Cardiovascular System Flashcards
Delayed capillary refill
-shock: hypovolemia, sepsis
- hypothermia: Low body temperatures can lead to vasoconstriction and slower CRT.
- peripheral vascular disease
- congestive heart failure
- dehydration
-
Quincke sign due to nail bed pulsation
- aortic regurgitation severe
Blood pressure
Wide: - arteriosclerosis
- hyperthyroidism
- severe anemia
- aortic regurgitation
-septic shock
- patent ductus arteriosus
Possible causes of a wide pulse pressure include anything that increases stroke volume (the amount of blood pumped by the heart per beat) or decreases arterial compliance (the ability of the arteries to expand and contract with changes in pressure).
Narrow: - Aortic stenosis
- hyovolemia
- heart failure
- hypovolemia
- cardiac tamponade
Shock may occur if systole is less than 90mmHg
Corrigan’s sign refers to visible carotid artery
- aortic regurgitation
Malar flush
Is a pale, flushed central cyanosis
- systemic lupus erythematous
- mitral stenosis
- low cardiac output
Impalpable apex beat
- dextrocardia
- obesity
- copd
- thick chest wall
- pericardial effusion
Hence roll patient onto the left lateral position this may enable apex beat to be palpated
Radio-femoral delay
Coarctation of the aorta
Radio-radial
Dissection aneurysm
Graves diseases
- exopthalmus
- goitre
Parasternal heaves
- sustained, thrusting usually felt at the left sternal edge
Right ventricular enlargement
Seen in pulmonary stenosis, cor pulmonale, ASD
Thrill
Palpable murmur but felt as a vibration
At the apex auscultation
- pansystolic murmur which radiates to the axilla
- mitral regurgitation
- mitral stenosis
- Aortic stenosis
- Aortic regurgitation
Nail fold infarcts aka splinter hemorrhage
- vasculitis
- infective endocarditis
- systemic lupus erythematous
- rheumatoid arthritis
- trauma
- microemboli
- sepsis from any source
Postural hypertension
Refers to a drop in systole greater than 20mmHg or diastole greater than 10mmHg upon standing for 3-5 minutes
Heaving
- caused by outflow obstruction leading to left ventricular hypertrophy
- e.g Aortic stenosis, systemic hypertension, tricuspid regurgitation
Results from pressure overload
Aortic stenosis radiates to the carotid artery
Displaced or thrusting
- caused by volume overload leading to left ventricular hypertrophy
- e.g Aortic or mitral incompetence
Tapping
Has a palpable S1 heart sound
In mitral stenosis
Diffuse apex beat
- left ventricular failure
- dilated cardiomyopathy
Double pulse
- hypertrophic obstructive cardiomyopathy
Causes of bruits
- atherosclerosis In elderly patients
- vasculitis In the young
Auscultation of the bases of the lungs
- basal crackles: fine crackles (pulmonary oedema)
But in the ward you can hear coarse crackles - pleural effusion
Tricuspid stenosis
Origin/cause: rheumatic heart disease
Common in females than males
Usually associated with MS
Rheumatic TS is associated in some degree with TR
Spleenomegaly
Infective endocarditis
Roth spots
Infective endocarditis
Cornea Arcus
- elderly patients
- hyperlipidemia
Cvs clubbing
- infective endocarditis
- cyanotic congenital
Osler nodes
Tender nodules in finger pulps
- infective endocarditis
- systemic lupus erythematous
- typhoid fever
- gonoccocal infection
Janeway lesions
Red maculaes on palms
- infective endocarditis
Cold extremities
- hypo perfusion
- peripheral vascular disease
- Raynaud phenomenon
- congestive heart failure
- anxiety
Koilynychia
- severe iron deficiency anemia
-
Peripheral cyanosis
Cold
Raynaud’s phenomenon
Congestive heart failure, mainly central but it causes peripheral cyanosis
Copd
Shock
Venous thrombosis
Capillary refill 10
If delayed is due to reduced cardiac output or peripheral vascular disease
- shock
- dehydrated
- anemia
- hypothermia
- peripheral vascular disease
- Raynaud phenomenon
- vasodilator drugs such as beta blocker, calcium channel blocker
Pyrexia
Infective endocarditis
First three days post MI
- malaria
Gastroenteritis’s
Pulse rate
Tachycardia: exercise, anxiety, pregnancy, hyperthermia, heart failure, pulmonary embolism, CO2 retention, thyrotoxicosis, hypovolemic shock, congenital (wolf Parkinson’s white syndrome)
Bradycardia: drugs such as beta blockers, calcium channel blockers; hypothyroidism, sick sinus syndrome, vasovagal stimulation, increased intracranial pressure, in athletes (normal)
Pulse rhythm
- regular: normal sinus rhythm
- regularly irregular: second degree heart block, sinus arrhythmia, ventricular extrasystole, ventricular bigeminus
- irregularly irregular: atrial fibrillation, multiple ventricular extra systole, atrial flutter with variable block, self limiting paroxysmal arrhythmia
Atrial fibrillation
FM
- hypertension
- cardiac failure
- myocardial infarction
- thyrotoxicosis
- alcoholic heart disease
- mitral Valve disease
- infection
- following cardio thoracic surgery
Pulse volume
Low/ thready: low cardiac output (aortic stenosis, aortic dissection, arterial occlusion, mitral stenosis, coarctation of the aorta), pump failure ( heart failure, cardiomyopathy, tacharrythmia, cardiac tamponade) aortic stenosis
