Cardiovascular system

Question 1

What cardiac signs and potential findings are there in the hands?

Answer 1

Temperature and capillary refill time - warm and well perfused or peripherally shut down (CRT >2)

Peripheral cyanosis - PVD, Raynaud’s, CCF or with central cyanosis

Tendon xanthomata - hypercholesterolaemia

Oslers nodes and Janeway lesions - IE

Question 2

What do you examine the nails for?

Answer 2

Finger clubbing
Koilonychia
Splinter haemorrhages
Nailfold infarcts

Question 3

Give the cardiovascular conditions associated with clubbing?

Answer 3

IE, cyanotic CHD, atrial myxoma

Question 4

What condition is koilonychia associated with?

Answer 4

Iron deficiency anaemia

Question 5

Splinter haemorrhages are associated with what?

Answer 5

IE, trauma (e.g. gardening, joinery)

Question 6

What might nailfold infarcts indicate?

Answer 6

Vasculitis, systemic lupus erythematosus

Question 7

List what you’re looking for in the radial pulse and potential findings

Answer 7

Rate (time over 15 seconds) - tachycardia/ bradycardia
Rhythm - regular/ irregular/ irregularly irregular
Volume - normal/ thread/ bounding
Character - Bisferiens pulse (mixed AR/AS), slow rising pulse (AS)

Question 8

In what condition could you find a collapsing pulse?

Answer 8

Aortic regurgitation

Question 9

Differential diagnosis for radio-radial (or femoral) delay?

Answer 9

Aortic dissection / coarctation, embolism

Question 10

List the signs and potential findings in the face

Answer 10

Malar flush - Mitral stenosis

Corneal arcus & xanthalasma - hypercholesterolaemia

Conjunctival pallor - anaemia

Central cyanosis - lung disease, cardiac shunt, abnormal Hb

Poor dentition - risk factor for IE

Question 11

Signs and indications in the neck

Answer 11

Carotid pulse (useful for assessing character): Corrigans sign (exaggerated pulsation - AR

JVP (normally

Question 12

Potential findings from inspecting the chest

Answer 12

Scars-
Pacemaker/ ICD - under either clavicle
Midline sternotomy - CABG, valve replacement
Left submammary - mitral valvotomy, pericardial windor
Legs - vein harvesting

Visible heave - Apical (LVH) or parasternal (RVH)

Question 13

Potential findings from palpating the chest

Answer 13

Apex beat - Tapping (MS), heaving (LVH), thrusting (MR/AR, LVF)

Left parasternal heave - right ventricular hypertrophy

Thrills - palpable murmur

Question 14

Concluding remarks for CVS examination

Answer 14

Review obs chard (BP, temp, SaO2)

Abdominal exam and peripheral pulses –> hepatomegaly & ascites (RHF), spenomegaly (IE), AAA

Investigations: ECG, CXR, echocardiogram
urinalysis –> Microscoptic haematuria (IE)

Question 15

Ddx Central cyanosis

Answer 15

• Hypoxic lung disease
• Right to left cardiac shunt (cyanotic congenital heart disease or Eisenmenger’s syndrome)
• Methasemoglobinaemia (drugs or toxins)

Question 16

Ddx peripheral cyanosis

Answer 16

Peripheral vascular disease
Raynaud's syndrome
Heart failure
Shock
(Central cyanosis when severe)

Question 17

Ddx Irregularly irregular pulse

Answer 17

AF
Ventricular ectopic beats (VEBs)
Complete HB + variable ventricular escape

Question 18

Causes of absent radial pulse

Answer 18

Congenital (usually bilateral)
Arterial embolism (e.g. due to AF)
Atheroma (usually subclavian)
Previous arterial line
Previous coronary angiography
Cervical rib
Coarctation of the aorta

Question 19

Six causes of AF

Answer 19

Ischaemic heart disease
Rheumatic heart disease
Thyrotoxicosis
Pneumonia
PE
Alcohol

Question 20

Kussmaul’s sign

Answer 20

Rise in JVP on inspiration (due to impaired RV filling)

Caused by tamponade, constrictive pericarditis, restrictive cardiomyopathy

Question 21

Causes of a non-palpable beat

Answer 21

1. Something between your fingers and apex
   
   • Adipose (obese pt)
   • Air (pneumothorax or emphysema)
   • Fluid (pleural or pericardial effusion)
2. Apex is not in its normal position
   
   • Displaced (usually laterally in LHF)
   • Dextrocardia

Question 22

Ddx heaving apex (LVH)

Answer 22

Aortic stenosis
Hypertension
Hypertrophic obstructive cardiomyopathy
Coarctation of the aorta

Question 23

CXR features of LHF

Answer 23

ABCDE

Alveolar oedema
kerley B lines
Cardiomegaly
upper lobe venous Diversion
pleural Effusion

Question 24

Causes of pericarditis

Answer 24

Viral (Coxsackie)
Bacterial / fungal
Immediately post -MI
Dressler's syndrome (2-10 weeks post MI)
SLE / RA/ scleroderma
Uraemia
Malignancy

Question 25

Heart sounds

Answer 25

S1 - Isovolumetric contraction - Closure of mitral and tricuspid valves

S2 - Isovolumetric relaxation - Closure of aortic and pulmonic valves

S3 - Early ventricular filling - Normal in children; in adults, associated with ventricular dilation (e.g. ventricular systolic failure)

S4 - Atrial contraction - Associated with stiff, low compliant ventricle (e.g., ventricular hypertrophy; ischemic ventricle)

Question 26

Causes of cardiac failure

Answer 26

1. Pump failure
   - IHD
   - Cardiomyopathy
   - Constrictive pericarditis
   - Arrhythmia
   - Iatrogenic (negative inotropes)
2. Excessive preload
   - Regurgitant valvular disease (MR / AR)
   - Fluid overload (renal failure, IV fluids)
3. Excessive afterload
   - AS
   - HTN
4. Isolated RHF
   - Cor pulmonary HTN
5. High-output failure (rare)
   - Anaemia
   - Pregnancy
   - Metabolic (hyperthyroidism, Pagets)

Question 27

Common presenting symptoms of heart disease

Answer 27

Chest pain
Dyspnoea
Palpitations
Syncope
Other - tiredness, lethargy, oedema,