5. the cardiac examination

Question 1

causes of bradycardia regular and irregular rhythm

Answer 1

> regular rhythm
Physiological (athletes, during sleep: due to increased
vagal tone)
Drugs (e.g. beta-blockers, digoxin, amiodarone)
Hypothyroidism (decreased sympathetic activity
secondary to thyroid hormone deficiency)
Hypothermia
Raised intracranial pressure (due to an effect on central
sympathetic outflow)—a late sign
Third-degree atrioventricular (AV) block, or seconddegree
(type 2) AV block
Myocardial infarction
Paroxysmal bradycardia: vasovagal syncope
Jaundice (in severe cases only, due to deposition of
bilirubin in the conducting system)

> irregular rhythm
-Irregularly irregular
Atrial fibrillation (in combination with conduction system
disease or AV nodal blocking drugs) due to:
• alcohol, post-thoracotomy, idiopathic
• mitral valve disease or any cause of left atrial enlargement
Frequent ectopic beats
-Regularly irregular rhythm
Sinus arrhythmia (normal slowing of the pulse with
expiration)
Second-degree AV block (type 1)
-Apparent
Pulse deficit* (atrial fibrillation, ventricular or atrial
bigeminy)

Question 2

causes of tachycardia regular rhythm

Answer 2

>regular
Hyperdynamic circulation, due to:
• exercise or emotion (e.g. anxiety)
• fever (allow 15–20 beats per minute per °C above
normal)
• pregnancy
• thyrotoxicosis
• anaemia
• arteriovenous fistula (e.g. Paget’s disease or hepatic
failure)
• beri-beri (thiamine deficiency)
Congestive cardiac failure
Constrictive pericarditis
Drugs (e.g. salbutamol and other sympathomimetics,
atropine)
Normal variant
Denervated heart, e.g. diabetes mellitus (resting rate of
106–120 beats per minute)
Hypovolaemic shock
Supraventricular tachycardia (usually >150)
Atrial flutter with regular 2 : 1 AV block (usually 150)
Ventricular tachycardia (often >150)
Sinus tachycardia, due to:
• thyrotoxicosis
• pulmonary embolism
• myocarditis
• myocardial ischaemia
• fever, acute hypoxia or hypercapnia (paroxysmal)
Multifocal atrial tachycardia
Atrial flutter with variable block

Question 3

causes of tachycardia irregular rhythm

Answer 3

> irregular rhythm
Atrial fibrillation, due to:
• myocardial ischaemia
• mitral valve disease or any cause of left atrial enlargement
• thyrotoxicosis
• hypertensive heart disease
• sick sinus syndrome
• pulmonary embolism
• myocarditis
• fever, acute hypoxia or hypercapnia (paroxysmal)
• other: alcohol, post-thoracotomy, idiopathic
Multifocal atrial tachycardia
Atrial flutter with variable block

Question 4

classification of Bp readings (category, systolic, diastolic)

Answer 4

optimal -  <120 <80
normal - 120-129 / 80-84
high normal - 130-139 / 85-89
mild HTN (grade 1) - 140-159 / 90-99
moderate HTN (grade 2) - 160-179 / 100-109
severe HTN (grade 3) >180/ >110

Question 5

causes of postural hypotension (HANDI)

Answer 5

H ypovolaemia (e.g dehydration, bleeding); hypopituitarism
A ddisons disease (adrenal gland failure)
N ueropathy - autonomic (e.g DM, amyloidosis, shy-drager syndrome)
D rugs (e.g VD and other antihypertenisves, tricyclic antidepressants, diuretics, antipsychotics)
I diopathic orthostatic hypotension (rare progressive degeneration of the anutonomic nervous system, usually in elderly men)

Question 6

jugular venous pressure (JVP)

Answer 6

JUGULAR VENOUS PRESSURE (JVP)
-Causes of an elevated central venous
pressure (CVP)
Right ventricular failure
Tricuspid stenosis or regurgitation
Pericardial effusion or constrictive pericarditis
Superior vena caval obstruction
Fluid overload
Hyperdynamic circulation

-Wave form
>CAUSES OF A DOMINANT A WAVE
Tricuspid stenosis (also causing a slow y descent)
Pulmonary stenosis
Pulmonary hypertension

> CAUSES OF CANNON A WAVES
Complete heart block
Paroxysmal nodal tachycardia with retrograde
atrial conduction
Ventricular tachycardia with retrograde atrial
conduction or atrioventricular dissociation
CAUSES OF A DOMINANT V WAVE
Tricuspid regurgitation
X DESCENT
Absent: atrial fibrillation
Exaggerated: acute cardiac tamponade,
constrictive pericarditis
Y DESCENT
Sharp: severe tricuspid regurgitation, constrictive
pericarditis
Slow: tricuspid stenosis, right atrial myxoma

Question 7

waves definition of JVP

Answer 7

a wave: coincides w/ right atrial systole, coicides w/ first heart sounds and precedes the carotid pulsation
V wave: due to atrial filling, in the period when the tricuspid valve remains closed during ventricular systole
X decent: caused by atrial relaxation
C point: due to transmitted carotid pulsation and coicides w/ tricuspid valve closure
Y decent: due to tricuspid valve opens and rapid ventricular filling occurs