Cardio Short Case Flashcards by Pinka R

Causes of clubbing

Due to platelet derived growth factor released in the nail beds causing fibrovascular proliferation
CVS- cyanotic HD, IE
Respi- lung carcinoma(non small cell), bronchiectasis, abscess, empyema,IPF, CF,mesothelioma, asbestosis
Gastro-cirrhosis,IBD,coeliac disease
Others- thyrotoxicosis, pregnancy, 2ndary parathyroidism, neurogenic diphragmatic tumours

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Features of marfan syndrome

Mitral valve prolapse, aortic regurgitation

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Features of down syndrome

VSD/ASD/PDA

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Features of turner syndrome

Coarctation of aorta/AS

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What are splinter haemmorhages?

Linear haemmorhages in nail beds lying parallel due to IE, SLE, antiphopholipid

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What are oslers nodes and janeway lesiosn?

Oslers-Rare manifestations of IE, raised, red tender palpable nodules on the pulps of fingers
Janeway- non tender red maculopapular lesions containing bacteria , rarely in palms or pulps of the fingers in IE

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Collapsing pulse

Happens in AR
water hammer pulse is felt as a tapping impulse that is transmitted through the bulk of the muscles.
This happens because the blood that is pumped to the arm during systole is emptied very quickly due to the gravity effect on the raised arm.
This results in the artery emptying back into the heart during diastole, increasing preload, and therefore increasing cardiac output

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Pulses paradoxus

Fall in pressure more than 10mmHg on inspiration
Seen in constrictive pericarditis, pericardial effusion, severe asthma

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What is anacrotic pulse? (3)

Small volume
Slow uptake
Notched wave on upstroke

Seen in Aortic stenosis

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What is plateau?

Slow upstroke
Seen in aortic stenosis

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Bisferiens

Anacrotic and collapsing pulse
Seen in AS and AR

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What is cause of collapsing pulse?

AR
Hyperdynamic circulation
PDA
Peripheral AV fistula
Arteriosclerotic aorta( seen in elderly patients)

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What does carotid and JVp tells us?

Carotid tells about aorta and left ventricular function
JVP tells about right atrial and right ventricular function

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What is kussmaul sign?

Rise of JVP on inspiration
Seen in constrictive pericarditis, cardiac tamponade

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Causes of elevated JVP

Right ventricular failure
Tricuspid stenosis or regurgitation
Pericardial effusion or constrictive pericarditis
SVC obstruction
Fluid overload

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Dominant a wave

Triscuspid stenosis
Pulmonary stenosis
Pulmonary htn

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Cannon a wave

Complete heart block
VT with retrograde atrial conduction

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Dominant v wave

Tricuspid regurgitation

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Steps in cardio exam before auscultate heart? part 1

1)Wash hands, introduce +consent, position , expose
2)General inspect- oxygen devices, click, distress, cyanosis( start thinking of pathology here already)
3)Hands- do with pulse together
Radial pulse- radial radial delay, radio femoral delay
( is it okay if I feel the pulse in your groin)
collapsing pulse- do you have any pain in your shoulder? I am going to lift your hand.
4)BP- I am gonna take your blood pressure
5) eyes: look up for me and pull eyelid down
6) open your mouth wide- cyanosis and high arched palate
7) turn your head slightly to your left, ask if you have any pain in your tummy, i am going to press gently for hepatojugular reflex
8) feel pulse in your neck -both sides one at a time

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steps after inspection in cardio exam? part 2

1) inspect chest for deformities, scars, insertable cardiac monitor devices site
2) feel for apex beat and count the ribs to confirm position
3) heel for parasternal heaves and palms for thrills( aortic and pulmonary area), then finger over remaining two valve areas-mitral and tricuspid
4) diaphragm over mitral area- take big breath in, hold your breath, big breath out, stop breathing , breathe normally, repeat at axilla
5) turn to left, bell over mitral area and repeat
6) lie flat- diaphragm in remaining 3 areas and repeat
7) ask to sit up, and palpate for palpable thrills over aortic pulmonary area
8) diaphragm over left sternal edge( for AR) and aortic area( AS)same method, and do at carotids again
9) do handgrip and valsava manourvre over mitral and aortic area
10) examine back and lower limbs and then thank patient

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what are blue patients?

