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Clinical Examination > Cardiology Examination > Flashcards

Cardiology Examination Flashcards

1
Q

What are pulse and BP findings in AS?

A

1) plateau or anacrotic pulse
2) late peaking - tardus
3) small volume - parvus
4) reduced pulse pressure

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2
Q

What are palpation findings in AS?

A

1) diffuse apex beat, may be displaced

2) systolic thrill at base of heart

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3
Q

What are auscultation findings in AS?

A

1) Narrowly split or reverse splitting of S2
2) Harsh ESM radiating to carotids, loudest on sitting forwards on full expiration
3) Commonly associated with AR
4) ejection click preceding murmur in congenital AS

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4
Q

What are signs of severe AS? (7)

A
  1. plateau pulse
  2. narrow pulse pressure
  3. thrill in aortic area
  4. soft S2, reversed splitting of S2
  5. S4
  6. long, late peaking murmur
  7. LVH (pre-terminal)
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5
Q

What are causes of AS?

A
  1. calcification of congenital bicuspid valve (40-60yrs), assoc with coarctation
  2. Progressive calcific disease of trileaflet valve
  3. Childhood rheumatic fever (invariably associated with mitral involvement)
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6
Q

What are investigations in AS?

A
  1. ECG - LVH, LV strain, LAH
  2. CXR - post stenotic diltation of ascending aorta
  3. TTE
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7
Q

What are echocardiographic findings of severe AS?

A

Valve area less than 1cm^2
Mean gradient >40mmHg
Aortic jet velocity >4m/sec

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8
Q

What monitoring is appropriate in AS?

A

Surveillance TTE

  • Q1y for severe 0Sx AS
  • Q2y for moderate
  • Q3y for mild
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9
Q

What are indications for surgery in AS?

A
  1. When symptomatic and severe

2. Severe AS w LVEF

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10
Q

What are findings on general examination in AR?

A

1) Marfan’s syndrome
2) Ankylosing spondylitis
3) Argyll robertson pupils

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11
Q

What are pulse and BP findings in AR?

A

Collapsing pulse, wide pulse pressure

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12
Q

What are findings on the neck in AR?

A

Corrigan’s sign - prominent carotid pulsation

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13
Q

What are findings on palpation in AR?

A

Apex beat displaced and diffuse

Diastolic thrill at LLSE when pt sits forwards in full expiration

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14
Q

What are findings on auscultation in AR?

A

Soft A2
Early decrescendo diastolic high pitched murmur at LLSE, increased w expiration.
Systolic ejection murmur also present (AS or torrential flow)
Austin flint murmur - rumbling mid-disatolic murmur at apex

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15
Q

What are signs of severe AR?

A
  1. collapsing pulse
  2. wide pulse pressure
  3. long decrescendo diastolic murmur
  4. Left ventricular S3
  5. Soft A2
  6. Austin flint murmur
  7. Signs of LVF
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16
Q

What are causes of AR?

A 
Valvular:
- congenital bicuspid AV
- rheumatic (rarely only AR)
- endocarditis
- dehiscence of prosthetic
Aortic root dilatation/disease:
- Marfans
- Ank spon
- Aortitis
- Dissecting aortic aneurysm
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17
Q

What are investigations in AR?

A

ECG - normal or LVH

CXR - normal, enlarged cardiac silhouette with LV contour, ascending aorta prominent, APO if acute

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18
Q

What are TTE findings of severe AR?

A

A regurgitant fraction 50%
Regurgitant volume 60ml/beat
Vena contracta width >6mm

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19
Q

What monitoring is indicated in AR?

A

Yearly TTE as LVEF and dilation my precede symptoms in 20% - high risk of SCD

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20
Q

When is surgery indicated in AR?

A

Severe symptomatic AR
Severe AR with LVEF less than 50% or FS less than 29
Severe AR with EDD >75mm or ESD >55mm
Moderate or severe AR in pts who require CAGS or other cardiac surgery
Severe AR - abnormal response to exercise

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21
Q

What is the place of vasodilator therapy in AR?

A

Short term bridge to surgery with elimination of congestive Sx
Where AVR is not possible
for LV dysfunction post AVR

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22
Q

What are examination findings in ASD?

A

Palpation - normal or RV enlargement

Auscultation - fixed split S2, low pitched diastolic TV flow murmur, pulmonary systolic ejection murmur

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23
Q

What are examination findings in VSD?

A

Palpation - diffuse displaced apex beat, thrill at LSE

Auscultation - harsh pansystolic murmur, maximal at and confined to LLSE, S3 + S4, sometimes assoc with MR

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24
Q

What are causes of VSD?

A
  1. congenital

2. Acquired - septal MI

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25
Q

What are indications for surgery in VSD?

A

Mod-large VSD with pulm to systemic flow ratio of >1.5:1

Lack of v. high pulmonary pressures

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26
Q

What are examination findings in PDA?

A

Pulse and BP - collapsing pulse with sharp upstroke, low diastolic BP
Palpation - diffuse apex beat
Auscultation - reversed split S2, loud continuous machinery murmur at L1stICS, mitral mid-diastolic murmur

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27
Q

what are features of tetralogy of fallot?

