Cardiology

Question 1

what questions should be asked in a cardiovascular history?

Answer 1

presenting complaint
chest pain; site, severity, character, duration, radiation, periodicity, frequency, episodic duration, precipitating/relieving factors, associated symptoms
dyspnoea
orthopnoea
paroxysmal nocturnal dyspnoea
ankle swelling
palpitations
syncope
claudication
PMHx: diabetes, HTN, MI, stroke, angina
DHx
FHX; IHD, diabetes, hyperlipidaemia, stroke, HTN
SHx
systematic questioning
summary

Question 2

what are the causes of dyspnoea?

Answer 2

anxiety
obesity
anaemia
heart failure
pulmonary disease
pleural effusions

Question 3

what are the causes of exertional dyspnoea?

Answer 3

cardiac failure
chronic pulmonary disease
poor physical condition

Question 4

what are the causes of paroxysmal nocturnal dyspnoea?

Answer 4

congestive cardiac failure

asthma

Question 5

what questions should be asked about palpitations?

Answer 5

fast
regular
irregular
skipped beats
how long they lasted for
associated symptoms; dyspnoea, chest pain, syncope

Question 6

describe the general inspection in the cardiovascular examination

Answer 6

cyanosis; peripheral vasoconstriction secondary to hypovolaemia, right-to-left cardiac shunting
dyspnoea; congestive heart failure, pericarditis, pneumonia, PE
pallor; haemorrhage, congestive heart failure
malar flush; mitral stenosis
oedema; congestive heart failure
medical equipment
mobility aids
pillows
vital signs
fluid balance
prescriptions

Question 7

describe the inspection of the hands in the cardiovascular examination

Answer 7

pallor; poor peripheral perfusion, congestive heart failure
tar staining
xanthomata; hyperlipidaemia
arachnodactyly; Marfan’s syndrome
finger clubbing; congenital cyanotic heart disease, infective endocarditis, atrial myxoma
temperature
cool; poor peripheral perfusion, CCF, acute coronary syndrome
sweaty/clammy; acute coronary syndrome
CRT; increased in hypovolaemia, CCF

Question 8

what signs in the hands are associated with endocarditis?

Answer 8

splinter haemorrhages
janeway lesions
osler’s nodes

Question 9

what is examined after hands in a cardiovascular examination?

Answer 9

radial pulse
collapsing pulse
brachial pulse
blood pressure
carotid pulse; palpation and auscultation
JVP; hepatojugular reflex

Question 10

what are the causes of radio-radial delay?

Answer 10

subclavian artery stenosis; compression by cervical rib
aortic dissection
aortic coarctation

Question 11

what are the causes of carotid bruits?

Answer 11

underlying carotid stenosis

radiating cardiac murmur; aortic stenosis

Question 12

what are the causes of a raised JVP?

Answer 12

venous hypertension
right-sided heart failure
tricuspid regurgitation
constrictive pericarditis

Question 13

what conditions are associated with a positive hepatojugular reflex?

Answer 13

right ventricle is unable to accommodate an increased venous return
constrictive pericarditis
right ventricular failure
left ventricular failure
restrictive cardiomyopathy

Question 14

describe the inspection of the face in the cardiovascular examination

Answer 14

eyes; conjunctival pallor, corneal arches, xanthelasma, Kayser-fleischer rings
mouth; central cyanosis, angular stomatitis, high arched palate, dental hygiene

Question 15

what are the causes of bradycardia?

Answer 15

healthy athletic individuals
atrioventricular block
sick sinus syndrome
medications

Question 16

what are the causes of tachycardia?

Answer 16

anxiety
supra ventricular tachycardia
hypovolaemia
hyperthyroidism

Question 17

what are the causes of a collapsing pulse?

Answer 17

fever
pregnancy
aortic regurgitation
patient ductus arteriosus
anaemia
arteriovenous fistula
thyrotoxicosis

Question 18

describe the inspection of the chest in the cardiovascular examination

Answer 18

scars; previous thoracic surgery
Pectus excavatum
Pectus carinatum
visible pulsations; ventricular hypertrophy

Question 19

describe the palpation of the chest in the cardiovascular exam

Answer 19

apex beat
heaves; parasternal heaves (RVH)
thrills

Question 20

name the steps of the entire cardiovascular exam

Answer 20

introduction
general inspections
hands
pulses
blood pressure
JVP
face
inspection of the chest
palpation of the chest
auscultation of the chest
thank patient

Question 21

describe the auscultation of the chest in the cardiovascular exam

Answer 21

hold carotid pulse
diaphragm; mitral, tricuspid, pulmonary, aortic
bell; mitral, tricuspid
special manoeuvre; roll onto left lateral position, palpate the apex beat, listen with the bell for mitral stenosis and axilla (mitral incontinence)
learn forward, inhale, exhale, hold breath; aortic and tricuspid (aortic incompetence)
carotids; aortic stenosis, bruits

