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Developmental Milestones and Cardio Whoops > Cardiovascular Clinical Signs > Flashcards

Cardiovascular Clinical Signs Flashcards

1
Q

Short 4th & 5th metacarpals
Hypoplastic/hyperconvex nails
Wide carrying angle
Low post hairline
Neck webbing
High palate
Shield chest and wide nipples
Bicuspid AV
Coarctation of the aorta

A

Turner’s
Assoc horseshoe kidney and AI hypothyroidism

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2
Q

Right HF

A

Hepatomegaly
Edema
Ascites
Distended neck veins

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3
Q

Left HF

A

Cough
Haemoptysis
Orthopnea (SOB)
Pulmonary congestion

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4
Q

Single palmar crease

A

T21

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5
Q

Arachnodactyly

A

Marfans

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6
Q

Radial thumb abnormalities

A

VACTERL & Holt Oram

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7
Q

Overlapping fingers, CLP, ASD, VSD, micrognathia and low set ears

A

T18 (Edward’s)

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8
Q

Polydactyly, CLP, cutis aplasia, microopthlamia
Rocker bottom feet
Omphalocoele
VSD/ASD/PDA/Coarctation/Bicuspid aortic

A

T13 (Patau’s)

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9
Q

HR 4-6 years

A

75-115

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10
Q

HR NN

A

110-150

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11
Q

HR 6+

A

60-100

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12
Q

HR 2-4 years

A

85-125

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13
Q

Collapsing pulse causes

A

AR, PDA (run-off lesions)

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14
Q

Slow rising pulse causes

A

AS (impaired ejection from ventricle)

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15
Q

Pulsus paradoxus

A

Tamponade. Pericarditis. Severe asthma
- Decreased right heart functional reserve = MI and tamponade
- Right ventricular inflow or outflow obstruction = SVC obstruction or PE
- Decreased blood to the left heart due to lung hyperinflation = Asthma or anaphylaxis

Exaggeration or an increase in the fall of systolic BP beyond 10 mmHg during inspiration.

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16
Q

BP Infant 0-2yrs

A

80-95 Systolic

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17
Q

BP 2-5 yrs

A

80-100 Systolic

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18
Q

BP 5-12 years

A

90-110 Systolic

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19
Q

BP > 12 years

A

100-120 Systolic

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20
Q

Right lateral thoracotomy

A

BT Shunt; Lobectomy; TOF repair

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21
Q

Left lateral thoracotomy

A

BT shunt; Coarct repair; PDA ligation; PA band; Lobectomy

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22
Q

Widely split S2

A

ASD:
RV volume overload, such as atrial septal defect (ASD), the split is usually wide and fixed.
PS:
RV outflow obstruction, such as pulmonary stenosis.
RBBB:
Delayed RV depolarization such as complete right bundle branch block.

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23
Q

Paradoxical Split S2

A

Severe AS, LBBB, HOCM
Delayed closure of the aortic valve

Normal: S1 A2P2 (splits on inspiration)
Paradox: S1 P2A2 (splits on expiration)

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24
Q

4th HS before 1st HS

A

Reduced ventricular compliance/ Pulmonary HTN . With tachycardia = Gallop rhythm
S4 – “atrial gallop”
Occurs in late diastole
Occurs during active LV filling
Almost always abnormal
Requires a noncompliant LV
Can be a sign of diastolic congestive HF

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25
Q

Ejection click

A

AV or PV stenosis; coarct of aorta; PDA
Thickened aortic valve leaflets - bicuspid aortic valve

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26
Q

ULSE ESM

A

Pulmonary Stenosis

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27
Q

URSE ESM to carotids

A

Aortic Stenosis

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28
Q

ULSE Continuous radiates to back

A

PDA

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29
Q

MLSE/LLSE Pansystolic

A

VSD; TR
HOCM (crescendo-decrescendo, midsystolic, increased by valsalva)

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30
Q

LLSE Diastolic
1x best in exp, sit forward
2x mid

A

AR (early, best in exp, sit forward)
Mitral Stenosis (mid)
Tricuspid Stenosis (mid)

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31
Q

MLSE Continuous/diastolic

A

ASD (if large)
Classically mid systolic murmur with a split S2

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32
Q

Apex (Mitral) Pansystolic

A

Mitral regurgitation (rad to axilla)
VSD
If late, MV prolapse

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33
Q

Expiration effect on murmurs

A

Emphasises Left sided murmurs

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34
Q

Case: Small, central cyanosis, no dysmorphism.
SOB, clubbed with peripheral cyanosis. R thoracotomy scar. Continuous murmur over the right side of the chest and single 2nd HS.

