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Basic Physician's Training Clinical Exam Monash > Cardiology Short Case > Flashcards

Cardiology Short Case Flashcards

1
Q

Causes of dominant a wave (JVP) (3)

A
  1. tricuspid stenosis
  2. pulmonary stenosis
  3. pulmonary hypertension
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2
Q

Cause of dominant v wave (JVP) (1)

A
  1. tricuspid regurgitation (important and common)
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3
Q

Causes of cannon a waves (JVP) (3)

A
  1. complete heart block
  2. paroxysmal nodal tachycardia with retrograde atrial conduction
  3. ventricular tachycardia with retrograde atrial conduction or AV dissociation
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4
Q

Causes of an elevated central venous pressure (6)

A
  1. right ventricular failure
  2. tricuspid stenosis or regurgitation
  3. pericardial effusion or constrictive pericarditis
  4. superior vena caval obstruction
  5. fluid overload
  6. hyperdynamic circulation
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5
Q

Anacrotic pulse (description and cause)

A
  1. small volume
  2. slow upstroke
  3. plus a wave on the upstroke
  4. caused by aortic stenosis
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6
Q

Plateau pulse (description and cause)

A
  1. slow upstroke

2. caused by aortic stenosis

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7
Q

Bisferiens pulse (description and cause)

A
  1. anacrotic plus collapsing

2. aortic regurgitation and aortic stenosis

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8
Q

Collapsing pulse (causes) (5)

A
  1. aortic regurgitation
  2. hyper dynamic circulation
  3. arteriosclerotic aorta
  4. patent ductus arteriosus
  5. peripheral arteriovenous aneurysm
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9
Q

Small volume pulse (causes) (2)

A
  1. aortic stenosis

2. pericardial effusion

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10
Q

Alternans pulse (description and cause)

A
  1. alternating strong and weak beats

2. caused by left ventricular failure

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11
Q

Causes of loud first heart sound (4)

A
  1. mitral stenosis
  2. tricuspid stenosis
  3. tachycardia
  4. hyperdynamic circulation
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12
Q

Causes of soft first heart sound (4)

A
  1. mitral regurgitation
  2. calcified mitral valve
  3. left bundle branch block
  4. first degree heart block
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13
Q

Causes of loud aortic second heart sound (A2) (2)

A
  1. congenital aortic stenosis

2. systemic hypertension

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14
Q

Causes of soft aortic second heart sound (A2) (2)

A
  1. calcified aortic valve

2. aortic regurgitation

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15
Q

Cause of loud pulmonary second heart sound (P2)

A

pulmonary hypertension

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16
Q

Cause of soft pulmonary second heart sound (P2)

A

pulmonary stenosis

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17
Q

Causes of increased normal splitting (4)

A
  1. right bundle branch block
  2. pulmonary stenosis
  3. ventricular septal defect
  4. mitral regurgitation (earlier A2)
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18
Q

Cause of fixed splitting

A

atrial septal defect

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19
Q

Cause of reversed splitting (P2 first) (4)

A
  1. left bundle branch block
  2. aortic stenosis (severe)
  3. coarctation of aorta
  4. patent ductus arteriosus (large)
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20
Q

Causes of a left ventricular third heart sound (S3) (6)

Mechanism - tautening of the mitral or tricuspid cusps at the end of rapid diastolic filling.

A
  1. physiological (ie. age <40 or pregnancy)
  2. left ventricular failure
  3. aortic regurgitation
  4. mitral regurgitation
  5. ventricular septal defect
  6. patent ductus arteriosus
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21
Q

Causes of a right ventricular third heart sound (S3) (2)

A
  1. right ventricular failure

2. constrictive pericarditis

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22
Q

Causes of a left ventricular fourth heart sound (S4) (5)

Mechanism - a high atrial pressure wave is reflected back from a poorly compliant ventricle, is always abnormal

A
  1. aortic stenosis
  2. acute mitral regurgitation
  3. systemic hypertension
  4. ischaemic heart disease
  5. hypertrophic cardiomyopathy
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23
Q

