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Showing posts with label Cardiology. Show all posts
Showing posts with label Cardiology. Show all posts

Treatment Options for Thoracic Inlet Syndrome

Treatment for Thoracic Inlet Syndrome - TIS depends on the severity of symptoms and the underlying cause. Conservative treatments are usually attempted first, and may include:

  1. Physical therapy: Exercises and stretches can help improve posture, strengthen muscles, and increase range of motion in the neck and shoulder.
  2. Medication: Nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids may be prescribed to manage pain and inflammation.
  3. Ergonomic adjustments: Modifying workstations or activities to reduce strain on the neck and shoulder can help alleviate symptoms.
  4. Heat or cold therapy: Applying heat or cold packs to the affected area can help manage pain and inflammation.

Diagnosis of Thoracic Inlet Syndrome

Diagnosing Diagnosis of Thoracic Inlet Syndrome - TIS can be challenging due to the variability in symptoms and the potential for overlap with other conditions. A thorough clinical examination, including a detailed medical history and physical examination, is crucial. Diagnostic tests may include:

  1. X-rays: To identify any anatomical abnormalities, such as cervical ribs or elongated transverse processes.
  2. Nerve conduction studies and electromyography (EMG): To assess the function of the nerves and muscles in the affected area.
  3. MRI or CT scans: To visualize soft tissues and detect any compression or inflammation.
  4. Doppler ultrasound or angiography: To evaluate blood flow through the subclavian artery and vein.

Symptoms of Thoracic Inlet Syndrome

Thoracic Inlet Syndrome -  TIS can present with a wide range of symptoms, depending on which structures are compressed. Common symptoms include:

  1. Pain in the neck, shoulder, arm, or hand
  2. Weakness or numbness in the arm or hand
  3. Swelling or discoloration of the arm or hand
  4. Coldness or tingling in the fingers
  5. Fatigue or heaviness in the arm
  6. Limited range of motion in the neck or shoulder
  7. Difficulty gripping objects or performing fine motor tasks

Causes of Thoracic Inlet Syndrome

Thoracic Inlet Syndrome(TIS) can be attributed to several factors that lead to the compression of neurovascular structures in the thoracic inlet. The main causes include:

  1. Anatomical abnormalities: Some individuals are born with an extra cervical rib, elongated C7 transverse process, or an abnormal fibrous band connecting the spine to the rib. These anomalies can reduce the space available for the neurovascular structures and cause compression.
  2. Poor posture: Slouching or maintaining a forward head posture can lead to muscle imbalances and strain in the neck and shoulder area, contributing to TIS.
  3. Repetitive activity: Overuse or repetitive movements, such as typing or playing certain sports, can cause inflammation and compression of the neurovascular structures in the thoracic inlet.
  4. Trauma: Injuries to the neck, shoulder, or clavicle may cause TIS due to inflammation, scar tissue, or displaced bones.
  5. Pregnancy: Hormonal changes and increased fluid retention during pregnancy can cause swelling and compression in the thoracic inlet.

A Comprehensive Guide to Thoracic Inlet Syndrome

II. Symptoms of Thoracic Inlet Syndrome

III. Diagnosis of Thoracic Inlet Syndrome

IV. Treatment Options for Thoracic Inlet Syndrome

V. Surgical options for Thoracic Inlet Syndrome


Exploring Normal Anatomical Variations: Understanding the Diversity of the Human Body

 Normal anatomical variations refer to the natural differences in the shape, size, position, and number of structures within the human body. These variations are considered normal because they are not associated with any disease or abnormality. Rather, they are part of the natural diversity of human anatomy. In this article, we will discuss some of the most common normal anatomical variations and their significance.

Palmaris Longus Muscle:

The Palmaris longus is a small muscle located in the forearm that runs from the elbow to the wrist. It is absent in around 14% of the population, making it the most common anatomical variation. Despite its absence, it is considered a non-functional muscle and its absence does not affect the function of the hand or wrist.

Plantaris Muscle:

The Plantaris muscle is a thin, long muscle located in the lower leg. It is absent in around 9% of the population. It is also considered a non-functional muscle and its absence does not affect the function of the leg or foot.

Renal Artery Variations:

The Renal arteries are the blood vessels that supply blood to the kidneys. In around 25% of the population, there is a variation in the number of renal arteries. Some people may have only one renal artery, while others may have two or even three. This variation does not usually cause any problems or affect kidney function.

Brachial Plexus Variations:

The Brachial Plexus is a network of nerves that originates in the neck and supplies the arm. In around 5% of the population, there is a variation in the branching pattern of the brachial plexus. This variation does not usually cause any problems or affect arm function.

Intestinal Length:

The length of the intestine varies widely between individuals. The small intestine can be anywhere from 10 to 30 feet long, while the large intestine can be anywhere from 3 to 6 feet long. This variation does not usually cause any problems or affect intestinal function.

