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Phase 2b > Cardio: History + Exam > Flashcards

Cardio: History + Exam Flashcards

1
Q

What are the risk factors for IHD?

A 
male sex
age
smoking
HTN
diabetes mellitus
FHx
hypercholesterolaemia
physical inactivity, obesity
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2
Q

What factors would indicate the cause of the chest pain is NOT cardiac ischaemia?

A

character: knife-like, sharp, stabbing, aggravated by inspiration
location: left submammary area, left hemithorax
exacerbating factors: pain AFTER completion of exercise, specific body motion

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3
Q

Why might someone get chest pain that is worse on lying flat?

A

decubitus angina secondary to left heart failure

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4
Q

What questions are important to ask about shortness of breath?

A

ONSET: acute, chronic, acute-on-chronic?
ASSOCIATED Sx: sweating, nausea, pain, cough, sputum (water/frothy, blood-tinged?), swollen ankles, palpitations, nocturnal micturition, rapid weight gain
TIMING: on exertion, rest? constant? at night?
EXACERBATING FACTORS: position - no of pillows > orthopnoea?
ALLEVIATING FACTORS: rest, medication, oxygen, sitting up straight
SEVERITY: debilitating? effect on ADLs? exercise tolerance?

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5
Q

What is the term for dyspnoea experienced at night?

A

paroxysmal nocturnal dyspnoea

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6
Q

What questions are important to ask about exercise tolerance?

A

distance able to walk on flat ground before needing to stop?
reasons for why walking distance is limited?
short of breath when walking e.g. up hills/stairs?
discomfort/tightness in chest when walking?
how long a go was the problem noticed > worse suddenly or gradually? ability to walk a year/month ago?

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7
Q

What questions are important to ask about palpitations?

A

any palpitations/feeling of heart racing?
anything that provokes it?
start suddenly/build up gradually? stop suddenly/gradually? duration?
any other symptoms with the palpitations?
tap the rhythm? regular, irregular, regularly irregular? fast or slow?

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8
Q

What specific cardiac conditions/surgery should be asked about in the past medical history?

A 
similar episodes > diagnoses, treatment and responses to treatment 
pervious cardiac surgery
HTN
hypercholesterolaemia
anaemia
diabetes
angina
MI
cerebrovascular accident/TIA
peripheral vascular disease e.g. intermittent claudication
cardiac failure
rheumatic fever
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9
Q

What specific medications should be asked about in the drug history?

A

antihypertensives
all cardiac drugs
drugs with cardiac SEs:
- corticosteroids > HTN, fluid retention
- salbutamol, theophylline, nifedipine, thyroxine > sinus tachycardia
over-the-counter drugs e.g. aspirin, NSAIDs

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10
Q

What specific questions should be asked about in the social history?

A 
occupation
smoking
alcohol
diet
stress
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11
Q

Why does alcohol need to be asked about in the social history?

A 
can cause:
AF
cardiomyopathy
HTN
tachycardia
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12
Q

What specific conditions should be asked about in the family history?

A

Fhx of IHD/cerebrovascular accident before the age of 65

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13
Q
  1. Inspection: what signs should be looked for on observation of the bed and general appearance of the patient?
A

around the bed: GTN spray?

general appearance: colour, comfort, breathing, position, build

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14
Q
  1. Inspection: what signs should be looked for on the hands?
A 
tar staining
vasodilation/constriction, temperature
sweating (increased sympathetic drive)
pallor of palmar creases
peripheral cyanosis
clubbing
splinter haemorrhages
osler's nodes, Janeway lesions
tendon xanthomas
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15
Q

What is tendon xanthomas?

A

cholesterol deposits on the tendons

present as subcutaneous nodules attached to the tendons, most often on dorsum of hand, achilles

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16
Q

What are osler’s nodes? What are they a sign of?

A

red raised tender lumps, often with a pale centre
pain often comes before they appear
usually on fingers/toes
sign of IE

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17
Q

What are splinter haemorrhages? What are they a sign of?

A

blood spots under the nail, look like splinters

sign of IE

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18
Q

What are Janeway lesions? What are they a sign of?

A

small non-tender, haemorrhagic lesion
palms of hands, soles of feet
sign of IE

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19
Q
  1. Inspection: what pulses and pulse signs should be felt for?
A

radial pulses > assess rate, rhythm
brachial pulse > character, volume (is it slow-rising, collapsing?
- check for pain in arm
- check for collapsing/waterhammer pulse = sign of aortic regurgitation
carotid pulse > character, volume

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20
Q
  1. Inspection: what signs should be looked for on the eyes?
A

subconjunctival pallor
corneal arcus (white ring around iris due to cholesterol)
xanthelasmata

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21
Q
  1. Inspection: what signs should be looked for on the face and mouth?
A

malar flush > mitral stenosis
central cyanosis (under tongue, inside lips)
high-arched palate > Marfan’s
dental caries > can predispose to IE

check for raised JVP: normal is 2-4cm above the sternal angle

  • position pt at 45o with head turned to left
  • IJV runs between the medial end of the clavicle and the ear lobe, under the sternocleidomastoid
  • measure JVP by measuring distance from sternal angle to top of pulsation point
  • will have a double waveform pulsation > differentiates it from the external carotid
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22
Q

What is a collapsing/waterhammer pulse? What is it a sign of?

