Cardiology

Question 1

What are the features of Marfans?

Answer 1

Tall with long limbs
High arched palate
Arachnodactyly
Positive wrist sign - when you wrap the hand aroud opposite wrist the fingers overlap
Positive thumb sign - when you make a fist with the thumb inside the fingers the end of the thumb sticks out
Scoliosis
Pes Planus - flat feet

Question 2

What are the cardiac abnormalities that are seen in Marfans?

Answer 2

Aortic root dilatation
Aortic regurgitation
Bicuspid valve
Mitral valve prolapse

Question 3

What are the features of Turners and what are the associated cardiac abnormalities?

Answer 3

Short stature 
Delayed or absent pubertal development 
Neck webbing 
Low set malrotated ears 
Wide carrying angle 
Associated with aortic coarctation and bicuspid aortic valves

Question 4

What causes an elevated JVP?

Answer 4

Right heart failure 
Tricuspid stenosis or regurg 
Pericardial effusion or constrictive pericarditis 
SVC obstruction
Fluid overload

Question 5

How can the arterial pulse character be described in AS (3)?

Answer 5

Anacrotic - slow volume, slow upstroke, plus a wave on upstroke
Plateau - Slow upstroke
Small volume

Question 6

What is a tapping apex beat?

Answer 6

A palpable first heart sounds felt in mitral stenosis, especially felt in the left lateral position

Question 7

When do you hear an S3?

Answer 7

Rapid diastolic filling - MR, AR, VSD

Question 8

When do you hear an S4?

Answer 8

When the atrium contracts, forcing blood into a non-compliant ventricle - AS, HOCM, pulmonary hypertension

Question 9

Differential diagnosis of a continuous murmur?

Answer 9

Patent ductus arteriosus

Dual pathology - AS with AR, MS with MR, AR and MR

Question 10

What is hepatojugular reflux?

Answer 10

Push down on the right upper quadrant of the abdomen to increase right sided venous return. In normal people the jugular veins may distend and JVP may increase for a few seconds before going back to normal. In right sided heart failure, remains distended and elevated

Question 11

What are the causes of mitral stenosis?

Answer 11

Rheumatic heart disease (by far most common), congenital, connective tissue disease (RA, SLE), carcinoid heart disease

Question 12

Mitral Stenosis signs

Answer 12

Murmur - mid-diastolic rumble
AF 
Small volume pulse (low output state if severe) with narrow pulse pressure 
Signs of pulmonary hypertension 
Signs of LV failure 
Malar flush 
Tapping apex beat 
Loud first heart sound with opening snap

Question 13

How do you accentuate a mitral stenosis murmur?

Answer 13

Get the patient to exercise
Left lateral position
Expiration
Heard with bell

Question 14

Signs of severity of mitral stenosis

Answer 14

Length of the murmur 
Thrill 
Pulmonary hypertension 
Left ventricular failure 
Opening snap 
Small pulse pressure

Question 15

Signs of pulmonary hypertension

Answer 15

RV heave 
Loud P2 
Prominent v wave 
Elevated JVP 
TR murmur 
May have sacral and pedal oedema 
May have pulsatile liver 
Can sometimes get pulmonary regurg murmur if severe from dilatation of the pulmonary artery 
Other signs of connective tissue disease

Question 16

What might you expect to see on ECG of mitral stenosis?

Answer 16

AF
P Mitrale if sinus
Right axis deviation

Question 17

What is the indication for surgery in MS?

Answer 17

Valve area < 1cm squared with exertional dyspnoea

Question 18

Why might you get a hoarse voice in valve pathology?

Answer 18

From an enlarged left atrium (as in MS), compressing the recurrent laryngeal nerve

Question 19

What are the causes of mitral regurgitation?

Answer 19

Chronic - degenerative, mitral valve prolapse, Rheumatic (not usually the only murmur), papillary mm dysfunction (previous MI), connective tissue disease, congenital, functional (left ventricular dilatation)
Acute - AMI (chordae or papillary muscle involvement), infective endocarditis

Question 20

What are the clinical signs of MR?

Answer 20

Pansystolic murmur over apex radiating to axilla 
Soft S1
S3 
AF 
Thrill
Signs of LV failure 
Signs of pulmonary Hypertension 
Volume loaded apex beat

Question 21

Mitral regurg signs of severity

Answer 21

Displaced apex beat 
Soft S1 
Pulmonary HT 
LV failure 
Small volume pulse 
Thrill 
S3 and S4

Question 22

Differentiating between TR and MR

Answer 22

TR - v waves, parasternal thrill, pulsatile liver, louder in inspiration, louder are left parasternal edge, parasternal heave
MR - radiation to axilla, louder in expiration, displaced apex beat, apical thrill

Question 23

ECG in MR

Answer 23

AF, P mitrale, right axis deviation if severe

Question 24

Clinical features of mitral valve prolapse (without significant MR)

Answer 24

Mid systolic click followed by late systolic crescendo decrescendo murmur
Valsalva accentuates the click and murmur
Handgrip or squatting - murmur shorter

Question 25

Which conditions are associated with mitral valve prolapse?

