Cause Of Loud 1st Heart Sound

• Mitral Stenosis.
• Tachycardia.
• Large Stroke Volume.
• Increased Cardiac Output

Cause Of Cardiomegaly

• Multiple Valvular Disease.
• CCF.
• Dialated Cardiomyopathy.
• Prolonged Hypertension.
• Severe Chronic Anemia.
• Beriberi. Ihd.
• Thyrotoxicosis.

Cause Of Diastolic Murmur

• Early Diastolic Murmur Due To.

• Aortic Regurgitation,

• Pulmonaru Regurgitation.

• Mid Diastolic Murmur Due To.

• Mitral Stenosis.

• Tricuspid Stenosis.

Management of Left Heart Failure

(This is a Written Question Of Final Professional MBBS ( Medicine) Examination of Bangladesh)

Symptoms

Due To Low Cardiac Output –

• Hypotension,
• Confusion,
• Convultion,
• Cold Clummy Skin,
• Oliguria,
• Uraemia.

Due To Pulmonary Oedema –

• Dyspnoea,
• Hypoxia,
• Cough With Frothy Expectoration.

Symptoms Due To Cause

• Chest Pain - Mi

Signs

General Examination –

• Anxious, Pale,
• Central Cyanosis May Be Present,
• Pulse=Tachycardia With Pulsus Alterance.
• Bp= Normal Or Increased.

Precordium-

• Apex Beat= Shifted Downwords Laterally Or Normal.
• Gallop Rythm.
• Loud 2nd Heart Sound.

Lungs - Bilateral Basal Crepitation, Cheyne Strokes Respiration.

Investigation.

Chest X Ray

• Enlarged Cardiac Silhouette,
• Hilar Congestion,
• Bilateral Hilar Opacity-Bat Wing Or Butterfly Shadow.
• Karley's B Line,
• Ground Glass Apperence Of Lung Fields,
• Plural Effussion.

ECG,

Echocardiography,

CBC,

Blood Urea And Serum Creatinine,

Serum Electrolytes,

Cardiac Enzymes.

General Treatment

Bed Rest.

• High Flow Oxigen.
• Iv Morphine 5mg.
• Inj Prochlorperazine.
• Iv Access By 5% Da.

Specific Treatment

• Diuretics - Frusemide And/Or Spironolactone.
• Vasodilators - Ace Inhibitor-Captopril, Enalapril. Prazosin, Hydralazine, Glycerine Tri Nitrate, Isosobride Dinitrate.
• Inotropic Drugs
• Cardiac Glycoside - Digoxin
• B Agonists - Dopamine, Dobutamine.
• Anticoagulant.
• Sublingual Nifedipine - If Required To Reduce Blood Pressure.
• Slow Iv Aminophyline 1amp Dissolved In 20ml Of 25% Glucose Over 10-15 Min If Associated Bronchospasm.

Monitoring

Input Output Chart.

Pulse, Temp, Bp, Blood Glucose.

Types Of Cardiac Impulse

(This is a Written Question Of Final Professional MBBS ( Medicine) Examination of Bangladesh)

• Heaving - Forcefull And Sustained Apical Impulse Due To Pressure Overload.
Causes:- Hypertension And Aortic Stenosis.

• Thrusting Apical Impulse - Forcefull But Not Sustained Apical Impulse Due To

Volume Overload. Causes:- Mitral Regurgitation, Aortic Regurgitation,
Dialated Cardiomyopathy.

• Dyskinatic - UnCoordinated Apical Impulse Felt Over A Large Area Due To.
Left Ventricular Sysfunction.

• Double Apical Impulse - 2 Distinct Apical Impulse In Precordium. Due To.
Hypertrophic Cardiomyopathy.

• Tapping Apex Beat - Palpable 1st Heart Sound Due To.
Mitral Stenosis, Tricuspid Stenosis.

Cause Of Shifted Cardiac Apical Impulse

(This is a Written Question Of Final Professional MBBS ( Medicine) Examination of Bangladesh)
Shifted Downwords Laterally –
Left Ventricular Hypertrophy Due To .
• Systemic Hypertension.
• Vulvular Heart Disease - Aortic Stenosis, Aortic Regurgitation, Mitral Regurgation.
• Dilalted Cardiomyopathy.
• Ischemic Heart Disease.
• Hyperdyanamic Circulation ( Anemia, Thyrotoxicosis, Beriberi)
Sifted Only Laterally –
Right Ventricular Hypertrophy Due To.
• Cor Pulmonale.
• COPD.
• Pulmonary HTN.

Other Things you Need to Know.
Precardium: Palpation

* Palpate the precordium with the palmar surface of your hand over the aortic, pulmonary, parasternal and apical areas of the heart.

* Determine the lower and outermost precardiac impulse, the apical impulse.

* Press your finger over the apical impulse identify its location, amplitude, duration and assess the rapidity of the upstroke and downstroke.

Normal: In thin individuals, the apical impulse is recognizable. Apical impulse is normally in 5th interspace just medial to midclavicular line and is about 1-2 cm in diameter. The apical impulse feels like a gentle tap and is small in amplitude and corresponds to first two thirds of systole.

Causes Of Non Palpable Apical Impulse Of Heart

(This is a Written Question Of Final Professional MBBS ( Medicine) Examination of Bangladesh)

• Obese person
• Thick muscular chest wall
• Soft tissue (breast)
• Emphysema
• Pericardial effusion
• Dextrocardia

Other Things you Need to Know.
Precardium: Palpation

* Palpate the precordium with the palmar surface of your hand over the aortic, pulmonary, parasternal and apical areas of the heart.

* Determine the lower and outermost precardiac impulse, the apical impulse.

* Press your finger over the apical impulse identify its location, amplitude, duration and assess the rapidity of the upstroke and downstroke.

Normal: In thin individuals, the apical impulse is recognizable. Apical impulse is normally in 5th interspace just medial to midclavicular line and is about 1-2 cm in diameter. The apical impulse feels like a gentle tap and is small in amplitude and corresponds to first two thirds of systole.