2. Cardio examiantion

Question 1

general inspection cardio

Answer 1

(colour, breathing, comfort, position,
build)

Question 2

cardiac signs in the hands

Answer 2

• Tar staining
  o Vasodilatation/constriction, temperature
  o Sweating (suggests increased sympathetic drive)
  o Pallor of palmar creases
  o Peripheral cyanosis
  o Clubbing
  o Splinter haemorrhages
  o Osler’s nodes and Janeway lesions
  o Tendon xanthomas

Question 3

what does sweating suggest cardiac

Answer 3

• pain –> sympathetic drive
• HF/MI - inadequate circualtion –> sympathetic drive

Question 4

what does pallor of palmar crease suggest

Answer 4

anaemia

Question 5

causes of clubbing

Answer 5

Causes of clubbing can be divided into: cardiac, repsiratory and other

Cardiac causes:
cyanotic congenital heart disease (Fallot’s, TGA)
bacterial endocarditis

Respiratory causes
interstitial pulmonary fibrosis
lung cancer
cystic fibrosis, bronchiectasis
lung abscess, empyema, tuberculosis
asbestosis, mesothelioma
fibrosing alveolitis

Other causes
Crohn’s, to a lesser extent UC
cirrhosis,
Graves’ disease

Question 6

examination findings infective endocarditis

Answer 6

inspection:
- splinter haemorrhages
- janeway lesions
- oslers nodes
- finger clubbing in long standing disease

auscultation:
- new or changing murmur

to complete:
- fundoscopy - roth spots

Question 7

what are janeway lesions

Answer 7

painless red flat macules on the palms of the hands and soles of the feet

suggestive of infective endocarditis

Question 8

what are oslers nodes

Answer 8

tender red/purple nodules on the pads of the fingers and toes

O = Ow

suggestive of infective endocarditis

Question 9

what are roth spots

Answer 9

haemorrhages on the retina seen during fundoscopy

suggestive of infective endocarditis

Question 10

what are tendon xanthomas

Answer 10

They commonly affect the tendons of the dorsal surface of the hands

Tendon xanthomas are cholesterol deposits in tendons.

Question 11

what is the waterhammer pulse

Answer 11

testing the brachial pulse for ‘collapsing pulse’ associated with aortic regurgitation

Question 12

cardiac signs in the eyes

Answer 12

o Subconjunctival pallor
o Corneal arcus
o Xanthelasmata

Question 13

what is corneal arcus

Answer 13

Corneal arcus is characterized by a white or grey opaque ring around the iris. Most often this affects both eyes (i.e., bilateral)

can be benign in older adults

however in ppl <40 arcus juvenilis may occur due to a lipid metabolism disorder, such as familial hyperlipidemia (i.e., elevated blood lipid levels), hypercholesterolemia (i.e. elevated cholesterol levels), or dyslipidemia (i.e., atypical lipid levels).

Question 14

cardiac face sign

Answer 14

o Malar flush (mitral stenosis)

Question 15

cardiac signs in the mouth/lips

Answer 15

o Central cyanosis (under tongue or on mucous membranes inside lips)
o High-arched palate (Marfan’s)
o Dental caries (may predispose to infective endocarditis)

Question 16

what vein is best to look at as a proxy fir central venous pressure

Answer 16

internal jugular vein

Question 17

how to distinguish between jvp and carotid pulsation

Answer 17

Number of pulses: the JVP has a double waveform pulse (i.e. 2 pulses) whereas the carotid artery has a single pulsation for each cardiac cycle.

Palpability: the pulse of the JVP is not easily palpable, whereas the carotid pulse is typically easy to feel.

Question 18

how to emasure the jvp? what is normal?

Answer 18

the vertical distance between the sternal angle and the top of the pulsation point of the IJV (in healthy individuals, this should be no greater than 3cm).

Question 19

what is the hepatojugular reflex?

Answer 19

apply pressure to the liver - if there is a sustained rise in JVP equal to or greater than 4cm this is deemed a positive result for raised JVP

In healthy individuals, this rise should last no longer than 1-2 cardiac cycles (it should then fall).

Question 20

causes of raised JVP?

Answer 20

hypervolemia
right sided heart failure
tricuspid regurgitation
obstructive shock
- consrrictive pericarditis
- pneumothorax
- superior vena cava obstruction

Question 21

JVP wave form and corresponding things:

Answer 21

A wave: atrial contarction

x wave 1 : atrial relaxation

c wave: tricuspid valve closure

x wave 2: (opposite as x1)- last part of ventricualr contraction

v wave : venous filling

y wave: eptying of right atrium into right ventricle

Question 22

what is a thoracotomy scar? where may it be? indications

Answer 22

A thoracotomy is a surgical procedure in which a cut is made between the ribs to see and reach the lungs or other organs in the chest or thorax.

• posterolateral thoracotomy: pulmonary resections (pneumonectomy/lobectomy/wedge)
• anterolateral thoracotomy:
  left sided = open chest massage
• axillary thoracotomy : pulmonary resections, pneumpthorax, pleurectomy
• mini-thoractotomy: right anterior mini thoractomy = accessing the aortic valve
  right lateral mini thoractomy = accessing mitral valve

Question 23

posterolateral thoracotomy indications

Answer 23

pulmonary resections (pneumonectomy/lobectomy/wedge)

Question 24

what is a midline sternotomy scar? indications?