A

Pulmonary Atresia
DORV
Univentricular heart + Pulmonary atresia

35
Q

Case: T21 features, No cyanosis or clubbing. Central sternotomy scar. Apex, systolic murmur

A

Mitral regurgitation after AVSD repair
If no corrected -> Eisenmenger’s

36
Q

Eisenmenger’s

A

Left to right shunt -> abnormally high blood flow and pressure to the right heart circulation = pulmonary hypertension as increased right-sided volume and pressure-> damage to the delicate pulmonary capillaries -> scar tissue. Less flexibility and compliance increases in pulmonary blood pressure, heart must pump harder, more capillary damage.
Due to increased resistance and decreased compliance of the pulmonary vessels, elevated pulmonary pressures cause RVH. When RVH causes right heart pressures to exceed that of the left , leading to reversal of blood flow through the shunt (i.e., blood moves from the right side of the heart to the left side).

37
Q

Case: Central cyanosis, normal pulses, median sternotomy scar, apex on right side with normal HS

A

Central shunt procedure: cavo-pulmonary anastomoses

38
Q

Case: Well, pink and no clubbing. Normal pulses with ESM 2/6, no radiation. Quiet when sitting forward. Normal HS

A

Innocent murmur

39
Q

Case: Well, no SOB, absent right radial pulse
Cardiac catheterisation scar. R thoracotomy scar and midline sternotomy scar.

A

Complex cardiac disease - non-specific

40
Q

Case: No cyanosis, no clubbing, no SOB. Normal pulses. 3/6 pansystolic murmur. HS normal, apex normal.

A

VSD
(Tx w diuretics +- ACE inhbitors. May need feed supplementation)

41
Q

Case: no clubbing, pulses normal, suprasternal and carotid thrill, G4 systolic murmur over aortic area with radiation to carotids PLUS G2 ESM in pulmonary area radiating to the back.
Face: widely spaced teeth, a long philtrum, and a flattened nasal bridge

A

AS, likely supravalvular 2ry to Williams PLUS branch pulmonary stenosis

Cocktail party attitude and stellate iris

42
Q

VSD
Assoc:
O/E: HS & Murmur

A

Commonest 1:500
LV overload and increased pulm blood flow
O/E: signs of HF. Displaced apex
Pansystolic murmur at LSE +- Diastolic murmur at apex = large defect.
Loud 2nd HS. Thrill L sternal edge

43
Q

VSD
ECG:
CXR:
Tx

A

ECG: biventricular hypertrophy +- LVH (Tall R waves V5 & 6; Inverse T in 1, aVL, V5 &6)
CXR: cardiomegaly
80% close spontaneously
Tx: diuretics/ACE inhibitors/supplements if mild. Surgical correction if pulm:systemic flow is >2:1.

44
Q

ASD
2 types
O/E: Murmur & HS

A

Commonest is ostium secondum (80%)
RV overload and increased pulm blood flow
O/E: Apex normal
ESM murmur at ULSE (or no murmur).
Large L -> R = Sometimes mid diastolic murmur (high flow across tricuspid)
2nd HS split and fixed.

45
Q

ASD
ECG:
Tx:

A

ECG: Secondum: RAD and pRBBB
Primum (partial AVSD): LAD and pRBBB
(Incomplete RBBB is defined as an RSR’ pattern in V1-3 with QRS duration < 120ms.)

