Cardiac discission1
cardiac symptoms(DOP CSTC)
1-dyspnea:there are 4 types
(1)dyspnea on exertion ---in all CVS diseases-anemia-respiratory diseases
(2)dyspnea at night or nocturnal dyspnea----in left side heart failure-aortic valve disease-cardiac arrythmias-bronchial asthma
(3)dyspnea on lying flat or orthopnea----persistent pulmonary odema – advanced heart disease
(4)periodic dyspnea in old people


2-odema:
*it's a fluid retention leading to accumulation of fluid under the skin causing pitting or non pitting odema.
*odema of cardiac origin usually starts to accumulate in the lower limb[in bedriddin patient it accumulate in the back,buttocks,thighs and abdomen]
*odema of renal origin usually begins to accumulate in the face causing puffness and periorbital odema.
*the most common causes of odema are---cardiac failure – renal dieases – chronic venous insuffiency – hypoalbunemia – drugs


3-palpitation:
*it's an awarenace of heart beats which is in the most cases have no relation to heart diseases
*if it's from cardiac origin it will be associated with arrythmias such as [regular paraxosmol tackycardia-irregular fibrillation – in hyperkientic circulatory state such as arteriovenous shunts , cor pulmonale and beriberi
*other causes [anemia-thyrotoxicosis-anxiety-smoking-coffee-kola over use-asthma medication-digitalis]

4-chest pain:
*features of cardiac chest pain are-----central and retrosternal pain radiated to left shoulder , or diffuse heavy pain increase by exertion and decrease by rest.
*non cardiac causes ----febrile episodes-anxiety-pnumothorax-pleurisy
*cardiac causes----myocardial infarction-angina-pericarditis-cardiac ischamia- aortic aneurysm.

5-syncope:
*it's fainting due to decrease cerebral perfusion causesd by
(1)cardiac arrythmias
(2)impaired venous return[hypovolemia-diabetis melitus-hemorrhage-cough]
(3)excessive vasodilatation[antihypertensive drugs]
(4)vasovagal
(5)acute heart failure[pulmonary embolism-myxoma-aortic stensis]

6-tirdness:occurs mainly in low cardiac output cases and anemias

7-cough:
*more commonlly associated with respiratory than cardiac diseases.
*cough of cardiac origin manifested by frothy sputum pricpitated by exertion.


Case1=mitral stenosis

1-history[to obtain symptoms] * symptoms of left side heart failure
-decrease cardiac output:---pallor,syncope,tirdness,decrease blood pressure,palpitation and cold periphry
-increase atrial pressure---pulmonary odema which will cause persistent dyspnea and basal crepitation
*more specific symptoms for mitral stenosis[heamoptysis-hoarsness of voice-symptoms of right side heart failure-palpitation]

2-examination[to obtain signs]
*regular or irregular pulse due to atrial fibrillation.
*raised jugular venous pressure.
*malar facies or malar rash.
*tapping apex beat in the 5th intercostal space.
*left retrosternal heave indicate right ventricular enlargment.
*loud 1st heart sound.
*opening snap best heard at the apex with the patient in the lateral decubitus position.
*Low pitched mid diastolic murmur best heard with the patient in the left lateral position on expiration.


Q1.what is the commenest cause of mitral stenosis?
A1.rheumatic heart disease

Q2.what are the other rarer causes of mitral stenosis?
A2.-rheumatoid arthritis
-systemic lupus erythromatosis
-congenital stenosis
-malignant calcinoid


Q3.what is the mechanism of tapping apex beat?
A3.it is due to accentuated 1st heart sound.


Q4.what does opening snap indicate?
A4.indicate the opening of stenosed non calcified mitral valve, because if calcified will be absent.

Q5.what is the mechanism of loud 1st heart sound?
A5.the valve open during diastole and suddenly slammed shut by contraction in systole.

