Crdiology - DR Abo-ElAsrar - by El Azhar Medical Students 2012

( BETA EDITION)
With
Prof. Dr Mohammed Abo El-Asrar
Edited By
El-Azhar Medical students 2012
Cardiology Dr. Abo El -Asrar

Cardiology INDEX
Total pages = 74
Total time = 17 hours & 24 minutes
Lecture number
Pages
1- lecture 18 4 - 10
introduction ( Page 4 )
2- lecture 19 10 - 16
cont. introduction ( page 10 )
3- lecture 20 17 24
VSD ( page 17 )
4- lecture 21 24 - 29
PDA ( page 24 )
5- lecture 22 29 - 37
Fallot's ( page 29 )
6- lecture 23 37 - 44
ASD ( page 37 ) + MS ( page 41 )
7- lecture 24 44 - 51
cont. MS ( page 44 ) + MR ( page 46 ) + AS ( page 48 ) + AR ( page 50 )
8- lecture 25 52 - 58
Rheumatic fever ( page 52 )
9- lecture 26 58 - 64
cont. Rheumatic fever ( page 58 ) + IE ( page 63 )
10- lecture 27 65 - 73
cont. IE ( page 65 ) + HF ( 69 )
11- lecture 28 73 - 74
cardiomyopathy ( page 73 )
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Cardiology Dr. Abo El -Asrar

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Cardiology Prof. Dr. Abo El -Asrar

18
cardiology
In Any lesion in congenital heart disease even rheumatic fever

:
1- Definition ) (
Defect in inter atrial septum ASD 2- Etiology
In any rheumatic heart disease RF
3- Hemodynamics
- Abnormalities in blood flow with this lesion
written ..
: 3
4- Clinical pictures
symptoms and signs 5- Complications
6- Investigations
7- Treatment
Introduction
1 ....
:
Etiology
What the is the etiology of congenital heart disease ???
A Idiopathic :
.. idiopathic 50 % B Acquired :
: 50 % congenital heart .. ) ( N.B. disease
rheumatic heart disease congenital heart disease Have familial tendency
gene factor .. 20
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congenital heart disease 1- Gene factor

2- Environmental factors :
a- Teratogens
( organogenesis) malformation factors In the first trimester
as :
1- Drugs
: .. heart malformation
A - Aspirin
.. NB. Aspirin may cause any congenital heart lesion except PDA
B - Lethium ( Anti depressant drug (
gene factor C - Warfarine ( Oral anti coagulant )
heparin shift DVT
2- Irradiations
.. teratogen
pregnancy test .. ..
b- May congenital infections :
placenta organism ,,, congenital heart disease is Rubella Infection congenital rubella syndrome
3 congenital heat
c- May maternal disease :
DM antenatal history has teratogenic effect 3 hyperglycemia
- May hypertensive mother anti hypertensive drug has teratopeneic effect
- Lupus + its drugs
d- Associated with chromosomal or genetic disorders
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:
commonest congenital heart disease
chromosomal and genetic disorder
1- Down syndrome
) common A-V canal Or called endocardial cushion defect ) congenital heart disease 2- Trisomy
mid-line defects As PDA, VSD, ASD
3- Turner's syndrome
Co-arctation of the aorta .
4- Marfan syndrome
Congenital aortic incompetence .
5- Nonann syndrome
Congenital pulmonary stenosis .
6- Dijeroge syndrome
Aortic arch anomaly .
7- Algea syndrome ( )
Pulmonary stenosis .

pulmonary aortic lesions syndromes
) ( features ,, features syndrome
heart
Clinical presentations
Symptoms
mother complaint 1- Most common asymptomatic
ECHO ..
Accidentally discovered
2- Congestive lung symptoms
pulmonary veins left atrium .. Pulmonary artery lung Lung : congestive lung symptoms
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pulmonary arterial flow called lung plethora

Congestion ( defect in drainage )
- & the Net result is congestive lung symptoms
items :
- Due to congestion to alveoli & airways
1- Dry cough
congestion
Irritation of cough receptors dry cough
2- productive cough
- then mucous secretions So, productive cough
) (
3- Dyspnea
- then O2 to tissues
tachypnea RC tissue hypoxia dyspnea
dyspnea during rest during effort 4- orthopnea
.. pathology
.. stagnation flat

5- paroxysmal nocturnal dyspnea
12 11 ..

hypoxia
RR during sleep
10 - 12 .. 18 cycle per min parasympathetic
Leading to Mild broncho spasm
O2 : .. .. Hypoxia sympathetic + RR

6- Hemoptysis
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- mucosa of airway markedly congested rupture hemoptysis

3- Palpitation
Awareness of heart beats
: .. heart beats Normal certain normal heart H.R. & Certain power of contraction
heart beats .. 4 - may low cardiac output symptoms
.. 3
: ..
a.
Brain hypoxia headache + lack of concentration .
cerebellar hypoxia dizziness .
syncopal attacks .
b.
heart anginal pain .
c.
skeletal muscles easy fatigability & muscle cramps .

: .. -
d.
RBF oliguria urine output
5- Cyanosis

- Peripheral mainly due to peripheral vasospasm
- central + Lips & tongue
Called potential cyanosis
permanent cyanosis NB. Congestive lung symptoms present in all except Falot tetrology
Examinations ( signs )
- local examination of the heart :
A- inspection & palpation
precordial pulge -1
.. heart apex comment -2
Site, size, character and thrill or not
: other pulsations and thrills -3
o
supra sternal notch
pulmonary area
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1st & ( 2nd aortic area = left parasternal area )
Epigastrium
Right parasternal pulsation

: heart surgical anatomy ) ) ( ( .. axis heart apex chest wall .. chest wall heart ) ( apex pulsation heart heart rotation .. intra uterine apex .. apical pulsation -
1- Dextrocardia
2- May apex behind rib
3- Thick chest wall as in obesity
4- Pneumothorax or effusions :
chest wall heart Pneumothorax pericardial or pleural effusion - site of the apex normally :
1 during infancy : ( birth 2 years )
Normally In the 4th left
ntercostals space outside midclavicular line
2- 2 years 7 years :
4th space at the clavicular line .. 3- > 7 years ( as adults ) :
adult .. 5th space inside the mid clavicular line
- Other areas are :
- Suprasternal area above suprasternal notch
2nd 2nd rib .. angle of louis notch space
pulmonary area left side 2nd space Just parallel to sternum 1st aortic area right side 2nd space 2nd aortic area .. left sternal border 3rd space Tricuspid area lower end of the sternum epigastrium 3rd and 4th left parasternal area Page |
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3rd and 4th right parasternal area chamber

19 18
A- inspection and palpation

1- Precordial bulge with RV enlargement
2- Comment on the apex :
apex comment - size of the apex
o
Localized apical pulse localize in one space ( by one finger )
Diffuse
pulsating pericardium diffuse .. the lower most & outer most apex -
- character
lesion -1
Tachycardia + power of contraction hyper dynamic apex
-2
heavy sustained apex
.. slapping apex -3
,,,
.. retrograde (
..
character ,,
)
- Thrill or not ( on the apex )
- Vibration sense over pulsation
thrill Pulsation
) vibration ( : .. thrill
1- Mean organic lesion in the heart 2- severe lesion
3- Other pulsations thrill
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areas 1. 1st aortic .

2. Pulmonary area .
3. A2 .
4. Left parasternal .
5. Right parasternal .
6. Tricuspid .
7. Epigastrium .
8. Supra sternal .
thrill ..

heart chamber
chest wall chambers chest wall chamber
pericardium Right ventricle apex .. left ventricle .. body of the sternum right aterium P. area pulmonary artery ascending aorta A1 arch of aorta manubrium sterni :
tip ( .. ) Ascending Aorta ( A1 ) ( pulsation .. aorta pulsation ) palmer surface
1 - If pulsation in the supra sternal notch aortic arch dilatation
2 - If pulsation in pulmonary area pulmonary artery
NB. Pulsation on pulmonary area called diastolic shock = palpable pulsation on pulmonary area
3 - If right atrium
pulsation in right parasternal area
3rd and 4th spaces tip of fingers right sternal border 4 - If right ventricle enlarged
precordial bulge .. .. .. chest wall
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inspection pericodium
Precordium = Intermammary area
mammary area
precordium Pectoralis major
.. flat .. bulge ( mammary area ( pectoralis major
precordium
precordium mammary Mammary Means precordial bulge and mean long standing cardiomegaly
long standing cardiomegaly
- Due to Right ventricular dilatation or hypertrophy since childhood period
chest wall .. - Here apex
- site :
in the 5th space (In the same expected space ) Outside the midcalvicular line ( Shifted outward apex )
) (
apex .. Horizontal right ventricle axis - Size of the apex :
Pulsate right ventricle Diffuse
- Other pulsations
Left parasternal pulsation
Then in epigastrium
pulsation .. left costal margin tip of fingers epigastric pulsation (
) pulsation .. xphisternum

pulsation -1
So, aortic pulsation
hyper dynamic circulation . aneurysm -2
Liver pulsation .. right edge of the hand
tricuspid regurge
tip of my fingers .. heart Pulsation -3
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N.B.
supra sternal pulsation .. pulsation

Hypertrophy dilatation pulsation

wall chamber cavity .. dilatation Lumen wall .. Hypertrophy ) lumen ( pulsation hypertrophy 6 - If left ventricular enlargement
anterior Shifted down and out apex Down and out oblique axis 5th 6th space
: .. right
No precordial bulge
No any other pulsation
Only apex shifted down and out + Localized apex

right and left ventricles ..
biventricular dilatation
- Apex diffuse + down and out

