Cardio Flashcards
Please present your cardiovascular exam (normal)
I examined this gentleman, who was alert and not breathless at rest, with no paraphernalia of disease around the bed.
He had a regular pulse of 72 beats per minute and a resp rate of 16. I would like to know the blood pressure.
His hands were warm and well perfused. There were no stigmata of endocarditis in the face and I would ideally examine the hands. The JVP was not raised and the carotid pulse was of good volume and normal character.
On inspection of the chest, no scars were noted.
The apex beat was not displaced and there were no heaves or thrills.
On auscultation, HS I and II with no added sounds.
The lung bases were clear and there was no peripheral oedema.
I would like to complete my examination by taking a set of obs, dipping the urine and performing a 12 lead ECG.
Please listen to this murmur and discuss your findings.
lub whOOsh dub - loudest in the right upper sternal edge, radiating to the carotids
I believe this is a systolic murmur, it’s position would be consistent with aortic stenosis but my differentials include mitral regurgitation, aortic sclerosis, HOCM or a right sided murmur.
I would further investigate by taking a history, taking baseline bloods, requesting a CXR and echocardiogram.
Management of AS is conservative, medical or surgical, including the optimisation of CV status with lifestyle measures and medication. I would refer patients with symptoms or relevant echo criteria to the valve MDT to consider suitability for open replacement or TAVI. Coronary intervention may be carried out at the same time.
Causes of aortic stenosis include degenerative calcification, bicuspid, rheumatic heart disease
Please listen to this murmur and discuss your findings.
(lub) BURRRR (dub) - loudest in the apex, radiating to the axilla
I believe this is a systolic murmur, it’s position would be consistent with mitral regurgitation but my differentials include mitral valve prolapse, aortic stenosis or a right sided murmur.
I would further investigate by taking a history, taking baseline bloods, requesting a CXR and echocardiogram.
Management of amitral regurgitation is conservative, medical or surgical, including the optimisation of CV status with lifestyle measures and medication (such as ACEi and anticoag for AF). I would refer patients with symptoms or relevant echo criteria to the valve MDT to consider suitability for open replacement or annuloplasty ring.
Causes of mitral regurg are categorised into primary (disorder of the valve leaflet - RHD, IE) and secondary (disorder of the ventricle or papillary muscle - post ischaemia, DCM)
Please listen to this murmur and discuss your findings.
lub dub BURR - loudest at the apex
I believe this is a diastolic murmur, it’s position would be consistent with mitral stenosis but my differentials include aortic regurgitation or a right sided murmur. I may find a irregular pulse and a mitral flush on examination.
I would further investigate by taking a history, taking baseline bloods and requesting a CXR and echocardiogram.
Management of mitral stenosis is conservative, medical or surgical. Conservative involves maximising CV status, including losing weight and stopping smoking. Medical management would include diuretics and rate control, and anticoagulation for AF. I would refer this patient to the valve MDT who would consider suitability for percutaneous or open replacement approaches.
Causes of mitral stenosis include rheumatic HD and congenital stenosis.
Please listen to this murmur and discuss your findings.
lub (dub)WHOOSH - loudest in the left lower sternal edge
I believe this is a diastolic murmur, it’s position would be consistent with aortic regurgitation but my differentials include mitral stenosis or a right sided murmur.
I would further investigate by taking a history, taking baseline bloods, requesting a CXR and echocardiogram.
Management of aortic regurgitation is conservative, medical or surgical, including the optimisation of CV status with lifestyle measures and medication (such as diuretics and ACEi). I would refer patients with symptoms or relevant echo criteria to the valve MDT to consider suitability for open replacement or TAVI. Coronary intervention may be carried out at the same time.
Causes of aortic regurgitation include connective tissue disease, rheumatic HD and infective endocarditis.
How would you Ix and manage this patient with heart failure?
I heard crepitations in both bases which could be consistent with heart failure. Other causes of crepitations include bronchiectasis and pulmonary fibrosis. I would ask the patient to cough to see if this would shift the crepitations. Following my history and examination, I would investigate this patient with bedside tests, bloods and imaging. At the bedside I would take a full set of observations, peak flow, ECG and urine dip. I would take bloods for FBC, U&Es, CRP, LFTs, lipids, HbA1c and BNP. I would request a CXR in the first instance. If BNP was high this would warrant referral for further Ix including echocardiogram, to assess cause and severity of heart failure.
Common causes of HF include - ACS, HTN, valvular disease, cardiomyopathy
Rx aims to improve symptoms and decrease mortality, and can be conservative or medical. Conservative includes lifestyle mods such as smoking cessation, exercise-based rehab, OT support and annual flu vaccination. Medical options include ACEi, beta blockers and spironolactone. Rx risk factors i.e. BP, DM, lipids.
Approach to infective endocarditis
Signs - clubbing, splinter haem, janeway, oslers. Fever, roth spots, splenomegaly, mic haematuria, new murmur
DUKE’S
BE - bacteriaemia and echo
FEVER - fever >38,, echo/BC not meeting major, vasc phenom, evidence of immunological phenom, risk factors - IVDU, valve disease
Ix: beside - obs, ECG, urine dip. bloods - baseline + BCs, imaging - CXR, echo
Subacute - wks-mnths ~ S viridans, damaged valve, poor dentition
Acute - days-wks ~ S Aureus, IVDU, normal valve
Other - HACEK
Rx:
C - Rx risk factors, sources
M - prolonged course of IV Abx - broad spectrum acc hospital guidelines (benpen + gent)
S - valve debridement, repair or replacement in refractory cases
