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Clinical Exam > Cardiac exam > Flashcards

Cardiac exam Flashcards

1
Q

Still’s mumur

A

prevalence: age 2-6yrs and resolves at adolescence

location: left lower sternal border

intensity: grade 1/2

quality: musical/vibratory

radiation: minimal

position: louder supine than sitting

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2
Q

Innocent mumurs

A

duration: short systolic

quality: musical or vibrational

radiation: minimal

intensity: grade 2 or less

position: louder supine than sitting

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3
Q

Pathological mumurs

A

intensity: grade 3 or higher with maximum at LUSB

timing: holosystolic or diastolic

quality: harsh or blowing, click

position: increased sitting

S2: abnormal with wide or fixed split

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4
Q

Systolic mumurs

A

early systolic: small muscular VSD

mid-systolic/ejection systolic: aortic stenosis

pansystolic: moderate/large VSD, mitral regurgitation

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5
Q

Diastolic mumurs

A

early distolic: aortic regurgitation, ASD with tricuspid stenosis

late diastolic: mitral stenosis

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6
Q

Mumurs

Right upper stenal border

A

pathogenesis: left ventricular outflow obstruction eg. aortic stenosis

radiation: usually to carotid region

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7
Q

Mumurs

Left upper sternal border

A

SYSTOLIC

cause: right ventricular outflow tract obstruction eg. pulmonary stenosis, benign flow mumurs

radiation: to axilla/back

DIASTOLIC

cause: aortic regurgitation or pulmonary regurgitation

radiation: left sternal border

CONTINUOUS

cause: PDA, cervical venous hum

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8
Q

Mumurs

Left lower sternal border

A

SYSTOLIC

cause: VSDs, tricuspid regurgitation, subvalvular AS, HCM, Still’s

DIASTOLIC

cause: semilunar valve regurgitation, tricuspid stenosis

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9
Q

Mumurs

Apex

A

SYSTOLIC

cause: mitral regurgitation

radiation: axilla

DIASTOLIC

cause: mitral stenosis

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10
Q

Cardiac failure

causes

A

congenital heart disease:

- volume overload: VSD, PDA, ASD, single ventricle

- pressure overload: AS, coarctation, PS

structurally normal heart:

  • cardiomyopathy, myocarditis, MI, arrhythmias (CHB, SVT, VT), drugs/toxins

non-cardiac:

  • sepsis, ESRF, HIV, SLE
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11
Q

Cardiac failure

clinical

A

cyanosis

tachycardia

hypertension

gallop rhythm (S3)

respiratory distress

hepatomegaly

jugular venous distension

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12
Q

Pulsus alternans

A

definition: varied pulse amplitude with alternate beats

causes:

  • hypertrophic CM
  • tachypnoea
  • severe arotic regurgitation
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13
Q

Pulses paradoxus

A

definition: drop >10mmHg with inspiration

causes:

  • cardiac tamponade
  • restrictive CM/pericarditis
  • hypovolaemic shock
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14
Q

Pulses bisferiens

A

definition: 2 systolic pulse peaks

causes:

  • AR
  • AS
  • HCM
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15
Q

Water hammer pulse

A

definition: abrupt rapid upstroke of pulse with collapse

cause: rapid LV volume against low resistance system

  • AR
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16
Q

Bounding pulse

A

definition: widened pulse pressue

cause: increased stroke volume

  • PDA
  • large AV fistula
  • hyperkinetic state
  • thyrotoxicosis
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17
Q

Chest wall scars

A
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18
Q

Fontan procedure

A

Single functional ventricles:

  • HLHS
  • tricuspid/mitral atresia
  • complex CHD

Stage I (Norwood): BT shunt

  • connecting brachiocephalic artery to right pulmonary artery

Stage II (Bidirectional Glenn): cavopulmonary shunt

  • BT removed
  • SVC anastomosed to PA

Stage III (Fontan): total cavopulmonary connection

  • IVC joined to PA

Issues

  • decreased exercise tolerance
  • decreased neurodevelopmental outcome
  • poor growth
  • thromboses
  • arrhythmias (SVT)