- Precordial bulge
- Left parasternal pulsation
apex shifted out precordial bulge ..
+ Diffuse. Left parasternal + epigastric
So, right ventricular enlargement
precordial bulge
) 4th space apex ( ..
down and out shifted down (5th space) and out side apex
Pulmonary pulsation epigastric pulsation left parasternal pulsation diffuse apex
supra sternal pulsation aortic pulsation
Biventricular , aorta , arch , pulmonary
As in complicated VSD

B - Percussion of the heart
:
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1- percussion of A1 and pulmonary

Lung .. resonant .. wall aorta pulmonary A1 and P heavy percussion .. Parallel to space .. space left and right sternal border
aorta pulmonary resonant
vessel dullness
2- right border of the heart ( Rt atrium ) on the Right sternal border

:
dullness ) Upper border ( liver mid clavicular line heavy percussion -A
resonant .. liver .. basal effusion Liver right sternal border ) parallel to right border ( One space right atrium dullness
space 3rd, 4th (and may 5th space) percussion -B
3- percussion outside the apex
apex dullness .. apex percussion text percussion ) ( obsolete plain X-ray
clinical sense ..
Investigations ..
C - Auscultation of the heart
comment

1- heart sound 2- murmurs 3- additional sounds
S1 & S2 heart sounds murmurs Timing , Character , Site of maximum intensity & Propagation of murmur
heart sounds ,,,
1- Heart sounds :
best area
a- 1st heart sound S1
- cause :
closure of mitral and tricuspid cause 2 atria .. diastole ventricles 2 atria

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- How to identify :

timing .. carotid pulsation .. sternomastoid medial border S1 carotid
- Best area of auscultation :
tricuspid ) apex ( Mitral ,,,
Tricuspid area Lower part of the sternum to the left side
b- second heart sound S2
- cause :
closure of Aorta and pulmonary cause

systole .. mitral tricuspid 50 Cm right left ( systole .. )
3
right left .. pulmonary aorta right left 10 pulmonary Pressure .. 80 aorta Pressure Pulmonary aorta
- How to identify :

second heart sound carotid .. carotid
- Best area of auscultation :
tricuspid apex aortic .. aortic
pulmonary area pulmonary area S2 comment 2- Murmurs :
- cause :
turbulence of flow Murmur - How to identify :
diastolic systolic
(area of maximum intensity (
timing Systolic or diastolic
- Site of maximum intensity

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.. Apex tricuspid A2 P A1 .. -1
( apex space ( mid axillary area
2 - Or start by mid axillary
A1 P A2 tricuspid apex
Site of maximum intensity murmur - Propagation :
3- Additional sounds :
additional sounds ) .. C/P .. (
Complications of congenital heart
1. Repeated chest infection .
Fallot congenital heart
2. Heart failure .
3. Infective endocarditis .
4. Eisenmenger's syndrome in all except in Fallot .
5. Stunted growth chronic
Investigations
1. Chest X-ray
Cardiomegaly or not .
Which chamber dilated .
Lung vascularity . Oligemia or .
2. ECG ) (
3. ECHO .
4. Catheterization.
Treatment
1. Surgical .
,,,
2. Medical .
prophylaxis against infective endocarditis

20 19
..
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VSD
Murmur clinical ..
Definition
Defect in inter ventricular septum
Etiology
1- 50 % idiopathic ( most common ) .
2- 50 % genetic base ( positive family history ) + the mother Gives history of environmental factors As :
Exposure to irradiation .
Drugs .
Congenital infection as rubella .
Maternal disease .
disease
Abnormal features chromosomal or genetic disorders As Down's syndrome .

Types
.. itme -
1- According to site
inter ventricular septum left and right ventricle - Has lower 2/3 part of muscular wall of the ventricle called muscular part of interventricular septum .
- & upper 1/3 is a layer of endocardium of Rt. V & a layer of endocardium of Lt. V . the 2 membrnes
adhere together Called membranous part
VSD
muscular part of the septum VSD muscular
membranous part of inter ventricular septum VSD membranous
: diameter .. ECHO
2- According to size of the VSD
a)
Wide VSD if > 1 cm .
b)
Small VSD if < 0.5 cm .
c)
Medium sized VSD if > 0.5 & < 1 cm .

small muscular VSD wide membranous VSD ,,

Hemodynamics
) ( signs symptoms
: systole and diastole cardic cycle -1
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gradient blood -2
flow 2 ventricles defect diastole systole
direction of flow
symptoms ..
atrium zero 2 ventricle pressure diastole diastole flow
systole flow ventricle pressure .. zero systole 120 mmHg pressure left side 25 mmHg right ventricle left ventricle pressure
tricuspid mitral A & P systole left ventricle pressure .. left ventricle Aorta VSD right Left
VSD .. .. items symptoms ..
- If small < 0.5 cm
1- asymptomatic :
asymptomatic case silent clinically
..
(accidentally discovered (
- If large > 1 cm ( large defect )
More blood from left to right
2- Congestive lung symptoms : ( )
Left ventricle .. Pulmonary artery right ventricle ( systole ( pulmonary artery dilatation pulmonary 50 Cm .. lung pulmonary .. 60 Cm
So, lung plethora
congestive lung symptoms
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MCQ
The first presenting symptom in VSD is congestive lung symptoms
3- Dysphagia :
lung left atrium left atrial dilatation posterior .. esophagus Left atrium esophagus ( )
dysphagia ..
4- Palpitation :
left atrium left ventricle Left ventricle diastole Pressure ( zero left ventricle )
So, dilated dilatation of Lt V
heart stretch ( muscle .. ) dilatation .. starling law within limits
) So, here Dilatation power of contraction palpitation ( Due to volume overload
)
5- Potential cyanosis :
AortaSo, no cyanosis oxygenated defect .. ( ) Central cyanosis on crying- Also, if constipation straining on defecation central cyanosis
Called potential cyanosis

Lung alveolus .. blood alveoli capillaries wall
( .. .. ..
.. ..
.. ..
tetany )
..
.. 100 Cm 40 Cm .. alveoli .. .. .. Against closed cord
N.B.
expiration
19

.. inspiration
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capillaries alveoli wall .. intra alveolar pressure right ventricle pulmonary Pressure Lung 90
pressure left ventricle left atrium ,,, 80
,,,,
.. ) Aorta ( left ventricle right ventricle ) (
Central cyanosis due to reversal of the shunt
intra alveolar pressure .. constipation wall local reflex rectum bladder evacuation relaxation sphincter
contraction
intra abdominal pressure .. ..

contraction to abdominal wall diaphragm Lung ..
vertical diameter and antero posterior diamtere
defecation & micturation
Called potential cyanosis Due to right ventricular pressure & Lt. Ventricular pressure .
mechanism
6- Low COP symptoms

section pulmonary serosal -1
mucosa -2
muscle -3
diastole dilatation systole pulmonary recoil
cycle
) ( Pulmonary Muscle ,,,
) P. stenosis ( lumen .. pulmonary Pulsation on pulmonary area .. chest wall sign Called diastolic shock
sign dullness If percussion on pulmonary area
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Pulmonary pulmonary pressure pulmonary Pressure .. Lumen hypertension

congestive lung symptoms Lung ,, ) 50 ( 40 left ventricle Left atrium 40 Lung
,,,,
Low cardic output symptoms
Syncopal attack ) ,,, ( flat .. 7- Permanaent central cyanosis ( Eisenminger $ )
Pressure .. pulmonary pressure So, pulmonary component Accentuated S2 ( as a sign )

low cardic .. pulmonary lumen ) ( (30 left side ( .. Pulmonary hypertension output
Pulmonary hypertension So, right ventricular hypertrophy ( late)
left .. left ventricle .. right ventricle pressure
reversal of the shunt right
so, flow from right to left ventricle (Non oxygenated blood) so, Permanent central cyanosis
Called Eisenminger syndrome (as a complication)
heart lung transplantation no role of surgical therapy
Clinical pictures
1- symptoms : hemodynamics
2- signs ( examination ) .

right ventricle Pulmonary A left ventricle left atrium
right atrium aorta

1- inspection & palpation :
A- precordial Bulge very very late ( if neglected cases only )
B- Apex
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Early ( only Lt. V enlargement )
Late ( Lt. & Rt. V enlargement )
1- Site
shifted down & out
shifted down & out ( more out )
2- Size
Localized
Diffuse
* Hyperdynamic
** Heavy sustained
May
May
3- Character
4- Thrill
* Why Hyperdynamic apex ??