A
  1. Large VSD
  2. Overriding Aorta
  3. Pulmonary stenosis
  4. Resultant RV hypertrophy

ECG shows RVH, RAD, tall peaked T-waves

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28
Q

What conditions are associated with eisenmenger syndrome?

A

ASD or VSD
PDA
Complex congenital abnormalities - single ventricle, ToF

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29
Q

What are features on Ex in Eisenmenger syndrome?

A
  1. Polycythaemia
  2. Clubbing - upper and lower limbs
  3. Central cyanosis (any cause of severe pulm HTN will lead to VQ-MM and central cyanosis
  4. 2nd heart sound - loud with pHTN, fixed split in ASD, single with VSD
  5. Pulmonary HTN
  6. Evidence of RHF (hepatomegaly, peripheral oedema, ascites)
30
Q

What are investigations in eisenmenger syndrome?

A
  1. ECG - R or bi-v hypetrophy, RA abnormality
  2. CXR - dilation of central pulmonary arteries, peripheral pulmonary artery pruning, neovascularity, right heart enlargement
31
Q

What are echo findings in eisenmenger’s syndrome?

A

increased RV wall thickness, septal bulging to L) with systole
RV dilatation and hypokinesis
RA dilatation and tricuspid and pulmonic regurgitation
Underlying abnormality may be difficult to see due to equalisation of pressures across chambers

32
Q

What is management of eisenmenger’s syndrome?

A
  1. pulmonary vasodilator theray - epoprostenol
  2. avoidance of volume depletion, pregnancy, isometric exercise, vasodilatation, high altitude (death due to TEmbo, hypovolemia, preeclampsia)
  3. extreme caution w non-cardiac surgery
  4. haematologic issues
  5. surgical options - Heart/lung transplan
33
Q

What are examination findings in HCM?

A 
Pulse - sharp, rising, jerky
JVP - prominent a-wave
Palpation - double or triple impulse
Auscultation:
- late systolic murmur at the LLSE, and apex
- Pansystolic murmur at apex (MR)
- S4
Dynamic manoeuvre - increase with valsalva, reduced with isometric exercise
34
Q

What are causes of HCM?

A
  1. AD
  2. idiopathic
  3. Fredreich’s ataxia
35
Q

What are ECG findings in HCM?

A

LAD
LVD
anterolat ST depression

36
Q

What are general examination findings in MR?

A

tachypnoea

mitral facies - malar flush

37
Q

What are findings on examination of the pulse in MR?

A

Normal or sharp upstroke

a-wave lost in AF

38
Q

What are findings on palpation in MR?

A

apex beat displaced and diffuse
pansystolic thrill at apex
parasternal impulse (LA enlargement)

39
Q

What are findings on auscultation in MR?

A

soft or absent S1 (MV leaflets fail to close properly)
LV S3 - rapid LV filling in early diastole or S4 (only in SR)
Pansystolic murmur at apex radiating to axilla (immediatley after S1, may obscure S2)

40
Q

What are signs of severe MR?

A
  1. small volume pulse (very severe)
  2. displaced apex, enlarged LV
  3. Soft S1, split S2, S3
  4. Early diastolic rumble
  5. Pulmonary hypertension
  6. LVD
41
Q

What are causes of MR?

A
  1. valvular apparatus abnormalities
    - IHD with pap muscle rupture
    - myxomatous degeneration
    - infective endocarditis
    - rheumatic heart disease
    - carcinoid syndrome
    - CTD - Ank spon, RA
  2. Functional/ventricular abnormalities
    - dilatation due to CM
42
Q

What are Ix in MR?

A

ECG - LA enlargement, may also see LVH +/- RVH
Echo
- VC width, regugitant fraction, slow reversal in pulmonary veins
- prominent flail MV leaflet or ruptured pap muscle

43
Q

What Mx is required in MR?

A

Surgery - MV repair preferable to replacement

  • symptomatic (Class III/IV) and severe MR
  • severe MR with LVEF 30-60%
  • Severe MR with pulmonary hypertension, systolic PAP >50mmHg at rest, or 60mmHg w exercise
44
Q

What are aspects of medical management in MR?

A

Vasodilators - ISMN, hydralazine, ACEi

  • afterload reduction is beneficial if fluid overload states
  • preload reduction can help loading abnormalities
  • revascularisation if ischaemia suspected
45
Q

What are examination findings in MVP?

A

Auscultation - systolic click (usually mid-diastolic), systolic murmur, high pitched, late systolic
Dynamic auscultation - valvasla, murmur and click louder and earlier
isometric - later and softer

46
Q

What are causes of MVP?

A
  1. myxomatous degeneration of mitral valve

2. associated with ASD (secundum) HCM or marfans

47
Q

What are general findings in Mitral stenosis?

A

tachypnoea
mitral facies
peripheral cyanosis

48
Q

What are pulse/bp findings in MS?

A

normal or reduced volume

AF

49
Q

What is the character of the JVP in MS?

A

prominent a-wave if pHTN present, loss of a-wave in AF

50
Q

What are findings on palpation in MS?

