Cardiovascular medicine

Question 1

Endocarditis signs/symptoms

Answer 1

Constitutional symptoms - fevers, chills, malaise
New onset murmur
Arrhythmias
Tachycardia + tachypnoae

Signs of HF

• Dyspnoea + cough (left-sided)
• Edema + raised JVP

Signs to other organs: glomerulonephritis, septic emboli

Question 2

Major risk factor for aortic aneurysm vs aortic dissection

Answer 2

Aortic dissection = hypertension (70%) or trauma

Aortic aneurysm = atherosclerosis.

Question 3

TCP myocarditis

Answer 3

25yo F presents with viral prodrome 1-2 weeks (fever, arthralgia, myalgia) now is experiencing palpitations (sec to arrhythmia) + chest pain (myopericarditis)

Question 4

What complication of myocarditis? Signs?

Answer 4

Pericarditis. You get chest pain, pain

Question 5

TCP prinzmetal angina

Answer 5

60yo F heavy smoker, drinker and drinks 9 cups of coffee a day present with transient chest pain waking her up between 12-8am from sleep, not exertional, at rest.

Question 6

TCP aortic dissection

Answer 6

63yo M with long-standing HTN presents with 10/10 chest pain, “tearing quality, very sudden onset, radiates to back and down left leg “tearing” quality.

Question 7

2 clinical signs of inferior wall infarct?

Answer 7

Epigastric pain + bradycardia

Question 8

Triad for RV infarct

Answer 8

Hypotension, clear lung fields, raised JVP

Question 9

Stable angina features

Answer 9

Not positional, no autonomic signs (diaphoresis)
Exertion
Pain subsides with rest or GTN

Common triggers are mental or physical stress, or exposure to cold.

Question 10

TCP unstable angina

Answer 10

64yo M with multiple CV risk factors experiences severe constant angina lasting >30 mins, getting worse (crescendo), came on at rest, not relived by GTN. Has autonomic signs.

Question 11

What clinical signs do we look for in constrictive pericarditis?

Answer 11

Signs of forward failure
Signs of backward failure - JVP raised, Kussmauls sign positive, tender RUQ
Signs specific to constrictive pericarditis:
- Pericardial knock ( + obvs friction rub - same signs as normal pericarditis)
- Pulsus paradoxus
- Apex beat impalpable

Question 12

Features of pericarditis ECG

ECG feature progression

Answer 12

 Widespread ST segment elevation= concave or “saddle-shaped”
 PR segment depression inferior leads
 Spodicks signs: down-sloping of TP segments lead II, lateral precordial
 IF there is an effusion: loss of R wave voltage, electrical alternaans, tachycardia
 After several days, ST segments normalise + T waves become inverted - absent Q waves

Progression
ST elevation widespread + PR depression in inferior leads
Pseudonormalisation of ST segment + T wave flattening
T wave inversion
normal ECG

Question 13

TCP pericarditis

Answer 13

25yo febrile pt with recent viral infection presents with sharp, pleuritic chest pain radiating to left shoulder, that is alleviated by sitting up and learning forward, exacerbated when lying down.

78yo man with chronic kidney disease that has acute hyperuricemia presents with sharp, pleuritic chest pain radiating to left shoulder, is alleviated by sitting up and learning forward, exacerbated when lying down.

Question 14

Sign of aortic regurgitation [2]

Answer 14

Diastolic decrescendo murmur + collapsing pulse

Question 15

10 things to examine for with aortic dissection

Answer 15

1. Signs of trauma
2. Syndromic features
3. Stigmata of atherosclerosis
4. Tamponade signs
5. Aortic regurgitation signs
6. Stroke signs (carotid dissection)
7. Radial-radial delay
8. Paraplegia – spinal cord artery
9. Abdominal pain – mesenteric ischaeime
10. Limb ischaemia

Not forgetting mucosal hydration and signs of decreased CO

Question 16

What are the two age groups that aortic dissection occurs in clinically?

Answer 16

Aortic dissection occurs mainly in two age groups:

1. Men aged 40-69 with hypertension (90% of cases)
2. Younger patients (<40) with CT abnormalities that affect the aorta (e.g. marfans) (10%)

Question 17

What is the most common cause of acute limb ischaemia?

Answer 17

Arterial emboli

Question 18

What is the oncogene involved in the development of melenoma - incorporate this into brief pathogenesis

Answer 18

UV exposure –> mutation in oncogene P53 –> dysplasia + neoplasia

Question 19

Risk factors for DVT using acronym

Answer 19

RISK FACTORS = “THROMBOSIS”
Travel + trauma
Hypercoagulable/HRT
Recreational drugs 
Old (>60)
Malignancy
Blood disorders 
Obesity/obstetrics
Surgery/smoking
Immobilisation/iatrogenic (thrombophlebitis)
Sickness – coronary heart disease/MI, nephrotic syndrome, vasculitis

Question 20

Signs of massive pulmonary embolus on examination? omit vitals, obviously bad

Answer 20

Loud P2
RV heave
S3 gallop over RV area
Raised JVP
Tricuspid regurgitation murmur

All of this: L) 2nd intercostal space

Question 21

Wells criteria DVT vs Wells criteria for PE - what do they look at ? What is their cut off for high likelihood?

Answer 21

Wells DVT - clinical risk stratification for DVT, ≥3 is high likelihood
Wells PE - determines clinical probability of PE, > 6 means PE likely

Question 22

Differentials for secondary hypertension? list 5

Answer 22

1. Cushings
2. Conns
3. Pheo
4. Hyperparathyroidism
5. Hyperthyroidism

Question 23

What investigations would you perform to exclude an aortic dissection?

Answer 23

Low risk patients = CXR only - widened mediastinum positive finding
Others: CXR with widened mediastinum –> CT angiogram