Cardiac examination Flashcards
What murmurs can you hear in the URSB and what is the potential origin?
Ejection systolic - aortic stenosis
Continuous - right BT shunt, venous hum
How can you increase the venous hum?
Turn child’s head to the left
What is a BT shunt?
Blalock Taussig shunt in CHD
What murmurs can you hear in the ULSB and what is the potential origin?
Ejection systolic - pulmonary stenosis, ASD, innocent murmur
How can you check if a murmur is innocent?
It will not radiate to the back
What murmurs can you hear in the LLSB and what is the potential origin?
Pansystolic - tricuspid regurg, VSD
Diastolic - tricuspid stenosis, aortic regurg, Still’s murmur
What is a Still’s murmur?
A benign flow murmur across the aortic valve from high cardiac output and/or increased contractility
What murmurs can you hear in the apex and what is the potential origin?
Pansystolic - mitral regurg, VSD
Late systolic - mitral prolapse
Ejection systolic - aortic stenosis
Mid-diastolic - mitral stenosis
Which structures form the right heart border?
SVC
RA
Which structures form the left heart border?
Aorta knuckle
PA knuckle
LA appendage
LV
Which structures form the anterior heart border?
RV
Which structures form the posterior heart border?
Descending aorta
LA
What are clinical signs of RV enlargement?
LPS
Epigastric heave
What are clinical signs of pulmonary hypertension?
Palpable P2
LPS
Epigastric heave
What are clinical signs of aortic stenosis?
Displaced apex (LVH) Suprasternal thrill
Name causes of central cyanosis
- Inadequate ventilation
- pneumonia
- airway obstruction
- lung changes
- CNS depression
- - inadequate ventilatory drive
- weak resp mm - Desaturated blood bypassing lungs
- cyanotic HD
- pulmonary AVMs
- PPHN - Methaemoglobinaemia
- congenital
- toxin - Poisoning
- carbon monoxide
Discuss your approach to oedema
Low protein
- Decr intake
- PEM - Decr production
- liver failure - Incr loss
- nephrotic syndrome
- PLE
Capillary leak
- CCF
- cor pulmonale
- sepsis
- anaphylaxis
What are the features of PEM to look out for in approach to oedema?
Skin lesions
Hepatomegaly
Plot growth
Deficiency (vitamins, iron ca)
What are the features of liver failure to look out for in approach to oedema?
Decr LOC Decr albumin Decr glucose Incr NH3 Incr INR
What are the features of nephrotic syndrome to look out for in approach to oedema?
Anasarca Urine dipstix Albuminuria Prot:creat TP normal Decr albumin Decr C3, C4 Incr chol
What are the features of PLE to look out for in approach to oedema?
Diarrhoea
Decr TP
Decr albumin
Decr globulin
What are the features of CCF to look out for in approach to oedema?
Cardiomegaly Hepatomegaly Tachycardia Tachypnoea CXR ECG Sonar Bloods
Define digital clubbing
Bulbuous uniform swelling of soft tissue of terminal phalanx with loss of normal angle between nail and nail bed
Name primary causes of clubbing
Idiopathic Inherited - pachydermoperiostosis - hypertrophic osteoarthropathy - familial
Name secondary causes of clubbing
1. Pulmonary Malignancy - lung carcinoma - pleural mesothelioma - lung mets CLD - bronchiectasis - cystic fibrosis - interstitial lung disease - idiopathic pulmonary fibrosis - sarcoidosis - pulmonary TB Suppurative - empyema - lung abscess Other - lipoid pneumonia - cryptogenic fibrosing avleolitis - PHT
- Cardiac
- CCHD
- R to L shunt
- IE
- PHT
- atrial myxoma
- limb vascular anomalies
3. GIT Inflammatory - UC - Chron's - proctitis - peptic ulcer - primary biliary cirrhosis - hepatic cirrhosis Other - malabsorption - achalasia - esophageal leiomyoma
- Malignancy
- thyroid Ca
- thymus Ca
- Hodgkin’s
- disseminated CML - Skin
- pachydermoperiostosis
- Bureau-Barriere-Thomas syndrome
- Fischer syndrome
- palmaplantar keratoderma
- volavsek syndrome - Misc
- acromegaly
- thyroid acropachy
- pregnancy
- sickle cell disease
- hypoxemia
What is POEMS syndrome?
Polyneuropathy Organomegaly Endocrinopathy Monoclonal gammopathy Skin changes
What is acropachy associated with?
Grave’s disease
What are the 5 steps of developing clubbing?
- Fluctuation + softening of nail bed
- Loss of lovibond angle
- Increased nail fold convexity
- Thickening of distal finger
- Shiny aspect and striation of nail + skin
How can you grade clubbing?
Grade 1: Nail bed fluctuation.
Grade 2: Obliteration of the Lovibond angle
Grade 3: Parrot beaking
Grade 4: Hypertrophic osteoarthropathy (HOA)
What do you call Filbert/watch glass nails? What is preserved?
Pseudoclubbing
Lovibond angle preserved
What are causes of pseudoclubbing?
Congenital
Hyperkeratosis (palms/soles)
What is the pathophysiology of clubbing?
Distal digital vasodilation -> hypervascularization!
Increased interstitial oedema followed by incr vascular connective tissue and change in vascular connective tissue
Terminal phalanx spurs
What are the proposed mediators of vasodilation in clubbing?
- Circulating/local vasodilator
- Neural mechanism
- Response to hypoxemia
- Platelet GF
- Genetic predisposition
- Combination
Explain the vasodilator theory of clubbing
Vasodilators bypass inactivation in lungs - ferritin - prostaglandins - bradykinin - adenine nucleotides - 5-hydroxytryptamine\ Issue: not always assoc with lungs
Explain the neural mechanism theory of clubbing
Vagally innervated organ pathology - regression after vaotomy
Issue: still found in other organ pathologies
Explain the hypoxia theory of clubbing
Hypoxia -> local vasodilator stimulation -> incr blood flow to digits
Issue: rest of conditions no hypoxia
Explain the platelet-derived growth factor theory of clubbing
Fragments of platelet clumps/megakaryocytes -> lodge in nail bed -> release platelet-derived GF -> incr capillary permeability + connective tissue hypertrophy
