1.

History taking
2. Physical examination
chest pain
dyspnea
3. Approach to CVS S&S
cyanosis
cardiac murmur
Underlying etiology
Anatomic abnormalities
4. Diagnosis
Physiologic disturbances
Functional disability
parasitic
bacterial
viral

Clinical diagnosis

Anatomy

macroanatomy (gross)
microanatomy (histology)

Infection

Heart

Pathology
pericarditis & cardiac tamponade
cardiomyopathy & myocarditis
arrhythmia
endocarditis & rheumatic HD Heart disease
valvular HD
congenital HD
HF & cor pulmonale
hypertension
atherosclerosis
chronic stable angina
ischemic HD
unstable angina
(CAD)
ACS
STEMI
Vascular disease
non-STEMI
aortic aneurysm / dissection
SVC obstruction
varicose vein of lower limb
vascular dz. of limbs
peripheral vascular occlusive dz
shock
Related disorders
metabolic syndrome

Physiology

Cardiovascular
disease
Biochemistry
Cardiovascular
system

regulation
circulatory dynamics & control
microcirculation
Circulation
regional circulation
blood coagulation (hemostasis)
Other condition exercise
heart
blood
EKG
Physical examination

Pathophysiology
Pathogesis

Lifestyle modification
anti-hypertensive drugs
anti-anginal drugs
anti-arrhythmic drugs
Pharmacology
drugs for HF & shock
lipid-lowering drugs
drugs for coagulation system
Intervention (catheterization)

characteristics & properties

Examination
Investigation

Other issues

Treatment
Management

electrical prop.
physical prop.

Heart examination

inspection
palpation
percussion
auscultation

BP measurement
lipid profile
Lab investigation
cardiac marker
chest radiography : CXR (plain film), CT
Others coronary angiography
echocardiogram

Medical ethics and professional laws

Holistic approach

fibrous pericardium
parietal layer (serous mesothelium)
potential space with lubricating fluid
Pericardium
serous pericardium pericardial cavity
transverse sinus
pericardial sinus
(fibroserous sac)
(irregular reflection) oblique sinus
visceral layer (*epicardium)
a : *pericardiophrenic, bronchial, esophageal
bv.+n. supply
n : phrenic
Location : inferior middle mediastinum (under sternal angle)
cardiac wall : endocardium+valve / *myocardium / epicardium
1. SA node (the Imp generator : initiate atrial systole)
Cardiac tissue
2. AV node (initiate ventricular systole)
excitable tissue
(specialize myocardium)
Lt. bundle br.
3. AV bundle of His
( distribute Imp to all ventricle) Rt. bundle br.

fetal circulation
umbilical v. : ligamentum teres hepatis (round lig.)
Embryonic
ductus venosus : ligamentum venosum
development
Remnant structure
foramen ovale : fossa ovalis+vulvula foraminis ovalis
(prenatal : postnatal)
ductus arteriosus : ligamentum arteriosum
umbilical a. : medial umbilical lig.
rough serous with *pericardial effusion (>50mL)
severe : cardiac tamponade (acute HF)
pericarditis
Lt. side of Xiphoid process Rx : pericardiocentesis
(dec. fluid+pressure)
Lt. 5th/6th ICS of sternal border
Clinical
cA obstruction via *atherosclerosis
correlation
: myocardial ischemia + infarction
refer to *T1-4 by symp. trunk
angina pectoris
CAD
(MI referred pain)
describe : viselike, constricting, crushing, pressed
percutaneous transluminal coronary angioplasty (PTCA) : balloon
Rx
coronary a. bypass grafting (CABG) : bypass surgery
internal jugular v.
Rt.+Lt. brachiocephalic (innominate) v.
subclavian v.
SVC
venous
azygos v.
system
IVC
Ascending aorta
Rt. common carotid a.
brachiocephalic trunk
Rt. subclavian a.
Lt. common carotid a. Arch of aorta
arterial
Lt. subclavian a.
system
bronchial a.
esophageal a.
pericardial br.
Thoracic aorta
mediastinal br.
(descending)
Great
vvs
post. intercostal a. (3 rd-11th)
T4-12
and
subcostal a.
Coronary vvs
sup. phrenic a.
SA nodal br.
Rt. marginal br.
**Post. IV (descending) br.
Rt. cA
: posterior 1/3 of IV septum
AV nodal br.
arterial supply
terminal br.
**Ant. IV a. (diagonal + septal br.)
: anterior 2/3 of IV septum
Lt. cA
circumflex br. (Lt. marginal)
coronary
great cardiac v.
system
middle cardiac v.
coronary sinus
small cardiac v.
oblique v.
Ant. cardiac v. venous return
least cardiac v. : in heart wall
(thebasian v. / venae cordis minimae)

External sulcus
CVS
gross anatomy

circumflex br. of Lt. cA / Rt. cA

coronary (A-V) sulcus
*coronary sinus / small cardiac v.
ant. interventricular (descending) br. of Lt. cA
ant. interventricular sulcus
great cardiac v.
post. interventricular (descending) br. of Rt. cA
post. interventricular sulcus
middle cardiac v.

