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..