Causes of a right ventricular fourth heart sound (S4) (2)

A
  1. pulmonary hypertension

2. pulmonary stenosis

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24
Q

Causes of a pan systolic murmur (4)

A
  1. mitral regurgitation
  2. tricuspid regurgitation
  3. ventricular septal defect
  4. Aorta-pulmonary shunts
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25
Q

Causes of a midsystolic murmur (4)

A
  1. aortic stenosis
  2. pulmonary stenosis
  3. hypertrophic cardiomyopathy
  4. pulmonary flow murmur of an ASD
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26
Q

Causes of an early systolic murmur (3)

A
  1. ventricular septal defect (either very small, or large plus 2. pulmonary hypertension)
  2. acute mitral regurgitation
  3. tricuspid regurgitation
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27
Q

Causes of a late systolic murmur (2)

A
  1. mitral valve prolapse

2. papillary muscle dysfunction (eg. hypertrophic cardiomyopathy)

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28
Q

Causes of an early diastolic murmur (2)

A
  1. aortic regurgitation

2. pulmonary regurgitation

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29
Q

Causes of a mid-diastolic murmur (5)

A
  1. mitral stenosis
  2. tricuspid stenosis
  3. atrial myxoma
  4. Austin Flint murmur of aortic regurgitation
  5. Carey Coombs murmur of acute rheumatic fever
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30
Q

Causes of a presystolic murmur (3)

A
  1. mitral stenosis
  2. tricuspid stenosis
  3. atrial myxoma
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31
Q

Causes of a continuous murmur (6)

A
  1. patent ductus arteriosus
  2. arteriovenous fistula (coronary artery, pulmonary, systemic)
  3. venous hum (over the right supraclavicular fossa and abolished by ipsilateral compression of the internal jugular vein)
  4. rupture of a sinus of Valsalva into the right atrium or ventricle
  5. aortopulmonary connection (eg. Blalock shunt)
  6. “mammary souffle” in late pregnancy or early postpartum period
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32
Q

Causes of mitral stenosis (4)

A
  1. rheumatic (women more often than men)
  2. severe mitral annular calcification (sometimes associated with hypercalcaemia and hyperparathyroidism - rare)
  3. after mitral valve repair for mitral regurgitation
  4. congenital (very rarely, eg. parachute valve, with all chord inserting into one papillary muscle
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33
Q

Clinical signs of severe mitral stenosis (5)

A
  1. small pulse pressure
  2. early opening snap (due to raised LA pressure)
  3. length of the mid-diastolic rumbling murmur (persists as long as there is a gradient)
  4. diastolic thrill at the apex
  5. presence of pulmonary hypertension
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34
Q

Clinical signs of pulmonary hypertension (5)

A
  1. prominent a wave in the JVP
  2. right ventricular impulse
  3. loud P2, a palpable P2 is more helpful
  4. pulmonary regurgitation
  5. tricuspid regurgitation
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35
Q

Causes of chronic mitral regurgitation (6)

A
  1. degenerative disease
  2. mitral valve prolapse
  3. rheumatic
  4. papillary muscle dysfunction - LV failure, ischaemia
  5. connective tissue disease - RA, ankylosing spondylitis
  6. congenital - endocardial cushion defect (including premium atrial septal defect and cleft mitral leaflet), parachute valve, corrected transposition
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36
Q

Causes of acute mitral regurgitation (4)

A
  1. infective endocarditis (perforation of anterior leaflet), rupture of myxomatous cord
  2. myocardial infarction (chordal rupture or papillary muscle dysfunction)
  3. trauma
  4. surgery
37
Q

Clinical signs of severe mitral regurgitation (8)

A
  1. enlarge left ventricle
  2. pulmonary hypertension (late sign)
  3. third heart sound
  4. early diastolic rumble
  5. soft first heart sound
  6. aortic component of second heart sound (A2) Is earlier
  7. small volume pulse (very severe)
  8. left ventricular failure
38
Q

