Cardiology Short Cases Flashcards
Interpret the following physical findings:
Collapsing pulse
Wide pulse pressure
Displaced apex
Early diastolic murmur, high-pitch, blowing quality best heard at tricuspid area
+/- mid-diastolic, low-pitch rumbling murmur
Systolic flow murmur in aortic area
Thursting apex
Dx and ddx?
What maneuver next?
Aortic regurgitation
Ddx:
- Pulmonary regurgitation: no displaced apex, no collapsing pulse, not high-pitch murmur
- Mitral stenosis: has opening snap in diastole, loud S1, radiated to axilla from apex, tapping and non-displaced apex
Sit up and lean forward for murmur, best heard at tricuspid area
Causes of Aortic regurgitation?
Cusp disease:
- Rheumatic heart disease
- Infective endocarditis
- Congenital bicuspid aortic valve
- Degenerative
- Aortic dissection/ trauma
Causes of dilated aortic root/ aortic aneurysm:
- Marfan syndrome,
- syphilic aortitis,
- Seronegative arthritis: ankylosing spondylitis, psoriatic arthropathy…etc
Additional peripheral signs related to Aortic regurgitation?
→ Duroziez sign: to-and-fro murmur over femoral arteries heard
when apply pressure with stethoscope
→ Quincke’s pulse: capillary pulsation in finger tips or mucous
membranes
→ Traube’s sign: ‘pistol-shot’ systolic and diastolic sounds over
large arteries
→ De Musset’s sign: head bobbing with each heartbeat
(↑SV → transfer of momentum to head/neck)
Investigations for Aortic Regurgitation?
Investigations:
□ Blood: VDRL, blood culture (IE)
□ ECG: initially normal, later LVH + T wave inversion
□ CXR: dilated aortic arch, cardiomegaly
□ Echo: LV size and function, aortic size and Doppler for severity of regurgitant jet
Interpret the following physical findings:
Small volume and slow rising pulse Sustained and heaving apex Systolic thrill in aortic area Deceased/ soft S2 +/- S4 Ejection systolic murmur radiating to both sides of the neck, harsh
Dx/ ddx?
Why does the murmur sometimes radiate to the apex?
Aortic stenosis
D/dx:
- Aortic sclerosis: normal volume pulse,
normal/wide pulse pressure, intact S2 and no LVH
- HOCM: jerky pulse, normal S2, ↑murmur on standing
- MR: pansystolic murmur best heard at apex with radiation to axilla
Causes of aortic stenosis
Why does the murmur sometimes radiate to the apex?
Degenerative calcification
Rheumatic heart disease
Congenital bicuspid aortic valve
AS murmur radiating to apex may be more musical (high frequency vibration) and louder, known as Gallarvardin phenomenon.
It is easily confused with MR. However, in MR the S1 should be soft
Investigations for Aortic Stenosis?
□ ECG: LVH with ‘strain’ pattern
→ Strain pattern: downsloping ST depression + T wave
inversion in lateral leads
□ CXR: usually normal except in LV failure stage
□ Echo:
→ Restricted valve opening with concentric LVH
→ Mean valvular pressure gradient: ≥40mmHg = severe
→ Aortic valve area (AVA): ≤1cm = severe
Interpret the following physical findings:
JVP elevated Parasternal heave Fixed wide splitting of S2 Loud S2 Ejection systolic murmur at pulmonic area Mid-diastolic murmur at tricuspid area
Dx/Ddx?
Cause of the murmurs?
Atrial septal defect
D/dx:
Pulmonary stenosis: Soft S2 (very rare as isolated disease, usually part of Tetralogy of Fallot)
Pulmonary hypertension: Loud S2 without splitting/ Single S2
ESM at LUSB due to ↑PV flow
MDM at LLSB due to ↑TV flow
Causes of ASD?
Syndromes associated?
Failure to close foramen secundum → secundum ASD
Failure to close foramen primum → primum ASD
Down syndrome: Secundum ASD
Noonan syndrome
DiGeorge syndrome
Eisenmenger syndrome
Investigation for ASD?
Ix: can be normal in small ASD
□ CXR: cardiomegaly, RA/RV dilation, enlarged pA, pulm plethora
□ ECG: R axis deviation, RA/V dilation
→ Incomplete RBBB (in V1) due to RV dilation
→ L axis deviation + 1st degree HB in primum defect
□ Transesophageal Echo: diagnostic, evaluate size
Interpret the following physical findings:
Stunted growth Central cyanosis Digital clubbing Large A wave in JVP Left parasternal heave Loud S2 Early diastolic murmur in pulmonary area Pansystolic murmur in lower left sternal border
Causes?
Eisenmneger Syndrome
Triad of (1) congenital L-to-R shunt (2) pulmonary arterial disease (3) cyanosis
Causes of Eisenmenger syndrome and their signs:
VSD: single/closely split S2 (equalization of pressure)
ASD: fixed widely split S2
PDA: normally split S2, differential cyanosis and clubbing
Interpret the following physical findings:
Irregularly irregular pulse Lack of a wave in JVP S1 variable loudness ECG: □ No distinct P wave ± irregular baseline (fibrillation waves83) □ Narrow but irregular QRS complexes
Dx/Ddx?
