Cardio History and Examination

Question 1

cardiac red flags in syncope?

Answer 1

abnormal 12 lead ECG
HF
heart murmur
new or unexplained SOB
structural HD
>65 with TLOC and no prodrome e.g. nausea, sweating, dizziness.
FH of sudden cardiac death under the age of 40yrs-people drowning or car accidents?
TLOC during exercise

Question 2

characteristics of syncope?

Answer 2

rapid onset
short duration
spontaneous complete recovery

Question 3

cardiac arrhythmias that may be responsible for syncope episodes?

Answer 3

bradyarrhythmia- SAN disease (sick sinus syndrome), AVN conduction system disease-stokes-adams attacks, drugs- beta blockers, digoxin, verapamil (rate-limiting).
paroxysmal SVT, VT
inherited- long QT, Brugada’s syndrome*
pacemaker or ICD malfunction

Question 4

In a patient presenting with syncope, and querying cardiac but pt thinks no FH of cardiac disease, what may it be important to ask in terms of the FH?

Answer 4

any sudden cardiac death in the family under the age of 40 yrs- anyone young died suddenly? e.g. car accident, drowning?

Question 5

in considering PMH, how might you ask the pt whether they have PVD?

Answer 5

asking if they have ever had tment for clots in their legs

Question 6

characteristics of the JVP?

Answer 6

non-pulsatile
double waveform- moving inwards, A and V waves, the A corresponding to atrial systole, x descent, then V wave- tricuspid valve prolapse into RA when RV contracts in early systole. The A wave is lost in AF.
able to change position in the neck, lowering the bed will make the JVP move up the neck.
waves will disappear if occlude the IJV at the bottom between the 2 heads of SCM.

Question 7

causes of lower limb oedema?

Answer 7

chronic venous disease
lymphoedema
heart failure- congestive and R sided
vasodilator drugs e.g. amlodipine (dihydropyridine \ca2+ channel blocker)
liver cirrhosis
nephrotic syndrome
AKI/CKD
pericarditis*
cardiomyopathy

Question 8

what is it important to ask about the presenting complaint in a pt with chest pain?

Answer 8

site- central, R of L side of the chest, back?, does it move to the jaw, neck, shoulders or arms?- even if pt says they only feel pain in their chest, qualify this by asking if they have pain in these specific places.
quality- dull? non-specific?- suggest angina, central crushing, consticting-?MI sharp?- pleuritic e.g. chest infection, PE, pericarditis- flu-like prodrome, assoc. SOB and fever, tearing- aortic dissection.
intensity- what has it stopped you from doing?
timing- gradual onset e.g. MI, sudden onset- minimum time to max pain- PE, pneumothorax or aortic dissection, how long for? at rest or on exertion?
aggravating factors e.g. inspiration-pleuritic, pericarditis, lying down- pericarditis
relieving factors- sitting forward?-pericarditis, GTN- angina, MI, oesophageal spasm
previous episodes- how does it compare?
secondary symptoms e.g. SOB, sweating, nausea, vomiting, fever.

CVS R/V- SOB, palpitations, syncope, oedema, IC?
RESP R/V- SOB, cough, sputum, haemoptysis, wheeze

Question 9

3 causes of sudden onset chest pain?

Answer 9

PE
pneumothorax
aortic dissection

Question 10

important points in drug history for cardiac symptom presentation?**

Answer 10

syncope- ?bradycardia- beta blocker tment or Ca2+ blockers, recent addition to tment or increase dose?
drugs post previous MI- aspirin, 2nd antiplatelet, ACEI, beta blocker, statin
IV drug use?- infective endocarditis risk, and increased risk of MI in young individual, can cause ischaemia through CA spasm* e.g. cocaine use.

Question 11

define syncope

Answer 11

an abrupt onset of transient LOC of short duration, assoc. with loss of voluntary muscle tone, with spontaneous and complete recovery.

Question 12

causes of exertional syncope- a red flag sign?

Answer 12

hypertrophic cardiomyopathy
aortic stenosis
AVRT

Question 13

the 6 P’s of a simple faint?

Answer 13

posture
provoking symptoms
pro-dromal features-dizziness, feeling hot, abdo discomfort, nauseous, visual changes- darkening from the periphery
post-syncope N or V
post recovery recurrence provoked by sitting or standing
previous episodes

Question 14

advice to pts who suffer vasovagal episodes?

Answer 14

reassure
avoid triggers- prolonged sitting/standing, fear, pain, emotion
ensure adequate hydration, limit alcohol

Question 15

factors that make epilepsy more likely than syncope?

Answer 15

circumstance e.g. watching TV, flashing lights. position- asleep or lying down
assoc aura e.g. unusual taste/smell, deja-vu, hearing voices.
abnormal behaviour
head turning to 1 side
typical tonic-clonic movements
incontinence
tongue biting-side of tongue
prolonged post-ictal drowsiness, confusion, amnesia and transient focal paralysis (Todd’s palsy)

Question 16

why might people with vasovagal syncope appear to ‘fit’?

Answer 16

reflex anoxic seizure- O2 lack from cerebral hypoperfusion

Question 17

what makes orthostatic/postural hypotension more likely as cause of syncope?

Answer 17

prolonged standing espec. in crowded, hot places
standing up too quickly
increased dose of vasodilator drug e.g. isosorbide mononitrate for angina
presence of autonomic neuropathy e.g. DM, parkinsonism
standing after exertion
endocrine disorder e.g. Addison’s disease
prolonged immobility or bed rest

Question 18

classification of syncope?

