Makindo Medical Notes

Related Subjects: |Cardiac Examination |Cardiology History Taking |Respiratory Examination |Gastroenterology Examination |Cardiac Anatomy and Physiology |Coronary Artery Anatomy and Physiology |Cardiac Electrophysiology |Cardiac Embryology

Beck's triad of acute cardiac tamponade DDD

• Distant heart sounds
• Decreased arterial BP
• Distended neck veins

Reversible causes of cardiac arrest (6H and 4T)

• Hypovolaemia
• Hypoxia
• H⁺ (acidosis)
• Hypothermia
• Hypoglycaemia
• Hypokalaemia
• Hyperkalaemia
• Tension pneumothorax
• Tamponade
• Thrombosis (PE/MI)
• Toxins

Pericarditis

• P - Post Traumatic
• E - Endocrine: Hypothyroid
• R - Renal Failure
• I - Infection: TB, Viral, Fungal, AIDS, Bacterial
• C - Collagen Vascular Disease (SLE, RA)
• A - Aneurysm
• R - Rheumatic Fever- Radiation
• D - Drugs: Hydralazine, Minoxidil, Procainamide
• I - Infarction - AMI
• TI - Tumour Invasion
• S - Syphilis, Scleroderma, Serum Sickness

Pleuritic chest pain 5P

• P - Pneumothorax
• P - Pleurisy from Pneumonia, Infarction, Inflammation
• P - Pulmonary Embolus/Infarction
• P - Pneumomediastinum
• P - Pericarditis

Hypertension Treatment ABCD

• A ACE inhibitors/Angiotensin-II-antagonists (sometimes Alpha-agonists also)
• B Beta blockers
• C Calcium channel blockers
• D Diuretics (Thiazides)

Innocent murmurs

• Soft ejection systolic
• Soft grade < 2
• There are no added sounds
• Normal heart sounds
• No thrill
• Normal ECG and CXR

Aortic stenosis

• Plateau pulse, narrow pulse pressure
• Displaced pressure loaded apex beat
• Harsh ejection systolic murmur/thrill
• Radiates to Neck and apex
• Soft A2, murmur softer as LV fails

Aortic Incompetence

• Wide pulse pressure, hyperdynamic collapsing pulse,
• Eponymous signs
• Apex displaced dynamic volume overloaded
• Ejection click + EDM down LSE
• Mid Diastolic Austin flint murmur

Eponymous signs of Aortic regurgitation

• Quincke's - nail bed pulsation
• Corrigan's pulse - waterhammer pulse
• Corrigan's sign - easily visible carotid pulse
• De Musset's sign = head nodding to pulse
• Duroziez' sign - audible femoral diastolic bruit
• Traube's sign - pistol shot femorals
• Muller's sign - uvula moves with pulse

Mitral stenosis

• Low volume pulse, AF
• Elevated JVP, Malar flush
• Tapping apex beat.
• Loud S1, Opening snap and low pitched rumbling MDM
• Best heard medial to apex beat on left side
• Graham Stell Murmur (functional PR)

Mitral Incompetence

• Atrial fibrillation, Raised JVP
• Soft S1, Displaced apex beat
• Loud PSM to the axilla +/- thrill
• Audible S3 + Pulmonary oedema

Tricuspid Regurgitation

• AF, Large V waves in JVP, RV heave LSE
• Soft PSM at low LSE louder with inspiration
• Pulsatile hepatomegaly
• Oedema, Ascites, Dyspnoea

Atrial septal defect

• AF, JVP may be elevated, RV lift
• Fixed split A2
• Pulmonary systolic flow murmur and tricuspid diastolic flow murmur

Chest leads

• V1 - Fourth intercostal space, right sternal border.
• V2 - Fourth intercostal space, left sternal border.
• V3 - Midway between V2 and V4.
• V4 - Fifth intercostal space, left midclavicular line.
• V5 - Level with V4, left anterior axillary line.
• V6 - Level with V4, left mid-axillary line