If <6mm usually close spontaneously
Tx: Surgical correction by 3 years - can be transcatheter. Needs Abx prophylaxis as per local guidelines

46
Q

AVSD
Assoc w:
O/E: HS and murmur

A

4% of anomalies - assoc w T21
L->R shunt
O/E: HF signs
Loud S2 = pulm HTN. Post op = residual MR at apex
RV heave; thrill LLSE & pansystolic murmur.
Hepatomegaly

47
Q

AVSD
ECG:
CXR:
Tx:

A

ECG: Superior axis, RVH, prolonged PR
CXR: cardiomegaly
Tx: diuretics/ACE inhibitors/supplements if mild. Surgical correction within 1st 6 months - prevent pulm HTN.

48
Q

AR
Assoc w:
O/E: HS and murmur

A

Assoc w Ehlers Danlos/Marfans/Turners. Rheum fever, SLE. Reduced exercise tolerance.

O/E: Bounding radial pulse. Wide PP.
Decrescendo diastolic murmur on LSE - Emphasised when sitting and expiration.
Soft S1
Austin-Flint: mid-diastolic rumble

49
Q

AR
ECG:
CXR:
Tx:

A

ECG: LVH (Tall R waves V5 & 6; Inverse T in 1, aVL, V5 &6)
CXR: Cardiomegaly
Tx: Valve replacement if exercise tolerance symptoms +- anticoagulation

50
Q

PS
Assoc:
O/E: Systemic. Murmur, HS

A

Supravalvular assoc w Williams & Rubella.
Periph PA Stenosis Rubella & Alagille.
Also Noonan
PS - RV overload. In NN cyanosis from shunting thru FP = prostaglandin
O/E: RVH or thrill
ULSE ESM radiate to back.
Split 2nd HS or absent p component

51
Q

PS
ECG:
CXR:
Tx

A

ECG: Normal. If severe - RVH and RAD
CXR: Normal ? prominent R A&V.
Tx: Balloon valvuloplasty = no scar
If surgical = midline scar. Post op = residual systolic & diastolic murmur

52
Q

AS
Assoc:
O/E: Systemic; Murmur & thrill

A

Valvular assoc with Coarct/ Turners
Supravalv assoc w Williams
LV hypertrophy. SOB, syncope, CP
O/E: Severe -> Weak peripheral pulses. Narrow PP.
Suprasternal/Carotid thrill. Displaced Apex.
Ejection click at LLSE. ESM at URSE radiating to neck.
If AR: early diastolic
Radio-fem delay

53
Q

AS
ECG:
CXR:
Tx:

A

ECG: Often normal. Poss LVH (Tall R waves V5 & 6; Inverse T in 1, aVL, V5 &6)
CXR: Often normal. ?Prominent LV
Tx: If gradient >60mmHg -> balloon valvuloplasty
Post op: AS murmur and AR murmur

54
Q

Coarctation of Aorta
Assoc:
O/E: Systemic. Murmur and HS

A

Assoc w Turners. Pre-ductal more serious
Disparity in BP for UL & LL - delay in fem. BP lower in legs than arms. If R arm > L arm = L SC artery involvement
O/E: radio-fem pulses and BP
N Apex. Systolic murmur loudest at back. Ejection click in bicuspid aortic valve (70%).

55
Q

Coarctation of Aorta
ECG:
CXR:
Tx

A

ECG: Often normal. Poss LVH (Tall R waves V5 & 6; Inverse T in 1, aVL, V5 &6)
CXR: Rib notching after 7 yrs
Tx: Subclavian flap - L sided thoracotomy if normal arch. Complications: re-coarct = balloon.

56
Q

Complex Cyanotic Cardiac Disease - Shunt options

A

Modified BT shunt: Synthetic tube from systemic artery (typically right subclavian) to pulmonary artery
RSC->Pulm Art

Rarely - Classic Blalock- Taussig shunt (BT shunt): subclavian artery to right pulmonary artery
SC->Pulm Art

Central shunt: Synthetic tube from the aorta to the pulmonary artery - median sternotomy or lateral thoracotomy
Aorta -> Pulm Art

Classic: subclavian artery (left or right) and anastomosis to the ipsilateral pulmonary artery (PA).
Advantage: Shunt grows with the patient
Disadvantage: Loss of pulses in the ipsi UL & resulting decreased growth.

Modified BT shunt (MBTS) a Gore-Tex (PTFE) graft
between the innominate or subclavian artery and the
ipsilateral pulmonary artery (PA). Routinely on right side, through a lateral thoracotomy.