Due to Volume overload power of contraction hyperdynamic apex .
** Why Heavy sustained apex ??
) P.Hypertension ( against pressure right ventricle C- other pulsations & thrills
sites ... Positive
* supra sternal no pulsation
* A1 never
aorta
* P pulsation if PH
* left parasternal may Systolic thrill
thrill
) ( right Left flow .. right left ventricle ) Systolic thrill( left parasternal area .. systole right ventricle wall
* right parasternal no ( as in VSD normal right atrium (
* may epigastric pulsation if right ventricle
N.B.
If Eisenminger is there a Thrill ?? No thrill
So, thrill is a good sign thrill .. (Right to left) flow
2 - percussion
A- A1 & P dullness on P if pulmonary hypertension .
B- right border never dullness no enlargement to right atrium .
C- No dullness outside apex .
3- Auscultation
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A- heart sounds
S1 normal and normal S2
Except if PH S2 ( accentuated )
B- murmur
- Timing : pansystolic murmur
) ( S1 and S2 systole
- Character :
) ( soft ) (harsh
.. pressure gradient murmur soft murmur 25
) ( harsh 25
) (So, harsh 120 - 25 = 95 mmHg - Site of maximum intensity :
left parasternal area - Propagation : propagated to all pericordium
back
N.B. Area of maximum intensity if Eisenmenger syndrome
flow .. back
Complication
1.
Repeated chest infection .
2.
Infective endocarditis .
3.
Heart failure .
left ventricular failure Right ventricular failure
.. - So Here, left ventricle enlargement early .. And late right ventricular enlargement
So, Left sided heart failure then right sided heart failure
4.
Eiseminger syndrome .
5.
Stunted growth .
Investigations
1.
Chest X-ray
Cardiomegaly all except
Lung plethora .
2.
ECG .
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3.
ECHO muscular or membranous .
4.
Catheterization
large small
Treatment
1. Prevention against IE .
2. Surgical :

ECHO
1- IF membranous :
.. membranous 2- IF muscular :
wide
medium sized or small
pulmonary .. ECHO 6 10 pressure
Eisemenger syndrome pulmonary pressure .. 10 5 21 20
PDA
Only Fallot and VSD
.. clinical -
Definition
Connection * between arch of Aorta and main pulmonary artery
We have 3 main arteries from arch of Aorta
1- In nominate artery ( )
right common carotid And right sub clavian ..
2- Left common carotid
3- Left sub clavian
umbilicus .. arterial supply to upper segment of the body

* Connection after the origin of left sub clavian artery

intra uterine Intra uterine ductus Page |
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Intrauterine
intra uterine
pulmonary branches .. collapsed Lung intra uterine Lung pulmonary right ventricle ) placenta ( collapsed lung
Aorta Pulmonary pressure umblical artery Aorta Ductus arterious Aorta pulmonary O2 .. placenta
Non oxygenated D.A. Intra uterine
O2 sensors .. lined by endothelium D.A. endothelium PO2 PGE2
Relaxation of the smooth muscle around the ductus

DA PO2 .. circular muscle

pulmonary Lung .. pressure
oxygenated blood pulmonary Aorta contraction of the smooth muscle around D.A. No PGE2 PO2
Called functional closure 15 end arteritis obliterans fibrosis ..Thrombus D.A. Ligamentus arterious
Etiology
As any congenital
A 50 % idiopathic .
B 50 % gene + environmental factors .
C - Specific factors
1- Aspirin :
.. PDA
Aspirin teratogen -
As it cause Cycoloxygenase enzyme

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Premature closure of DA ) ( PGE 2 .. ( endomethacin 24 DA .. ) ( contraction of smooth muscle )

2- Congenital rubella :
DA rubella virus .. PDA congenital rubella Proliferation of DA endothelium PGE2 secretion more smooth muscle relaxation
No functional closure
3- Atopic disease
Maternal disease As asthma, allergic, rhinitis, dermatitis .
So, PGE2 in mother PGE2 in fetus
) stress (
4- any cause of neonatal hypoxia after delivery
So, PO2 ( )
a- May apnea ( central cause )
DA .. Aorta PO2 lung 3
b- Also, lung surfactant
So, any cause of neonatal hypoxia
delayed closure of the DA
Hemodynamics
items symtoms .. VSD ) PDA
) .. UL ( So, blood to lower limbs pulmonary Aorta - Also, pulmonary artery receive blood from right atrium So,
Lung plethora .. Lung P.Artery

1- Asymtomatic :
Asymptomatic .. lung
2- congestive lung symptoms :
- If large amount of blood congestive lung symptoms
3- dysphagia :
Then blood to left atrium More blood in left atrium Left atrium dilatation
dysphagia
4- Palpitation :
- Then blood to left ventricle volume overload power of contraction
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) ( palpitation
- Water hammer pulse ( as a sign )
left ventricular dilatation 600 500 Left ventricle dilatation Aorta N.B Amount of blood every systole called stroke volume . ( SV )
SV x HR = Cardic output . So, here COP .. & COP affect systolic blood pressure .
) adult ( 170 systolic pressure : diastole systole ( .. 10 pulmonary .. (80) aorta ) diastole
) ( Diastolic blood pressure Aorta Pressure Net result systole & diastole .
So, pulse pressure ( systole - diastole )
water hammer pulse sign 5- Low COP :
If neglected more and more
pulmonary dilatation during and recoil during diastole During systole Pulmonary
) ( PH Narrow lumen + hypertrophy in wall
so, blood in lung blood to left side
+ ) COP ( ) lower part of the body ( low cardic output
PDA
6- Potential cynaosis in lower limbs : ..
If straining
blood left side aortic pressure pressure in pulmonary So, blood from pulmonary to Aorta (
reversal of the shunt ) ( ) In the lower part of the body
Called potential cyanosis in lower limbs only ( )
,,, : ... ..
7- Eisemenger syndrome :
- pulmonary artery pressure
) .. ( Eisemenger syndrome Aortic
peripheral cyanosis
- not improved by warming
- Clubbing In the lower limbs
N.B Central cyanosis in lower part of the body Is Called differential cyanosis
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- Very very very very very rare right ventricular hypertrophy

Aorta .. Pulmonary pressure ) PDA aorta .. "" (
symptoms
On Examination ( signs )
1- In general
water hammer pulse .
2- Local examination

arch of Aorta pulmonary Left ventricle Left atrium

A - Inspection and palpation
) .. ( precordial bulge
1- Apex :
- Site : shifted down and out the Lt. Ventricle
- Size : localized .
- Character : volume overload so, hyperdynamic apex
- No thrill
2 - Other pulsations
- Supra sternal arch enalrgment
- A1 & P IF Pulmonary hypertension ( PH )
- No left or epigastric pulsations
B - Percussion
: dullness
A1 and pulmonary ( Not on right border )
C - Auscultation
1 - normal S1 - If PH S2
2- Murmur :
- Timing : pansystolic & pan diastolic murmur
25 /10 pulmonary 120/80 Aorta pressure .. adult - In systole 120 25 = 95 mmHg pressure gradient
- In Diastole 80 10 = 70 mmHg pressure gradient
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So, murmur in both systole and diastole systole & diastole flow
- type : continuous murmur
- character :
) murmur ( harsh 25 pressure gradient character Harsh all time but more in systole called machinery murmur .
- site of maximum intensity
Just above the pulmonary area Left clavicle
- Propagation : To pulmonary and may A1
....
VSD pan systolic PDA
) Eismeniger syndrome ( PH ,,,
) E. syndrome PH ( : ..
40
In aorta Systolic pressure -
) ES .. pulmonary ( 30 ..70 pulmonary

40 pulmonary .. 40 aorta diastolie harsh systole .. diastole In VSD more in left parasternal VSD below left clavicle But in PDA
Complications
1.
Repeated chest infections.
2.
IE as any congenital heart disease .
3.
HF left sided heart failure only .
4.
Eisenmenger syndrome .
5.
Stunted growth .
,,,
Any systemic disease cause proportional short stature Except one diseaseCause disproportionate short stature
.. What is this disease ??
Lower limbs PDA ,,
Investigations
1.
Chest X ray .
- Cardiomegaly left ventricle .

- Lung plethora .
2.
ECG .
3.
ECHO .
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4.
Catheterization .
Treatment
1 - Medical treatment .
Preventive against IE.
If so early diagnosis endomethacin that PGE2

,,,
What is the Congenital heart disease Closed by medical therapy ?? early diagnosed PDA
2 - Surgical : closure of PDA .

.. ) ( 3 - 2
22 21
Fallot's tetraology
clinical
:
1- Fallot 1888
2- tetraology
heart anomaly
Definition
....
1- Overriding of the aorta ( occur intrauterine )
right ventricle left Aorta 2- No membranous part of inter ventricular septum . ( non functioning )
So, wide membranous VSD ( also , since intrauterine life )
3- hypertrophy of the infundibulum of the pulmonary artery ( after birth )
origin embryology ... Heart P & A A - Heart from cardiac tube
B - Big vessels ( aporta & pulmonary ) from truncus arteriosis .
infandibulum truncus arterious cardiac tube right ventricle pulmonary ... Left ventricle Aorta
Infandibulum is the Muscular part of the ductus arteriousus
valve
: .. Fallot
- Within 1st six months hupertrophy of infandibulum of pulmonary artery
) infandibulum (
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6 variable So, pulmonary stenosis Due to subvalvular cause ( subvalvular pulmonary stenosis)
4- Right ventricular hypertrophy :
.. Pressure .. left ventricle Aorta right ventricle ..
So, here VSD is non functioning
N.B. All Fallots occur intrauterine , except hypertrophy of pulmonary artery Infandibulum
Etiology
1- 50 % idiopathic 2- 50 %
Hemodynamic
,,,
items symptoms
: systole right ventricle To Aorta right ventricle .. .. Mitral valve tricuspid Pulmonary
) ( pulmonary artery Aorta .. - Then from pulmonary small amount of blood to lung
So, oligemia in lung Lung ,,,
So, no congestive lung symptoms
1- central cyanosis :
- Less blood to left side
Mixed Aorta .. Non oxygenated Aorta
central cyanosis
un oxygenated hemoglobin % 5 gram central cyanosis ,,,
clinically 5
As un oxygenated hemoglobin > 5 gm % central cyanosis
,,,,
cyanotic congenital heart disease as TGA Fallot
central cyanosis So, onset of cyanosis in Fallot shortly after birth
,,, ..
) ... . . 2 . (
..
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, , , ,

:
Fallot So, at birth No hypertrophy in infandibulum
blood right ventricle .. Pulmonary
Lung Oxygenated Left ventricle aorta
So, mixed blood in aorta mainly oxygenated ( un oxygenated blood < 5 gram % ) So, no central cyanosis
hypertrophy .. pulmonary
,,,
ductus Arterious delayed closure of DA
As mixed blood in aorta then Through DA PO2
PGE 2 Delayed closure of DA 15 Pulmonary Lung left side
So, more oxygenated blood in aorta So, no cyanosis
cyanosis DA infandibulum hypertrophy
: 2- Squatting position
Fallot Squatting position ( .. Ischemia ) Lower limbs