Answer 24

open heart surgery

• valve surgery (aortic, mitral most common)

congenital heart defect correction

CABG (if seen, ask to look for vein harvesting scar on legs)

Question 25

cardiac signs inspection of the chest wall

Answer 25

sternotomy scars thoractotomy scars pectus excavatum kyphoscoliosis

Question 26

heaves vs thrills

Answer 26

heaves = abnormally large pulsation of the heart felt on palpation thrills = palpable murmur (vibrations/buzzing feeling)

Question 27

what do heaves indicate?

Answer 27

right ventricular enlargement, or. rarely, severe left atrial enlargement which pushes the right ventricle forwards.

Question 28

what grade murmur does a palpable thrill indicate

Answer 28

grade 4

Question 29

SCRIPT examination of a murmur

Answer 29

S – Site: where is the murmur loudest? C – Character: soft / blowing / crescendo (getting louder) / decrescendo (getting quieter) / crescendo-decrescendo (louder then quieter) R – Radiation: can you hear the murmur over the carotids (aortic stenosis) or left axilla (mitral regurgitation)? I – Intensity: what grade is the murmur? P – Pitch: is it high-pitched or low and rumbling? Pitch indicates velocity. T – Timing: is it systolic or diastolic?

Question 30

grades of murmurs

Answer 30

Grade I: Difficult to hear Grade II: Quiet Grade III: Easy to hear Grade IV: Easy to hear with a palpable thrill Grade V: Audible with stethoscope barely touching the chest Grade VI: Audible with stethoscope off the chest

Question 31

stenosis and hypertrophy?

Answer 31

When pushing against a stenotic valve, the muscle has to try harder, resulting in hypertrophy: Mitral stenosis causes left atrial hypertrophy Aortic stenosis causes left ventricular hypertrophy

Question 32

regurgitation and dilatation

Answer 32

When a leaky valve allows blood to flow back into a chamber, it stretches the muscle, resulting in dilatation: Mitral regurgitation causes left atrial dilatation Aortic regurgitation causes left ventricular dilatation

Question 33

o/e aortic stenosis

Answer 33

ass bump murmur: ejection-systolic crescendo-decrescendo murmur radiation: to carotids pulse: slow rising pulse other: narrow pulse pressure, thrill in aortic area

Question 34

o/e arotic reguargitation

Answer 34

ard fall murmur: early diastolic Switch back to the diaphragm, sit the patient forward and auscultate at the 4th/5th intercostal space to the left of the sternum on held expiration pulse: collapsing pulse (waterhammer), other: wide pulse pressure

Question 35

o/e mitral stenosis

Answer 35

msd u murmur: mid- diastolic low pitched rumbing Switch to the bell and auscultate the apex with the patient rolled 45° to the left pulse: may have irregularly irregualr pulse (AF) other: tapping apex beat, malar flush, atrial fibrilation

Question 36

o/e mitral regurgitation

Answer 36

mrs through murmur: pan-systolic high pitched whistling murmur, radiate to axilla. third heart sound pulse: Atrial fibrillation (irregularly irregular pulse)

Question 37

o/e tricuspid regurgitation

Answer 37

mumur: pan-systolic murmur other: prominent/giant V waves in JVP, pulsatile hepatomegaly, left parasternal heave

Question 38

o/e marfans cardio exam

Answer 38

inspection: - hands: arachnodactyly - mouth : high arched palate - chest: pectus excavatum auscultation: aortic regurgitation (due to dialtion of aortic root) murmur: early diastolic Switch back to the diaphragm, sit the patient forward and auscultate at the 4th/5th intercostal space to the left of the sternum on held expiration pulse: collapsing pulse (waterhammer), OR mitral valve prolapse --> mitral regurgitation murmur: pan-systolic high pitched whistling murmur, radiate to axilla. third heart sound

Question 39

o/e HOCM

Answer 39

can be normal murmur: Late ejection systolic murmur exacerbated by valsalva manoeuvre, reduced when squatting Does NOT radiate to the neck Best heard at left sternal edge, 3rd-4th intercostal space pulse: atrial fibrilation Occurs in 20% of patients other: prominent JVP a wave, abnormal blood pressure response to exercise, foreceful apex beat

Question 40

what to examine if ? coarctation

Answer 40

auscultate to the left of the spine in the 3rd/4th intercostal space Check the femoral pulses. Check synchrony with the radial pulse (radiofemoral delay in coarctation). (In the OSCE, you should state that you would do this).

Question 41

if there is pitting oedema at the ankles, what else should you test?

Answer 41

If this is present, you should always also check for ascites (see test for shifting dullness above).

Question 42

to complete cardiac examination

Answer 42

- Check the blood pressure in both arms and lying and standing in one arm. ● Perform ophthalmoscopy for hypertensive retinopathy ● Obtain a 12-lead ECG (In the OSCE, you should state that you would do this).

Question 43

Presenting cardiac examination

Answer 43

Today I completed a cardiac examination on xyz On inspection there was xyz / there were no signs of cardiovascular disease. The pulse rate was x with a regular rhythm. On palpation there was xyz / there were no heaves or thrills and no lateral displacement of the apex beat On auscultation there was xyz/ normal heart sounds with no additional sounds. The lung bases were clear There were no other positive findings In summary this examination is most consistent with...