57
Q

Inotropes post shunt

A

If inotropic support required:
1st line: adrenaline to support cardiac performance
2nd line: noradrenaline or vasopressin if low diastolic pressure/ over-shunting (Noradrenaline or vasopressin increase SVR)

Some random shit:
Manoeuvres to increase PVR (to reduce Qp)
-Reduce oxygen
-Increase PEEP
-Allow pCO2 to rise gently (aim arterial PaCO2 ~8Kpa)
Manoeuvres to reduce SVR (to increase Qs)
-Consider reducing vasopressor therapy slowly
-Consider vasodilation – e.g. Milrinone or SNP. This may potentially worsen coronary steal by lowering diastolic BP further (discuss with intensive care consultant)

58
Q

Cardiac causes of cyanosis

A

Decreased pulmonary blood flow, e.g. tetralogy of fallot, pulmonary atresia, Ebstein’s anomaly, tricuspid atresia
Poor mixing e.g. transposition of the great arteries
Common mixing, e.g. truncus, arteriosus double outlet right ventricle, total anomalous pulmonary venous, drainage or univentricular heart

59
Q

Pulmonary atresia

A

Poor prognosis
Treatment by unifocalisation - fashioning a main pulmonary artery like structure out of which other vessels available. This can be incorporated into Glenn or Fontan operation.

60
Q

Transposition of the great arteries

A

Neonates at presentation need a prostaglandin infusion and transfer to Cardiology unit
Arterial switch is performed in the first few days

61
Q

Truncus arteriosus

A

Associated with 22Q deletion syndrome

62
Q

Double outlet right ventricle

A

Early pulmonary, banding if pulmonary blood flow is high or shunt procedure followed by definitive repair later

63
Q

Univentricular heart?

A

Palliation only
Shunt procedure if cyanosis severe
Pulmonary artery banding, if the pulmonary blood flow is high
Glenn procedure - superior vena cava to pulmonary artery
3-5y: Fontan procedure - total cavopulmonary, anastomosis

64
Q

Hypoplastic left heart syndrome

A

Left sided heart structure are underdeveloped so blood flow to aorta is minimal and therefore PDAs are essential to maintain peripheral circulation
Tx: Norwood
Bidirectional Glenn
Fontan
60% success rate

65
Q

Fallots tetralogy
Pathology
CXR & ECG
To
Complications

A

Right ventricular outflow obstruction: infundibular or pulmonary stenosis
Ventricular septal defect
Overriding aorta
Right ventricular hypertrophy

CXR: boot shaped, heart, and oligaemic lung fields
ECG: RAD RVH RAH
Tx: 1st year VSD repair and widen PS
BT shunt is a bridging option

Complications:
SOB - tet spells
Brain abscess or thrombosis
Infective endocarditis
Arrthymias

66
Q

Case: Cyanosis or clubbing
Normal pulses or absent left sided, pulse and left sided thoracotomies scar
Central sternotomy scar
Right ventricular impulse
Systolic thrill at LLSE
ESM 3/6 at ULSE -radiating to back
Shunt murmur if thoracotomy
Single 2nd HS

A

Tetralogy of Fallot

67
Q

Central cyanosis with clubbing
RV heavE
Short ESM and ejection click
Loud S2
CXR: right, ventricular prominence with small, peripheral, pulmonary vessels
ECG:RAH (peaked p waves) RVH (tall waves in V1)

A

Eisenmenger syndrome
Treated with heart, Lung transplant

68
Q

Hypertrophic cardiomyopathy

A

Auto Dom in >50%
Thick and stiff heart muscle leads to decreased cardiac output
Decrease exercise tolerance, cough and arrhythmias
End stage: LVF
Murmur: ESM or MR murmur
Tx: beta blockers and antiarrhythmics
Myectomy

69
Q

Dilated cardiomyopathy

A

Assoc muscular dystrophies, Barth syndrome
Preceding viral illness in 50%
Dilation and systolic dysfunction L>R
Sx: Cough, poor feeding, sweating, poor weight gain, shortness of breath
CXR: massive cardiomegaly w pulmonary oedema
Mx: diuretics, digoxin, ACE inhibitors, B-Blockers, ICD
End stage: transplant

