Cvs examination
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Transcript of Cvs examination
14/03/2006 YLM 1
CVS Examination
Prof Yan-Lynn Myint
MBBS,MMedSc (Int.Med.)
MRCP(UK) FRCP Edin.
14/03/2006 YLM 2
Why CVS in Dental practise?
• Dental practise/ procedures that induce
CVS diseases
• CVS diseases that can be exacerbated by
dental procedures
14/03/2006 YLM 3
History
• Name, age, sex, address, occupation
• Chief complaints
• HOPI
• PH
• FH/SH
• Personal history
• O & G history
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Cardinal/common symptoms Symptoms CVS causes Other causes
Chest discomfort 1. MI
2. Angina
3. Pericarditis
4. Aortic dissection
1. Oesophageal spasm
2. Pneumothorax
3. MS pain
Breathlessness 1. Heart failure
2. Angina
3. Pul embolism
4. Pul HT
1. Resp disease
2. Anaemia
3. obesity
Palpitation1. Tachyarrhythmia
2. Ectopic beats
1. Anxiety
2. Hyperthyroidism
3. drugs
Syncope/dizziness 1. Arrhythmias
2. Postural hypertension
3. Aortic stenosis
4. HOCM
5. Atrial myxoma
1. Simple faints
2. epilepsy
oedema 1. Heart failure
2. Constrictive pericarditis
3. Venous stasis
1. Nephrotic syndrome
2. Liver disease
3. drugs
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Type of cardiac pain
Type Causes Characteristics
Angina Coronary stenosis (rarely aortic stenosis, HOCM)
Ppt by exertion, eased by rest and/or GTN
Characteristic distribution
Myocardial infarction
Coronary occlusion Similar sites to angina, more severe, persist at rest
Pericarditic pain Pericarditis Sharp, raw or stabbing
Varies with movement or breathing
Aortic pain Dissection of aorta Severe, sudden onset,
Radiate to back
14/03/2006 YLM 6
Angina pectoris• Site and radiation
• Duration, precipitation and relieving factors
• Character, severity
• Special types – Unstable, crescendo, nocturnal,
Aggravating Relieving
•Exertion•Emotional excitement•Cold weather•Exercise after meal
•Rest•GTN•Warm up before exercise
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Differential Diagnosis
Angina Oesophageal pain
Usu. Ppt by exertion Can be worsened by exertion, but often present at other time
Rapidly relieved by rest Not rapidly relieved by rest
Retrosternal and radiate to arms and jaw
Retrosternal or epigastric, sometimes radiate to arms or back
Seldom wakes patient from sleep Often wakes patient from sleep
No relation to heartburn (but often have wind)
Sometimes related to heartburn
Rapidly relieved by nitrates Often relieved by nitrates
Typical duration 2-10mins Variable duration
14/03/2006 YLM 8
Differential Diagnosis
Angina Myocardial infarction
Site: retrosternal, radiate to arm, epigastrium, neck
As for angina
Ppt by exercise or emotion Often no obvious precipitant
Relieved by rest, nitrates Not relieved by rest, nitrates
Mild/moderate severity Usually severe (may be silent)
Anxiety absent or mild Severe
No increased sympathetic activity Increased sympathetic activity
No nausea or vomiting Nausea and vomiting are common
14/03/2006 YLM 9
Pericardial pain
Site Retrosternal, may radiate to left shoulder or back
Prodrome May be preceded by a viral illness
Onset No obvious initial precipitating factor;tends to fluctuate in intensity
Nature May be stabbing or raw – like sandpaper. Often described as sharp, rarely as tight or heavy
Made worse by Changes in posture, respiration
Helped by Analgesics, especially NSAIDs
Accompanied by Pericardial rub
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Dissection of thoracic aorta
Site Often first felt between shoulder blades, and/or behind the sternum
Onset Usually sudden
Nature Very severe pain, often described as tearing
Relieved by No, tend to persist. Patient often restless with pain
Accompanied by Hypertension, asymmetric pulses, unexpected bradycardia, early diastolic murmur, syncope, focal neurological symtoms and signs
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Breathlessness
• Awareness of one own breathing
– Dyspnoea on exertion
– Orthopnoea
– Paroxysmal nocturnal dyspnoea
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Palpitation
• Sensation of the heart beating in the chest
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Syncope and dizziness
• Postural hypotension
• Arrhythmias