Question 22

describe the process of taking an ECG

Answer 22

introduction; explanation
chest electrode placement
limb electrode placement
ask the patient to stay still
check the electrodes are placed correctly
press button to record ECG
once recorded, switch off the machine
remove the leads
thank the patient
label the ECG with the patient's details; name, DOB, H&C, indication for ECG

Question 23

describe the placement of the ECG chest leads

Answer 23

V1; 4th intercostal space right sternal edge
V2; 4th intercostal space left sternal edge
V3; between V2 and V4
V4; 5th intercostal space mid-clavicular line
V5; left anterior axillary line at the same level as V4
V6; left mid-axillary line at the same level as V4 and V5

Question 24

describe the placement of the ECG limb leads

Answer 24

red; ulnar styloid process of RA
yellow; ulnar styloid process of LA
green; medial/lateral malleolus of LL
blue; medial/lateral malleolus of RL

Question 25

describe the process of interpreting an ECG

Answer 25

``` confirm details heart rate heart rhythm cardiac axis P waves PR interval QRS complex ST segment T waves U waves document interpretation ```

Question 26

what questions should be asked in the presenting compliant of a haematology history?

Answer 26

``` fatigue weakness palpitations swollen ankles postural dizziness bleeding bruising fever night sweats weight loss jaundice lymph node enlargement lumps bone pain tingling and loss of sensation skin rash ```

Question 27

what questions should be asked in the past medical history and family history of a haematology history?

Answer 27

``` pregnancy menstrual history frequency infection diarrhoea tarry stools blood in stools recent trauma with bleeding radiotherapy previous cancers GIT surgery transplants bleeding disorders previous transfusions rheumatoid arthritis ```

Question 28

what drugs are important to ask about in the social history of a haematology history?

Answer 28

``` NSAIDs anticoagulants thrombolytics steroids vitamin supplements allergies ```

Question 29

name the steps of a haematology exam

Answer 29

``` inspection; general hands arms axilla face neck chest abdomen legs ```

Question 30

describe the general inspection in a haematology exam

Answer 30

``` race; thalassaemia, sickle cell anaemia gender pale; anaemia jaundice; haemolytic anaemia cyanosis; haemoglobinopathy, polycythaemia bruising; clot disorder scratch marks; lymphoid cancer plethoric red face; polycythaemia wasted/cachexic; cancer ```

Question 31

describe the inspection of the hands in a haematology exam

Answer 31

``` nicotine staining koilonychia; iron deficiency pale nails; anaemia clubbing; cancer vasculitis of the nail bed; bacteraemia palmar creases; anaemia joints gouty topi; secondary to myeloproliferative disease hot hands; febrile pulse; shock, peripheral B12 neuropathy ```

Question 32

describe the inspection of the arms and axilla in a haematology exam

Answer 32

blood pressure scratch marks palpable purpura; vasculitis, septicaemia enlarged nodes; central, lateral, pectoral, intraclavicular, subscapular

Question 33

describe the inspection of the face in a haematology exam

Answer 33

eyes; jaundice, conjunctiva pallor, haemorrhage, injected sclera mouth; hypertrophied gums, bleeding, scurvey tongue; glossitis, ulcerated, tonsillar/adenoid enlargement

Question 34

describe the examination of the neck and chest in a haematology exam

Answer 34

auscultation; carotid bruit inspect nodes; submental, submandibular, preauricular postauricular, occipital, jugular chain, post triangle, supraclavicular, paratracheal bone pain; knock on ribs feel for apex beat

Question 35

describe the examination of the abdomen in a haematology exam

Answer 35

``` lie patient down abdominal breathing; anaemia dyspnoea palpate liver and spleen with respiration scars pulsatile stretch marks ascites black umbilicus portal hypertension; caput medusae inguinal nodes ```

Question 36

describe the inspection of the legs in a haematology exam

Answer 36

``` ulcers bruising ecchymosis petechiae peripheral stocking neuropathy; B12 deficit popliteal nodes swollen leg; uni/bilateral purpura varicosity toe clubbing nail changes; similar to fingers? ```

Question 37

what aspects are assessed in examining the arterial pulses?

Answer 37

``` rate rhythm character; collapsing pulse volume symmetry vessel wall character presence of bruits ``` examine on both sides

Question 38

which arterial pulses are examined?

Answer 38

radial brachial; medial to the medial head of biceps carotid; medial border of sternocleidomastoid muscle and lateral to thyroid cartilage, should not examine both at the same time femoral; inferior to mid inguinal point popliteal; deep in the popliteal fossa posterior tibial; against the tarsal bones dorsalis pedis; usually 1cm behind the medial malleolus

Question 39

what are the causes of a raised JVP?

Answer 39

right sided heart failure fluid overload tricuspid regurgitation massive PE

Question 40

how do you examine JVP?

Answer 40

semi-supine position rest their head against a pillow neck flexed slightly and looking to the left inspect between the heads of the sternocleidomastoid muscle just above the clavicle hepatojugular reflex; press on the RUQ should return to normal after a few seconds if it remains at the new high level; right sided heart failure