Pulmonary hypertension

• AF, loud P2, Right ventricular heave
• Tricuspid regurgitation
• Pulmonary regurgitation (Graham Stell murmur)

Hypertrophic cardiomyopathy

• SR or AF, Jerky pulse
• Mid to late systolic murmur
• Double apical impulse
• PSM due to mitral regurgitation
• Audible S4 if in SR
• Systolic murmur louder on standing
• Systolic murmur softer on Valsalva

Endocarditis

• Fever, malaise
• Clubbing
• Janeway lesions
• Splinter haemorrhages
• Osler's nodes
• Changing murmurs
• Roth spots
• Splenomegaly

Heart Failure

• Determine is it Muscle / Valve / Pericardium
• is it Reversible

Heart Failure Causes

• Ischaemic
• Tachycardia
• Toxic (Chemo, EtOH)
• Metabolic (thiamine, HHC, T4, phaeo etc)
• Infective

Aggravating factors

• Anaemia
• HTN
• Ischemia
• NSAIDS
• Hyperthyroid

Heart & Liver disease

• Alcohol abuse (Kupfer cells inc.)
• Haemochromatosis (Kupfer cells spared (Perl's stain)
• Pericardial constriction
• Chronic TR
• Carcinoid ? liver mets.
• Sarcoid
• HIV
• Neoplasia
• Amyloid
• Infection (Mycoplasma, legionella, coxiella)
• Storage dis

NEUROPATHY & CCF

• DM
• Amyloid
• Sarcoid
• Vasculitis
• FRAT
• Alcohol High MCV
• B12/thiamine def
• Lactic acidosis

CNS & Heart disease

• TB
• HIV
• Syphillis
• Lyme disease
• RhF
• SBE
• Alcohol
• Amphetamine
• TCA
• Lithium
• SLE
• Connective tissue
• Vasculitis
• Sarcoidosis
• NF
• Tuberous sclerosis
• Friedereich's ataxia
• Myotonic dystrophy
• Duchenne's muscular dystrophy
• AIP
• GB
• Mitochondrial disease
• Down's

RENAL & HEART FAILURE

• HTN
• DM
• Atherosclerosis
• Vasculitis
• Amyloid
• Systemic sclerosis
• Pericardial effusion
• Neuroectodermal dis
• Sickle synd
• Toxins e.g. methanol, ethylene glycol

TALL R IN V1

• RVH
• RBBB
• Posterior MI
• Dextrocardia
• WPW (A)
• HOCM
• Duchenne MD

Digoxin TOXICITY

• CKD
• Hypokalaemia
• Hypomagnesaemia
• Hypercalcaemia
• Hypothyroidism
• Hypothermia
• Amyloidosis
• Acute myocardial infarction Drugs
• Amiodarone
• Warfarin
• Diltiazem
• Verapamil
• Quinidine
• Propafenone
• Cyclosporin
• ACEi
• NSAIDS

INDICATIONS FOR DIGIBIND

• If >10 mg (adult) or >4 mg (kids)
• Plasma dig >13
• K⁺ > 6 resistant to Insulin.dextrose
• Bradyarrhythmia unresponsive to Atropine? cardiac compromise
• Tachyarrhythmia (esp ventricular) ? cardiac compromise

TIMI SCORE FOR UNSTABLE ANGINA / NSTEMI

Historical Points
• Age >65
• >3 cardiac risk factors (FHx, HTN, high chol, DM, smoker)
• Known CAD (stenosis >50%)
• ASA use in past 7 days 1 1 1 1 Presentation
• Recent (<24hr) severe angina
• ? cardiac markers
• ST deviation >0.5mm 1 1 1 Risk of cardiac event (%) by 14 days in TIMI 11B Risk score Death or MI Death, MI or urgent revasc 0/1 2 3 4 5 6/7 3 3 5 7 12 19 5 8 13 20 26 41

