Today I switched from my TCM rotations to Cardiology with Arthur and Christine because I was having a hard time following their conversations in Taiwanese. TCM was interesting and I recommend it to people who are more fluent in Chinese (I still speak Chinglish) and have a more solid background in TCM.
I had a lot of catching up to do with ultrasound but luckily Arthur and Christine helped me out and gave me an idea of the doctor systematically looked at the heart. Once the system is down, Doctor Huang moves quickly and efficiently.
1. Parasternal long axis view: LA, LV, MV, RV, AV
2. RV inflow view -> check tricuspid valve.
3. Rotate probe clockwise to check the pulmonic valve
4. Short axis and measure diameter and width of left ventricle, left ventricle, aortic root, and left atrium.
5. LV apex view = 4 chamber view
6. Ejection Fraction = measured by Simpson method. Interesting side note- we learned how to do this in Calculus right before taking integrals. Simpson's method is basically taking the total area of rectangles.
7. Rotate counter clockwise 30-60 degrees to attain a 3 chamber view.
Each of these views offer the doctor important information about heart function. Regurgitation is found using Color doppler ultrasound. Blue marks the blood flowing away from the transducer and red marks the blood flowing towards the transducer. Therefore in a 4 chamber view with the ventricles at the 'top' of the echo and atriums at the bottom, if you see blue flowing towards the atrium, you can diagnose mitral or tricuspid regurgitation. I thought that was pretty cool to see the actual action of regurgitations.
This is just a basic overview of how Dr. Huang systematically looked at ultrasound. Here are some clinical pearls:
1. tissue doppler is used to test diastolic function
2. M-mode is a one dimensional mode in which you can capture width of chambers or vessels.
3. chest tightness is a broad term that could be originating from any organ. angina specifically means chest pain of cardiovascular origin.
4. If there are no problems that can be found on the ultrasound with a patient presenting with angina, the next step is to order a stress test which would indicate some form of ischemic heart disease. You could also order a blood test to check for dyslipidemia. As for controlling risk factors and treatment, the doctor could prescribe light aspirin, nitrate, and beta blockers. If the patient doesn't improve, you would have to use cardiac angiography.
5. T-wave inversions indicate ischemia changes
6. RV should be a 1/3 size of LV
7. IVC is measured at the compressed point to check for pulmonary hypertension. If it is completely compressed, it could be due to dehydration. If it cannot be compressed, it is dilated and usually indicates pulmonary hypertension. Normal IVC diameter should be < 1.75 cm.
8. Typical Heart Failure X-ray: Bronchus angle > 90 degrees, LA dilation, pulmonary edema, RA dilated, engorged pulmonary artery.
9. LV>1cm means LVH
10. Small pericardial effusion is treated by diurtics.
11.Dilation and hypertrophy is usually due to poor BP control.
12. 39% of Heart failure patients also have diabetes and hypertension. 60-70% etiology of HF is due to IHD. 10% due to HTN. 1% due to DM cardiomyopathy. The next step to determine etiology is to test for coronary function, the stress test, or a thallium scan.
13. Bowel gas can block the view for the IVC
14. If patient is obese and the fat obscures the view in ultrasound, your other options are TEE (transesophageal echo) or try to change the position of the patient to get a better view.
One patient reaction I found particularly interesting was when a patient was recommended to have mitral valve replacement surgery. She kept telling the doctor that she was "terrified to death" of having surgery. In Asian culture it is common for people to be very antagonistic towards surgical and invasive. Even though the doctor recommended it, he did hedge saying that if she did not have any particularly severe symptoms (dyspnea) that they could just wait and check on it every 6 months. He said, "It's too bad, how could I tell you that you need surgery?" They had known each for awhile and it must have pained him to tell her this. She kept telling him how terrified she was, and then said that she had "never done anything wrong" in her life. She repeated that a couple times. I think it's a superstitious statement that wouldn't be said in the U.S.
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