Dynamic manoeuvres for mitral valve prolapse (2)

A
  1. Valsalva (decreases preload) - murmur longer, click earlier
  2. Handgrip (increases afterload) or squatting (increases preload) - murmur shorter
39
Q

Associations of mitral valve prolapse (2)

A
  1. Marfan’s syndrome

2. ASD (secundum)

40
Q

Complications of mitral valve prolapse (2)

A
  1. Mitral regurgitation

2. Infective endocarditis

41
Q

Causes of chronic aortic regurgitation (7)

A

Valvular

  1. Rheumatic
  2. Congenital (eg. bicuspid valve; VSD - an associated prolapse of the aortic cusp)
  3. Seronegative arthropathy especially ankylosing spondylitis

Aortic root (murmur may be maximal at right sternal border)

  1. Marfan’s syndrome
  2. Aortitis
  3. Dissecting aneurysm
  4. Old age
42
Q

Causes of acute aortic regurgitation (4)

A

Valvular
1. Infective endocarditis

Aortic root

  1. Marfan’s syndrome
  2. Hypertension
  3. Dissecting aneurysm
43
Q

Clinical signs of severity in chronic aortic regurgitation (7)

A
  1. Collapsing pulse
  2. Wide pulse pressure
  3. Length of the decrescendo diastolic murmur
  4. Third heart sound (left ventricular)
  5. Soft aortic component of the second heart sound (A2)
  6. Austin Flint murmur (a diastolic rumble caused by limitation to mitral inflow by the regurgitation jet)
  7. Left ventricular failure
44
Q

Indications for surgery in aortic regurgitation (3)

A
  1. Symptoms
  2. Worsening LV function such as low EF
  3. Progressive LV dilatation on serial echocardiograms - LV end-systolic dimension of >5.5cm
45
Q

Causes of aortic stenosis (3)

A
  1. Degenerative senile calcific aortic stenosis (most common cause in elderly)
  2. Rheumatic (rarely isolated)
  3. Calcific bicuspid valve
46
Q

Clinical signs of severity in aortic stenosis (6)

A
  1. Plateau pulse
  2. Aortic thrill
  3. Length, harshness, and lateness of the peak of the systolic murmur
  4. Fourth heart sound (S4)
  5. Paradoxical splitting of the second heart sound (delayed left ventricular ejection and aortic valve closure)
  6. Left ventricular failure (a late sign - right ventricular failure is preterminal)
47
Q

Clinical signs of tricuspid regurgitation (5)

A
  1. JVP - large v waves
  2. Right ventricular heave
  3. Pansystolic murmur, maximal at lower end of sternum and on inspiration
  4. Pulsatile, large and tender liver
  5. Ascites and oedema
48
Q

Causes of tricuspid regurgitation (7)

A
  1. Functional (no disease of the valve leaflets) from RV failure
  2. Rheumatic (usually mitral valve disease also present)
  3. Infective endocarditis (in IVDU)
  4. Congenital - Ebstein’s anomaly
  5. Tricuspid valve prolapse (rare)
  6. Right ventricular papillary muscle infarction
  7. Trauma (usually a steering-wheel injury to the sternum)
49
Q

Clinical signs of pulmonary stenosis (8)

A
  1. Peripheral cyanosis
  2. Reduced pulse volume
  3. Giant a waves (JVP)
  4. Right ventricular heave
  5. Thrill over pulmonary area
  6. Harsh ejection systolic murmur maximal in pulmonary area and on inspiration, may be preceded by an ejection click
  7. Fourth heart sound
  8. Presystolic pulsation of the liver
50
Q

Signs of severe pulmonary stenosis (4)

A
  1. Ejection systolic murmur peaking late in systole
  2. Absence of an ejection click (also absent when the pulmonary stenosis is infundibular ie. below the valve level)
  3. Presence of fourth heart sound
  4. Signs of right ventricular failure
51
Q