Answer 18

neurally mediated/reflex syncope e.g. vasovagal, situational-cough, micturition and carotid sinus hypersensitivity
orthostatic hypotension
cardiac-arrhythmias, AS, HOCM

Question 19

what makes cardiac syncope more likely?

Answer 19

sudden LOC, no warning
pallor
recovery within s to min, often with flushing- may also occur with vasovagal
definite structural HD
FH of sudden cardiac death or channelopathy
during EXERTION or supine
sudden onset palpitation followed by syncope
ECG abnormalities: bifascicular block= LBBB or RBBB with L anterior or posterior fascicular block
intraventricular conduction abnormalities- QRS 120ms or more
Mobitz type 1 2nd degree AV block (Wenckebach)
asymptomatic inappropriate sinus bradycardia (HR less than 50), SA block or sinus pause 3s or more in absence of negatively chrontropic medications
short or long QT intervals
pre-excited QRS complexes
early repolarisation
non-sustained VT (less than 30s)
RBBB pattern with ST elevation in V1-V3 (Brugada syndrome)
negative T waves in R precordial leads, epsilon waves and ventricular late potentials suggestive of ARVC- arrhythmogenic RV cardiomyopathy
Q waves suggesting MI

Question 20

what does syncope post fear e.g. hearing a loud noise, make you worry about?

Answer 20

long QT syndrome

Question 21

investigations in cardiac syncope if an arrhythmia is likely?

Answer 21

ambulatory ECG, inpatients can be monitored via cardiac monitor, consider implantable loop recorder if infrequent episodes (less than every 2 weeks)
ECHO if known HD or suspicion of structural HD
EP study in older pts with LV dysfnction or abnormal ECG
carotid sinus massage in those >40

Question 22

causes of orthostatic syncope?

Answer 22

high dose vasodilator med e.g. isosorbide mononitrate
autonomic neuropathy e.g. DM, parkinsonism
multi-system atrophy
hypovolaemia

Question 23

in querying syncope, when is the diagnosis of postural orthostatic tachycardia syndrome (POTS) indicated?

Answer 23

rise in HR of 30beats/min or more on standing
or to rate of 120bpm or more with significant hypotension
can be diagnosed with tilt studies

Question 24

when should carotid sinus massage be avoided?

Answer 24

those with history of TIA, stroke or MI within past 3 mnths

those with carotid bruits- excep if Carotid Doppler studies have excluded significant stenoses.

Question 25

timing of angina pain?

Answer 25

intermittent, last less than 30 mins

Question 26

timing of MI pain?

Answer 26

continuous, typically over 30 mins, not relieved by rest or nitrates.

Question 27

aggravating and relieving factors for oesophagitis and oesophageal spasm chest pain?

Answer 27

aggravating: supine, post-prandial, alcohol, NSAIDs
relieving: antacids e.g. ranitidine, PPIs- lanosprazole

Question 28

how is oesophagitis confirmed?

Answer 28

OGD endoscopy

Question 29

what history and exam indicated pneumothorax?

Answer 29

sudden onset chest pain, central or side of chest
with abrupt breathlessness
reduced breath sounds
hyper-resonance to percussion
tracheal deviaton and distress
decrease BP and increase HR- haemodynamic compromise in tension pneumothorax

Question 30

how is aortic dissection confirmed?

Answer 30

CT or MRI showing loss of single, clear lumen

Question 31

indications for aortic dissection diagnosis?

Answer 31

sudden onset 'tearing' pain, often radiating to back
abnormal or absent peripheral pulses
early diastolic murmur
low BP
widened mediastinum on CXR

predictable outcome of management: O2, analgesia, large-bore IV access, blood transfusion- X matching 6 units, and urgent surgical intervention.

Question 32

what is chest wall pain e.g. Tietze’s syndrome indicated by?

Answer 32

chest pain and chest wall tenderness on neck twisting or twisting of thoracic cage
confirmed by normal (or no changes in) troponin, ECG and CXR
finalised by improvements with mangement- simple analgesia e.g. NSAIDs, and avoidance of strenuous activity until pain is less.

Question 33

what else would I like to do following completion of CVS examination?**

Answer 33

full peripheral vascular examination
abdominal examination for signs of hepatosplenomaegaly
fundoscopy- examine retina for HTN
urine dipstick
obs including temperature
ECG

Question 34

which vein are we assessing when looking for the JVP and why?

Answer 34

IJV
valveless, so pulsations from the R side of the heart can be visualised directly in this vein. Allows assessment of RA pressure.

Question 35

3 classic features of aortic dissection?

Answer 35

chest pain that is tearing or ripping
difference in BP of more than 20mmHg between arms
mediastinal or aortic widening on CXR

Question 36

how is the JVP altered in AF?

Answer 36

the ‘a’ wave is not present as this corresponds to R atrial contraction.

Question 37

questions to determine likelihood of MI in chest pain presentation when considering ANS activation?*

Answer 37

presence of sweating?
N and V?
dry mouth?

Question 38

what can assessing the JVP tell us with regards to cardiac causes of syncope?

Answer 38

look for cannon waves=exaggerated a waves-these occur in complete heart block (‘Stokes-Adams attacks’)
cannon waves result of RA contraction against a closed tricuspid valve after ventricular contraction has closed the valve.

Question 39

how is orthostatic hypotension defined?

Answer 39

drop in systolic BP of 20 or more, or in diastolic of 10 or more, within 2 mins of standing from lying down.