CARDIAC AXIS

Using leads I and aVF the axis can be calculated to within one of the four quadrants at a glance. If the axis is in the "left" quadrant take your second glance at lead II.
• both I and aVF +ve normal axis
• both I and aVF -ve NorthWest territiory
• lead I -ve and aVF +ve right axis deviation
• lead I +ve and aVF -ve
• lead II +ve normal axis
• lead II -ve left axis deviation

Right axis deviation

• Normal finding in children and tall thin adults
• RVH
• Anterolateral MI
• Left posterior hemiblock
• PE
• WPW
• left sided accessory pathway
• ASD & VSD
• Chronic lung disease (even without PHT)

Left axis deviation

• Left anterior hemiblock
• Q waves of inferior MI
• Artificial cardiac pacing
• COPD
• Hyperkalaemia
• WPW
• right sided accessory pathway
• Tricuspid atresia
• Ostium primum
• ASD
• Injection of contrast into left coronary artery Note: left ventricular hypertrophy is not a cause left axis deviation

Northwest axis (no man's land)

• COPD
• Hyperkalaemia
• Lead transposition
• Artificial cardiac pacing
• VT

AXIS DEVIATION & BUNDLE BRANCH BLOCK

LAD/LBBB RAD/RBBB

• IHD
• HTN
• Aortic valve disease
• Cardiomyopathy
• Myocarditis
• Pacing wire
• Conduction dis
• RV strain (resp dis, chronic PE)
• ASD (LAD = 1, RAD = 2
• IHD
• Myocarditis

ATRIAL/VENTRICULAR HYPERTROPHY on ECG

Right atrium Left atrium Lead II 2 sq down 3 sq across Lead V1 2 sq down 1 sq x 1 sq RVH LVH R:V1 + S:V5/6 > 12.5 sq S:V1 + R: V5/6 > 40 sq

PACING

Condition PPM Pure sustained AF VVI or VVIR Pure sinus node dysfunction without evidence of AV block at rapid heart rates AF AAIR or DDDR 2nd or 3rd degree AVB Other bradyarrhythmia with visible p waves DDD or DDDR
• Pure ATRIAL PPM = if pure sinus node dis without AF (but may = AV nodal, therefore, most put in dual chamber)
• VENTRICULAR PPM = if slow atrial fibrillation = VVI
• All others = Dual Chamber with slow rate and visible 'p' waves

Heart block (Mobitz 2 + 3rd AVB) with :

• symptoms
• haemodynamic compromise
• asystole
• bilateral BBB
• following MI
• following cardiac surgery

MI

• (inc. inferior) with heart block = temporary pacing

PPM indications

• Symptomatic Mobitz I (DDDR)
• Mobitz II (DDDR)
• CHB (DDDR)
• Sinus pause >3 secs (day) >5 secs (night)
• Symptomatic nodal bradycardia (DDDR)
• AF with long pauses = VVIR

Pacing Codes

• 1st suffix : chamber paced
• 2nd suffix : chamber sensed
• 3rd suffix : I (inhibits itself in event of pts own complex)
• 4th suffix : usu R = rate responsive

Biventricular pacing

• NYHA III/IV despite medical Rx
• EF < 25%
• Conduction defect (QRS >120 ms)
• (NOT FOR AF)

CARDIAC TROPONINS

• MI
• Myocarditis
• Tachyarrhythmias
• DCCV
• PE
• Sepsis
• COPD
• Renal failure

SUDDEN DEATH

• WPW
• Amphetamine
• Focal myocorditis
• Commotio cordis
• LQTS
• Brugada's

BRUGADA SYNDROME

• Abnormal sodium ion channels
• AD
• Seen in Far East
• Ventricular arrhythmia (during sleep or at rest)
• Deaths in males
• ECG: RBBB; ST elevation in V1/2/3
• Will be a survivor of VF
• Needs ICD
• Screen family
• if ECG normal: give flecanide & rpt ECG to look for changes

Amiodarone USE

• Peri-arrest
• AF, SVT or VT with cardiomyopathy
• If AF and Rx with Digoxin, then starting Amiodarone halve dose of Digoxin

