intensity – Scale of 6 grades.Site of maximum intensity.Site of maximum intensity.Radiation.Radiation.Maneuvers which increases or decreases Maneuvers which increases or decreases its intensity.its intensity.

e.g. e.g. - PSM due to MR- PSM due to MR Best heart over the mitral area.Best heart over the mitral area. handgriphandgrip Radiates to axillaRadiates to axilla

- PSM PSM TR TR Beast Heard at TR area.Beast Heard at TR area. deep inspirationdeep inspiration

- PSM due to VSDPSM due to VSD Best heard at 3Best heard at 3rdrd & 4 & 4thth LICS LICS Radiates to Rt. Side of the chest.Radiates to Rt. Side of the chest. hand griphand grip

- ESM due to valvular AS:ESM due to valvular AS: Best heard on aortic areas.Best heard on aortic areas. By expirationBy expiration Hand gripHand grip Radiates mainly to the neck (carotid arteries).Radiates mainly to the neck (carotid arteries).

- ESM ESM HOCM:HOCM: - - Best heard at lower LSB and Mitral Area.Best heard at lower LSB and Mitral Area.

- - Valsalva Maneuver (straining phases). Valsalva Maneuver (straining phases).

- - Hand grip Hand grip

- ESM due to PSESM due to PS Best heard over the P. Area.Best heard over the P. Area. By deep inspiration.By deep inspiration.

- EDM EDM AR AR Best heard over aortic areas.Best heard over aortic areas. by hand grip and expiration.by hand grip and expiration. sitting up and leaning forward.sitting up and leaning forward. Radiates to the lower LSB and C. Radiates to the lower LSB and C.

Apex.Apex.

- MDM MDM MS MS Best heard over the M. Area.Best heard over the M. Area. Little exercise (Little exercise (HR).HR). Left decubitus position.Left decubitus position.

- MDM MDM TS TS Best heard over T. areas.Best heard over T. areas. by deep inspiration.by deep inspiration.

- Mid-Late Apical Systolic Murmur Mid-Late Apical Systolic Murmur MVP MVP Best heard at M. area.Best heard at M. area. by hand grip & sitting position.by hand grip & sitting position. by valsalva maneuver.by valsalva maneuver. by Amyle Nitrite Inhalation.by Amyle Nitrite Inhalation.

Examination of Other Parts of the Body:Examination of Other Parts of the Body:

BackBack– Fine bilateral basal crepitationFine bilateral basal crepitation

LV FailureLV Failure

– Sacral edema.Sacral edema.

LiverLiver Pulsatile & tender hepatomegaly. Pulsatile & tender hepatomegaly.

Sometimes Sometimes Ascitis & splenomegaly. Ascitis & splenomegaly.

Examination of Other Parts of the Body:Examination of Other Parts of the Body:

Lower limbsLower limbs::

A) Cardiac Edema:A) Cardiac Edema:– Bilateral & Pitting.Bilateral & Pitting.– Grades:Grades:

1+1+ Around ankle Joint.. Around ankle Joint..

2+2+ Below knee joint. Below knee joint.

3+3+ Above knee joint. Above knee joint.

4+4+ Scrotal edema, hydrocele, and edema of the Scrotal edema, hydrocele, and edema of the ant. abdominal wall.ant. abdominal wall.

B) Peripheral Circulation:B) Peripheral Circulation:– Inspection:Inspection:

Pallor.Pallor.

Hair loss.Hair loss.

PVDPVD (Arterial stenosis) (Arterial stenosis)

Signs of Gangrene Signs of Gangrene PVD PVD Total arterial occlusion Total arterial occlusion..

– Palpation:Palpation: Cold limb.Cold limb.

Sensation loss.Sensation loss.

Dry skin.Dry skin.

B) Peripheral Circulation (cont’d):B) Peripheral Circulation (cont’d):

– Weak or absent pulsations:Weak or absent pulsations:Dorsalis pedis.Dorsalis pedis.Tibialis posterior.Tibialis posterior.Medial popliteal.Medial popliteal.Femoral artery.Femoral artery.

– Poor capillary filling.Poor capillary filling.

C) Varicose Veins:C) Varicose Veins:– InspectionInspection

Dilated superfacial tortous veins.Dilated superfacial tortous veins.– Long saphenous vein.Long saphenous vein.– Short saphenous vein.Short saphenous vein.

Ulceration.Ulceration.Pigmentation.Pigmentation.Eczema.Eczema.

D) Deep Venous Thrombosis (DVT)D) Deep Venous Thrombosis (DVT)::– Unilateral Pitting edema.Unilateral Pitting edema.– Darker skin than the other limbs.Darker skin than the other limbs. surface temperature.surface temperature.– Tense and painful calf.Tense and painful calf.– Superfacial varicosity.Superfacial varicosity.

Level:Level:– below knee joint below knee joint medial popliteal veinmedial popliteal vein– above knee joint above knee joint long saphenous vein or long saphenous vein or

femoriliac venous thrombosis.femoriliac venous thrombosis.

D) Deep Venous ThrombosisD) Deep Venous Thrombosis::

Leg circumference is usually Leg circumference is usually 2.5cm than 2.5cm than the other leg (anatomical reference the other leg (anatomical reference tibial tuberositytibial tuberosity

Thigh circumference Thigh circumference 5cm than the other 5cm than the other thigh. (Anatomical land mark medical or thigh. (Anatomical land mark medical or lateral epicondyle of the femor bone)lateral epicondyle of the femor bone)

E) Peripheral signs of Severe AR:E) Peripheral signs of Severe AR:– Pistol shot (Traub’s sign).Pistol shot (Traub’s sign).

– Durozie’s sign.Durozie’s sign.

– Quinck’s sign.Quinck’s sign.

F) Signs of Hyperlipidemia:F) Signs of Hyperlipidemia:– Arcus cornealis.Arcus cornealis.

– Xanthelasm.Xanthelasm.

– Tendon Xanthomatosis.Tendon Xanthomatosis.

– Xanthoma Palmaris.Xanthoma Palmaris.