A

tapping, palpable S1
RV heave and palpable P2, pulmonary hypertension
diastolic thrill (pt in LL position)

51
Q

What are findings on auscultation in MS?

A

loud S1
loud P2, pulmonary hypertension
opening snap
low pitched diastolic murmur accentuated with exercise

52
Q

What are signs of severe MS?

A

(valve area

53
Q

What are causes of MS?

A
  1. rheumatic heart disease
  2. infective endocarditis
  3. progressive annular calcification in ESRF
  4. congenital parachute valve
54
Q

What are investigations in MS?

A

ECG - AF, p-mitrale (bifid p-waves), changes of pulmonary HTN and RVH

CXR - LA enlargement - double shadow

55
Q

What are echocardiographic signs of severe MS?

A

mean gradient >10, valve area less than 1cm^2, systolic PAP >50

56
Q

What are management considerations in MS?

A

Medical - secondary prevention of rheumatic fever, prevention of endocarditis, prevention of thromboembolism.

Surgery when symptomatic and mod-severe MS
moderate severe MS with systolic PAP >50
moderate or severe MS in pts requring other CTS
severe MS with abnormal response to exercise

57
Q

What are examination findings in pulmonary stenosis?

A

peripheral cyanosis
normal or reduced pulse
JVP: giant a-waves due to RA hypertrophy, may be elevated
RV heave, thrill over pulmonary area
Ejection click preceding harsh ESM at pulmonary area, RV S4 (RA hypertrophy)
Presystolic pulsation of the liver

58
Q

What are signs of severe PS?

A
  1. ESM peaking late in systole
  2. Absence of ejection click
  3. Presence of S4
  4. Signs of RV failure
59
Q

What are causes of Pulmonary stenosis?

A
  1. congenital

2. carcinoid syndrome (rare)

60
Q

What are examination findings in pulmonary regurgitation?

A

Decrescendo, diastolic high pitched murmur (graham-steel murmur)
signs of pulmonary hypertension

Causes: pulmonary hypertension, infective endocarditis, congenital absence of the pulmonary valve

61
Q

What are core clinical signs of pulmonary hypertension?

A
  1. signs of pulmonary hypertension:
    - palpable and loud pulmonary component of S2 with splitting
    - right ventricular heave
    - pulmonary ejection flow murmur (mid-systolic)
    - prominent a-wave (forceful atrial contraction)
  2. signs of RHF
    - RV chamber dilatation resulting in tricuspid regurgitation
    - pulmonary artery dilatation, leading to pulmonary regurgitation
    - increased JVP and peripheral oedema

PLUS - tachypnoea, low CO, peripheral cyanosis, low volume pulse, S4

62
Q

What are the 5 classes of pulmonary hypertension?

A
  1. Pulmonary artery hypertension
  2. Pulmonary hypertension due to left heart disease
  3. PH due to hypoxic respiratory disease
  4. Chronic thromboembolic PH
  5. Miscellaneous
63
Q

What are causes of pulmonary arterial hypertension?

A
  1. idiopathic PAH
  2. Associated PAH
    - CTD - scleroderma, RA
    - Eisenmenger syndrome
    - Portopulmonary hypertension
    - Haematological malignancies
    - HIV infection
    - Anorexigens, drugs and toxins
64
Q

What are causes of pulmonary hypertension due to left heart disease?

A

LV dysfunction
- hypoxaemia, pulmonary oedema, sleep disordered breathing
Mitral and aortic valve disease
Restrictive cardiomyopathy or constrictive pericarditis

65
Q

What are causes of PHTn due to hypoxic disease?

A

COPD
ILD
OSA

66
Q

What are examination findings in TR?

A

JVP - large v waves, elevated if RVF
palpation - RV heave
Auscultation - pansystolic murmur at LLSE, maximal on inspiration
Abdomen - pulsatile, large tender liver, asctes

67
Q

What are causes of TR?

A 
Functional (RVF)
Valvular
- IHD with Rv pap muscle infarction
- Myxomatous degeneration
- TV prolapse
- Rheumatic (usually in combo with MR)
- Infective endocarditis (IVDU)
- Congenital (ebstein's)
- Trauma
68
Q

What are features of ebstein’s anomaly?

A
  • tricuspid leaflets displaced down towards the RV
  • atrialised RV portion
  • deficient or absent leaflets
  • often assoc with ASD

ECG shows large P waves and prolonged PR interval. RBBB, WPW.

Mx with TV replacement and closure of ASD

69
Q

What are examination features of TS?

A

JVP - giant a-waves, with slow y-descent

Auscultation - diastolic murmur at LLSE, maximal with inspiration
TR and MS often also present
No signs of pulm HTN
pre-systolic pulsation of liver (forceful atrial systole)

Causes - rheumatic heart disease

70
Q

What are fundoscopic changes of hypertension?

A

stage 1 - silver wiring
stage 2 - silver wiring + AV nipping
stage 3 - silver wiring AV nipping, haemorrhages and hard/soft exudates
Grade 4 - silver wiring, av nipping, haemorrhages, exudates and papilledema

Clinical Examination (3 decks)

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