A

aortic regurgitation

bounding and forceful pulse, rapidly increasing and then collapsing

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23
Q

Why might the JVP be raised?

A

right heart failure

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24
Q
  1. Inspection: what signs should be looked for on the chest?
A

sternotomy scar
severe pectus excavatum/funnel chest (sternum sucked into chest)
severe kyphoscoliosis
visible cardiac pulsation

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25
Q
  1. Palpation: what should be palpated for?
A

apex beat
parasternal heaves (outward displacement of hand by cardiac contraction)
thrills (palpable murmurs)

lay pt flat: hepatomegaly
- if enlarged, feel for pulsation > tricuspid regurgitation
suspect ascites? > shifting dullness

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26
Q

Where can the apex beat be palpated?

A

left 5th intercostal space, mid-clavicular line

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27
Q
  1. Auscultation: what should be auscultated on the anterior of the patient?
A

aortic valve: right 2nd ICS, right sternal border
pulmonary valve: left 2nd ICS, left sternal border
tricuspid valve: left 5th ICS, left sternal border
mitral valve: left 5th ICS, mid-clavicular line

left axilla > mitral incompetence (doesn’t close properly)
use BELL: at apex with patient rolled 45o to left > mitral stenosis
pt sat forward:
switch back to diaphragm: 4th/5th ICS, left of sternum on held expiration > aortic regurgitation
lung bases > assess for sacral oedema
is coarctation suspected? auscultate to left of spine in 3rd/4th ICS

pt sat back again:
carotids for bruits/transmitted systolic murmur

28
Q

If extra heart sounds are done what should be done to time them?

A

palpate the carotid pulse to time them with 1st and 2nd heart sounds
start of the carotid pulsation will by synchronous with the 1st heart sound

29
Q

What are the steps needed at the end of the exam?

A

femoral pulses, check synchrony with radial pulse > radio femoral delay in coarctation
pitting oedema at the ankles > definitely check for ascites if present

state you would do:
blood pressure in both arms and lying and standing in one arm
ophthalmoscopy for hypertensive retinopathy
12-lead ECG

30
Q

What is radiofemoral delay a sign of?

A

coarctation (congenital narrowing of a section of the aorta)

31
Q

What are the normal heart sounds?

A

S1, S2 (S3)

32
Q

What causes the S1 heart sound?

A

closing of the atrioventricular valves (mitral and tricuspid)

due to the start of systole > contraction of the ventricles
valves must close so that blood doesn’t flow back into the atria

33
Q

What causes the S2 heart sound?

A

closing of the semilunar (aortic and pulmonary valves)

at the end of systole/ventricular contraction to prevent blood flowing from the aorta and pulmonary artery back into the ventricles

34
Q

What do the S1 and S2 heart sounds usually sound like? And if there is an S3?

A

lub dub

lub de dub when S3 is heard

35
Q

When does the S3 heart sound happen?

A

0.1s after S2 = very subtle

36
Q

What causes the S3 heart sound?

A

rapid ventricular filling

cause the chordae tendineae to pull to full strength and ‘twang’

37
Q

Is the S3 heart sound normal?

A

yes, in younger pts > ventricles easily and rapidly fill with blood

in older pts > can indicate HF (ventricles and chordae are stiff and weak so reach limit much quicker than normal)

38
Q

What is the S4 heart sound? When is it heard?

A

immediately before S1
always abnormal, rare

indicates stiff/hypertrophic ventricles
caused by turbulent flow from atria into a ventricle which doesn’t want to fill with blood

39
Q

What do S4, S1 and S2 sound like together?

A

le lub dub

40
Q

Which part of the stethoscope is used to hear murmurs?

A

bell for low pitched

diaphragm for high pitched

41
Q

Where is each valve heard?

A

aortic valve: right 2nd ICS, right sternal border
pulmonary valve: left 2nd ICS, left sternal border
tricuspid valve: left 5th ICS, left sternal border
mitral valve: left 5th ICS, mid-clavicular line (apex)

42
Q

Where is Erb’s point? What is it?

A

3rd ICS, left sternal border

best placing for listening to heart sounds

43
Q

What special manoeuvre can you do to hear mitral stenosis better?