Post operative mumur

  • AV regurgitation
  • subaortic stenosis
  • VSD

Associated conditions: PLE, plastic bronchitis

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19
Q

Continuous mumurs

A

Aneurysm

ASD

AV malformation

Blalock-Taussig Shunt

Collateral Vessels

pDA

vEnous hum

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20
Q

Mumur timing

A
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21
Q

Mumur site of intensity

A
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22
Q

Complex cyanotic heart disease

5 T’s

A
  1. Transposition Great Arteries (TGA)
  2. Truncus Arteriosus (TA)
  3. Tetralogy of Fallot (ToF)
  4. TAPVD
  5. Tricuspid valve anomalies

OTHER: HLHS, DORV, pulmonary atresia

23
Q

Eisenmenger’s syndrome

A

Triad

  1. pulmonary to systemic shunt
  2. pulmonary artery disease
  3. cyanosis

associated defects: VSD 33%, ASD 30%, PDA 14%

clinical:

  • cyanosis, clubbing
  • RV impulse, palpable P2
  • elevated JVP, oedema
  • tricuspid/pulmonary regurgitation
24
Q

Pulmonary flow mumur

A

prevalence: very common

timing: brief in mid-systole

position: loudest lying down

associated: hyperdynamic states

25
Q

Venous hum

A

prevalence: ages 2-6yrs

timing: diastolic component loudest

location: supraclavicular fossa on the right and may radiate

quality: associated thrill

position: disappears when flat

26
Q

VSDs

A

inspection: no cyanosis/clubbing

clinical:

  • pansystolic mumur maximal at left sternal edge
  • loud S2
  • active praecordium
  • thrill at left sternal edge
  • no radiation but heard all over chest wall
  • diastolic rumble at apex

haemodynamically significant if:

  • symptoms including tachypnoea
  • mumur may be softer
  • hyperactive praecordium
  • loud S2
  • displaced apex
  • diastolic mumur
  • growth decreased

treatment:

- medical: diuretics, ACEi

- surgical (age 4yrs or shunt>2:1): pulmonary artery banding 1st if complication, VSD repair

27
Q

ASD

A

haemodynamic: RV overload during diastole with an increased pulmonary blood flow secondary to shunt

complications: atrial arrhythmias, pulmonary HTN, heart failure

clinical:

  • parasternal heave
  • ejection systolic mumur left sternal edge
  • S2 widely split
  • diastolic mumur due to flow across tricuspid valve

ECG:

  • ostium secundum: RAD, partial RBBB
  • ostium primum: LAD, partial RBBB

treatment: surgical closure 4th/5th decade

28
Q

AVSD

A

pathophysiology: left to right shunt through ASD/VSD

clinical: hyperdynamic apex beat, RV heave, palpable thrill LLSE

  • loud pansystolic mumur LLSE, MR at apex

complications: atrial dilation, arrhythmias, volume loaded ventricles, pulmonary HTN

ECG: superior axis (-40 to -150), RVH

CXR: cardiomegaly, pulmonary plethora

Treatment: repair 4 to 6 months, diuretics

  • delaying treatment increases the risk of pulmonary hypertension
29
Q

Sign of cardiac failure

A
30
Q

Cardiac lesions T21

A
31
Q

Aortic regurgitation

A

congenital: Ehlers-Danlos, Marfan syndrome, Turner syndrome

acquired: rheumatic fever, post operative, infective endocarditis

pathophysiology: LV overload, pulmonary oedema

clinical:

  • collapsing pulse
  • decrescendo diastolic mumur LSE
  • increased sitting forward in expiration
  • associated thrill

ECG: LVH

CXR: cardiomegaly

32
Q

Pulmonary stenosis

A

associated syndromes: Noonan’s, Williams

pathophysiology: RV overload

clinical:

  • thrill over pulmonary area
  • RV heave
  • ejection systolic mumur LUSE
  • radiation to back
  • widely split S2

ECG: RVH, tall p waves

CXR: normal

treatment: surgery depending on pressure gradient

post repair: residual systolic and diastolic mumur

33
Q

Aortic stenosis

A

associations: Turner syndrone, Williams (supravalvular), coarctation

pathophysiology: LV overload

symptoms: syncope, pain on exertion

clinical:

