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OSCE PRATICALS > Cardio Year 2 > Flashcards

Cardio Year 2 Flashcards

1
Q

what are you looking for when you look at the precordium

A

: inspect, palpate for heaves & thrills, apex beat, auscultate heart sounds.
Lung bases: fine crepitations.

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2
Q

what do you palpate for

A

oedema

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3
Q

what is included in general demeanour

A

Alert and oriented? This includes talking coherently etc.

Are they in obvious pain? (this includes writhing or continually moving with colicy pain (abdomen wise), & keeping absolutely still with peritonitis.

Do they look ill?

Is there any medical equipment round the bed?
Intravenous infusion? Ambulant oxygen?
Ventilator? Tablets, Sputum pots

Are there any indicators of disability?
Wheelchair? Crutches? Limb in plaster? Amputation? Etc, etc.

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4
Q

what do you look for in the legs

A

Amputations? Bandages etc. Gross oedema- get this in heart failure? Ulcers?
Varicose veins? Scars? Colour, colour difference?
Are the legs moving?

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5
Q

what do you look form in the abdomen

A

Re cardiovascular system: pulsating mass of AAA - abdominal aortic aneurysm

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6
Q

what do you look for in the chest

A

moving? Symmetrical? Any obvious abnormality or effort in respiratory movements? Obvious pulsation? Drains?

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7
Q

what do you look form in the arms and hands

A

amputations? Bandages etc? Swelling? Scars? Shunts or fistulae? Colour, colour difference? Are they moving?

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8
Q

what do you form in the neck

A

obvious pulsation? Obvious swelling? Tracheostomy/tomy?

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9
Q

what do you look for in the face

A

Obvious cyanosis, Obvious pallor, Obvious jaundice? Facial flush? symmetrical? Moving?

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10
Q

what does vitamin B12 deficiency lead to

A

pernicious anaemia

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11
Q

what do you look for in the hands

A

colour? Temperature/sweaty? Peripheral cyanosis- poor circulation? Tar staining? Clubbing? Splinter haemorrhage? Osler’s nodes (etc)? Koilonychia? Dupuytren’s contracture? Capillary refill

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12
Q

what is sinus arrhythmia

A
  • heart rate speeds up and slow down as you breath in and out - not pathological
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13
Q

what should you look for in the mouth

A

Sores around mouth, & at corners (angular stomatitis, or angular cheilosis), Central cyanosis, Glossitis? Mouth ulcers? (Soft palate & tongue movements)

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14
Q

what should you look for in the eyes

A

Mucosal pallor, scleral jaundice, xanthelasmata, arcus, pupils (equal?), (squints & eye movements

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15
Q

what should you take in regards to circulation

A

Take the pulse: rate rhythm, character/volume.
Rate: count for 15 or 20 secs, multiply appropriately.
Rhythm: regular or irregular. If there is sinusarrhythmia (speeds up & slows down as breathes in and out) you should comment on this, but not pathological.
Character/volume: slow rising pulse of aortic stenoisis, collapsing pulse of aortic regurgitation, fast weak “thready” pulse of shock, asymetrical pulse of coarctation or vascular disease: you need experience for this!

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16
Q

Kolionychia is classically due to…

A

iron deficiency anaemia

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17
Q

how should a patient sit in a Cardio examination

A
  • exposed from waist up sitting at 45 degrees
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18
Q

where is the radial pulse

A

lateral side of the wrist, lateral to the FCR

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19
Q

what do you look for in the radial pulse

A
  • rate
  • rhythm
  • character volume
  • symmetry
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20
Q

what are the other pulses

A
  • brachial
  • carotid
  • dorsalis pedis
  • posterior tibial
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21
Q

how do you do blood pressure

A
  • locate radial pulse (lateral – thumb side of wrist) & brachial pulse (medial side arm!).
  • Put on cuff, & pump up while feeling radial pulse. When pulse disappears is systolic BP approximately.
  • Let down, & put on stethoscope (if you are slick, don’t have to let down)
  • Pump up cuff to higher than your estimate of systolic.
  • Listen over brachial pulse: you hear nothing.
  • Let down cuff slowly: the pressure when the Korotkoff sounds appear is systolic, the pressure when they disappear is diastolic.

when the cuff is above the systolic pressure you don’t hear anything
when they appear it is systolic
stop hearing them when diastolic

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22
Q

what are korotkoff sounds due to

A
  • turbulent blood flow under the cuff
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23
Q

how do you measure theJVP

A

You are looking for the pulsation of the internal jugular vein in the neck, & measure its height vertically above the angle of Louis.

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24
Q

where is the internal jugular vein

A
  • between the two heads of SCM
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25
Q

when does the external jugular vein rise

A
  • when they talk as they raise the intrathoracic pressure
26
Q

how can you see the external jugular vein

A

a) lower the patient down, or b) press over liver, or c) get them to take a long slow breath in and out, or d) lift up their legs.

27
Q

how is the external jugular different from the carotid arterial pulse

A

Waveform, position, & pulse not palpable distinguish it from carotid arterial pulse.

28
Q

when is the JVP raised

A

The JVP will be raised in Right heart failure, & low in hypovolaemia

29
Q

how to measure the JVP

A
  • from the top of the pulsation to the angle of Louis
30
Q

what are the three peaks of the venous pulse

A

A
C - tricuspid valve close a start of ventricular systole
V- maximum atrial filling pressure before ventricular diastole

31
Q

what is the praecordium

A

front of the chest

32
Q

what do you do at the precordium

A

Praecordium
1 inspect. This is more careful than in “feet to face”. Pulsation, scars, pectus excavatum etc. Look at back now, or when you auscultate for fine basal crepitations.