,,
femoral popletial artery Pressure Aorta pulmonary .. oxygenated blood .. hypoxia cyanosis
( ,,, )
)
.. ( ,,, abdominal wall intra abdominal pressure .. venous return squeezing of abdomen Lower limbs
blood .. blood to right ventricle Pulmonary ( oxygenated blood ) ,,, ... Aorta
... Rt V aorta .. pulmonary Aorta
3- clubbing :
32

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, , , ,
2012

So, hypertrophy of nail bed peripheral hypoxia .. central cyanosis clubbing .. clubbing (cyanotic type(
4- cyanotic spells :
.. : ,,,
) more deep cyanosis ( syncopal attack ) ( cyanotic spells ...
) hypoglycemia viral ( ,,, .. pulmonary .. spasm of infandibulum of pulmonary
: .. So, all aortic blood is non oxygenated Aorta
- Anoxia of brain syncopal attack
- All art blood non oxygenated More cyanosis ) (
- Brain hypoxia anerobic metabolism
convulsion irritation Metabolite
.. relaxation of the infandibulum Muscles hypoxia ..
)
( 5
Examination
1- General
Squatting position
Central cyanosis .
Clubbing .
2- Local examination
,,,
) right ventricle .. wall (
A Inspection and palpation normal .
B Percussion normal .
C Auscultation :
ausculation
1- Heart sounds
So, normal S1 M & T - S2 single accentuated S2
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, , , ,

: .. 10 Pulmonary .. 80 pressure Aorta ( pulmonary area )

:
Why accentuated S2 ??
.. diastole recoil systole wall .. 2chambers Aorta Pulmonary .. wall
So, aortic component of S2 ) 80 pressure ( diastole
Why single S2 ??
So, diastolic pressure (< 10) .. Pulmonary .. pulmonary component
So, S2 only one component
So, single S2 & accentuated

2- Murmur
NB. No murmur of VSD ( VSD is one of fallot components )
- Timing :
So, murmur of pulmonary stenosis pulmonary artery So, systolic murmur Ejection
Why Ejection ??
ejection systolic phase pressure gradient
,,,

) (single or double .. accentuated .. single S2 ejection harsh Harsh ejection Murmur
.. ejection

,,,
- Normally In Rt. Side
A - in diastole :
Pulmonary ) 5 Rt atrium zero Rt. V ( tricuspid ) 10 (
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, , , ,

- & the pressure in Rt. Side as the following :

- Rt. atrium 5
- Rt. V 0 ( zero )
- pulmonary 10
venous return zero ( 2 .. atrium systole .... )

B in systole :
tricuspid ..) diastole 0 ( 3 So, pressure contraction Ventricle S1 atrium 2
10 Rt. V Pressure valves Called isometric contraction phase
) 10 p ( pulmonary 11 Rt. V )Pulmonary (ejection phase .. P
systole .. S2
ejection phase murmur .. pulmonary stenosis So, P. stenosis cause ejection systolic murmur
NB. But in VSD pan systolic murmur
- Harsh or soft ( character )
) stenosis ... 10 ( 6 pulmonary
( ) left ( 120 right ventricle
(25
very harsh murmur .. 114 ... harsh 25
- Site of maximum intensity On pulmonary area
- Propagated to any site .
Complications as any cong. But :
NB. NO Repeated chest infection
1- High incidence of pulmonary T.B.

Fallot congenital ) O2 ( Is micro aerobic bacteria T.B. bacilli
) fallot ( mixed blood
,,,
manifestations of T.B. toxemia in Fallot tetraology ???
night sweating Night fever ) / .. night ( night
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, , , ,

T.B. acitivity PO2

T.B. .. So, PO2 tidal volume respiratory rate ,,,
day and night fever and sweating ,,,
Due to PO2 all the time .
2- Tissue hypoxia erythropiotein polycythemia incidence of thrombosis
cerebral thrombosis
3- incidence of brain abscess
phagocytic function ...... lung functions ) filtration (
3 branches ) ( lung Aorta So, may brain abscess brain Arch
4- May right ventricular failure .
5- May IE but rare .
N.B. no Eisenmenger
6- Cyanotic spells
Investigations
1 - Chest X - ray
Cocur en sabot specific configuration of heart .
Oligemic lung .
2 ECG . 3 ECHO .
4 - Cathetrization .
Treatment
1 - Medical treatment .
a- As any congenital prophylaxis against IE .
b- If cyanotic spells .
squatting position oxygen Relaxation of infandibulum IV indral ( B blocker) .. canula tissue hypoxia acidosis NaHCO3 ) (life threatening drug morphine Indral -
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, , , ,

c- Iron & folic acid

Due to hyperactive bone marrow iron folic acid 2 - Surgical :
Palliative surgery .
) graft NB)
Infandibulum : PDA Shunt between right subclavian and left pulmonary
pulmonary Aorta
22
23 22
ASD
Definition
Defect in inter atrial septum
Etiology
As any congenital heart disease
Types
1 - Patent foramen ovale :
: interatrial septum embryology a - Septum secondum
b - Septum primum
embryology primum secondum secondum primum
: primum secondum .. line Called foramen ovale 2 septa
.. right side umblical vessels Oxygenated blood ... Intra uterine
Left oxygenated
foramen ovale secondum primum
: intra uterine .. secondum .. left side pressure right side pressure
foramen ovale
: secondum .. Left side pressure right side pressure Page |
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37
, , , ,

) Immediately after delivery( foramen ovale primum line

foramen ovale .. ) ( fixed secondum Patent foramen ovale ASD
ECHO 2 - Ostium secondum defect :
defect .. secondum by ECHO Appears as defect in upper part of the septum .
3 - Ostium primum defect
by ECHO Appears as defect In lower part of the septum
4 - commom AV canal :
tricuspid leaflet mitral leaflet primum membranous part of inter ventricular septum
So, ASD + VSD + MR + TR
endocardial cushing defect commom AV canal commonest congenital heart disease in Down's syndrome
( common AV canal VSD .. clinically
)
Hemodynamics
clinical
(as a symptoms ( items
ASD
diastole ) mmHg ) 6 5 left atrium Pressure ) 4 3 ( 4 3 right atrium right left ,,, 6 - 3 = 3 mmHg
right Left ... 3 right atrium
So, mild right atrial dilatation
1- May cause palpitation and may not :
power of contraction right ventricle
May cause palpitation and may not
2- congestive lung symptoms :
Then to pulmonary to lung Then congestive lung symptoms
To left atrial .. So, mild left atrial dilatation ( no compression symptoms )
3- maimly asymptomatic :
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, , , ,

Mostly asymptomatic normal complaint

Examination
A Inspection & palpation
May apex shifted downward .
May hyperdynamic apex ) (
B - Auscultation
- S1
- Murmur
pressure gradient
- May functional pulmonary stenosis murmur
Soft ejection systolic murmur ASD
- S2
) ( professional ... ) ( Basics
- We have inspiration , expiration and inter respiratory period
expiration Inspiration .. inter respiratory
pulmonary component Aortic component S2 pulmonary higher than before Aortic
left sides of the heart right Inter respiratory phase ) 5 chamber ( :
1 during deep inspiration :
suction negative intra thoracic pressure inspiration ... deep inspiration of blood from whole body
right side 6 venous return
:Left side left side Lung
Left ... right
- conclusion : during inspiration in normal persons :
6 liter of blood in Rt. Ventricle
4 liter of blood in Lt. Ventricle
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, , , ,

splitting of 2nd heart sound .. 2 component S2

2 during full expiration :
Full expiration 4 blood to right side VR
6 Aorta .. 6 Left single S2 during expiration .. Pulmonary
Pulmonary area Normal
ASD

Wide fixed spliting of S2
1 - during inspiration
wide .. item ) ( 4 .. 6 ( 5 mmHg left atrial pressure .. ) ( 4 right atrial pressure )
) 5 - 4 = 1( 1 mmHg Pressure gradient
0.5 1 mmHg
to Rt. Rt. atrium 6.5 .. Lt . atrium 0.5 ... Rt ventricle
left ventricle ... ) 4 ( 3.5 Left atrium - conclusion : during inspiration in ASD :
6.5 liter of blood in Rt. Ventricle
3.5 liter of blood in Lt. Ventricle
- So, during inspiration
Pulmonary Aorta
So, wide spiltting of second heart sound
2 - during expiration
fixed .. item ) ( 4 .. 6 ) ( 6 left atrium .. ) ( 3 right atrium 3 mmHg Pressure gradient
So, 1.5 liter from Lt. to Rt
right Left
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, , , ,

4.5 liter left ventricle .. 5.5 liter So, right ventricle

4.5 .. 5 Normal Aorta 5.5 .. 5 Pulmonary So, here spiltting of S2 during expiration
CONCLUSION
So, wide fixed splitting of S2
What is the meaning of fixed splitting ?? means splitting during inspiration & expiration
Complications
1.
Repeated chest infection ( rare )
2.
Heart failure (rare )
3.
IE ( rare )
4.
Eisenmenger syndrome ( rare )
5.
Stunted growth ( rare )
6.
Lutembacher syndrome ) ( (mitral valve disease in ASD patient )

rheumatic fever 15 ASD mitral valve disease
Investigations
1.
Chest X - ray
Left ventricle lung plethora -
2.
ECG just association right bundle branch block .
etc ) other investigation (

Treatment
Prophylaxis against IE + surgical closure
Mitral valve lesion s
valve .. valve
all caused by rheumatic fever .
Mitral stenosis
Heodynamics & symptoms
end stage + 3 stages
diastole ) ( stenosis ventricle atrium -
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pressure gradient 70 %
atrial contraction 30 %
41
, , , ,

