Approach To Patients With Cardiovascular Disease

Question 1

What are the symptoms of CVD

Answer 1

Dyspnoea
Cough with or without sputum production
Pedal swelling
Right hypochondrial pain from an enlarging liver
Abdominal distention from an enlarging liver and/or ascites
Anorexia or poor appetite
Early satiety
Palpitation (awareness of the heart beat)
Dizziness (should be distinguished from vertigo)
Syncope
Chest pain
Fatigue
Intermittent claudication

Question 2

What are the forms of dyspnoea

Answer 2

Dyspnoea on exertion
Orthopnoea
Paroxysmal nocturnal dyspnoea

Question 3

Functional status of patients with heart diseases

Answer 3

NYHA (New York Heart Association) classification

Question 4

What is NYHA I

Answer 4

No dyspnoea on physical activity

Question 5

What is NYHA II

Answer 5

Dyspnoea on extraordinary activities

Question 6

What is NYHA III

Answer 6

Dyspnoea on ordinary activities

Question 7

What is NYHA IV

Answer 7

Dyspnoea at rest

Question 8

What causes cough in patients with CVD

Answer 8

Pulmonary congestion

Question 9

Nature of cough in a CVD patient

Answer 9

Dry In early stages
Productive of frothy sputum which may be blood stained (haemoptysis) from a ruptured pulmonary vein

Question 10

What could cause abdominal swelling in a CVD patient

Answer 10

Ascites
Hepatomegaly

Question 11

Ascites is massive in what diseases

Answer 11

Constrictive pericarditis
Endomycardial fibrosis
When liver condition from heart failure has caused cirrhosis of the liver

Question 12

_________ appears later than ankle swelling in heart failure

Answer 12

Ascites

Question 13

Chest pain in CVD patients may arise from

Answer 13

Pericardium - Pericarditis
Myocardium - Myocardial ischemia or infarction
Aorta dissecting aneurysm - May resemble MI however tends to be more severe

Question 14

What is the order of physical examination on a CVD patient

Answer 14

General examination
Examination of the pulse
Measurement of the blood pressure
JVP
Position of the apex beat
Palption of the precordium
Auscultation of the heart
Examination of the lungs and abdomen

Question 15

What should you look for when you hold a patient’s hand in cardiovascular exam

Answer 15

Temperature (may be cold in congestive heart failure)
Sweat
State of the nails
Splinter hemorrhages
Finger clubbing
Xanthomata
Osler’s nodes
Janeway lesions
Conjunctiva of the lower eyelids (pallor)
Proptosis
Pallor and cyanosis of the tongue
Edema of the sacrum and lower extremities

Question 16

Describe stage 1 finger clubbing

Answer 16

Increased sponginess of the nail bed

Question 17

Describe stage 2 finger clubbing

Answer 17

Obliteration of the angle between the nail and the nail fold

Question 18

Describe stage 3 finger clubbing

Answer 18

Increased convexity of the nail longitudinally and transversely

Question 19

Describe stage 4 finger clubbing

Answer 19

Bulbous swelling of the distal end of the finger

Question 20

Cardiovascular causes of finger clubbing

Answer 20

Cyanotic congenital heart disease
Infective endocarditis
Endomyocardial fibrosis
Atrial myxomas

Question 21

What are raised yellow lesions caused by a buildup of lipids beneath the skin often seen on tendons at the wrist

Answer 21

Xanthomata

Question 22

What is a red, tender nodules on the finger pulps or thenar eminence called

It is a rare manifestation of infective endocarditis

Answer 22

Osler’s nodes

Question 23

What are non-tender maculopapular erythematous lesions seen on palm or finger pulps as a rare feature of bacterial endocarditis

Answer 23

Janeway lesions

Question 24

What are the various rhythms of pulses

Answer 24

Regular and irregular

Question 25

What are the subcategories under irregular heart pulse

Answer 25

Regularly irregular Irregularly irregular - AF or multiple extrasystoles

Question 26

Examination of pulses

Answer 26

Rate Rhythm Volume - small, normal or large Character- collapsing Radio-femoral delay Palpation of peripheral pulses