A

roll onto left side

44
Q

What special manoeuvre can you do to hear aortic regurgitation better?

A

sit up, learn forward

breathe out and hold

45
Q

What features of a murmur should be listened for?

A

Site > where is it loudest?
Character > soft, blowing, crescendo, decrescendo
Radiation > carotids (AS), left axilla (MR)
Intensity > grade
Pitch > high, low and grumbling? indicates velocity
Timing > systolic, diastolic

46
Q

What happens to the heart muscle in hypertrophy?

A

thickens INTO the chambers of the heart

47
Q

What happens to the heart muscle in dilatation?

A

thins and expands

48
Q

What happens to the heart muscle when a pt has a stenotic valve?

A

heart muscle has to work harder to push blood through valve

> hypertrophy

49
Q

Where does the hypertrophy in the heart occur in mitral and aortic stenosis?

A

mitral stenosis > left atrial hypertrophy

aortic stenosis > left ventricular hypertrophy

50
Q

What happens to the heart muscle when a pt has a leaky valve?

A

allows blood to flow back into the previous chamber

stretches the muscle > dilatation

51
Q

Where does the dilatation in the heart occur in mitral and aortic regurgitation?

A

mitral stenosis > left atrial dilatation

aortic stenosis > left ventricular dilatation

52
Q

What happens in mitral stenosis? What can it be caused by?

A

mitral valve narrowed

rheumatic heart disease
IE

53
Q

What murmurs can be heard in mitral stenosis? Why do they happen?
What does this sound like in terms of lub dub?

A

mid diastolic low pitched rumbling murmur > due to low velocity of blood flow

loud S1 > due to thick valves that require large systolic force to shut, when it reaches the threshold, it shuts suddenly

LUB! dub durrrrrrr

54
Q

What signs other than the murmur can be seen in mitral stenosis? Why are they seen?

A

palpate tapping apex beat (loud S1)
malar flush (back pressure of blood into the pulmonary system > increase in CO2 + vasodilation
AF (left atrial strain > disruption to electrical conduction)

55
Q

What is mitral regurgitation?

A

incompetent mitral valve > blood flows back through during systolic contraction of LV

56
Q

What murmurs can be heard in mitral regurgitation? Why do they happen?
What does this sound like in terms of lub dub?

A

pan-systolic murmur (THROUGHOUT systolic period)
high pitched whistling > high velocity of blood through valve

BURRRRRR

57
Q

What signs other than the murmur can be seen in mitral stenosis? Why are they seen?

A

radiation to left axilla
congestive cardiac failure (reduced ejection fraction > backlog of blood waiting to pass through left side of heart
> possible S3 HEART SOUND)

58
Q

What are the causes of mitral regurgitation?

A 
idiopathic weakening with age
IHD
IE
rheumatic heart disease
connective tissue disorders e.g. Ehlers-Danlos, Marfan's
59
Q

What is aortic stenosis?

A

most common valve disease

narrow aortic valve > turbulence of blood flow through valve during systole

60
Q

What murmurs can be heard in aortic stenosis? Why do they happen?
What does this sound like in terms of lub dub?

A

ejection systolic murmur (whilst blood is ejected from ventricle)
high pitched > high velocity of systolic contraction
crescendo-decrescendo (louder > quieter due to speed of flow during different times of systolic contraction)

S1 > murmur that gets louder then quieter > S2
BURRRR DUB

61
Q

What signs other than the murmur can be seen in aortic stenosis? Why are they seen?

A

radiates to carotids (turbulence continues into neck)
slow rising pulse
narrow pulse pressure (systolic and diastolic BP close together)
exertional syncope (difficulty maintaining good flow to brain through narrowed valve)

62
Q

What are the causes of aortic stenosis?

A

idiopathic age related calcification

rheumatic heart disease

63
Q

What is aortic regurgitation?

A

incompetence aortic valve > blood can flow back from aorta into LV

64
Q

What murmurs can be heard in aortic regurgitation? Why do they happen?
What does this sound like in terms of lub dub?

A

early diastolic soft murmur
(leaking happens during diastole)

S1 > S2 > murmur
lub tarrrr (v subtle!)
65
Q

What signs other than the murmur can be seen in aortic regurgitation? Why are they seen?

A

corrigan’s/collapsing pulse (rapidly appears > disappears as blood is pumped into the ventricles then immediately goes back in)

heart failure (back pressure of blood waiting to get through left side of heart)

Austin flint murmur (heard at apex, early diastolic rumbling as blood flows back through aortic valve and over the mitral valve, causing the leaflets to vibrate)

66
Q

What causes aortic regurgitation?

A

idiopathic age related weakness

connective tissue disorders e.g. Ehlers-danlos, marina’s > weakness of valve leaflets

Phase 2b (3 decks)

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