[Dr Najeeb Lectures Cardiovascular Pathology
Luther Lazaro
Taking the pulse is one of the simplest, oldest, and yet most informative of all clinical tests. As you pick up the patient's hand, you should check for clubbing and any peripheral signs of endocarditis (see Table 3). Note the rate and document the rhythm of the pulse. The character and volume of the pulse can also be useful signs and traditionally it is believed that these are easier to detect in larger arteries such as the brachial and the carotid (see Table 4).
Checking both radials simultaneously is important in all cases of chest pain as a gross screening test for aortic dissection. Adding radiofemoral delay (or radiofemoral difference in volume) may alert you to coarctation as a rare cause of hypertension.
Of all the elements of clinical examination, the jugular venous pressure (JVP) is the most mysterious. It is highly esoteric, and whilst some people wax lyrical about the steepness of the "y" descent, others will feel grateful to be convinced they see it at all. Two things are very clear: (1) the JVP is a very useful clinical marker in many situations, and (2) the exact height of the JVP is a poor guide to central venous pressure. Taken together, this suggests that noting whether the JVP is "up" or "down" is good practice in every cardiac patient. In particular, it can be very useful in diagnosing right-sided heart failure and in differentiating a cardiovascular cause of acute shortness of breath (right ventricular failure, pulmonary embolism) from an intrinsic pulmonary cause (asthma, chronic obstructive pulmonary disease). For the general physician, the waveform of the JVP (see Figure 1) is, for most purposes, only of academic significance.
The JVP should be assessed with the patient reclined at a 45 angle (see Figure 2). Accepted practice is that only the internal jugular vein should be used, as only this vessel joins the superior vena cava at a 180 angle. The JVP is defined as the height of the waveform in centimeters above the sternal angle (
A third heart sound may be heard soon after the second heart sound. It is thought to be due to rapid, high-volume filling of the left ventricle. As such, it is found in pathological (left ventricular failure) as well as physiological (athletic heart, pregnancy) states.
When you have considered these heart sound variations, move on to consider the gaps between the heart sounds. If you hear a murmur, first establish whether it occurs in systole or diastole (time against the carotid pulse if necessary). Then determine its length and, if short, its exact position (early, mid, or late; systole or diastole) (see Figure 3).
An opening snap occurring after the second heart sound represents a diseased mitral valve opening to a stenotic position. An ejection click soon after the first heart sound occurs in aortic stenosis and pulmonary stenosis. A mid systolic click is heard in mitral valve prolapse.
Listen to the base of the lungs for the fine inspiratory crackles of pulmonary edema. If you suspect right-sided cardiac pathology, palpate the liver, which will be enlarged, congested, and possibly pulsatile in cases of right ventricular failure or tricuspid valve disease. Also, check the patient's ankles for swelling.
A careful clinical examination can reveal much about the condition of your patient's heart. In addition, noting the findings of a full examination will greatly facilitate specialist referral. In an age of high technology, skilled clinical examination has yet to be surpassed in terms of convenience, safety, and value for money.
The AMSS is pleased to offer you this updated and expanded guide to assist in your learning. It's well worth your time, so be sure to check it out in full. Below you'll find online textbook banks, go-to resources for different specialities, gold-mines for most things medicine, MCQ banks, online lecture resources, podcasts frequented by medical students and more!
We're always looking to optimise this guide. So if you know of an awesome medical resource that's not listed below which you would like to recommend for the guide, please get in touch by emailing our Vice President (Education) via v...@amss.org.au.
Textbook Talk is an AMSS publication that aims to help you decide which are the best textbooks to buy. It is packed with information about the more commonly used textbooks, as well as recommendations from older students.
Search clinical eBooks, eJournals, practice guidelines, patient handouts, and cases on a wide area of clinical medicine in a single unified search engine. Also provides access to the Australian Medicines Handbook via the "Drugs" tab.
Check the eTG! Ever reliable, the Electronic Therapeutic Guidelines (eTG) comprehensively covers the up-to-date management of common disorders seen in clinical practise. The guidelines are independent, unbiased and are quotable in CBL and on the wards.