Question 27

Examples of peripheral pulses

Answer 27

Radial pulse Brachial pulse Carotid pulse Femoral pulse Popliteal pulse Posterior tibial pulse Dorsalis pedis pulse

Question 28

Methods of measuring BP

Answer 28

Palpation Auscultatory - korotkoff sounds Oscillatory - pulse wave

Question 29

How do you assess JVP

Answer 29

Measure the JVP If the JVP is raised determine whether it is pulsatile or not Pulsatile raised JVP - right heart failure Non-pulsatile raised JVP - superior vena caval obstruction

Question 30

The size of the heart is assessed clinically by locating the position of the

Answer 30

Apex beat

Question 31

What is the outermost and lowermost cardiac impulse

Answer 31

Apex beat

Question 32

How do you locate the apex beat

Answer 32

The palm of the right hand is placed across the patient’s left chest so that it covers the area over the heart. The heel should rest along the sternal border while the extended fingers lying below the left nipple The normal sized ventricle will generate an impulse that is best felt in the mid-clavicular line, roughly at the 5th intercostal space if the ventricle becomes enlarged, the apex beat is displaced laterally. In cases of significant enlargement, the AB will be located near the axilla

Question 33

What is the normal location of the apex beat in adults

Answer 33

5th left intercostal space in the mid-clavicular line

Question 34

What does a left parasternal heave represent in the palpation of the precordium

Answer 34

Right ventricular hypertrophy

Question 35

What are thrills

Answer 35

Palpable murmurs

Question 36

The diaphragm is pushed more gently and the bell with much more force during auscultation of the heart True or false

Answer 36

False *It is the other way round*

Question 37

Which part of the stethoscope is used for low-pitched sounds such as the murmur of mitral stenosis

Answer 37

The bell

Question 38

Which part of the stethoscope is used for high-pitched sounds such as the murmur of mitral regurgitation

Answer 38

The diaphragm

Question 39

Pansystolic murmur is best heard on which part of the body

Answer 39

The apex radiating to the axilla

Question 40

Rumbling mid-diastolic murmur is best heard on which part of the body

Answer 40

At the apex with patient lying on his left lateral side

Question 41

What are the normal heart sounds

Answer 41

S1 and S2

Question 42

What does S1 signify

Answer 42

Closure of the mitral and tricuspid valves

Question 43

What does S2 signify

Answer 43

Closure of the pulmonary and aortic valves

Question 44

What are the abnormal heart sounds

Answer 44

S3 S4 Murmurs

Question 45

What causes S3

Answer 45

Rapid ventricular filling in early diastole when the AV pressure is high *It is sometimes audible in individuals below the ages of 40 years, but its appearance thereafter usually means a change in ventricular compliance or stiffness as a result of a disease. Eg. LV diastolic dysfuncrion*

Question 46

When does S4 occur

Answer 46

When there is a bolus of blood is delivered into the ventricle from atrial contraction *It is usually abnormal irrespective of age. It is usually associated with reduced ventricular distensibility (LV diastolic dysfunction)*

Question 47

What are the two types of murmurs

Answer 47

Systolic and diastolic murmurs

Question 48

What are some things examined for in the abdomen during a CVS exam

Answer 48

Tender soft hepatomegaly Ascites

Question 49

Orthopnoea is associated with what disease

Answer 49

Bilateral paralysis of the diaphragm

Question 50

Paroxysmal nocturnal dyspnoea is a classical symptom of what disease

Answer 50

Left heart failure

Question 51

What is the commonest cause of splinter haemorrhages

Answer 51

Trauma

Question 52

Radio-femoral delay is characteristic of what disease

Answer 52

Coarctation of the aorta

Question 53

Heart rate in which amplitude and timing are irregular is described as

Answer 53

Irregularly irregular

Question 54

What are splinter hemorrhages

Answer 54

They are small streak-like bleeding in the nail bed

Question 55

What should be the position of the patient during a cardiovascular exam

Answer 55

Position patient at 30-40 degrees and expose the precordium and the legs and start at the foot end of the patient’s bed and do a general inspection