eisenmeger syndrome, VSD,ASD,PDA, TOF

Noonan syndrome

Pulmonary stenosis

How do you check thrills?

if thrill coincides in time with apex beat- systolic thrill and if does not coincides, then it is diastolic thrill

Explain 1st heart sound

closure of mitral and tricuspid valves
beginning of ventricular systole

explain 2nd heart sound

softer, shorter closure of aortic and pulmonary valves marks beginning of diastole sometimes can have splitting of 2nd heart sound in pulmonary area as pulmonary valve closure delayed with inspiration due to increased venous return to the right ventricle

causes of loud S1( 2)

mitral stenosis tachycardia- reduce diastolic filling time

causes of soft S1? ( 3)

due to prolonged diastolic filling ( first degree HB) delayed onset of left ventricular systole MR

causes of loud S2?

loud A2 in hypertension & aortic stenosis loud P2- in pulmonary HTN

soft A2?

in AR, calcified aortic valve

when does increased normal splitting of 2nd heart sound occur?

pulmonary stenosis VSD MR ( increased in normal splitting on inspiration)

fixed splitting 2nd heart sound, no variation with respiration?

ASD

when does reversed splitting occur?

P2 comes first, then splitting occur in expiration due to severe AS coarctation of aorta

what is 3rd heart sound?

low pitched, mid diastolic sound - like gallop rhythm( Kentucky) due to reduced ventricular compliance left ventricular S3 heard loudest at apex and on expiration- due to LVF, AR, MR,VSD, PDA right ventricular S3- loudest at left sternal edge with inspiration- due to RVF , constrictive pericarditis

what is 4th heart sound?

late diastolic sound pitched higher than S3( Tennessee), due to high pressure atrial wave reflected back from a poorly compliant ventricle left ventricular S4- AS, MR, HTN, IHD, advanced age right ventricular S4- pulmonary HTN, pulmonary stenosis

what is opening snap?

high pitched sound in MS, best heard in lower left sternal edge with diaphragm

what is systolic ejection click?

early systolic high pitched sound heard over aortic or pulmonary in AS, PS

non ejection systolic click?

high pitched sound hearing in systole best in mitral area

pansytolic murmurs

MR TR VSD

midsystolic murmurs

AS or aortic sclerosis PS HCM ASD

late systolic murmur

papillary muscle dysfunction MVP

early diastolic murmur

AR PR

mid diastolic

MS TS atrial myxoma austin flint murmur of AR

continuous murmur

PDA AV fistula

pericardial friction rub

superficial scratching sound, not confined to diastole or systole often louder when patient sitting up or breathing out

grading of murmur

grade 1/6- very soft, not heard at first 2/6- soft, but detected immediately 3/6- moderate, no thrill 4/6- loud, thrill just palpable 5/6- very loud, thrill easily palpable 6/6- very very loud, can heard without placing stethoscope

effect on respiration on murmur

RIN- right sided increase with inspiration left sided- increase with expiration

special manoeuvres?

1) left lateral position- MS heard best with bell, if still cant listen, need to exercise the patient and hear again 2) lean forward in full expiration- AR can be heard best and pericardial friction rub also 3) valsalva - forceful expiration against closed glottis, listen over left sternal edge- louder for HCM, mitral area for MVP where systolic click and murmur begin earlier and last longer 4) sustained hand grip- MR murmur louder

causes of pitting unilateral LL edema?

DVT compression of large veins by lymph nodes or tumours

causes of non pitting LL edema?

hypothyroidism lymphoedema-malignancy, congenital, allergy, infectious( filariasis) myxoedema lipodema- fat deposition in the ankles

features of acute pericarditis?

fever, dyspnoea, pericardial friction rub causes-viral infection, MI, after pericardiotomy, CKD, neoplasia( breast, bronchus, lymphoma), connective tissue disease ( SLE, RA), hypothyroidism, acute rheumatic fever, TB

features of chronic constrictive pericarditis?

cachexia pulses paradoxus ( more than 10mmHg fall in arterial pulse on inspiration), low BP JVP raised, kussmaul signs apex beat not palpable early S3 early pericardial knock hepatomegaly peripheral edema

acute cardiac tamponade?

tachypnoea, anxiety tachycardia, pulses paradoxus, hypotension JVP raised soft heart sounds dullness and bronchial breathing at the left base