1 silent MS : asymptomatic
mild mitral stenosis atrial contraction 50 % ... pressure gradient ,,,,
So, 50 %
asymptomatic mitral stenosis mitral stenosis

silent mitral stenosis
2 Congestive MS : congestive lung symptoms
Moderate stenosis ,,, atrial contraction 70 % pressure gradient 30 % So, left atrial hypertrophy ,, .. atrium
Stagnation of blood Lung .. pressure
symptoms of pulmonary congestion
3 Hypertensive MS : low COP symptoms + dysphagia + may orthopnea & hemoptysis
atrial contraction 80 % pressure gradient 20 % 50 80% .. diastole %
low cardic output to aorta to left ventricle ) 50 + 20 ( 70 %
symptoms
) (So, dysphagia So, dilatation 30 % atria More blood in lung lung Lt atrium Pressure hemoptysis Orthopnea
- Stagnation in pulmonary pulmonary hypertension
Pulmonary hypertension + low cardic output
Called Hypertensive mitral stenosis
4 MS with Rt. V failure ( end stage MS ) systemic venous congestion symptoms
: Right ventricular hypertrophy Right ventricluar failure Stagation of blood in superior vena cava
Systemic venous congestion
end stage
Examination
A - General examination

Asymptomatic
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, , , ,

Lung congestion
inelastic wall of alveoli fine crepitation

Hyper tensive mitral stenosis malar flush erythema
) ( With no any explanation )

( ,,,
Right sided failure
Congested pulsating neck vein
Enlarged tender liver
Pitting odema
Ascites
B - Local examination
right ventricular failure ..
1- Inspection and palpation
a- Precordial bulge if right ventricular failure
b- Apex normal except if Right ventricular enlargement :
- Site : Shifted out
- Size : Diffuse
- character : slapping apex
- May thrill diastolic as blood pass through stenotic mitral valve during diastole .
c- Other pulsations
o
No Supra sternal
NO Aortic
Pulmonary if hypertensive stage
Right parasternal , left parasternal & epigastric
2- Percussion
- Pulmonary dullness if pulmonary hypertension
3- Auscultation
a- Heart sounds
1- S1 :
S1 valve .. membrane A-V valve .. .. membrane ... atrium Accentuated S1 ) ( valve
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, , , ,

- & may palpable S1 ( ) called slapping apex

2 - S2 :
S2 Except in pulmonary hypertension ... Normal S2 b- Murmur
- Timing in diastole ( filling phase )

80 Aorta 5 Left atrium 120 Left ventricle pressure pressure ventricle .. mitral ... systole 80
... mitral ,, ) (S2 ,,, Aorta 5 Pressure ,,, ventricle murmur ,,, Mitral ... isometric relaxation phase
filling phase mitral - Character :
Interrupted .. by pressure gradient atrium ) ( .. ) (
So , Rumbling murmur
-Then atrial contraction
) So, presystolic accentuation( S1
- Site of maximum intesity at apex
- propagation : Localized and may be propagated to the medial of the apex .
cone
23
24 23
mitral stenosis

c- Additional sounds
- Opening snap
) ( Called opnening snap valve At the end of isometric relaxation & begining of filling

1 the wall of the leaflet is still healthy NO Calcification .. 2 - Means isolated mitral stenosis NO MR
Complications of mitral stenosis
1- Complications on the valve itself
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, , , ,

Rheumatic fever activity

Caused by streptococcal Called rhematic activity For another time rheumatic fever susceptible -
May IE
May pathological calcifications

No opening snap
2- Left atrium
a- Pressure manifestations due to enlargement
o
Dysphagia
Press on bifurcation of trachea Irritative cough ( brassy cough )
Hoarsness of voice compression of left recurrent laryngeal nerve

heart lesion with hoarsness of voice ,,,,,
b- Atrium
But within limits contraction volume overload ventricle atrium : So, leading to Failure of contraction of atrium over dilatation atrium 1- low COP symptoms
2- Aslo, no presystolic accentuation

character rumbling murmur
over dilatation
ventricle A.V. node S.A.node left atrium right atrium muscle fibers signals normal atrium ) from both Lt. & Rt. atria (
A.V. node left and right atrium
( .. Left atrium Overstretched muscle )
) ( 5 sginals ventricle signals
So, heart rate AF
: refractory period A.V. node 5 Irregular irregularity Irregular heart rate
palpaitation ( irregular ) .. rhythm Heart rate VSD & PDA .. irregular
c- Stagnation of blood liable to form thrombus thrombo ebolism
sudden death .. Aorta thrombus ..
3- Lung
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, , , ,

Repeated chest infection lung congestion

hemoptysis
May pulmonary embolism

May DVT or systemic embolization systemic venous congestion
right ventricular failure -
May pulmonary infarction pulmonary right ventricle embolus

What is the most common causes of hemoptysis in children ???
a)
Chest infection
b)
T.B.
c)
Tight mitral stenosis
d)
Malignancy
Investigations
1.
Chest X - ray
Lung congestion + Aorta left ventricle -
2.
ECG
3.
ECHO
Treatment
1 Medical prophylaxis against IE & Rheumatic fever activity

2- Surgical treatment
- May ballon dilatation
isolated mitral stenosis calcified
valve replacement MR calcification Mitral regurge
Hemodynamics & symptoms
So, appear in systole .. valve 1- Palpitation :
To aorta and left atrium .. Mitral Aorta Left atrial dilatation volume overload ..pulmonary veins Left atrium Power of contraction .. dilatation Left ventricle Palpitation
late palpitation MS ,,, .. MR earliest complaint ... complaint 2- Congestive lung system :
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, , , ,

lung congestion .. Left ventricle .. palpitation

Congestive lung symptoms
3- Lt. V failure :
Left ventricular failure
More congestive lung symptoms and low COP ( both so late MS )
4- May pulmonary hypertension + right ventricular failure :
May pulmonary hypertension + right ventricular failure ) Rt. V failure (
Local Examination
A Inspection & palpation :
1- No precordial bulge
2- Apex
- Down and out , Localized , hyperdynamic ( volume overload )
- May systolic thrill due to flow of blood during systole through m. valve.
3- Other pulsation
o
May pulmonary pulsation if reach pulmonary hypertension
B Percussion
- If pulmonary hypertension dullness on pulmonary
C - Auscultation
: .. leaflet 1- H. sounds :
) ( muffled S1 S1 So, here
2- Murmur
- Timing : systolic ( all phases isometric contraction + ejection ) so, pansystolic .
- character :
The Pressure gradient
: valve murmur .. 120 left ventricle 6 left atrium a- if narrow harsh
b- if wide may soft
So, variable intensity according to severity

- site of maximum intensisty & propagation :
Here, mitral valve has two leaflets :
Anterior or posterior leaflet Leaflet site of maximum intensity a- Propagated to axilla if anterior leaflet incomptenance the commonest
b- Propagated to left parasternal if posterior leaflet incomptenance
c- Propagated to axilla and left parasternal if double leaflet MR
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, , , ,

Complications
: MS
1.
Valve
Rheumatic fever ..etc as MS

2.
Atrium as MS
3.
Lung as MS
investigations
as MS
treatment
1.
Medical as MS
2.
Surgical valve replacement

Aortic st enosis
systole
Types
May :
1- Valvular leaflet
- Congenital or rheumatic
2- Subvalvular hypertrophy of the infandibulum called idiopathic hypertrophic sub aortic stenosis IHSS
) (
- congenital ( not common )
) ( .. Mild stenosis left ventricle Left ventricluar hypertrophy ( not dilatation )
1- Low COP symptoms :
ejection .. left ventricle .. Aortic stenosis ..
low cardic output symptoms 70 % in Aorta ) 30 % ( left ventricle 2- may anginal pain :
Due to hypertrophy + dilatation Left ventricle
Volume overload Left atrium .. 30 %
anginal pain May left ventricular ischemia O2 .. muscle
Called premature angina anginal pain 40 N.B.
.. typical anginal pain angina .. 12 ,,,
sudden death .. ) ,, (
3- Lt. v failure & congestive lung symptoms :
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, , , ,

Left ventricular failure Stagnation in lung Congestive lung symptoms
Examination
A inspection & palpation :
1- No precordial bulge
2- Apex
- Shifted down and out , Localized
- Heavy sustained
So platue pulse ) ( ventricle - No thrill
3- other pulsations and thrill:
.. Aorta ventricle pressure Aorta wall ) (
chest wall Aorta .. post stenotic dilatation
So, pulsation on A1
So, thrill on A1 wall Aorta .. - Also, systolic thrill on carotid
B - Auscultation
1- H. sounds :
S1 normal
S2 muffled
Limited mobility leaflet
2- Murmur
- timing : ejection systolic murmur
- character : Harsh ( very harsh )
- association :
May ejection click murmur - maximum on A1 flow
- Propagated to root of neck , To A2 & may to apex.
Complications

Left ventricular failure
Infarction & even sudden death

Investigations
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, , , ,

As before
Treatment
As before + if IHSS give propronalol
relaxation
Aortic regurg e
diastole .. diastole valve
1- palpitation :
left Ascending Aorta leaflet .. pressure ventricle left ventricle .. Left atrium .. ventricle
Volume overload power contraction
palpitation
.. 2- very late Lt. v failure & congestive lung symptoms .
left ventricular failure regurge
Lung congestion ( very very very very late )
Examination
A - General
A.R.
1- water hammer pulse :
: systole cardic .. stroke V .. 5.5 .. 5 ventricle
systolic blood pressure ouptut
:diastole Left ventricle 80 Aorta pressure Pressure Aorta - So, pulse pressure water hammer pulse ( Diastolic pressure may reach zero )
2- suprasternal pulsation
Aorta supra sternal pulsation 3- corrigan's sign
- Also, prominent carotid pulsation called corrigan's sign
4- Demussiet sign :
)
( Demussiet sign .. -
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, , , ,