Adrenal Gland Variations:

The Adrenal glands are located above the kidneys and produce hormones that regulate metabolism, blood pressure, and stress response. In around 50% of the population, there is a variation in the shape and size of the adrenal glands. This variation does not usually cause any problems or affect hormone production.

Thyroid Gland Variations:

The Thyroid gland is located in the neck and produces hormones that regulate metabolism. In around 10% of the population, there is a variation in the shape and size of the thyroid gland. This variation does not usually cause any problems or affect hormone production.

Dental Variations:

The number and shape of teeth can vary widely between individuals. Some people may have extra teeth, while others may be missing teeth or have teeth that are abnormally shaped. This variation does not usually cause any problems or affect dental function.

Nasal Septum Variations:

The Nasal septum is the wall of bone and cartilage that separates the two nostrils. In around 80% of the population, there is a variation in the shape of the nasal septum, which can cause one nostril to be slightly larger than the other. This variation does not usually cause any problems or affect nasal function.

Hand and Foot Size:

The size and shape of the hands and feet can vary widely between individuals. Some people may have large hands and feet, while others may have small hands and feet. This variation does not usually cause any problems or affect hand or foot function.

Thyroid and cardiac abnormalities

Thyroid examination is done for evidence of hypo  and hyperthyroidism  which can lead to heart disease.
Signs of thyroid dysfunction
Hands
  • Tachycardla/bradycardia, tremor, warmth
Eyes
  • Exophthalmos and eye signs
Neck
  • Goitre


Mechanism of continuous murmur

1.High pressure system communicating with low pressure system
Intracardiac
  • RSOV to RV, RA ,Pulmonary artery.
  • Coronary artery fistula to cardiac chamber.
Extracardiac
  • PDA.
  • Aorto pulmonary septal defect.
  • Pulmonary AVF.
  • Systemic AVF.
  • Anomalous left coronary artery from pulmonary artery.
2.Narrowing of vessel
  • Coarctation of aorta.
  • Peripheral pulmonary artery stenosis.
  • Carotid stenosis.
3.Increased blood flow through vessels
  • Venous hum - Devil’s murmur - root of neck.
  • Venous hum (Cruveilhier – Baumgarten murmur) - umbilicus - in portal hypertension.
  • Intercostal arteries - Coarctation of aorta.
  • Bronchopulmonary anastomoses.
  • Pulmonary atresia and TOF.
  • Internal mammary artery - Mammary Souffle in pregnancy.

What is Gallop rhythm

3 sounds heard during each cardiac cycle produce triple rhythm

Triple rhythm with sinus tachycardia produce Gallop rhythm imitating the sounds of galloping horse.
LV S3 gallop - is an important auscultatory sign of Left ventricular failure.
LVS3 is a sign of systolic dysfunction of ventricle.
Early S3 is heard in RVEMF -this is due to sudden limitation of ventricular filling.
Pericardial knock - An early S3 in constrictive pericarditis as in RV EMF.

S3 gallop is common in:
  1. Dilated cardiomyopathy.
  2. Decompensated aortic valve disease.
  3. Decompensated hypertensive heart disease.
RV S3 is always pathological
It is heard at LLSB.
Inspiratory augmentation is  present.
This is  associated with tricuspid regurgitation.
Atrial gallop S1,S2, S4
Ventricular gallop S1, S2, S3

Quadruple Rhythm
Quadruple rhythm is the presence of 4 heart sounds
(S1, S2, S3 and S4).

Summation Gallop
Summation is the presence of S1,S2 with merged S3 and S4

Types of continuous murmur

 Continuous murmur with cyanosis

  • TOF with PDA
  • Pulmonary atresia with bronchopulmonary anastomoses
  • Pulmonary AVF
Continuous murmur with systolic > diastolic component
  • PDA
  • Peripheral Pulmonaryartery stenosis
  • Broncho pulmonary anastomoses
Continuous Murmurs with Diastolic Accentuation
  • Rupture of sinus of Vakalva (RSOV)
  • Coronary arteriovenous fistula
  • Anomalous origin of left coronary artery from pulmonary artery (ALCAPA)
  • Pulmonary arteriovenous fistula

Causes of fourth heartsound

 LV S4  causes

  1. Systemic hypertension
  2. AS (left ventricular hypertrophy)
  3. LV myocardial infarction
RVS4  causes
  1. Pulmonary hypertension
  2. Pulmonary stenosis (Right Ventricular hypertrophy)
  3. RV myocardial infarction.
Features of RVS4
  1. Heard at LLSB
  2. Inspiratory augmentation present
  3. Associated with  a wave in JVP
  4. Seen in PAH and pulmonary stenosis
Triple rhythm
S1+S2+S3/S4

Quadruple rhythm
S1,S2 + S3 + S4.

