Ward Round Notes

Grade 1 - heard by specialist in optimum conditions Grade 2 - heard by non specialist in optimum conditions Grade 3 - Easily heard no thrill Grade 4 - loud murmur with thrill Grade 5 - very loud heard over wide area with thrill Grade 6 - Murmur heard without stephoscope Douglas G, Nicol F, Robertson C, Macleod's clinical examination 12th ed . Edinburgh, churchill livingstone, 2009. 

Immediate ECG changes (stage1)  Widespread, saddle shaped ST elevation (except AvR and lead 1)  PR interval depression (except AvR and lead 1)  Reciprocal changes in lead 1 and AvR.  Sinus tachycardia due to pain or effusion.  (taken from: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/03/V5-pericarditis.jpg)  1-3 weeks (stage 2)  Flattened T waves, no ST elevation or PR interval depression.  3- several weeks (stage 3)  Inverted T waves several weeks + (stage 4) ECG returns to normal *not all patients go through the later stages of ECG changes. http://lifeinthefastlane.com/ecg-library/basics/pericarditis/ (this is a brilliant site!) http://emedicine.medscape.com/article/156951-overview

"Pulsus paradoxus" refers to an abnormal decrease of over 10mmHg in pulse pressure and subsequently pulse volume on inspiration. It is caused by a decrease in intrathoracic pressure.  On inspiration the intrathoracic pressure decreases The pressure intrathoracically is lower than the pressure extrathoracically which leads to an increased venous return to the right ventricles The right ventricles bulges into the left side reducing left ventricular volume.  Reduced intrathoracic pressure also leads to dialation of the pulmonary vessels Blood from the right ventricle pools in the lungs leading to reduced blood returning to the left ventricles Reduced blood in the left ventricles leads to a reduced stroke volume according to starling's law.  Reduced thoracic pressure on the aorta also contributes to the reduced pulse pressure Reduction of pulse pressure leads to a weaker or absent pulse volume being felt whist a contraction is heard on auscultation.  Pu...

Definition and demographics heart failure occurs when the heart function fails to perfuse the body adequately under normal physiological conditions. Heart failure can be divided into acute or chronic heart failure, may be caused by reduction of ejection fraction (systolic failure) or failure for the heart to fill (diastolic heart failure or heart failure with preserved ejection fraction), affect the left heart or the right heart, or both sides. It can also be divided into heart failure caused by an intrinsic disease of the heart(high output), or due to increased demands of the body (low output).  There is an increasing prevalence of heart failure patients due to the increase in older individuals and better outcomes for other cardiovascular diseases. The prevalence of heart failure is around 2-3% in the general population, with increasing incidence amongst older people. There is a slightly higher incidence amongst men compared to women, especially in the middle aged populat...

causes of a raised troponin:  Myocardial infarction Massive pulmonary embolism - leads to increased work of the right ventricles which damage cardiac muscles releasing troponin Chronic kidney disease (especially in later stages, although they may also have concurrent acute coronary syndrome - look for an increase from baseline)  Myocarditis  Sepsis/other critically ill (increased work of the heart leading to myocyte damage)  Aortic dissection severe tachycardia/bradycardia Stroke or subarachnoid haemorrhage Medical treatment for patients with acute coronary syndromes on presenting (before PCI) :  M orphine O xygen N itrates A spirin C lopidigrel Medicines after an MI A torvastatin B- blocker C heck all else

Definition: The transient loss of conciousness caused by transient global hypoperfusion of the brain. Syncope is sudden onset, occurs for a short duration, and is characterised by spontaneous complete recovery. Causes and Differentials:  Syncope presents as a transient loss of conciousness but is defined by its pathophysiology (transient global hypoperfusion) and is therefore different to other causes of loss of conciousness. Syncope can be divided into 3 main types which are summarised below:  Reflex syncope is the most common type.  

Definition: Accumulation of fluid in the pericarial space leading to restriction of the heart's pumping action and reduced cardiac output which may lead to hypoperfusion and failure of other organs. Different to cardiac effusion which is an umbrella term for a fluid collection in the pericardial space with or without haemodynamic compromise.  Pathophysiology A cardiac tamponade is caused by an increase in the pressure in the pericardial sac. The pericardial sac usually has a level of compliance (stretch) and therefore an increase in fluids in this space initially has little effect on the pressure. It is only when the sac has reached the limit of it's stretch that the pressure increases. The compliance of the pericardial sac can also be increased in a chronic effusion and as much of 2000mls of fluid can be present before it causes a tamponade. Compliance can also be reduced by some disease states.