Cardio Short Case Flashcards
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
Features of marfan syndrome
Mitral valve prolapse, aortic regurgitation
Features of down syndrome
VSD/ASD/PDA
Features of turner syndrome
Coarctation of aorta/AS
What are splinter haemmorhages?
Linear haemmorhages in nail beds lying parallel due to IE, SLE, antiphopholipid
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
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
Pulses paradoxus
Fall in pressure more than 10mmHg on inspiration
Seen in constrictive pericarditis, pericardial effusion, severe asthma
What is anacrotic pulse? (3)
Small volume
Slow uptake
Notched wave on upstroke
Seen in Aortic stenosis
What is plateau?
Slow upstroke
Seen in aortic stenosis
Bisferiens
Anacrotic and collapsing pulse
Seen in AS and AR
What is cause of collapsing pulse?
AR
Hyperdynamic circulation
PDA
Peripheral AV fistula
Arteriosclerotic aorta( seen in elderly patients)
What does carotid and JVp tells us?
Carotid tells about aorta and left ventricular function
JVP tells about right atrial and right ventricular function
What is kussmaul sign?
Rise of JVP on inspiration
Seen in constrictive pericarditis, cardiac tamponade
Causes of elevated JVP
Right ventricular failure
Tricuspid stenosis or regurgitation
Pericardial effusion or constrictive pericarditis
SVC obstruction
Fluid overload
Dominant a wave
Triscuspid stenosis
Pulmonary stenosis
Pulmonary htn
Cannon a wave
Complete heart block
VT with retrograde atrial conduction
Dominant v wave
Tricuspid regurgitation
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
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
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