  1. Palpate. Heaves & thrills. Parasternal heave is due to R ventricular hypertrophy or enlargement. Thrills are palpable murmurs.

Locate apex beat, counting down ribs & intercostal spaces from angle of Louis (second rib). Normal position is 5th intercostal space mid-clavicular line.

  1. Auscultate for murmurs: mitral area is at apex. Mitral stenosis murmur is low pitched: use bell. Mitral regurgitation murmur may radiate into axilla. Mitral murmurs are best heardwith patient rolled onto L side. Tricuspid area is in 4th intercostal space at L sternal edge. Pulmonary area is in 2nd intercostal space L sternal edge, & aortic area is 2nd intercostal space R sternal edge. Aortic regurgitation also audible at L sternal edge 3rd intercostal space sitting up in expiration. Aortic stenosis may radiate to carotids.
  2. Pericardial friction rub etc.
  3. Identify first & second heart sounds by feeling carotid pulse: pulse is just on or after 1st heart sound.
33
Q

what is a parasternal heave due to

A

Parasternal heave is due to R ventricular hypertrophy or enlargement that pushes against the sternum

34
Q

what are thrills

A

palpable murmurs

35
Q

where is the apex beat

A

counting down ribs & intercostal spaces from angle of Louis (second rib). Normal position is 5th intercostal space mid-clavicular line.

36
Q

where are the valves

A
  • mitral - 5 intercostal space mid clavicular line
  • tricuspid - 4th intercostal space left sternal edge
  • pulmonary - 2 intercostal space L sternal edge
  • aortic - 2nd intercostal space right sternal edge
37
Q

where is aortic regurgitation audible at

A

Aortic regurgitation also audible at L sternal edge 3rd intercostal space sitting up in expiration.

38
Q

where does aortic stenosis radiate to

A

Aortic stenosis may radiate to carotids.

39
Q

describe mitral stenosis

A

mid-diastolic murmur. Best heard at apex (mitral area), while lying on left side. best heard with a bell

Also loud first heart sound, tapping apex beat, opening snap. Malar flush.

Signs of Right heart failure.

40
Q

what is mitral stenosis best head at

A

Best heard at apex (mitral area), while lying on left side.

41
Q

what is mitral stenosis a sign of

A

Signs of Right heart failure.

42
Q

describe mitral regurgitation

A

pan-systolic (throughout systole) murmur, best heard over apex, when lying on L side, radiates into axilla. High-pitched. Loud Second sound. Often third heart sound.

43
Q

where can you hear mitral regurgitation

A

best heard over apex, when lying on L side

44
Q

patients with mitral valve lesions are….

A

prone to develop Atrial Fibrillation.

45
Q

describe aortic stenosis

A

mid-systolic murmur best heard in aortic area, radiating into carotids R>L.

46
Q

describe aortic regurgitation

A

early diastolic murmur, Left sternal edge, loudest in 3rd intercostal space

47
Q

what do you listen to the lung bases for

A

Listen to lung bases for Fine crepitations

48
Q

where are the lung bases

A

This is on the back, one hands-breadth below scapula.

49
Q

how do you test for oedema

A

Palpate feet for pitting oedema. Press over bone firmly with thumb for 10 secs, then stroke to see if has pitted.
If patient had been bedbound, pitting oedema is over sacrum.

50
Q

what causes clubbing

A

Lung disease: chronic infection & inflammation: lung abscess, longstanding empyema, TB, interstitial lung disease. Neoplasia of lung: carcinoma & mesothelioma,

51
Q

what can cause heart disease

A

infective endocarditis, any cyanotic heart disease, atrial myxoma (a benign neoplasm).

52
Q

what causes cirrhosis of the liver

A

Esp primary biliary cirrhosis.

53
Q

what is graves disease part of

A

thyroid acropachy

54
Q

what can cause fine tremor

A

thyrotoxicosis

salbutamol

55
Q

what can cause coarse flapping tremor

A
  • versions of this in co2 retention, liver failure, uraemia
56
Q

describe symptoms of infected endocarditis

A

Looks ill. Splinter haemorrhages, clubbing, Osler’s nodes, Janeway lesions, lymphadenopathy, heart murmurs, fever, Roth spots in retina, red cells in urine etc.

57
Q

describe iron deficiency anaemia symptoms

A

koilonychia, sore corners of mouth.

58
Q

describe B12 deficiency symptoms

A

sore tongue, pallor, sometimes slight jaundice.

59
Q

what can cause left sided heart failure

A 
systemic hypertension
 mitral and aortic valvular disease, 
myocardial disease 
(ischaemic, inflammatory, others), 
arrhythmia.
60
Q

what are the effects of left heart failure

A

: Pulmonary oedema (SOB on lying flat = orthopnoea, fine crepitations).
- Peripheral oedema due to fluid retention possibly because raised renin, poor renal perfusion pressure.

Weak pulse tachycardia.

Fatigue, lethargy etc.
Findings due to the causes: murmurs, displaced apex beat etc.

61
Q

what can cause right sided heart failure

A

pulmonary hypertension (esp COPD) “cor pulmonale”, tricuspid or pulmonary valvular disease,
myocardial disease,
2ary to L sided heart failure

62
Q

what are the effects of right sided heart failure

A

raised JVP,

enlarged liver (engorged with blood)

peripheral oedema (raised venous pressure).

OSCE PRATICALS (28 decks)

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