cvs for mrcpch clinical
TRANSCRIPT
CVS for MRCPCH Clinical
BY
DR \ Mohammed AyadMRCPCH
General rulesThe aim of this presentation is how to interpret the signs you have gathered from your examination .and not how to examine or to do a full CVS examination.
I will not talk here about how to examine a case in CVS station as this is easily done by watching the videos of clinical examination which are
on the youtube.
But I strongly recommend this one
:// . . / ? = - 0 2 4https www youtube com watch v nq pc Ty n
CVS short case scheme
This scheme has 6 main questions so as to reach a diagnosis or at least a DD
1 -syndromic or not? 2 -water hammer pulse or not?
3 -cyanotic or not? 4 -carotid or suprasternal thrills or not?
5 -scars or not? 6 -auscultation findings ..
1-Syndromic or not
Common syndromes in CVS station 1 -TS ….. COA , rare AS , AR
2 -DOWN $ …. AVSD or rare VSD.. 3 -NOONAN $ … PS..
4 -William’s $ … AS5 -MPS …. AR or MR..
2-Water hammer pulse or Not?Causes of WHP in the exam are AR and rarely other
causes as anemia..
If there is a WHP what shall I do? 1 -complete your examination as usual.
2 -these findings increase the possibility of AR Head nodding – no cyanosis – no clubbing – hyperdynamic apex – lt middle sternal border
diastolic murmur..
3 -these signs exclude AR Cyanosis – scars – systolic murmurs..
4 -if your findings go with AR ask the examiner to
•Auscultate the femoral arteries
3-Cyanosis or Not? Cases of central cyanosis in the exam
1 -cyanotic CHD mainly TOF..2 -Eisenmenger syndrome..
TOF EISENMENGER $
Usually with a scar Usually no scars
Usually with murmur Usually no murmur
S2 usually single S2 is very loud
4-Carotid thrill or No?
AS is the only case in the exam with carotid thrill and this diagnosis is augmented by the
ejection systolic murmur over A1..
AS rarely comes in the exam with no thrill but with murmur.. My exam case was AS with faint thrill ..
5-Scars or No scars 1 -median sternotomy
Usually complex CHD.. but also may be used for correction of VSD in
Egypt ( my mock exam case ).. 3-Rt lateral
thoracotomy2-Lt lateral
thoracotomyTOF repair COA correction
PDA ligation
PA banding
Lobectomy lobectomy
Modified BT Modified BT
6-Auscultation findings You should be systematic
1 -localize the apex2 -auscultation orders
Apex then LLSB , then A2 then P then A1 then axillae , neck and back
3 -you should comment onHeart sounds then murmurs ( full comment ) then additional sounds
Common Heart murmurs in the exam
DIASTOLIC WITH CYANOSIS
SYSTOLIC
AR TOF ASDVSD
PSAS
MR
DD of common CVS murmursAt APEX
A1AS with ejection systolic murmur radiating to the
neck.. Take care of William’s $
MS MR
DIASTOLICLOCALIZED
SYSTOLICRADIATING TO AXILLA
ACCENTUATED S1 WEAK S1
LSB
P areaASD and PS as above
Special situation
Lt lateral thoracotomy + DEXTROCARDIAThis would be
KARTAGNER $NB .. NEVER to miss DEXTROCARDIA
SYNDROMESYou should offer to search for other signs of the syndrome
How to differentiate1 -systolic VS diastolic murmur
PULSE
2 -Ejection VS pan SYSTOLIC MURMURSAccording to maximum intensity
ES usually at P and A area and never at apex..
PAN systolic usually at APEX and LSB and never at A or P areas
3 -in AS You should examine the femoral puLse to exclude COA..
IMPORTANT discussion points1 -signs of moderate to large VSD
Soft murmurMurmur of functional MSCardiomegallyPlethora
Eisenmenger $
2 -indications of interventions in PSPressure gradient across the valve > 40..
RV Pressure > 60 mmHg..
3 -complications of TOFSTROKECyanotic spells
4 -management of cyanotic spells in TOFSquatting positionO2MorphiaBB
5 -prophylaxis against IEMany debates but this is according to NICE guidelines
6 -NEVER to miss Long acting Penicillin in management of rheumatic heart disease..
7 -AS Needs restriction of activities in most cases..