Seen In:
  • Cardiomyopathy
  • Coronary artery disease
Summation gallop
S, S3 with merged S, & S4.

Causes of pathological S4
  1. Hypertrophic cardiomyopathy
  2. Systemic hypertension
  3. Coronary artery disease
  4. Myocardial infarction
  5. Ventricular aneurysm.
S3 -Ventricular distension sound.
S4 -Atrial contraction sound.

Achronym
LV : Left Ventricular
AS : Aortic Stenosis
RV : Right Ventricular

S1 - First Heart Sound
S2 - Second Heart Sound
S3 - Third Heart Sound
S4 - Fourth Heart Sound

Syncope due to reflex affecting heart

Vasovagal syncope

It  is a very common cause of dizziness or syncope that  is characteristically seen in response to the following.
  • Fear
  • Sudden emotional stress
  • Anxiety
  • Physical or mental exhaustion
  • Pregnancy 
  • Anaemia. 
Vasovagal syncope is always preceded by warning symptoms such as nausea. weakness, sweating, epigastric discomfort, blurred vision, headache, tinnitus, difficulty  in concentrating, sighing and dizziness.

The heart rate decreases, and the patient appears pale. The syncope is transient,and  last a few seconds to a few minutes, and this may be prevented by immediately lying down. Rarely, this type of syncope can occur when the patient is recumbent.

Orthostatic hypotension
Orthostatic hypotension produces dizziness on arising or after prolonged standing and this can be related to reduction  in effective blood volume, autonomic nervous system dysfunction, or rarely, to circulating vasodilator substances.

Causes are 
  • Drugs-antihypertensive or antidepressant medications, vasodilators, and beta blockers
  • Diabetic autonomic neuropathy
  • Anaemia
  • Low blood volume
  • Large varicose veins
  • Pregnancy
  • Addison's disease (rare cause)
  • Secondary hypertension-pheochromocytoma.
Hypersensitive carotid sinus
It is suspected when the patient describes dizziness or syncope after hyperextension of the neck, turning of the head, or pressure over the area of the carotid sinus from a necktie or during shaving. The syncope is evanescent, with rapid and complete recovery.

Method of Cardiac Auscultation

Patient is asked to be in supine position or in propped up position if orthopnoea present. The conventional sequence of auscultation of areas - Mitral area - tricuspid area - pulmonary area - aortic area - second aortic area

One should start auscultating mitral area with bell, then with diaphragm of stethoscope. For better appreciation, patient can be put in left lateral position.

Mitral area
Search for abnormality of S1 and presence of S3, S4, Opening snap and mitral systolic and diastolic murmur, conduction of systolic murmur to axilla

Tricuspid area 
You should look for diastolic and systolic murmurs of tricuspid valve disease, augmentation with inspiration in the sitting position is noticed

Pulmonary area 
Identify the abnormality of S2, alteration in intensity and split, ejection click, systolic, diastolic and continuous murmur

Aortic area 
Ask the patient to be in the sitting posture ,leaning forward and breath held in expiration. Look for intensity of aortic component of S2, aortic, systolic and early diastolic murmur

Second aortic area 
Sometimes aortic events are better heard in the 2nd aortic area and the position of the patient is as above. 

Symptomatology in cardiovascular disorders

Presenting symptoms in chronological order include

  1. Dyspnoea
  2. Palpitation
  3. Chest pain
  4. Cyanosis
  5. Edema
  6. Syncopal attack
  7. Cough
  8. Cough due to recurrent respiratory infection as in Mitral valvular disease, left to right shunt
  9. Nocturnal cough in PND
  10. Cough with pink frothy sputum in pulmonary edema.
  11. Hemoptysis
  12. Fatigue.
  13. Fever
  14. Joint pain

Importance of joint involvement in cardiovascular system :

  1. Acute rheumatic fever
  2. Rheumatoid arthritis. SLE. ankylosing spondylitis may be associated with Aortic or mitral regurgitation
  3. Infective endocarditis

How to examine for Dorsalis pedis pulse:an OSCE guide


Dorsalis pedis pulse is  located on top of the foot, immediately lateral to the extensor of hallucis longus (dorsalis pedis artery).
The dorsalis pedis pulse is palpated in the groove between the first and second toes slightly medial on the dorsum of the foot (i.e., dorsolateral to the extensor hallucis longus tendon and distal to the dorsal prominence of the navicular bone) with the middle and/or index fingers

Feel the pulse lateral to the extensor hallucis longus tendon and proximal to the first metatarsal space.

Comment on the following
  • Rate, rhythm, character, volume.
  • Character of the vessel wall.
  • Palpability of all vessels.
Clinical significance

Dorsalis pedis pulse is absent in condition of proximal vessel occlusion  such as embolism to popliteal artery or in peripheral vascular disease.