Causes of pulmonary stenosis (2)

A
  1. Congenital

2. Carcinoid syndrome

52
Q

Clinical signs of chronic constrictive pericarditis (6)

A
  1. Low blood pressure and pulses paradoxus
  2. Raised JVP with Kussmaul’s sign and prominent x and y descents
  3. Impalpable apex beat
  4. Distant heart sounds with early pericardial knock or an early third heart sound
  5. Hepatosplenomegaly, ascites, oedema
  6. Cachexia
53
Q

Causes of chronic constrictive pericarditis (6)

A
  1. Radiation
  2. Tumour
  3. Tuberculosis
  4. Connective tissue disease
  5. Chronic renal failure
  6. Trauma
54
Q

Clinical features of hypertrophic cardiomyopathy (5)

A
  1. Sharp, rising, jerky pulse
  2. Prominent a wave (JVP)
  3. Double or triple impulse apex beat
  4. Auscultation
    - late systolic ejection murmur (left sternal edge)
    - pan systolic murmur (apex) from mitral regurgitation
    - fourth heart sound
  5. Dynamic manoeuvres
    - murmur is louder with Valsalva manoeuvre, standing and isotonic exercise
    - murmur is softer with squatting, raising the legs and isometric exercise (forceful handgrip)
55
Q

Echocardiogram features of hypertrophic cardiomyopathy (5)

A
  1. Asymmetrical hypertrophy of the ventricular septum
  2. Systolic anterior motion of the anterior mitral valve leaflet
  3. Midsystolic closure of the aortic valve
  4. Doppler detection of mitral regurgitation
  5. Doppler estimation of the gradient in the left ventricular outflow tract
56
Q

Clinical features of ASD: ostium secundum (3)

A
  1. Fixed splitting of the second heart sound
  2. Pulmonary systolic ejection murmur (increasing on inspiration)
  3. Pulmonary hypertension (late)
57
Q

ECG and CXR findings of ASD: ostium secundum (3 &4)

A

ECG

  1. Right axis deviation
  2. RBBB
  3. Right ventricular hypertrophy

CXR

  1. Increased pulmonary vasculature
  2. Enlarge RA and RV
  3. Dilated main pulmonary artery
  4. Small aortic knob
58
Q

Echocardiogram features of ASD: osmium secundum (5)

A
  1. Paradoxical septal motion
  2. Echo dropout in atrial septum
  3. Doppler detection of a shunt at the atrial level
  4. Shunt (bubble) study using agitated saline
  5. Right ventricular dilation
59
Q

Features of ASD: ostium primum

Clinical (6) and ECG (3)

A 
Endocardial cushion defect
Clinical 
1. Signs are similar to ASD ostium secundum with addition of 
2. Mitral regurgitation 
3. Tricuspid regurgitation
4. VSD 
5. Presence of Down syndrome 
6. Presence of skeletal upper limb defects (Holt-Oram syndrome)

ECG

  1. Left axis deviation
  2. Right bundle branch block
  3. Prolonged PR interval
60
Q

Clinical features of VSD (4)

A
  1. Palpable thrill
  2. Harsh pan systolic murmur confined to the left sternal edge
  3. Sometimes mitral regurgitation
  4. Down syndrome (association)
61
Q

Indications for surgery for VSD (3)

A
  1. Left to right shunt is moderate to large
  2. Pulmonary to systemic flow being >1.5 to 1
  3. Right ventricular dilatation
62
Q

Clinical features of patent ductus arteriosus (2)

A
  1. Differential cyanosis and clubbing (of toes, not fingers) (from reversal of the shunt)
  2. Continuous murmur
63
Q

Clinical features of coarctation of the aorta (7)

A
  1. Better developed upper body
  2. Radiofemoral delay
  3. Hypertension in the arms only
  4. Chest collateral vessels
  5. Midsystolic murmur over the precordium and back
  6. Hypertensive changes in fundi
  7. Turner’s syndrome (association)
64
Q