A.R. .. A.R. )
( ..
5- prominent capillary pulsation :
diastole .. systole nail Called prominent capillary pulsation
6- Pistol shots :
pistol shots radial femoral ) psitol shots ( systole collapsed diastole artery 7- Pendol sign :
poplieteal artery ) ( pendol sign systole diastole
8- systolic & diastolic Bl. Pressure
) systole & diastole ( B - Local examination
a- inspection & palpation :
No precordial buge
Apex
Shifted down and out
Localized
Hyperdynamic
May diastolic thrill on apex
b- Auscultation
- S1 normal & S2 muffled
- Murmurs
by pressure gradient diastole
- timing : diastolic
- character : soft
- site of max. intensity : A2 & On leaning forward

- propagation : Localized on apex
peripheral signs
Complications, investigations and treatment
As before
24
25 24
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, , , ,

Rh eumatic fever
.. over diagnosis
Definition & introduction
an auto immune disease (Antibodies against own body )
.. Not genetic Which is a common infection streptococcal infection rheumatic fever rheumatic fever ..
but it has familia tendency
)cross infection( ) .. (
gene factor with environmental factor So, rheumatic fever has genetic basis
Rheumatic fever streptococcal infection
) ( tissues anitgenicity toxins : most accepted theory cross similarity Between cells of the body and streptococcal strains
antigenisity antibodies
: Rheumatic fever arthritis chorea .. carditis
.. carditis & chorea
So, variable clinical pictures, but same in the same family

Epidemiology
- Age :
.. 15 5 .. age
) autoimmune ) ( (
,,,
a- Never below 3 years

not mature enough 3 .. immune system
) strepto cocci gene (
b- rare after 25 years :
Rheumatic fever 25

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, , , ,

As streptococcal infection is a common So, persons Who reach 25 years , mainly exposed to all strains of
streptococci ( as it is a very common infection ) although, no antibodies were formed Againt their tissues
So, there is no genetic factor present
c- never after 60 :
.. 60 auto immune disease .. 60
Diagnosis of Rheumatic fever
Rheumatic fever is a clinical diagnosis
( mainly clinical (
over diagnosis Rheumatic fever until proved ) ( .. .. otherwise
) ( generalized bone ache myalagia
ESR .. leucocytosis CBC
ASOT .. C- reactive protein
,,, Rheumatic fever ..
.. .. ,,,
) Jone ( Jone's criteria 5 minor 5 major criteria ..
: minor 5
- 1 hisotry History of Rheumatic fever
- 2 Clinical Arthralagia ( with no limitation ) only pain + Fever
- 2 Investigations Acute phase reactant ( ESR, C reactive protein and leucocytes )
ECG prolonged PR interval
: In Jone's
1- 2 major only or
2- 1 major and 2 minors ( )
major arthritis .. prolonged PR interval carditis ,,,
minor arthalagia
3- any child has chorea ( ONLY )
Rheumatic fever
other collagen Rheumatic fever .. ) SLE Rheumatoid arthritis ( disease
both may affect the heart, the joints, neurological and other skin manifestations
Evidence of previous streptococcal infection ,,, Page |
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, , , ,

) criteria (
evidenace
1- Sure history of scarlet fever
strept .. ) sore throat (
2- or Throat culture Pathogenic streptococci ( as a history )
3- or Antibodies against streptococci
Modified Jone's criteria Jone' 1 - 2 major only or
2- 1 major and 2 minors ( )
major arthritis .. prolonged PR interval carditis ,,,
minor arthalagia
+ Evidence of previous streptococcal infection ( for both 1 & 2 )
.. chorea criteria
As it Occurs after streptococcal infection
acute phase reactant or evidence of previous stept. infection 4 3
: major criteria
1 - Arthritis
has the following 4 criteria :
1- Joint are Red, hot, swollen, tender with complete loss of function
) (
.. ,,,
2- But more in In big joints ( hip, shoulder, knee, ankle, elbow and wrist )
3- Has fleeting character
) ( ,,, ,,, ..
4- Therapeutic test :
: criteria
Give Asprin as anti inflammatory .. complete cure ( dramatic response to salicylate Indicate rheumatic
fever ) Without any residual damage
,,,
complete normal joint
salicylate .. synovial membrane Inflammation antibodies /
good excretion in synovial fluid Complete anti inflammatory action Complete cure
,,,
fleeting arthritis Rheumatic fever
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, , , ,

So, early treatment joint affection ,,,

N.B. May 2 joints at same time
2 - Rheumatic carditis
Carditis in Rheumatic fever is a pancarditis means any layer of the heart may affected
myo endo pericarditis ..
1- Pericardium pericarditis ( dry )
Symptoms :
- Inflamation Between parietal and visceral surfaces So, are both rough
So, pain retrosternal, stitching pain pain receptor parietal layer
D.D. from dry pleurisy
Here, not related to respiration or cough ( in dry pleurisy )
On examination pericardial rub
- Both systolic and diastolic As PDA murmur
but PDA maximum below left clavicle but here all over the percordium
B - Myocarditis ( atria and ventricle )

.. ventricle myocardium atria & ventricles myocardium

heart Criteria of myocarditis
: .. items
1- tachycardia disproportionate to fever
: Heart neuronal fibers called Conductive system of the heart ( S.A. node, conductive of atrium, A.V. node etc (
tachycardia disproportionate to fever H.R. myocarditis
15 10 pulse febrile state .. 90 Normal pulse 5 38
Tachycardia out of fever 105 .. 105 -100 Pulse
fever HR NB
.. S.A. node activation fever pyrogens
As in diphtheria heart Infection
2- muffled H. sounds :
chambers Pressure cardic muscle
Left atrium . 5 6 mmHg

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, , , ,

Right atrium .. 3 4 mmHg
Right ventricle .. 25 0 mmHg
Left ventricle 120 0 mmHg
Aorta .. 120 80 mmHg
Pulmonary . 25 10 mmHg
Heart sounds vlaves pressure
So,here pressure so, muffled heart sound
valves pressure ,,,
3- may Heart faliure gallop rhythm

,,, rate .. congestive heart failure .. Biventricular heart failure heart failure Gallop rhythm ) ( additional sound 4- multiple regurge leaflets
) ( .. ( : cardic muscle ) failure
valves ) ( circular muscle
On mitral area MR
On tricuspid area TR
On A2 AR
On P PR
Heart -
Called multiple regurge leaflets

multiple regurge leaflets
5- cardiomegaly & HB :
- X- ray cardiomegaly , If ECG prolonged PR interval Why ????
As P-R interval From beginning of P (atrial systole) to beginning of R (Ventricular systole) P-R represent
conduction bet. Atria & ventricles
prolonged 5
Means time between atrial and ventricular contraction due to odema (from inflammation in myocardium)
Odema around A-V node delay AV conduction Cause heart block ( 1st degree heart block )
,,, tachycardia
S.A.node refractory period
) tachycardia( heart rate .. ( shortness of RF ) RF Heart inflammation
Due to excitation of S.A.node
3- Endocarditis : Affect left side more than right side
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, , , ,

(mitral stenosis) odema mitral valve leaflet Inflammation

Criteria
.. items
1- muffled hart sounds :
- S1 & S2 muffled leflaets
2- Called transient mitral stenosis Called Carey comb's murmur
Mid diastolic murmur Rumbling without presystolic accentuation, weak, localized on apex
Called Carey comb's murmur Called transient mitral stenosis odema
3- Permenant mitral stenosis :
Permenant mitral stenosis ) ( ,,, - Also, in Aorta may AS
4- single valve regurge :
valve Chorda tendenae Papillary muscle .. ) prolapse (
) In one valve only( regurge leaflet inflammatory reaction (reversible) .. ) irreversible )
Change of previous murmur .. V. lesion 3 - Chorea
Inflammation in Caudate lobe of basal ganglia
- Occur after streptococcal infection
acute phase reactant or evidence of previous stept. infection 4 3
Sudden jerky, semi purposeful movement :
.. .. ) ms. Weakness ( ) ( (Emotional instability(
) abnormal movement NB ( abnormal movement
Dancing gait

.. .. (
)
: criteria
1- Ms weakness
2- emotional instability
3- abnormal movement
.. aggressive ,,, ,,, : signs

1- piano sign :
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57
, , , ,

) ( Called piano sign small muscle of the hand

2- forking sign :
) ( :
- Semi flexion in wrist + Metacarbophalangeal extension + Interphalangeal flexion
) !!!! ( forking sign choreaic hand
3- milk maid sign :

Chorea here is a self limited
25
26 25
4- Subcutaneous nodul es
) Lymph node ( Nodules

On extensor surface of bony prominent as in elbow, tibial tuberosity, chin of the tibia, mastoid process
.... lymph node ) mastoid process (
) Lymph node (
5- Erythema marginatum
Erythema = redness + Marginatum= margin
Due to inflammatory reaction
) clear ) ,,, .. trunk

.. 3
- 2 -
) ( ,,

D.D.
Tenia circinata
Non itching itching tenia non scales .. scales tinea Both erythema marginatum and subcutaneous nodules are very rare
Jones
Investigations
1- Acute phase reactant
CBC WBCs
ESR more than 100
C- reactive protein positive

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, , , ,

2- X- ray cardiomegaly
3- ECG PR interval
4- Evidence of previous streptococcal infection
) Swab and culture ( throat pathogenic streptococci
Antibodies ASOT
333 ( / ) 250 333 ( contaminated area 300) active

Treatment
A - Prophylaxis ( prevention )
3
1- 1ry prevention
Prevent the 1st attack a- proper hygiene & avoid over crowdness
streptococcal infection droplet infection
So, proper hygiene , avoid crowding , Good nutrition, avoid contacts ..etc.