Q6.what are the complication of mitral stenosis?
A6. 1)systemic embolisation
2)left atrial enlargment and atrial fibrillation
3)pulmonary hypertension
4)tricispid regurgitation
5)right side heart failure


Q7.what are the investigation?
A7. 1)ECG:broad P wave[P mitrale]
2)chest x ray
3)echocardiography:the investigation of choice
4)cardiac catheterization


Q8.how would you manage this patient?
A8.- asymptomatic patient:--only prophylaxis aganist infective endocarditis - mild sypmtoms:--diuretics to reduce atrial pressure - atrial fibrillation:---(1)to control atrial rate[digitalis-beta blockers or channel calcium blockers,(2) anticogulants - moderate to sever symptoms or pulmonary hypertension----(1)ballon valvotomy or percutanous mitral ballon valvoplasty,(2)surgery


Q9.what is ortner's syndrome?
A9.refers to the hoarsness of voice caused by left vocal cord paralysis associated with atrial enlargment




case2/hypertension
1.history
*chest pain/dyspnea
*intermittent claudication
*headaches/visual disturbance
*family history of hypertension
*ask about hypertension in pregnancy
*medications

2-examination
look for aetiology:
-cashingoid face
-radiofemoral delay
-examine blood pressure in both arms
-listen for renal bruit of renal stenosis,feel for polycystic kidney

look for organ damage:
-examine the heart for left ventricular hypertrophy
-look for signs of heart failure
-examine the fundus for hypertensive retinopathy
-check the urine for evidence of renal failure[protein or sugar

Q1. what are the causes of hypertension?
A1.- unknown or idiopathic 90% - renal cause :diabetic nephropathy , renal artery stenosis , glomerulonephritis , pyelonephritis. - endocrine cause :cushing syndrome, pheochromocytoma , steriod therapy - others:coaraction of aorta , toxemia of pregnancy , contraceptives


Q2.what are the causes of blood pressure discrepancy between the arms or between the arms and legs?
A2.- coaraction of aorta -dissecting aortic aneurysm
-atrial occlusion or stenosis
-patent ductus arteriosis
-thoracic outlet syndrome



Q3.how you would you investigate a patient wth hypertension?
A3.CBC – serum urea and electrolyte – serum creatinine – fasting lipids – fasting blood sugar – serum uric acid – ECG – chest x ray – 24 hour urine collection to measure vanillylmandelic acid


Q4. what spcial investigation would you perform to screen for the underlying cause ?
A4. - renal digital subtraction angiography
-24 hour collection urinary catecholamines
-dexamethasones suppression test

Q5.which drugs should be used as 1st line treatment?
A5.- the older 1st line [beta blockers/thiaziades]
- the newer 1st line [Ca blockers/ACE inhibitors]


Q6.what is the appropriate interval before assessing the response to therapy?
A6. most of the antihypertensive drugs have their maximum blood pressure lowering affect 2 to 4 weeks although thiazide diuretics may take slightly longer [most physcians take around 6 weeks before assesing the efficasy.


Q7.what drug combination are effective?
A7. step1: monotherapy
step2: A or B + C or D
step3: consider 2ry hypertension and specialist refer
A=ACE inhibitors B= beta blockers
C= Ca blockers D=thiazides


Q8.what are the indication,adverse effects and contrindications for thiazides ?
A8.- there is no specific indication
-the contraindications are [gout/renal impairment/sever hepatic impairment/pregnancy]
-the adverse effects are[gout/ rashes/hyponatremia/hypotension]


Q9.what are the contraindication and adverse effects for beta blockers?
A9.-the contraindication[asthma/COPD/heart failure]
-the adverse effects [signs of central effect---tiredness/nightmares/insomnia/sexual dysfunction]


Q10.what are the drug of choice for each of the following:-
uncomplicated HTN------ diuretics(hydrothiazides-furosemide-spirolactone)
diabetes melitus and proteinuria----ACE inhibitors(captopril-enalopril)
heart failure------ACE inhibitors/diuretics
mycardial infarction----ACE inhibitors /beta blockers
angina-----beta blockers / Ca blockers
renal insuffeciency----ACE inhibitors
benign prostatic enlargment[BPE]---- alph blockers

Reference::250 cases in clinical medicine