Cardiology Examination and Clinical Signs Flashcards
What are splinter hemorrhage and digital infarcts?
Causes of splinter haemorrhages?
Occlusion of small vessels/capillaries (dermal papillary vessels) resulting in longitudinal hemorrhage under the nails
Causes: (m:TICS)
- Trauma (most common)
- Infective endocarditis (15%)
- Connective tissue diseases (SLE)
- Systemic vasculitis (polyarteritis nodosa)
Causes of displaced apex beat
- Left sided valvular regurgitation (AR, MR, VSD)
- Left heart failure
- Dilated CMP
Causes of undisplaced but abnormal apex beat
Heaving
- Aortic stenosis
- Coaractation of aorta
- Hypertension
Tapping
- Mitral stenosis
Causes of dextrocardia
- Kartagener syndrome
(triad: chronic sinusitis, situs inversus, bronchiectasis) - Turner syndrome
- Asplenia
Midline sternotomy scar in Cardiology
- CABG surgery - concomittant vein harvesting in lower limbs
- Valvular surgery
- Complex heart repair
Left and right thoracotomy scars in Cardiology
Right side:
- BT shunt
- PA banding
Left side:
- Coaractation repair
- PDA ligation
- BT shunt
- PA banding
Always lift up the left breast to examine for scars in female patients
What is collapsing pulse?
Causes of collapsing pulse?
Pulse with fast upstroke and fast downstroke on raising of arm
- Volume overload -> high stroke volume and bounding pulse
- Diastole -> arterial pressure fall significantly causing pulse to collapse -> widened pulse pressure
Causes:
- Aortic regurgitation (classic)
- AV fistula
- PDA
- Hyperdynamic circulation: anaemia, thyrotoxicosis, CO2 retention, fever
Description of JVP
A C X V Y
A wave: atrial systole, peaks with S1
C point: ventricular contraction, coincides with tricuspid closure
(usually not visible)
X descent: atrial relaxation, ventricular systole
V wave: passive filling of right atrium while tricuspid valve closed. Peaks after S2
Y descent: decrease right atrial pressure deu to opening of tricuspid valve
Causes of Elevated JVP
- Right heart failure
- Volume overload
- Tricuspid stenosis or regurgitation
- Pericardial effusion or constrictive pericarditis
- SVC obstruction
Causes of prominent A wave
Increased resistance to atrial emptying (during right ventricular systole)
- RV diastolic dysfunction (reduced RV compliance)
- Tricuspid stenosis
- Pulmonary hypertension
- Right ventricular outflow tract obstruction
> PS (Pulmonary stenosis)
> HOCM
Cannon A wave: RA contracts against closed TV (presystolic event)
Rises more rapidly, flickering motion
- Complete heart block
- Paroxysmal SVT or junctional tachycardia
Causes of X descent abnormalities
Exaggerated: cardiac tamponade
Diminished: AF/flutter
Causes of prominent V wave
- Tricuspid regurgitation
- ASD (v wave as high as a wave)
Causes of Y descent abnormalities
Sharp Y: constrictive or restrictive heart disease
Slow Y: tricuspid stenosis
Causes of wide pulse pressure
- High output states
- Thyrotoxicosis
- Severe anaemia
- Paget’s disease
- Beri-beri
- Pregnancy - Increased run-off of left ventricular outflow
- PDA
- AR
- AV fistula
Causes of narrow pulse pressure
- Pump problem
- Pericardial effusion
- Constrictive pericarditis
- Cardiogenic shock - Obstructive
- AS - Hypovolaemia
What is the murmur of mitral regurgitation?
Pansystolic
Loudest at apex
Radiates to axilla
What is the murmur of mitral stenosis?
Low pitch, rumbling diastolic murmur
Loudest at the apex, best heard with the patient in the left lateral position with their breath held in expiration
What murmurs might you hear in mixed aortic valve disease?
Ejection systolic murmur
Early diastolic murmur
Austin Flint murmur - rergurgitant jet passing through the aortic valve and hitting the adjacent mitral valve leaflet
What are the causes of secondary hypertension?
Renal : renal parenchymal disease, revovascular disease, CKD
Endocrine: Cushing’s, hyperaldosteronism, adrenal hyperplasia, phaeochromocytoma, acromegaly, thyroid disease
Drug induced : NSAIDs, decongestants, oral contraceptives, corticosteroids, ciclosporin, anabolic steroids, illicit drug use
OSA
Coarctation of the aorta
Which patients with hypertension should receive treatment?
10 year cardiovascular risk score >20%
Persistent BP of >160/100
All patients with co-existing diabetes or cardiovascular disease
What are the causes of unilateral diminished or absent radial pulse?
(M: STARE)
- Shunt (Blalock-Taussig) - right/left thoracotomy scar corresponding to side of diminished pulse
- Takayasu arteritis
- Atherosclerosis - a/w diabetes mellitus
- Rib (cervical) - palpate anterior to trapezius muscle
- Embolism (AF)
Describe this heart murmur
Ejection systolic murmur - AS
Crescendo-decrescdo murmur after S1, peaks in mid to late sustole and ends before S2
What is the underlying pathology of malar flush?
Development of severe pulmonary hypertension leading to low output cardiac state
Describe this heart murmur
Pansystolic murmur - MR
Describe this heart murmur
Mid diastolic murmur - MS
Describe this heart murmur
Early diastolic murmur - AR
Describe this heart sound
S3
Describe this heart sound
S4
Describe this heart sound
Midsystolic click
Cardiology Examination Steps
Inspection
1. Oxygen requirement and respiratory status (non hypoxic, not in respi distress)
2. Exposure for
- Scars: sternotomy scar, lateral chest scars, inframammary scar, lower limb scars
- Pacemaker
Peripheral
3. Digital clubbing
4. Peripheral cyanosis
5. Osler node, Janeway lesion
6. Pulse and radial-radial delay
- Rate, rhythm, character/volume
7. Collapsing pulse
Face and neck
8. Scleral jaundice, conjunctival pallor
9. High arched palate
10. JVP and hepatojugular reflex
Mediastinum
11. Re-examine scars if forgotten
12. Hear and audible clicks
13. Apex beat (and left lateral position)
- Showmanship (normal 5th ICS MCL)
- Character (heave, tapping, thrusting) and location (displaced / undisplaced)
14. Auscultate mitral, tricuspid, pulmonary, aortic
- Always palpate and time carotid pulse
- Mandatory left lateral position + expiration for mitral area (use bell also)
- Radiates to axilla
- Mandatory sitting up + expiration for aortic area (use bell also)
- Radiates to carotids
Closing
15. Bibasal crepitations
16. Sacral oedema and pedal oedema
Wishlist
17. Vitals
18. ECG