70
Q

Case: displaced Apex beat. Mitral regurgitation or tricuspid regurgitation.
Third heart sound
Signs of left or right heart failure

A

Dilated cardiomyopathy

71
Q

Infective endocarditis

A

Associated with disease teeth
Signs
Fever
Oslers nodes, Janeway lesions, splinter, haemorrhages, conjunctival, petechiae, clubbing, hepatosplenomegaly, congestive cardiac failure. Mama Roth spots (retinal haemorrhage with pale centre, ) microscopic haematuria.

72
Q

Sandal gap
Middle ear disease
Hypotonia
Characteristic facies
50% CHD - VSD, AVSD then PDA or ToF

A

T21

73
Q

Hypotelorism
Antimongoloid slant
Epicanthic folds
Ptosis
Micrognathia
Low set ears
Wide nipples
Short stature, pubertal delay, cryptorchidism, hernias
Pulmonary stenosis
ASD, cardiomyopathy

A

Noonan Syndrome

74
Q

Round face with full cheeks and lips
Stellate Iris,
Strabismus
Supravalvular aortic, stenosis
Branch pulmonary artery stenosis
Hypercalcaemia
Friendly personality,

A

Williams

75
Q

Narrow palpebral fissures
Bulbous, nasal tip
Nasal speech
Cleft lip or palate
Hypotonia
Hypocalcaemia
Immune deficiency
Long face
Hypospadias
Long fingers
Aortic arch, abnormality,
Truncus arteriosus
Pulmonary atresia, or VSD

A

DiGeorge
or CATCH 22

76
Q

Coloboma
Heart disease - Fallot/ VSD/AVSD/DORV
Atresia Chonae
Retarded growth
Genital abnormalities
Ear abnormalities

A

CHARGE

77
Q

Vertebral defects
Anal atresia
Cardiac defects - Fallot/ VSD
TOF
Renal defects
Limb Abnormalities

A

VACTERL

78
Q

Abnormal tone
Microcephalic
Wide fontanelle
Growth retardation
Rocker bottom feet
Overlapping fingers
VSD/ASD/PDA/coarctation of aorta /bicuspid, aortic valve

A

T18

79
Q

Tall stature
Hypermobile
Wide span
Hi arched palate
Lens abnormalities - up and out
Scoliosis
Aortic aneurysm
AR/MR

A

Marfans

80
Q

Cigarette paper scarring
Easy bruising
Joint hypermobility
Flat foot arch
Aortic root dilation

A

Ehlers Danlos

81
Q

Flat philtrum
Developmental delay
Course features
VSD/ PDA/ ASD/ToF

A

Fetal alcohol syndrome

82
Q

Lentigines
ECG conduction abnormalities
Ocular hypertelorism
PS
Abnormalities of genitalia
Retardation of growth
Deafness

A

Leopard syndrome 

83
Q

Clubbing Differential

A

Cardiac
Congenital heart disease with cyanosis
Infective endocarditis
AV malformations

Endocrine
Acromegaly
AI Hyperthryoidism (Graves’) - acropachy
Hyperparthryoidism

Gastrointestinal
Achalasia
Coeliac disease
Cirrhosis
Crohn’s disease
Tropical sprue
Ulcerative colitis

Infectious disease
Tuberculosis

Pulmonary
Cystic fibrosis
Interstitial lung disease – particularly bronchiectesis
Abscess and empyema
Lung cancer – primary and metastatic
Sarcoidosis

Other
Hypertrophic osteopathy – primary and secondary
Malignancy
Palmoplantar keratoderma
Pregnancy
Pseudoclubbing - familial inheritance

84
Q

Pericarditis

A

Sharp CP better when sitting up, worse on inspiration
Fever, Weakness, Palpitations, SOB

Pericardial rub on LLSE, diaphoresis, hpotension, muffled HS and distension of jugular vein.

Often viral

ECG: electrical alternans

Tx: anti-inflammatory drugs
Colchicine

Developmental Milestones and Cardio Whoops (2 decks)

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