• Left ventricular outflow obstruction
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Peripheral oedemaUnilateral•Deep vein thrombosis•Soft tissue infection•Trauma•Immobility, e.g. hemiplegia
Bilateral•Heart failure
•Chronic venous insufficiency
•Hypoproteinemia, e.g. nephrotic syndrome, kwashiorkor, cirrhosis
•Lymphatic obstruction, e.g. pelvic tumor, filariasis
•Drugs, e.g. NSAIDs, Nifedipine, amlodipine, fludrocortisone
•IVC obstruction
•Thiamine deficiency (Wet Beri Beri)
•Milroy’s disease
•immobility
14/03/2006 YLM 15
CVS disease presenting with non-cardiac symptoms
System Symptom Causes
CNS Stroke
•Cerebral embolism•Endocarditis•Hypertension
GI
Jaundice •Liver congestion•2˚to heart failure
Abdominal pain Mesenteric embolism
Renal Oliguria Heart failure
14/03/2006 YLM 16
Presenting complaint
• Recent onset
• Slowly progressive
• Functional assessment
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Past history
• Rheumatic fever
• Diabetes mellitus
• Hypertension
• Thyroid disease
• Recent dental works
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Drug historyDyspnoea Exacerbation of heart failure by β-blockers, some
CCB, NSAIDs
Dizziness Vasodilators, e.g. nitrates, alpha-blockers, ACEI
Angina Aggravated by thyroxine, drug-induced anaemia, e.g. aspirin, NSAIDs
Oedema•Fluid retention from steroids, NSAIDs•Oedema from CCB (nifedipine, amlodipine)
Palpitation
•Tachycardia and/or arrhythmia from thyroxine, beta-2 stimulant (salbutamol), •digoxin toxicity, •hypokalemia from diuretics, tricyclic antidepressants
14/03/2006 YLM 19
Family history
• IHD, HT
• Sudden death at young age
14/03/2006 YLM 20
Social history
• Smoking– CHD, PVD
• Alcohol– AF, HT
• Caffeine– palpitation
14/03/2006 YLM 21
Occupational history
Occupational exposure associated with CVD
Organic solvents Arrhythmias, cardiomyopathy
Vibrating machine tools Raynaud’s phenomenon
Publicans Alcoholic cardiomyopathy
Occupational exposure exacerbating pre-existing cardiac conditions
Cold exposure Angina, Raynaud’s disease
Deep-sea diving Embolism through foramen ovale
Occupational requirements for high standards of CVS fitness
Pilots, public transport, HGV drivers, armed forces, police
14/03/2006 YLM 22
Physical examination• General examination
– face• Dyspnoeic or not• Pallor• Cyanosis• Xanthoma, xanthelesma, arcus
– hands• Signs of infective endocarditis
– Splinter haemorrhage, clubbing, Osler’s nodes, Janeway’s lesion
– Feet/sacral area• Oedema, petichial haemorrhage,
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Pulses
Fast heart rate (tachycardia, >100/min)Sinus tachycardia Arrhythmia•Exercise•Pain•Excitement/anxiety•Fever•Hyperthyroidism•Medications:
–Sympathomimetics–vasodilators
•Atrial fibrillation•Atrial flutter•Supraventricular tachycardia•Ventricular tachycardia
14/03/2006 YLM 24
Pulses
Slow heart rate (bradycardia, < 60/min)Sinus bradycardia Arrhythmia
•Sleep•Athletic training•Hypothyroidism•Medications:
–Beta-blockers
–Digoxin
–Verapamil, diltiazam
•Carotid sinus hypersensitivity•Sick sinus syndrome•Second-degree heart block•Complete heart block
14/03/2006 YLM 25
Causes of irregular pulse•Sinus arrhythmia•Atrial extrasystoles•Ventricular extrasystoles•Atrial fibrillation•Atrial flutter with variable response•Second-degree heart block with variable response
Common causes of atrial fibrillation•Hypertension•Cardiac failure•Myocardial infarction•Thyrotoxicosis•Alcohol-related heart disease•Mitral valve disease•Infection, e.g. respiratory, urinary tract•Following surgery, especially cardiothoracic surgery
14/03/2006 YLM 26
Blood pressure
• Rest
• Sitting for ambulant
• Support the arm at about heart level
• Apply the cuff
• Inflate the cuff
• Deflate the cuff
• Systolic
• diastolic
14/03/2006 YLM 27
Differences between carotid and jugular pulsation
Carotid JugularRapid outward movement Rapid inward movement
One peak per heartbeat Two peaks per heartbeat
palpable Impalpable
Pulsation unaffected by pressure at the root of neck
Pulsation diminished by pressure at the root of neck
Independent of respiration Height of pulsation varies with respiration
Independent of position Varies with position of patient
Independent of abdominal pressure
Rises with abdominal pressure