How to examine for Collapsing Pulse an OSCE guide

The term collapsing pulse is used to describe a pulse with a rapid upstroke and descent, and is characteristically described in aortic regurgitation.
Other  names of the collapsing pulse
  • Watson's water hammer pulse
  • Cannonball pulse 
  • Pulsus celer.
How to elicit collapsing pulse?
To elicit the collapsing pulse you have to palpate the carotids or the radial pulse.
For the radial pulse:
  • Ask the patient to fully pronate his forearm.
  • Place your right hand on the radial pulse.
  • Grasp the patient's forearm with left hand (with your palm on the flexor aspect of patient's forearm).
  • Raise the hand above the level of the patient's head
  • Repeat the manoeuvre to note the accentuation of the collapse in the elevated position.

How to examine for radiofemoral delay.an OSCE guide

Radiofemoral delay is an important clinical sign that help to detect the coarctation of aorta
How to elicit radiofemoral delay?
To detect the radiofemoral delay you have to palpate the radial and femoral artery simultaneously.Normally the time taken for the pulse wave to reach the radial artery after the cardiac systole is 80 milliseconds and for the femoral artery it is 75milleseconds.If the femoral pulse is delayed compared to radial pulse it is called as radiofemoral delay.
Causes of radiofemoral delay
Coarctation ol aorta
Atherosclerosis of aorta.
Thrombosis or embolism of aorta
 Aortoarteritis.



How to examine for Femoral pulse:an OSCE guide

The femoral pulse is palpated over the ventral thigh between the pubic symphysis and anterior superior iliac spine with the middle and index fingers.
How to examine for femoral pulse?
  • Ask the patient to lie supine,
  • Make the leg partially flexed: abduct and externally rotate the hip,
  • Feel the pulse below the midinguinal point.
Comment on the following
  • Rate, rhythm, character, volume.
  • Character of the vessel wall.
  • Palpability of all vessels.
  • Radio-femoral delay.
Clinical significance
Examination of peripheral pulse is imporatant for detection of radiofemoral delay

This is very important for students preparing for USMLE and MRCP

How to examine for carotid artery an OSCE guide

The common carotid artery is palpated on the neck below the jaw and lateral to the larynx/trachea (that is mid-point between your earlobe and chin) using the middle and index fingers.
It can be felt between the anterior border of the sternocleidomastoid muscle, above the hyoid bone and lateral to the thyroid cartilage
Precaution on palpating the carotid artery
  • The carotid artery should be palpated gently 
  • The patient should be in  sitting or lying down posture. 
  • Stimulating its baroreceptors with low palpitation can result in  severe bradycardia or even stop the heart in some sensitive persons. 
  • Two carotid arteries of a person should not be palpated at the same time. as it may limit the flow of blood to the head, possibly leading to fainting or brain ischemia.
How to examine for carotid pulse?
  • Ask the patient to look straight ahead
  • Use your thumb and press it backwards
  • The pulse is felt at the level of the medial border of the sternomastoid muscle and lateral to the thyroid cartilage.
Comment on the following
Rate, rhythm, character, volume.
Character of the vessel wall.
Palpability of all vessels,


This is very important for students preparing for USMLE and MRCP

How to examine for Brachial pulse:an OSCE guide

Brachial artery pulse is located on the inside of the upper arm near the elbow
The brachial artery is palpated on the anterior aspect of the elbow by gently pressing the artery against the underlying bone with the middle and index fingers. 
Clinical significance 
This pulse is commonly used to measure blood pressure with a stethoscope and sphygmomanometer
How to examine for brachial artery pulse?
  • Partially flex the elbow,
  • Feel the pulse over the elbow with thumb or fingers
Comment on the following
Rate, rhythm, character, volume.
Character of the vessel wall.
Palpability of all vessels,

How to examine for Radial pulse:an OSCE guide

Radial artery pulse is located on the lateral of the wrist , it can also be found in the anatomical snuff box
The radial pulse is palpated immediately above the wrist joint near the base of the thumb (i.e., common site), or in the anatomical snuff box (i.e., alternative site), by gently pressing the radial artery against the underlying bone with the middle and index fingers.
Clinical significance
The examination of radial pulse is very useful in the following condition
Radioradial delay-seen in thoracic inlet syndrome and takayasu disease
Radiofemoaral delay in Coarctation of aorta
How examine for radial pulse
  • Semipronate the forearm,
  • Flex the wrist
  • Feel the pulse near the wrist,
Comment on the following
Rate, rhythm, character, volume.
Character of the vessel wall.
Palpability of all vessels,
Radio-femoral delay.


This is very important for students preparing for USMLE and MRCP