Atrial fibrillation
Ddx:
Atrial flutter with variable block
Atrial tachycardia with variable block
Frequent multifocal ectopic beats
Causes of A-fib?
Mitral valve disease**
Ischemic heart disease
Thyroid heart disease
Alcohol
Hypertension
Interpret:
- Displaced Apex
- Systolic thrill
- Left parasternal heave
- Soft/ absent first heart sound + Pansystolic murmur at apex, radiation to axilla + Obscured S2
+/- ankle or sacral edema - Sinus rhythm, regular pulse
D/dx?
Causes?
Mitral regurgitation
D/dx: - VSD: murmur best heard at parasternal border and radiate to Rt sternum - TR: giant V wave in JVP, systolic murmur at Lt sternal border and pulsatile liver, accentuated by inspiration
Causes of Mitral regurgitation?
Causes:
Valvular leaflet diseases
→ Rheumatic: commonest, 50% a/w MS
→ Mitral valve prolapse due to myxomatous
degeneration of valvular leaflet
→ Infective endocarditis
→ HOCM with systolic anterior movement of mitral leaflet
□ Annulus dilatation due to LV dilatation (CAD, DCMP)
□ Ruptured chordae tendineae:
→ Degenerative or collagen disease
→ Infective, eg. IE
→ Acute rheumatic heart disease
□ Papillary muscle dysfunction: ischaemia or MI
Interpret:
Sacral or ankle edema Parasternal heave Tapping apex, not displaced Loud S1, +/- opening snap Mid-diastolic, rumbling/ low-pitch murmur at apex Redness of cheeks
Next maneuver for murmur?
D/dx?
Mitral Stenosis
Left lateral position to accentuate murmur
D/dx:
- Austin-Flint murmur of AR:
S1 soft, no Opening Snap, AR murmur
- Lt atrial myxoma
Causes of Mitral Stenosis?
Early vs late clinical outcomes?
Rheumatic heart disease (95%): less common nowadays
Others: congenital (infants), mitral annular calcification (elderly), radiation-associated (classically in
Hodgkin disease survivors), carcinoid valve disease, SLE/RA, mucopolysaccharidoses
Early: insidious onset of SOB
Late:
→ SOB at rest + orthopnoea + PND
→ Right heart failure with systemic oedema
→ Gross LAE: compression of RLN (hoarseness) and oesophagus
(dysphagia, also known as Ortner syndrome)
Interpret:
Mid to late systolic click + murmur
Best heard at apex
Next maneuvers to accentuate murmur?
D/dx?
Mitral valve prolapse
Sudden standing = earlier MVP click in systole
Sudden squatting = delayed MVP click in systole
D/dx:
- Other causes of MR, eg. DCMP
- TR
- AS
- HOCM: ESM at LLSB, non-displaced apex
Cause of MVP?
Degenerative: myxomatous degeneration
Congenital: primary AD inheritance
(Marfan’s syndrome), secundum ASD, Turner’s
syndrome, PDA …etc
Interpret:
Cyanosis and clubbing of toes
Large pulse volume or collapsing pulse
Continuous murmur across S1 S2 S1 +/- increased P2
D/dx?
Patent ductus arteriosus
D/dx: Coarctation of aorta Ruptured sinus of Valsalva aneurysm into right heart Coronary arteriovenous fistula Pulmonary arteriovenous fistula VSD and AR Venous hum
Causes of PDA?
Pulmonary trunk connected to aortic arch, causing LA, LV and PA dilation
Congenital: idiopathic or secondary to maternal rubella
Associated with other congenital heart diseases
Preterm, birth in high altitude
Interpret:
Visible, elevated JVP, one wave
Parasternal heave
Pansystolic murmur loudest in LLSB
Ankle edema
Next maneuver for murmur?
2 more classical signs?
D/dx?
Tricuspid regurgitation
Pansystolic murmur - Louder during inspiration, reduced during expiration
Pulsatile liver
Ascites
MR
VSD
Causes of Tricuspid regurgitation? (10)
Functional: right ventricular hypertrophy secondary to left ventricular failure
Rheumatic heart disease
Infective endocarditis
Pulmonary hypertension: cor pulmonale, ASD
Infarct of right ventricular papillary muscles
Tricuspid valve prolapse
Carcinoid heart disease
Trauma
Congenital
Endomyocardial fibrosis
Interpret:
Displaced apex Parasternal heave Raised JVP Systolic thrill Loud S2 Pansystolic murmur at LLSB Ejection systolic murmur at pulmonary area Mid diastolic murmur at apex
D/dx?
Causes (2)
VSD
MR, TR
Congenital: isolated or with other defects
Anterior myocardial infarction
List the cardiovascular diseases associated with: Turner's Marfan Down Cushing
Turner’s = coarctation of aorta
Down = AVSD, VSD
Marfan = MR, AR
Cushing’s = hypertension with LV hypertrophy
D/dx splinter hemorrhage
→ Most commonly due to trauma
→ Classically due to IE
→ Other causes: vasculitis (and other A/I), sepsis, haematological malignancy, profound anaemia
Differentiate Osler nodes and Janeway lesions
Osler’s nodes: red, raised, tender palpable nodules on pulp of fingers (or toes) or on thenar or
hypothenar eminence
Janeway lesions: non-tender erythematous maculopapular lesions on palms or pulps of fingers