) b- proter ttt of any upper resp. tract infection ( proper antibiotics , dose & duration
Upper respiratory tract .. infection
( .. symptoms ) 1ry etiology
:
) ) ( gm or mg / kg ( - proper antibiotics + in a proper dose
+ In proper duration of therapy
48 .. .. 10
( antibiotic )
: .. :
:
: 500
:
( antibiotics - - )

: 10 !! ( )
:
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streptococci sore throat

gram positive sore throat .. culture
viral .. anti gram negative 48 .. anti gram +ve
,,,
broad spectrum
- if no availabe culture & there is upper respiratory tract infection
48 .. amoxacillin gram positive
bacteria .. cephalosporin gram negative
partial improvement
antibiotic .. gram positive and gram negative gram negative
2- 2ry prevention
strain infection .. ( genetic susceptibility ( Rheumatic attack
antibiotics ,,, So, give long acting penicillin 1,200,000 IU
6 6 ..
) ( 15 15 serum N.B.
sensitivity test Long acting penicillin
1000
) benzathin penicillin (
) 250,000 ( 12 .. Oral penicillin sensitive Give erythromycin (250 mg) oral penicillin Or Sulphadiazine ,,,
last attack 5 -
,,,
oral
15 .. daily .. compliance

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, , , ,

3- 3ry prevention
) ( IE complications prevent
B - Curative treatment
Immune system
1 - Eradication of streptococci
gram positive procain penicillin
2- ttt of manifestations :
a- If arthritis only + ( 2 minors ) Give salicylate
Why ??? ( mechanism )
PGE2, throboxane A2, prostacycline inflammatory mediator arthritis cyclo oxygenase enzyme arachidonic acid
- So, asprin cyclo oxygenase
100 - 120 mg / kg / day dose
gastritis dose
.. Complete clinical cure ,,, .. ESR
- If there is a Contraindiaction of aspirin use in rheumatic arthritis Give corticosteroids
arachidonic acid : ,,,
Rheumatic arthritis aspirin
aspirin
contraindications of aspirin therapy
when give steroids in arhritis
,,,
1- If any manifestations of viral infection
massive liver cell failure Reye syndrome
... Upper respiratory ,,, cattarahal
2- Bleeding tendency
3- Bronchial asthma
As aspirin may induce asthma
- IF aspirin is CI Give predinosolone 2 mg /kg / day
2 - 1 Normal ESR
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, , , ,

b- If carditis only as a major

carditis aspirin leukotriens carditis leukotriens LOX arachidonic acid COX
carditis aspirin arthritis .. cortisone aspirin aspirin sub clinical carditis
- if carditis only Give cortisone same dose as above
:
till ESR normal ,,, 6 - 4
cortisone So, gradual stop of steroid over 2 weeks under umberlla of aspirin ( if no CI of aspirin )
) contraindications (
Why under umberlla of salicylate
rebound arthritis cortisone

permenant suppression cyclo oxygenase ( COX ) cortisone
) ( lipo oxygenase ( LOX ) permenant suppression
early recovery ) COX ( ..
convert all arachidonic acid to PGE2 etc.( as there is suppression of LOX for long period ) Affect
joints ( called reboun arthritis )
salicylate
2 2 .. cortisone 6 ) cortisone circadian ( 1 - 2 2 ,,,
) 3 ( 1 2 .. 2 2

( Gradual tappering till reach 1/2 dose of steroids )
Now add aspirin ( after reach hace dose of cortisone ) (If not contraindicated)
75 mg / kg /day
cortisone
cyclo oxygenase suppression cortisone dose

To suppress cyclo oxygenase aspirin
c- If carditis + arthritis
- As carditis only
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, , , ,

d- Chorea
stress ) chorea ) ( sedative (
As diazepam ..etc. To abnormal movement
self limited
,,,
anti leukotriens
) ( side effects ..
Infective endocarditis
Types
May acute or sub-acute
1- Acute
Highly virulent organism + Affect normal or diseased heart
acute
2- Sub-acute type
,,,
a)
Cardic lesion ( congenital or rheumatic ) +
b)
Bacteremia
.. endocardium Infection
fibers of chorda tendenea Papillary muscle normal heart .. flow .. very smooth membrane endocardium stagnation
cells flow bacteria cardic lesion
roughness to endocardium
rouhgness
,, ( rough endocardium .. abnormal flow lesion )
bacteremia rough surface
1- Gram +ve :
strep. Viridans Bacterial flora oral mucosa ) ( bacteremia blood vessels ..
- Or streptococcal fecalis after surgical removal of anal polyp
- Or sever abrasion in skin staph albus enter and cause bacteremia
- Or contaminated catheterization
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, , , ,

staph. Aureus
gram positive 2- May gram negative as H. influenza
3- May fungal as Aspergellius
canula VSD immunity neonates -1
IE May bacteremia contamination
contaminated injection addict Heart -2
Immuno compromised -3
local inflammation roughness flow Heart ( for localization of infection coagulation ) coagulation cascade platelets activation
Infected thrombus
,,,
left side common in right side IE
Common in left side

,,,
.. curve ..
) (
Left High pressure roughness ) mitral ( regurge stenosis
regurge IE
As in stenosis pressure gradient is 6 - 0 = 6 mmHg
But in regurge pressure gradient is 120-2 = 118 mmHg
flow ,,, regurge
AS AR
AR AS
( ventricle ( ,,, flow stenosis
VSD ASD
large VSD Small VSD .. ASD VSD
pressure gradient rare IE Heart failure -
26
27 26
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, , , ,

right Left
ASD VSD
MS MR
AR AS
large VSD Small VSD
pressure gradient ..
Clinical manifestation of IE

A Manifestations of toxemia
.. vegitations bacteria
1- Fever
- Mainly low grade but may be high grade .. Mainly intermittent
.. vegitations bacteremia fibrin clot vegitation
2- Anorexia
- due to Central effect of toxins on feeding centre and also leading to loss of weight
3- May toxins suppress bone marrow or hemolysis to RBCs
So, pallor
4- Specific toxemic manifestations
liable to bleed .. small blood vessel .. vasculitis
a- In eye
o
Sub conjunctival hemorrhage if its vessels affected
On Fundus changes if retinal vessels affection

vessel ) ( Pink
hemorrhage .. pale .. arteriole
Roth spots pale area
- Roth spot is a Ring of hemorrhage around pale area
b- In hands
1- Hypertrophy of nail bed clubbing ( pale type )
2- Splinter Hge
) ( Called splinter hemorrhage capillaries 3- Osler's nodule :
small intra cutaneous nodule Head of metacarpal bones .. ) ( Very painful
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4- Jane way nodule :

On theaner eminenance & hypo theaner blue not tender nodule
c- Spleen may splenomegaly
N.B. If severe toxemia toxic heart failure
B Emolic manifestations
fraible vegitations Infected emboli .. detatchment 1- Non infected emboli :
Occlusion Infarction end artery
) collaterals ( ischemia end artery
2- infected :
a- Also, if infective emboli cause infarction ischemia

b- may mycotic aneurysm & Hge :
artery embolus .. branches artery
artery ..wall of vessel Inflammation .. If infected
wall inflammation pressure
herniation before site of obstruction
& form what is called mycotic aneurysm asymmetrical bulge
) irregulary colony fungus mycotic (
May rupture severe bleeding IC He
3- Kidney :
Kidney
1- If non infective emboli
- massive renal infarction Massive hematuria
Acute renal failure then chronic renal failure
2- May small embolus

-small arteriole Cortical infarction ( not medulla) Then fibrosis ( micro infarction ) ( )
Flea bitten kidney
) flea ( depressed
3- May GN :
glomerulonephritis Immune complex C - Underlying cardic lesion :

1- If the cardiac lesion was MR :
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, , , ,

.. ) Inferior surface of the valve( MR vegitations

) Musical character( murmur leaflet ... chorda tendinea Due to rupture of chorda tendinea
2- if the lesion was MS :
) Apperance of new murmur( double mitral stenosis .. leaflet If MS
IE ... MS MR
Investigations

1- ECHO to see vegitations
2- Blood culture for bacteremia
4 : culture ) .. ( intermittent
) ( febrile - 3 - 3 - culture 3
,,,
- If positive + vegitations = IE
etc..... ESR Infection investigation )
RF ( Kidney -
Urine analysis ( for hematuria ) + renal functions

Complications
complications 3 a)
Embolization In coronaries brain
b)
Heart failure
c)
Renal failure
Treatment
- Specific anti - microbial therapy According to culture and senstivity
,,, parenteral form .. bacterocidal
clinical improvement 4 - 6 .. maximum dose dose ) IV or IM ( Parenteral
72 broad spectrum antibiotic ( gram positive and gram negative )

N.B.
prevention ,,, complications cure
Prevention of IE
) bacteremia ( factor cardic lesion
1- early & proper ttt of any infection :

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, , , ,

bacteremia
2- any procedure in tooth :
Mucosa ( .. )
2 1 ( )
( Procain penicillin + crystalline penicillin .. ) IM

Crystalline ( )
Procaine 12
oral penicillin ( 8 250,000 IU 48
7 ) ..