Heart
eustachian valve (IVC opening)
2 part divided by
smooth : sinus venarium
thebasian valve (c. sinus opening)
sulcus/crista terminalis
RA
rough : RA proper (with Rt. auricle) - pectinate m.
(ext / int)
function : receive blood from SVC+IVC+coronary sinus
Atrium
interatrial septum : *fossa ovalis (RA) - vulvula foraminis ovalis (LA)
LA function : receive blood from pulmonary v. (Rt+Lt)
smooth
:
conus
ateriosus
/
infundibulum
2
part
divided
by
**Chamber
RV supraventricular crest rough : RV proper - papillary m. (trabeculae carnae)
function : transfer blood to lung by pulmonary trunk
membranous portion (upper) : thin+weak
Ventricle interventricular
muscular portion (lower) : * moderator / septomarginal band
septum
(connect to ant. papillary m.)
LV function : transfer blood to body by aorta
tricuspid valve (RA-RV)
pulmonary semilunar valve (RV-ptA)
**valve
bicuspid / mitral valve (LA-LV)
aortic semilunar valve (LV-Ao) aortic sinus of Valsava + * opening of Lt+Rt cA
blood supply : coronary system
blood and
parasymp : vagus n.
ANS
innervation
to
SA
node
nerve supply
(superficial+deep cardiac plexus) symp : sympathetic trunk

pulmonary circulation : gas exchange

systemic circulation : perfusion
arterial portal
portal circulation

glomerulus
hepatic
(between
2
cap.
beds)
Circulation
venous portal
Hypothalamo-hypophyseal
collect excess fluid as lymph return to blood cir.
lymphatic circulation
transport chylomicron, lipid from lacteal
(no central pump)
immune cell trafficking
barrier : selective permeability
vascular wall component
anti-thrombogenic /
: TI / TM / TA
thrombogenic activity synthetic + metabolic activity
: vasoactive agent, GFs,
(parenchyma : *endothelial cell )
regulation sm.
*vWb factor, cytokine
inflame cell trafficking
newly synthesis (embryo)
vasculogenesis
angioblast
(migratory vascular endothelial progenitor)
Vascular morphogenesis
synthesis from preexisting vvs. (embryo+adult)
(development)
capillary sprout
*angiogenesis
(activated by VEGF, Ang1)
tumor angiogenesis (neoangiogenesis)
mesothelium (visceral layer)
Epicardium
fibroelastic CT, adipose with bv+n supply
*contractile cardiocyte
ANP : myoendocrine cardiocyte **Myocardium
SA+AV node : nodal cardiocyte (pacemaker cell)
conducting system (Purkinje cell)
subendocardial layer
papillary m. + chordae tendineae
subendothelial CT layer Endocardium
endothelial layer
endocardial fold
valve
with cardiac skeleton core
4 annulus fibrosus (valve support)
*cardiac skeleton
1 septum membranaceum
(dense fibroelastic CT)
2 trigona fibrosi

General
characteristic

Cardiac tissue
(muscular pump)

CVS
Histology

Vascular
tissue

adipose with loose areolar CT

tunica adventitia
*bv+n supply : vasa vasorum + nervi vasorum
vascular tunica media *external elastic lamina (TM-TA junc.)
circular smooth m. layer + elastic fiber
wall
*internal elastic lamina (TI-TM junc.)
tunica intima subendothelial CT layer
endothelial layer
large elastic a. *prominent TM : elastic sheath (no IEL+EEL)
(conducting)
eg. aorta and great a.
medium-sized TM : smooth m. (*IEL+EEL)
muscular a.
Artery
eg. br. of great a.
(distributing)
: bv from heart
blood
TM : sm. 1-5 layers (IEL)
vessel
arteriole
peripheral resistance vvs.
(smallest m a.) (ctrl distribution+MAP by vasodilate+vasoconstrict)
eg. terminal br. of a.
diffusion / filtration (bulk flow) / vesicle
discontinuous sm. wall
metarteriole
(terminal arteriole)
precapillary sphincter : ctrl perfusion
large & small capillary (preferential / throughfare ch.)
TJ, BM cont.
*continuous
capillary bed
true capillary
pinocytotic vesicle (shuttle)
Microvascular : only endothelium
: exchange
TJ,
BM
cont.
bed
type
fenestrated
(pericyte)
- diffusion
fenestration pore ( +diaphragm)
- filtration (bulk flow)
discontinuous BM discont. / absent
-vesicle
(sinusoidal)
paracellular gap
postcapillary venule
only endothelium (pericyte) but large lumen
**A-V anastomosis / shunt (bypass capillary bed)
: peripheral thermoregulation
collecting venule
TM : smooth m. 1-2 layers
muscular venule
thin TA : loose CT
Vein
: bv to heart small v. TM : smooth m. 2-3 layer with large lumen
reservoir
medium v.
*prominent TA (large v. have sm.) with large lumen
large v.
dural venous sinus, retinal v, meningeal v. : no sm. in TM
atypical vvs. great saphenous v. : have long. sm. in TI+TA
umbilical + uterine v. (preg) : many layers of sm. in TM
only endothelium with intermittent BM
lymph. capillary (1st)
anchoring filament (prevent collapse)
lymphatic lymph. vvs / duct larger lumen with *valve
Rt. lymphatic duct
vessel
main lymph. duct to Rt. brachiocephalic v.
(3 tunics + *valve)
*thoracic duct
to Lt. jugular-subclavian junc.

th

normal : 5 ICS x midclavicular line

location

shift to lateral side : cardiomegaly

point of maximal imp. (PMI)

heave (narrow F)
inspection
palpation

Main Topic

CVS
Examination & Investigation

Physical
examination

impact force
thrill (wide + turbulent F)
neck v. engorgement (jugular v. distention) : Rt. HF

Heart examination
percussion
normal sound
auscultation
abnormal sound

surface location

valve

murmur : stenosis / regurgitation

auscultation area

vertebral lvl

3rd sternochondral junc.

Lt. 2nd ICS

T6

3rd ICS

Rt. 2nd ICS

T7

Lt.
sternal
border

4th sternochondral junc.

apex

T8

mid

4th ICS

xiphisternal junc.

T9

Apex (PMI)

5th ICS x midclavicular line

T10