  • collapsing pulse
  • suprasternal/carotid thrill
  • apex displaced
  • ejection click LLSE
  • ejection systolic mumur at LLSE radiating into the neck

ECG: LVH (tall R waves V5/V6, inverted T in 1, aVL, V5-6)

CXR: prominent LV

treatment: valve replacement if gradient >60mmHg

post repair: mumur of aortic stenosis and regurgitation

34
Q

Coarctation of the aorta

A

associations: Turner’s, biscuspid valve (70%)

clinical:

  • high BP arms, low in legs (20mmHg difference)
  • radiofemoral delay
  • systolic mumur loudest at left interscapular area
  • ejection click LUSE if biscuspid aortic valve

ECG: LVH

CXR: cardiac enlargement, rib notching

treatment: end-end anastomoses via left thoracotomy

complications: residual HTN, recoarctation

35
Q

Causes cardiac cyanosis

A

decreased pulmonary blood flow:

  • tetralogy of fallot
  • pulmonary atresia
  • Ebstein’s
  • tricuspid atresia

poor mixing:

  • transposition great arteries

common mixing:

  • truncus arteriosus
  • DORV
  • TAPVD
  • univentricular heart
36
Q

Tetralogy of Fallot

A

Tetrad:

  1. RVOT obstruction
  2. VSD
  3. Overiding aorta
  4. RVH

Variations: 25% Right sided AA

clinical:

  • FTT, clubbing, cyanosis
  • RV impulse
  • systolic thrill ULSE
  • systolic ejection mumur ULSE

CXR: prominent RV, small pulmonary arteries, oligaemia

ECG: RAD, RVH, tall p wave

treatment:

  • modified BT Shunt
  • corrective survery 4-12 months

complications:

  • exertional dyspnoea
  • cerebral thrombosis/brain abscess
  • infective endocarditis
  • arrhythmias

tx tet spells: morphine, beta blockers, vasoconstrictors

37
Q

Hypertrophic cardiomyopathy

A

familial: AD 60%

HOCM: associated with septal hypertrophy or abnormal MV movement causing LVOTO

symptoms: angina, syncome, arrhythmias, sudden death

clinical:

  • systolic ejection mumur from LVS hypertrophy or mitral regurgitation

treatment: beta blockers, endocarditis prophylaxis, myectomy

38
Q

Dilated cardiomyopathy

A

most common cardiomyopathy

cause: usually idiopathic, toxic insult

pathophysiology: dilation 4 chambers

clinical:

  • displaced apex
  • MR or TR mumur
  • 3rd heart sound
  • left and right sided cardiac failure

symptoms: weakness, pulmonary oedema

treatment: medical, transplantation

39
Q

Trisomy 21

cardiac

A
40
Q

Turner syndrome

cardiac

A
41
Q

Noonan syndrome

cardiac

A
42
Q

William syndrome

cardiac

A
43
Q

22q11

cardiac

A
44
Q

CHARGE

cardiac

A
45
Q

VACTERL

cardiac

A
46
Q

Marfan

cardiac

A
47
Q

Ehler Danlos

cardiac

A
48
Q

Fetal alcohol syndrome

A
49
Q

LEOPARD syndrome

A
50
Q

Repair procedures

A
  • VSD
  • ASD
  • TOF: BT shunt then definitive procedure at 1 year
  • TGA: arterial switch
51
Q

Pallative repairs

A

Can be temporary or permanent

  • BT shunt
  • Pulmonary banding
  • Atrial septostomy
52
Q

Timing of cardiac surgery

A

1st week:

  • duct dependent
  • severe obstructive lesion

First month:

  • severe pulmonary pressure: PA banding or BT shunt
  • obstructive lesions eg. TAPVD

Infants:

  • left to right shunt to prevent pulmonary HTN
  • RVOTO

Children:

  • staged procedures
  • asymptomatic lesions

Adolescence:

  • surgery for acquired diseases
  • stent procedure eg. non duct dependent CoA
  • repeat procedures
53
Q

Complications post cardiac surgery

A
  • diaphragmatic palsy
  • arrhythmias
  • vocal cord palsy
  • protein losing enteropathy (post Fontan)
  • developmental problems
54
Q

CXR in cardiac disease

A

Clinical Exam (16 decks)

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