.. injection : .. a- resist oral form
b- or severe infectiom
,,,
( )
1 - Amoxacillin 50 mg / kg / dose
7 ,,, ) 25 mg / kg / dose(
20 mg / kg / dose 1st dose erythromycin 10 mg / kg / dose 2nd dose
1st dose procedure ( 12 )
( .. ( 6 ... 7 ) )
3- if perianal surgery :
contamination gram negative
canula ( 2 mg / kg garamycin ) gr. vegiven only IM 20 mg / kg streptomycin
gram positive) So, add ampicillin Or if hypersensitivity give vancomycin (All parenteral
Only single dose No other dose
..
antibiotics prophylaxis
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Heart failure
cardiomyopathy ..

definition
Means failure of the cardic muscle to supply the tissues with their requirments of blood flow

It is a clinical syndrome in which the heart cant maintain sufficient cardic output to meet the metabolic
needs of the body inspite of normal venous return
Causes
1- May deue to congenital heart disease
o
VSD left 1st then right late
ASD right ventricular failure
PDA left ventricular failure ,,, rare right VF
Fallot if heart failure right VF
AS ( congenital ) left VF
Coarctation of Aorta left VF
2- If Rheumatic disease
o
MS right only
MR left and rare right
AS or AR left ventricular failure
3- Cardic muscle itself

o
Cardiomeglay
Rheumatic carditis
Infective endocarditis
Toxic or viral myocarditis ( as viral bacterial pneumonia )
4- May activity or activity

o
Tachyarrhythmia
Or bradyarrhythmia due to block
High cardic output failure ( as in thyrotoxicosis thyroxin severe tachycardia )
Or anemia make compensatory tachycardia if severe anemia
Anemic heart failure
Arterio venous fistula venous return congestive heart failure
5- May Cor pulmonale obliterate pulmonary vessels pulmonary hypertension right sided heart failure
6- Systemic hypertension
o
Left ventricular contract against pressure

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, , , ,

Left ventricular hypertrophy then failure
7- Pulmonary embolism pulmonary hypertension right sided heart failure

8- Over hydration by IV fluids
congestive heart failure due to volume overload of blood
Clinical manifestations
cardic muscle
1- low COP :
to left side in lung
blood in pulmonary right ventricular failure ) low COP ( blood in Aorta
- Also, if left VF blood in Aorta ( low COP )

So, all heart failure ,,, low cardic output
stagnation ventricle 2- stagnation of blood :
a- if Rt VF manifestations of ststemic congestion
stagnation in SVC and IVC stagnation in right atrium right - So, manifestations of systemic congestions
.. ,,,
congested pulsating neck veins ,,,
+ enlarged tender liver + shifting dullness ( ascites ) + Odema lower limb
so, no dyspnea , no orthopnea etc. No lung congestion
b- If left sided heart failure congestive lung symptoms :
- Stagnation in left atrium stagnation in lung congestive lung symptoms
- If neglected stagnation in pulmonary Rt V F ( )
) Lt VF ( lt Rt .. Rt Lt ..
heart failure
1- Low cardic output symptoms + auscultations

+ 2 variables
2- systemic venous congestion manifestations right sided heart failure

3- or manifestations of pulmonary venous congestion left sided heart failure
- And if both ( 2&3) biventricular failure = congestive heart failure
auscultation
- In all tachycardia As a compensation ( stroke volume ,, heart rate to keep COP )
chorda tendenea vibration .. .. ventricle Page |
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, , , ,

diastole ventricle
- & at end of diastole atrial contraction another sound
So, either 3rd or 4th additional sound
- Tachycardia with 3rd or 4th called gallop rhythm
If best heard on tricuspid right ventricular failure
If best heard on mitral left ventricular failure
If all through biventricular failure
,,,
tricuspid congestive lung symptoms + low cardic output -1
gallop
So, right ventricular failure
congestive lung symptoms + systemic venous congestion + low cardic output -2
+ gallop on mitral Lt V F
3- If all biventricular F ( congestive heart failure )
lung or systemic Low cardic output ..

symptoms
:
congestive lung symptoms dyspnea Or refuse feeding poor feeding So, poor Wt gain
) ( tachypnea signs
signs
1- Generalized odema even puffiness
2- Tender hepatomegaly if right VF
3- Pitting odema + ascites
4- Crepitation in chest if left side VF
5- + gallop , tachycardia ..etc.
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, , , ,

Investigations
Only to know underlying etiology .. But, heart failure itself is a clinical diagnosis only
1- Chest X -ray may pneumonia
2- ECG enlargement or not
3- ECHO
4- Blood gases as distressed
5- Serum electrolytes
Treatment
Rest + 3 D + SAVO
1- Rest
heart rate ,,,
2- Diet
- Small frequent meales

dyspepsia ..
- Low salt diets load on heart + Low in fat ) (

3- Diuretics
o
Lasix should give K with it
May aldactone ( without K )

) acute stage (
May combination of both if severe
4- Digitalis
- Dose
( 0.05 mg / kg single dose Single dose ( Loading) digitalization ..
)

rapid digitalization ,,,
) ( ( )
1 mg digitalis = 0.05 X 20 20 Kg ..
- At first Give 1/2 mg ( 1/2 dose ) slowly IV
- Then give 1/4 mg after 8 hours ..
- Then give 1/4 mg after another 8 hours ( after 16 Hrs of the 1 st dose )
- Then after another 8 hours give maintenance dose ( any maintenance = 1/5 loading dose )
So, here in our Ex. 1/5 X 0.05 = 0.01 mg / kg / day
digitalis toxicity K follow up
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, , , ,

Then SAVO
5- S sedatives
.. ( .. ) Not major sedative ( anxiety )
HF drugs .. tachycardia under stress
6- A aminophyllin
aminophyllin A
7- V vasodilators
- Arteries or veins
- Na nitroprusside for both
Mechanism
VD in arteries after load + If venous pre load
.. ICU Na nitroprosside 8- O Oxygen therapy
ICU digitallis NB
- As Dopamine, Dobutamine Powerful inotropic ( cardic stimulant )
27
28 27
.. cardiomyopathy .. ) ( 28 27
27 27
Cardiomyopathy

1ry ..
1ry type
,,,
cardic output heart cardic muscle ) 2ry type ( heart .. 1ry cardiomyopathy A - dilated cardiomyopathy
) ( prognosis complete dilatation diastole ) starling low ( Over stretched over dilatation of Ms So, contractility stroke volume COP Manifestations of heart failure
congestive heart failure B - hypertrophic cardiomyopathy
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, , , ,

( ) ( Inter ventricular septum )

lumen ventricle
limitation of movement
- in diastole pressure never reach 0 so, Bl. Volume received by Lt. Ventricle from atrium
- during systole contraction of both septum & ventricle
.. ,,, .. valve closure of infandibulum of Aorta Aorta
Sub valvular stenosis low COP + all other manifestations of HF
No tachycardia and no gallop .. inotropic ( )
Beta blocker
C - Restrictive cardimyopathy Limited contraction & limited relaxation

diastole .. Pressure zerono good filling No full contraction systole - heart-lung transplantation
.. cardio
.. cardio genetics

www.facebook.com/dr.tafreegh

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Crdiology - DR Abo-ElAsrar - by El Azhar Medical Students 2012

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( BETA EDITION)

Cardiology Dr. Abo El -Asrar

Cardiology Dr. Abo El -Asrar

Cardiology Prof. Dr. Abo El -Asrar

In Any lesion in congenital heart disease even rheumatic fever

Cardiology Prof. Dr. Abo El -Asrar

congenital heart disease 1- Gene factor

Cardiology Prof. Dr. Abo El -Asrar

Cardiology Prof. Dr. Abo El -Asrar

Cardiology Prof. Dr. Abo El -Asrar

- mucosa of airway markedly congested rupture hemoptysis

Brain hypoxia headache + lack of concentration .

cerebellar hypoxia dizziness .

heart anginal pain .

skeletal muscles easy fatigability & muscle cramps .

RBF oliguria urine output

supra sternal notch

Cardiology Prof. Dr. Abo El -Asrar

1st & ( 2nd aortic area = left parasternal area )

Right parasternal pulsation

ntercostals space outside midclavicular line

Cardiology Prof. Dr. Abo El -Asrar

3rd and 4th right parasternal area chamber

A- inspection and palpation

Localized apical pulse localize in one space ( by one finger )

Cardiology Prof. Dr. Abo El -Asrar

areas 1. 1st aortic .

Cardiology Prof. Dr. Abo El -Asrar

Cardiology Prof. Dr. Abo El -Asrar

Hypertrophy dilatation pulsation

No any other pulsation

Only apex shifted down and out + Localized apex

- Apex diffuse + down and out

) 4th space apex ( ..

Cardiology Prof. Dr. Abo El -Asrar

1- percussion of A1 and pulmonary

Cardiology Prof. Dr. Abo El -Asrar

- Site of maximum intensity

Cardiology Prof. Dr. Abo El -Asrar

Cardiology Prof. Dr. Abo El -Asrar

Congenital infection as rubella .

Abnormal features chromosomal or genetic disorders As Down's syndrome .

Wide VSD if > 1 cm .

Small VSD if < 0.5 cm .

Medium sized VSD if > 0.5 & < 1 cm .

Cardiology Prof. Dr. Abo El -Asrar

Cardiology Prof. Dr. Abo El -Asrar

Cardiology Prof. Dr. Abo El -Asrar

intra abdominal pressure .. ..

Cardiology Prof. Dr. Abo El -Asrar

Pulmonary pulmonary pressure pulmonary Pressure .. Lumen hypertension

Pressure .. pulmonary pressure So, pulmonary component Accentuated S2 ( as a sign )

Cardiology Prof. Dr. Abo El -Asrar

Early ( only Lt. V enlargement )

Late ( Lt. & Rt. V enlargement )

shifted down & out

shifted down & out ( more out )

* Why Hyperdynamic apex ??

Cardiology Prof. Dr. Abo El -Asrar

Repeated chest infection .

Cardiomegaly all except

Cardiology Prof. Dr. Abo El -Asrar

ECHO muscular or membranous .