Answer 25

Marfan's, Ehlers Danlos, SLE, PKD, osteogenesis imperfecta

Question 26

Causes of aortic regurgitation

Answer 26

Chronic - rheumatic (rare to be only murmur), connective tissue (esp ank spon), congenital (eg - bicuspid valve, Marfan's), HT, old age, syphilis Acute - IE, dissection

Question 27

Clinical signs of AR

Answer 27

``` Early diastolic decrescendo murmur heard loudest in left sternal edge leaning forwards and expiration Collapsing pulse Corrigans pulse Displaced apex beat S3 Wide pulse pressure Soft A2 LVF Volume loaded apex beat ```

Question 28

Aortic Regurgitation signs of severity

Answer 28

``` LVF Collapsing pulse Wide pulse pressure (esp > 100) Length of the murmur Austin Flint murmur - a separate mid-diastolic murmur from the regurgitant jet hitting the mitral valve causing a functional mitral stenosis LVF and signs of PH S3 Thrill in aortic region ```

Question 29

AR - what can you see on ECG

Answer 29

LVH from diastolic overload

Question 30

Causes of Aortic Stenosis

Answer 30

Degenerative Rheumatic Congenital Calcific bicuspid valve

Question 31

Signs of aortic stenosis

Answer 31

Ejection systolic murmur that radiates to the carotids and louder in expiration Narrow pulse pressure Plateau or anacrotic pulse or low volume pulse S4 Aortic thrill Signs of LVF Pressure loaded apex beat Reversed splitting of the second heart sound

Question 32

Signs of severity of AS

Answer 32

``` Narrow pulse pressure LVF Late peaking murmur Plateau pulse Thrill S4 Reversed splitting of the second heart sound ```

Question 33

Differential diagnosis of ejection systolic murmur

Answer 33

Pulmonary stenosis - louder on inspiration over pulmonary region HOCM - louder of left sternal edge accentuated with valsalva Aortic sclerosis - shouldn't radiate to carotids

Question 34

ECG of Aortic stenosis

Answer 34

LVH Left axis deviation COnduction abnormalities (LBBB, 1st degree HB)

Question 35

Features of tricuspid regurgitation

Answer 35

Prominent v waves Pan-systolic murmur loudest at left sternal edge in inspiration Pulsatile liver Right ventricular heave

Question 36

Causes of TR

Answer 36

Functional - in pulmonary hypertension or RV failure Congenital - Ebstein's anomaly IE - especially if history of IVDU Rheumatic - rare to be the only murmur Infarct affecting papillary muscles - rare

Question 37

What might you see on ECG for Pulmonary HT?

Answer 37

RV strain pattern - ST depression and TWI in leads anterior leads corresponding to the RV (V1- V3), right axis deviation, RBBB

Question 38

Treatment of primary pulmonary hypertension

Answer 38

Phosphodiesterase inhibitors like sildenafil | Endothelin antagonists like bosentan

Question 39

Clinical signs HOCM

Answer 39

``` Ejection systolic murmur loudest over left sternal edge, louder with valsalva Pansystolic murmur from mitral regurg Double carotid arterial impulse JVP - prominent a wave Apex beat NOT displaced but pressure loaded Double apical impulse Reversed splitting second heart sound S4 Look for device - ICD ```

Question 40

ECG changes in HOCM

Answer 40

``` LV hypertrophy left axis deviation Deep Q waves Lateral ST segment/T wave changes Conduction defects ```

Question 41

VSD clinical signs

Answer 41

parasternal thrill Harsh sounding pan-systolic murmur loudest over the left sternal edge Can be associated with Downs Syndrome

Question 42

What are the complications of VSD?

Answer 42

IE Pulmonary hypertension Eisenmenger's syndrome Ventricular arrhythmias

Question 43

How do you tell the difference between a metallic aortic vs mitral prosthesis on clinical exam easily?

Answer 43

Mitral valve - hear the click with the carotid pulse | Aortic valve - hear the click just after the carotid pulse

Question 44

Which patients commonly have mixed aortic valve disease?

Answer 44

Patients with a Biscuspid aortic valve

Question 45

if you think you have mixed aortic valve pathology then what should you do?

Answer 45

Look for signs so that you can point out the predominant lesion Predom AS - Low pulse volume, slow rising pulse, minimally displaced apex, thrill, narrow pulse pressure, low BP Predom AR - large pulse volume, collapsing pulse, displaced apex, thrill may not be present, wide pulse pressure, high BP

Question 46

What are the clinical signs of an ASD?

Answer 46

Fixed splitting of the second heart sound Ejection systolic murmur at the pulmonary region (from increased flow) Pulmonary Hypertension (late)

Question 47

What is patent ductus arteriosus?

Answer 47

connection between where the pulmonary veins split and the aorta

Question 48

PDA clinical signs

Answer 48

Continuous murmur heard loudest over the left subclavicular area Increased pulse pressure (if large) Signs of pulmonary HT Collapsing pulse Displaced apex beat when severe (high volumes returning to left heart) If Eisenmenger's - cyanosis and clubbing of toes not fingers

Question 49

DDx of continuous murmur

Answer 49

PDA MR and AR VSD and AR

Question 50

What are the complications of PDA?

Answer 50

LV dysfunction Pulmonary HT Eisenmenger's

Question 51

Aortic coarctation clinical signs

Answer 51

``` Better developed upper body HT in the arms only Radial-femoral delay Midsystolic murmur over the praecordium and back Changes of HT in the fundi Features of Turner's syndrome ```

Question 52

Four features of tetralogy of Fallot

Answer 52

Right ventricular outflow tract obstruction (pulmonary stenosis) Right ventricular hypertrophy VSD Overriding aorta

Question 53

Clinical features of tetralogy of Fallot

Answer 53

``` Thoracotomy scar Parasternal heave Systolic thrill at the upper left sternal edge (RV outflow tract obstruction) SIngle second heart sound Short pulmonary ejection murmur ```

Question 54

What is Eisenmenger's syndrome and what are the Hallmark signs?

Answer 54

Right to left shunting through longstanding defect either ASD, VSD, PDA Central cyanosis Pulmonary HT Clubbing

Question 55

What sign do you see on chest xray when there is left atrial enlargement

Answer 55

Double density sign at the right heart border on CXR