Cardiac Examination

Question 1

Osler’s nodes

Answer 1

Painful purple papules on pulps

Question 2

Jane way lesions

Answer 2

Erythematous macules on palms

Question 3

Radio-radial delay

Answer 3

Aortic dissection
Aortic coarctation

Question 4

Radio-femoral delay

Answer 4

Aortic coarctation

Question 5

Collapsing pulse

Answer 5

AR
Patent ductus asteriosus
High output states eg. Anaemia, thyrotoxicosis
Physiological states eg. Pregnancy, fever

Question 6

Wide pulse pressure

Answer 6

AR

Question 7

Narrow pulse pressure

Answer 7

AS

Question 8

Mallar Flush

Answer 8

MS

Question 9

Impalpable apex beat

Answer 9

DOPE
Dextrocardia
Obesity
Pericardial effusion
Emphysema

Question 10

Mitral valve manoeuvre

Answer 10

Listen at 45 degrees
Listen to axilla for radiation
Roll patient onto left side and listen with bell over the apex on expiration

Question 11

Aortic valve manoeuvre

Answer 11

Listen at 45 degrees
Listen over right carotid with breath held (AS)
Sit patient forward and listen at Erb’s point on expiration (AR)

Question 12

Cardiac auscultation tips

Answer 12

Right valves heard better at full inspiration
Left valves heard better at full expiration
Never put the stethoscope on top of the best- listen in inframammary fold
Systolic murmurs radiate (MR, AS)
Diastolic murmurs need accentuating (MS, AR)

Question 13

Auscultation positions

Answer 13

G

Question 14

Erb’s point

Answer 14

3rd ICS on the LHS

Question 15

Systolic murmurs

Answer 15

AS
Aortic sclerosis
MR
Mitral valve prolapse
Ventricular septal defect
TR

Question 16

Diastolic murmurs

Answer 16

MS
AR

Question 17

Aortic stenosis

Answer 17

Ejection systolic murmur heard best at 2nd ICS RHS sternum. Appropriate manoeuvre
Lead to LV hypertrophy (heaving apex beat)
Aortic valve thrill
Exertion also dyspnoea, syncope, angina
Slow rising pulse, narrow pp, heaving apex beat, pulmonary oedema (crackles)
Causes- ABC’s
Age
Bicuspid aortic valve (Turner’s)
Congenital
Strep-associated (rheumatic heart disease)

Question 18

Aortic sclerosis

Answer 18

Ejection systolic
Valve not narrowed- turbulence only
No symptoms
No abnormal signs
Cause: senile calcification

Question 19

Mitral regurgitation

Answer 19

Pansystolic
Leads to pulmonary hypertension
Orthopnoea, PND, fatigue, palpitations
AF, RV heave, pulmonary oedema
Cause: papillary muscle dysfunction, dilated cardiomyopathy, rheumatism heart disease, congenital, Marfan’s

Question 20

Mitral valve prolapse

Answer 20

Mid systolic click or late systolic murmur
Leads to MR
Atypical chest pain
Murmur only
Associations: congenital, Marfan’s, PKD, congestive cardiomyopathy, HOCM, myocarditis, Ehlers-Danlos, SLE, MD

Question 21

Ventricular septal defect

Answer 21

Pansystolic murmur
No symptoms usually
Signs of pulmonary hypertension eg. RV heave
Cause: congenital, complication post-MI

Question 22

Tricuspid regurgitation

Answer 22

Pansystolic murmur (loudest on inspiration- RHS)
Fatigue, ascites, peripheral oedema, hepatic pain
Signs of venous congestion eg. JVP, hepatomegaly
Cause: pulmonary hypertension, rheumatic heart disease, IE (IVDU)

Question 23

Mitral stenosis

Answer 23

Opening snap diastolic murmur
Leads to pulmonary hypertension
Dyspnoea, fatigue, haemoptysis, chest pain
Malar flush, AF, signs of pulmonary hypertension
Cause: rheumatic heart disease, congenital

Question 24

Aortic regurgitation

Answer 24

Early diastolic
Increased LV volume
Fatigue, SOB, palpitations
Collapsing pulse, wide PP, displaced apex, corrigans sign, de Mussets sign, Quinckes sign
Cause: aortic dissection, IE, Marfan’s, long-standing HTN, bicuspid aortic valve

Question 25

Differentiating the JVP from the carotid pulsation

Answer 25

JVP has a double waveform JVP not palpable JVP descends with inspiration Hepatojugular reflex increases the JVP

Question 26

Focused Exam- AS

Answer 26

Dyspnoea Pulsus parvus et tardus Postural hypotension Narrow pulse pressure Slow rising carotid pulse Displaced apex beat Systolic murmur best heard at right sternal edge of 2nd ICS Radiates to the carotids Aortic valve thrill Pulmonary crepitations

Question 27

Focus Exam- Aortic Regurgitation

Answer 27

Dyspnoea Quinkes sign- throbbing nail bed on light palpitation Wide pulse pressure Collapsing pulse De Mussets sign- head bobbing with the heart beat Landolfi sign- systolic contraction and diastolic relaxation of the pupil Displaced apex beat Diastolic murmur best heard at Erb’s point, sat forward with full expiration Aortic valve thrill Pulmonary crepitations

Question 28

Focused Exam- Mitral Regurgitation

Answer 28

Dyspnoea Displaced apex beat Systolic Murmur best heard at apex point Radiates to the axilla Mitral valve thrill Pulmonary crepitations

Question 29

Focused Exam- Mitral Stenosis

Answer 29

Dyspnoea Atrial fibrillation Raised JVP Mallar flush Displaced apex beat Diastolic murmur best heard at apex point with the bell and the patient lying on their LHS Mitral valve thrill Pulmonary crepitations

Question 30

Focused Exam- RHS HF

Answer 30

Oedema- ankles, sacrum, ascites Dyspnoea Facial engorgement Raised JVP Right parasternal heave Hepatomegaly S3 heart sound

Question 31

Focused Exam- LHS HF

Answer 31

Dyspnoea Wheeze Bibasal crackles on auscultation Displaced apex beat S3 heart sound

Question 32

Focused Exam- infective endocarditis

Answer 32

Splinter haemorrhages, Jane way lesions (palms) Oslers nodes (fingers) Poor dentition Fever New murmur or change to an existing one Embolic phonomenae- ask about any pain/ neurological Sx

Question 33

Focused exam- atrial fibrillation

Answer 33

Irregularly irregular pulse Tachycardia Irregular heart sounds on auscultation Dyspnoea

Question 34

Causes of a third heart sound

Answer 34

Physiological; -healthy young adults -athletes -pregnancy -fever Pathological; -mitral regugitation -poorly contracting left ventricle (ie. LVF)

Question 35

Causes of a split S2

Answer 35

RBBB LBBB ASD VSD Pulmonary HTN HOCM PS AS