*Cardiovascular System (CVS) – Practical Exam
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Revision Guide**
In the **MBBS final year practical exams**, the **Cardiovascular System (CVS)** is a crucial
topic. It includes case presentations, clinical examinations, investigations, and viva questions.
Below is a **detailed revision summary**:
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## **1. General Approach to CVS Case Presentation**
- **Chief Complaints:** Chest pain, breathlessness, palpitations, syncope, pedal edema,
fatigue
- **History of Present Illness:**
- Onset, duration, progression
- Exacerbating/relieving factors
- Associated symptoms (e.g., orthopnea, paroxysmal nocturnal dyspnea)
- **Past Medical History:** Hypertension, diabetes, past MI, surgeries, history of rheumatic
fever
- **Family History:** Hypertension, CAD, congenital heart disease
- **Personal History:** Smoking, alcohol, sedentary lifestyle
- **Drug History:** Antihypertensives, anticoagulants, lipid-lowering agents
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## **2. Cardiovascular Examination Steps**
### **A. General Examination**
- Pulse: Rate, rhythm, volume, character (bounding, thready), radio-radial & radio-femoral
delay
- Blood Pressure: Measure in both arms
- Respiratory Rate: Tachypnea in heart failure
- Jugular Venous Pressure (JVP): Elevated in heart failure, tricuspid regurgitation
- Cyanosis, clubbing, pallor, edema, xanthelasma, signs of infective endocarditis
### **B. Systemic Examination**
#### **1. Inspection**
- Precordial bulge (suggestive of cardiac enlargement)
- Visible pulsations (apex beat displacement, parasternal heave)
- Scars from previous surgeries
#### **2. Palpation**
- **Apex Beat:**
- Location (5th intercostal space, midclavicular line)
- Shifted in cardiomegaly, LVH
- **Parasternal Heave:** Right ventricular hypertrophy (RVH)
- **Thrills:** Suggestive of murmurs (valvular lesions)
#### **3. Percussion**
- Done if apex beat is not palpable to assess cardiac dullness
#### **4. Auscultation**
**Heart Sounds (S1, S2, S3, S4):**
- **S1 (Lub):** Loud in mitral stenosis, soft in mitral regurgitation
- **S2 (Dub):** Loud in hypertension, split in ASD/Pulmonary Hypertension
- **S3 (Ventricular Gallop):** Seen in heart failure
- **S4 (Atrial Gallop):** Seen in hypertension, aortic stenosis
**Murmurs:**
- **Systolic Murmurs:**
- Aortic stenosis → **Ejection systolic murmur** (radiates to carotids)
- Mitral regurgitation → **Pansystolic murmur** (radiates to axilla)
- **Diastolic Murmurs:**
- Aortic regurgitation → **Early diastolic murmur**
- Mitral stenosis → **Mid-diastolic murmur with opening snap**
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## **3. Common CVS Cases for Exam**
### **1. Hypertension (HTN)**
- **Symptoms:** Asymptomatic or headache, dizziness, blurred vision
- **Signs:** High BP (>140/90 mmHg), hypertensive retinopathy, LVH
- **Investigations:** ECG (LVH), Fundoscopy (AV nicking, hemorrhages), Lipid Profile
- **Management:** Lifestyle changes, antihypertensives (ACE inhibitors, CCBs, Beta-blockers)
### **2. Coronary Artery Disease (CAD) – Myocardial Infarction (MI)**
- **Symptoms:** Chest pain (crushing, radiating to left arm/jaw), sweating, nausea
- **Signs:** Hypotension, tachycardia, new murmurs, S3 gallop
- **Investigations:** ECG (ST-elevation in STEMI, T-wave inversion in NSTEMI), Troponins
- **Management:** MONA (Morphine, Oxygen, Nitrates, Aspirin), thrombolysis, PCI
### **3. Heart Failure**
- **Symptoms:** Dyspnea, orthopnea, pedal edema, fatigue
- **Signs:** Elevated JVP, pitting edema, crackles in lungs, S3 gallop
- **Investigations:** BNP levels, Echocardiography (EF <40%), Chest X-ray (Cardiomegaly,
Pulmonary Edema)
- **Management:** Diuretics, ACE inhibitors, Beta-blockers, Digoxin
### **4. Valvular Heart Diseases**
- **Mitral Stenosis:** Mid-diastolic murmur, opening snap
- **Mitral Regurgitation:** Pansystolic murmur radiating to axilla
- **Aortic Stenosis:** Ejection systolic murmur, syncope
- **Aortic Regurgitation:** Early diastolic murmur, wide pulse pressure
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## **4. Important Investigations in CVS**
### **1. ECG (Electrocardiogram) Interpretation**
- **Normal Sinus Rhythm:** P before every QRS
- **Myocardial Infarction:** ST-elevation, T-wave inversion, Q waves
- **Atrial Fibrillation:** Irregularly irregular rhythm, absent P waves
- **Heart Blocks:**
- 1st Degree – Prolonged PR interval
- 2nd Degree – Dropped beats
- 3rd Degree – Complete dissociation
### **2. Chest X-ray Findings**
- Cardiomegaly (Enlarged Heart Shadow)
- Pulmonary Edema (Bat-wing pattern)
- Aortic Dissection (Widened Mediastinum)
### **3. Echocardiography**
- Ejection Fraction (EF) in heart failure
- Valvular Lesions (Regurgitation/Stenosis)
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## **5. OSCE (Objective Structured Clinical Examination) Tips**
- **Blood Pressure Measurement:** Ensure proper technique
- **Pulse Examination:** Check rate, rhythm, volume, character
- **JVP Measurement:** Differentiate between normal and raised JVP
- **ECG Reading:** Identify MI, AF, and heart blocks
- **Drug Viva:** Know common antihypertensives and cardiac drugs
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## **6. High-Yield Viva Questions**
1. How do you differentiate between systolic and diastolic murmurs?
2. What are the different causes of heart failure?
3. How do you manage an acute myocardial infarction?
4. What are the complications of hypertension?
5. How do you differentiate between aortic stenosis and mitral regurgitation clinically?
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