CCF IN ONCOLOGY

• Doxorubacin
• Amyloid
• RCM
• Endocarditis
• Malignant effusion

AORTIC DISSECTION

• Investigations: TOE CT Chest (contrast)
• Management : IV labetalol or nitroprusside Cardiothoracic surgeons (Keep SBP <100)

Risk factors

• Afro-Carribean
• Marfan's
• Ehlers-Danlos
• Pseudoxanth
• Coarcation
• Relapsing polychondritis
• PG

BIOPROSTHETIC VALVE & HAEMOLYSIS

• End of life of the valve
• Endocarditis

MANAGEMENT OF VT

• Haemodynamically stable?
• No = DCCV
• Yes = Amiodarone
• Procainamide negatively inotropic
• Sotalol
• Lignocaine
• less effective

VT ON ECG

• Broad complex
• Extreme axis deviation
• Concordance in chest leads
• RSR in V1
• Deep S in V6
• Fusion/Capture bends
• Dissociated 'p' waves

ANTICOAGULATION IN PG

• CCF severe
• Metal valve

ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY

• Rare
• Familial, occurs during exercise
• Fibrofatty replacement of R ventricle
• Fatal ventricular arrhythmias from R ventricle
• ECG = VT with LBBB
• Usu during exercise
• ECG abnormal in 90%
• TWI: V1-3/4
• Epsilon wave on ECG
• No more sport
• ICD
• Sotalol

BIVENTRICULAR PACING

• NYHA 3/4 despite medical Rx
• EF < 25%
• Conduction defect (QRS >120 ms)
• (NOT FOR AF)

Infective Endocarditis

• Fever & changing murmur but up to 15% no murmur on 1st examination
• Manifestations are Infective, Embolic, Vasculitic
• Fever (90%)
• Wt loss
• Clubbing
• Malaise
• Night sweats
• Splenomegaly
• Anaemia
• CVA
• Digital ischaemia
• Mycotic aneurysms
• Microscopic haematuria
• Splinter haemorrhages
• Osler's nodes (painful)
• Janeway lesions (painless)
• Roth's spots
• Renal failure (IC mediated GN)
• Causes any bacteraemia (60% nil found)
• Strep viridans (50% SBE)
• Staph aureus (20% cases but 50% acute, esp. IVDU)
• Strep bovis (often assoc with Ca colon)
• Also; Enterococcus, Haemophilus, Strep pneumoniae, Cardiobacterium hominis, Gram -ve, Coxiella burnetti, Chlamydia, HACEK group, SLE (Liebman-Sacks), Malignancy
• Post-valve replacement, commonest = Staph epidermidis

Infective Endocarditis Risk factors

• Rheumatic HD
• Congenital HD
• Degenerative HD
• MVP
• HOCM
• IVDU
• Prosthetic valves Valves Normal valves Chronic RhF Congen IVDU Prosthetic 40-50% 30% } usu subacute 10% } 10%
• R sided, lung abscess 10%

Poor Px Indications for surgery

• CCF
• Prosthetic valve
• Staph aureus (30% mortality)
• Culture negative
• Gram -ve
• Fungal
• Complement
• Aortic valve
• Renal failure
• CCF
• Extensive valve incompetence
• Large vegetations
• Septic emboli
• Septal abscess
• Fungal infection
• Abx resistant strain
• Unresponsive to medical Rx
• Haemodynamic embarrassment
• Overwhelming sepsis (no improvement 48 hrs)
• Recurrent emboli
• Prosthetic valve Antibiotic prophylaxis higher risk with more abnormal flow (e.g. MR>MS, VSD>ASD) and high jet, high pressure High risk Intermediate risk Low risk Not required
• Prosthetic valves
• Previous endocarditis
• Cyanotic congenital HD
• PDA
• VSD
• AR/AS
• MR
• MR & MS
• Coarctation
• MVP with regurgitation
• Pure MS
• T or P valve dis
• Bicuspid aortic valve
• HOCM
• MVP with click
• Secundum ASD
• Cardiac cath
• PPM insertion
• Bronchoscopy
• Endoscopy
• NVD
• D&C