CXR findings of coarctation of the aorta (6)

A
  1. Enlarged left ventricle
  2. Enlarged left subclavian artery
  3. Dilated ascending aorta
  4. Aortic indentation
  5. Aortic prestenotic and poststenotic dilation
  6. Rib notching - second to sixth ribs on the inferior border
65
Q

Echocardiogram findings of coarctation of the aorta (3)

A
  1. Left ventricular hypertrophy
  2. Coarctation shelf in the descending aorta
  3. Abnormal flow patterns in the same area
66
Q

Clinical features of Eisenmenger’s syndrome

A
  1. Cyanosis
  2. Clubbing
  3. Polycythaemia
  4. Dominant a wave (JVP) and sometimes prominent v wave
  5. Right ventricular heave
  6. Palpable pulmonary component of the second heart sound (P2)
  7. Loud P2
  8. Fourth heart sound
  9. Pulmonary ejection click
  10. Pulmonary regurgitation
  11. Tricuspid regurgitation
  12. Decide on level of shunt
    - wide fixed split = ASD
    - single second sound = VSD
    - normal second sound or reversed splitting = PDA (look for differential cyanosis)
67
Q

ECG and CXR findings of Eisenmenger’s syndrome (2 & 4)

A

ECG

  1. Right ventricular hypertrophy
  2. P pulmonale

CXR

  1. Right ventricular and right atrial enlargement
  2. Pulmonary artery prominence
  3. Increased hilar vascular markings but attenuated peripheral vessels
  4. Heart that is not boot shaped
68
Q

Four features of tetralogy of Fallot (4)

A
  1. VSD
  2. Right ventricular outflow obstruction (determines severity)
  3. Overriding aorta
  4. Right ventricular hypertrophy
69
Q

Clinical features of tetralogy of Fallot (8)

A
  1. Cyanosis
  2. Clubbing
  3. Polycythaemia
  4. Right ventricular heave
  5. Left sternal edge thrill
  6. No cardiomegaly
  7. Single second heart sound
  8. Short pulmonary ejection murmur
70
Q

ECG and CXR findings of tetralogy of Fallot (2 and 4)

A

ECG

  1. Right ventricular hypertrophy
  2. Right axis deviation

CXR

  1. Normal sized heart with boot shape
  2. Right ventricular enlargement
  3. Decreased vascularity of lung vessels
  4. Right sided aortic knob, arch and descending aorta (25%)
71
Q

Renal causes of hypertension (2)

A
  1. Renovascular disease (renal artery atherosclerosis, fibromuscular disease, aneurysm, vasculitis)
  2. Diffuse renal disease
72
Q

Endocrine causes of hypertension (7)

A
  1. Conn’s syndrome
  2. Cushing’s syndrome
  3. 17 and 11-B-Hydroxylase defects
  4. Phaeochromocytoma
  5. Acromegaly
  6. Myxoedema
  7. Contraceptive pill
73
Q

Other causes of hypertension (8)

A
  1. Coarctation of the aorta
  2. Polycythaemia rubra vera
  3. Uraemia
  4. Toxaemia of pregnancy
  5. Neurogenic (increased intracranial pressure, acute intermittent porphyria, lead poisoning)
  6. Hypercalcaemia
  7. Alcohol
  8. Sleep apnoea
74
Q

Grades of hypertensive changes on fundoscopy (4)

A

Grade I - silver wiring
Grade II - arteriovenous nipping
Grade III - haemorrhages (flame-shaped), soft exudates (cotton wool spots) due to ischaemia and hard exudates due to lipid residues from leaky vessels
Grade IV - papilloedema

75
Q

Clinical features of Marfan’s syndrome (9)

A
  1. Arachnodactyly (spider fingers), joint hypermobility, long and thin limbs
  2. Long/narrow face
  3. Lens dislocation or blue sclerae
  4. High arched palate
  5. Pectus carinatum or excavatum
  6. Aortic regurgitation or mitral valve prolapse, look for signs of dissecting aneurysm or coarctation of aorta
  7. Kyphoscoliosis
  8. Arm span exceeding height
  9. Upper segment to lower segment ratio less than 0.85 (upper segment is from crown to symphysis pubis, and lower segment is from symphysis pubis to ground)
76
Q