The AMH is an independent (not supported by drug companies), evidence-based Australian website/textbook containing information on just about every drug an Australian doctor is likely to see. Access is available via CANVAS, on the Exam Course for year level.
The South Australian Perinatal Practice Guidelines are clinical guidelines established by the Department of Health for the care of obstetric patients in South Australia. These guidelines are used and quoted extensively by clinicians at the Women's and Children's Hospital and are hence a definitive reference for diagnostic and management criteria.
A great go-to-source for all things kids in medicine. The RCH Clinical Practice Guidelines contain reliable assessment and management algorithms for all the common paediatrics conditions. Content is also accessible offline via the RCH phone app.
Sti.guidelines.org contains the official guidelines for the management of sexually transmitted infections in Australia. The guidelines are somehow both concise and comprehensive, covering important specific details such as requirements for notification and tests of cure.
This manual, from the Royal College of Pathologists of Australia, aims to provide useful guidelines for the use and selection of pathology tests. It describes how to select pathology tests and how to interpret the results. The Manual consists of several sections including: Clinical Problems, Pathology Tests and Pathology Decision Support Tools.
A great resource for pre-clinical and clinical students alike, Medscape contains thousands of free articles, ranging from diseases to investigations to drug profiles, written by experts, usually from the United States. Pre-clinical students have been known to get through entire CBL sessions with only a Medscape article, printed moments before the session is to begin, in their hands. Clinical students have been known to utilise the Medscape app to pass the time during long ward rounds. You'll need to create a free Medscape account to access. To use the Medscape app offline, click the dropdown menu in the top-left-hand corner of the screen >> data updates >> download clinical reference.
Once students start using it, many find that UpToDate is something that they can't live without. UpToDate is quite possibly a clinical student's best friend. It is widely available in the hospitals and it has a knack for containing just the right information you need, when you're desperately searching minutes before a ward round. There's also PLENTY in it for pre-clinical students too, particularly when specific clinical details cannot be found elsewhere.
BMJ Best Practice combines the latest evidence and expert opinion and presents it in a concise fashion. Useful for CBL and in the clinical years, this resource provides excellent detail regarding disease risk factors and differential diagnoses. There is also a drug database that contains hundreds of drugs alphabetically and is especially useful for understanding drugs and their adverse effects.
These useful resources are directed at General Practitioners but can be of great use to medical students as well. They contain articles focused on the clinical details of both disease profiles and investigations. A great place to start for third year CBL, due to its clinical focus.
These useful resources are directed at General Practitioners but can be of great use to medical students as well. They contain articles focused on the clinical details of both disease profiles and investigations. A great place to start for third year CBL, due to its clinical focus. You'll need to create a free medical student account to access.
Known for being the go-to ECG resource, Life in the Fast Lane (LITFL) is actually much more. It is the brainchild of an Dr Mike Cadogan, an emergency physician and passionate advocate of FOAM (Free Open Access 'Meducation'), and contains concise summaries of everything critical care and practise cases surrounding CXRs, ABGs, trauma, ECGs (of course) and more!
A one stop shop for succinct mechanisms underlying a wide variety of conditions with reliability generally ensured by the review of all materials undertaken by the University of Calgary. Mechanisms are generally of sufficient detail for examinations though can be insufficiently detailed for CBL. Make sure to check out the cardiology section, a gold-mine of useful mechanisms for CBL. Quick tip: if you can't find what you are looking for with the search engine (it can be very specific), try the contents menu.
The place to go when Calgary guide lacks the detail you need. McMaster's (often called pathophys.org) provides well referenced pathophysiology in a well explained easy to read format. They have particularly good sections for: ischaemic heart disease, heart failure, breast cancer, lung cancer and PCOS.
A great free resource to learn basic anatomy in a simple easy to read way. Relied on by first years for their excellent upper and lower limb sections, the detailed full colour images are a great place to go when starting studying anatomy for a CBL case. The level of detail can often be limited so make sure to supplement your knowledge with another source.
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