Causes of oedema (8)

A
  1. Drugs - calcium channel blockers
  2. Cardiac - congestive cardiac failure, cor pulmonale, constrictive pericarditis
  3. Renal - nephrotic syndrome
  4. Hepatic - cirrhosis
  5. Malabsorption or starvation
  6. Protein-losing enteropathy
  7. Myxoedema
  8. Cyclical oedema
77
Q

Causes of non-pitting oedema (5)

A
  1. Malignant infiltration
  2. Congenital disease
  3. Filariasis
  4. Milroy’s disease
  5. Myxoedema
78
Q

Causes of superior vena caval obstruction (5)

A
  1. Lung carcinoma (90%)
  2. Retrosternal tumours - lymphoma, thymoma, dermoid
  3. Retrosternal goitre
  4. Massive mediastinal lymphadenopathy
  5. Aortic aneurysm
79
Q

Cardio exam position and exposure

A

45 degrees

Chest and neck exposed

80
Q

Findings on general inspection

A

Congenital syndromes: Marfan’s, Turner’s, Down
Ank spond
Acromegaly
Dyspnoea

81
Q

Findings in hands

A 
Peripheral cyanosis
Clubbing (demonstrate Schamroth's sign)
Peripheral stigmata of IE:
-splinter haemorrhages
-Osler's nodes
-Janeway lesions
Tendon xanthomata
Also take pulses:
-right, left
-radiofemoral delay if hypertension
82
Q

Cardiovascular causes of clubbing (2)

A

Infective endocarditis

Cyanotic congenital heart disease

83
Q

Findings in face

A 
Eyes:
-arcus cornea
-pallor
-jaundice
-Argyll-Robertson pupil if aortic regurgitation present
-Xantelasma
Malar flush
Mouth:
-cyanosis
-high arched palate
-dentition
-petechiae
84
Q

Findings in neck

A 
JVP height and character
-assess on right
-measure height from sternal angle
-assess throughout respiration (assess for Kussmaul's sign)
-hepatojugular reflux
Carotid pulse:
85
Q

Chest - inspection

A 
scars - front and back
pacemaker/ICD
deformities
position and character of apex beat
visible pulsations
86
Q

Chest - palpation

A

Apex beat
-5th ICS, 1cm medial to MCL
-character (pressure loaded AS, volume loaded AR MR, tapping MS, dyskinetic MI, double/triple impulse HCM)
Parasternal impulses
-left parasternal: RVH, LA enlargement
-base of heart: palpable P2, aortic thrills

87
Q

Chest - auscultation

-list the steps

A 
Mitral area
-bell then diaphragm
-identify splitting
Aortic and pulmonary areas
-time with carotid pulse
Below left clavicle for PDA
Left lateral position
-palpate for apex first
-listen with bell for MS
Sit forward
-palpate for thrills at left sternal and base again
-listen at left sternal and base, particularly AR
If systolic murmur heard - perform valsalva
88
Q

Steps after chest auscultation

A 
Respiratory
-inspect back deformity
-percuss for pleural effusion
-auscultate for crackles
-if radiofemoral delay, auscultate back for coarctation murmur
-palpate sacral oedema
Abdomen
-lay patient flat
-assess for hepatomegaly and pulsatile liver
-assess for splenomegaly
-assess for aortic aneurysm
Legs
-palpate femoral arteries and other peripheral pulses
-peripheral oedema
-toe clubbing
-achilles tendon xanthomata
-signs of peripheral vascular disease
-IE stigmata
Ask for:
-urinalysis - haematuria for IE
-temperature chart - fever for IE
-examine fundi - Roth's spots, hypertensive changes

Basic Physician's Training Clinical Exam Monash (22 decks)

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