Bounding: thyrotoxicosis, Co2 retention, aortic regurgitation, sepsis, exercise, pregnancy, anxiety, severe anemia, fever, patent ductus arteriosus
Collapsing pulse or Watson’s water hammer pulse
- exercise
- beriberi
- pregnancy
- anxiety
- fever
- thyrotoxicosis
- aortic regurgitation
- severe anemia
- sepsis
- chronic alcoholism
- Co2 retention
- patent ductus arteriosus
- ventricular septal defect
- atrial septal defect
- arterioventricular malformations
Palpable arterial wall
Atherosclerosis
Arterial aneurysm
Arterititis as seen in Takayasu arteritis, temporal arteritis
Old age
Cordlike pulse- a pulse that is thickened and not compressible
- artherosclerosis
Macroglossia
Amyloidosis
Beckwith Weidemann syndrome
Congenital hypothyroidism ( cretinism)
Down syndrome
Acromegaly
Angioedema
Neurofibromatosis
Marfan syndrome
- arachynodactyl
- high arched palate
- lens displacement superior temporal
- long limbs
- tall for age or tall stature
- mitral valve prolapse leading to a mitral regurgitation
- curved spine
- chest abnormalities: Pectus carinatum or Pectus excavatum
Corrigan’s sign
Prominent carotid pulsations seen in Aortic regurgitation
Gum disease
- malnutrition
Infective endocarditis
- Osler nodes
- Janeway lesions
- bad oral hygiene
- Roth spots
- spleenomegaly
Elevated JVP is above 4cm above the sternal angle
Fluid overload: excessive IV fluids, renal disease, heart failure
Right ventricular systolic failure: cor pulmomale, left ventricular failure
Right ventricular diastolic failure:constrictive pericarditis and tamponade
Pulmonary hypertension
Exercise
Walking
Pericardial effusion
Tricuspid regurgitation
internal jugular vein acts as a capricious manometer of right atrial pressure. Look for the right internal
jugular vein as it passes just medial to the clavicular head of the sternocleidomastoid up behind the angle of the jaw to the earlobes. Pressure at zero (at the sternal angle) is 5cm, so add the height of the JVP with 5cm to obtain the right heart filling pressure in cm of water. A pressure above 9cm (4cm above the sternal angle at 45°) is elevated.
The carotid is not palpated at the same time
- in order to prevent stimulating reflex bradycardia due to brain hypoxia
Pulses
Pulsus tardes et parvus: Aortic stenosis
Plateau pulse: Aortic stenosis , poorly functioning left ventricule
Anacrotic pulse: Aortic stenosis
Pulsus alternates: left ventricular failure
Pulsus bisferans: Aortic stenosis, aortic regurgitation, hypertrophic cardiomyopathy, subaortic stenosis
Pulsus bigeminus: family history, caffeine, nicotine, recreational drugs, herbal medicine, over the counter drugs, thyroid disease
Bounding pulse
- anxiety
- fever
- exercise
- thyrotoxicosis
- hypertension
- aortic regurgitation
- arteriosus venous fistula
- CO2 retention
- patent ductus arteriosus
- liver failure
- sepsis
Pulsus paradoxus
- asthma
- copd
- superior vena cava obstruction
- pericardial constriction
- cardiac tamponade
- obstructive sleep apnea
systolic pressure weakens in inspiration by >10mmHg). it’s an exaggeration of the normal decrease in blood pressure that occurs when a person inhales. Pulsus paradoxus is often associated with conditions that impede the filling of the heart or that restrict heart function.
Positive hepatojugular
- right heart failure
- tricuspid regurgitation
- cardiac tamponade
- pericarditis
- inferior vena cava obstruction
Displaced apex beat laterally
- Cardiomegaly
- left ventricular dilation
- mediastinal shift: massive pleural effusion and tension pneumothorax
Parasternal heaves
- right ventricular hypertrophy
Investigations done in cvs
8
- electrocardiograph
- echocardiogram
- ambulatory ecg
- cardiac catherization
- coronary angiopathy
- cardiac stress imaging
- chest X-rays
- Ct scan and MRI
Tapping apex beat
Mitral stenosis
Mask and oxygen delivery
Patient is being given oxygen via a …. At a rate of …. L/min
Nasal prongs- 4-6l/min
Simple face mask- 8-10l/min
Rebreather or Venturi mask- 12-14l/min
Non-rebreather mask: 15l/min
Midline sternotomy scar
- Cardiac surgery: open heart surgery procedures such as CABG, heart valve repair, heart transplantation
- Thoracic surgery: thymectomy, mediastinal tumor resection, treatment for Pectus excavatum
Lung surgery: lung transplantation
Trauma for surgical exploration
Aortic regurgitation
The symptoms and signs of aortic regurgitation can vary widely, from none to severe, and may include:
Dyspnea: Shortness of breath, particularly with exertion or when lying down.
Orthopnea: Difficulty breathing while lying flat.
Paroxysmal Nocturnal Dyspnea: Waking up at night with difficulty breathing.
Fatigue or weakness: Particularly with physical exertion.
Pulmonary edema: Fluid build-up in the lungs, causing breathlessness.
Chest pain: Usually described as a pressure or tightness in the chest, typically increasing with activity and decreasing with rest.
There are also several characteristic physical examination findings, including:
Diastolic Murmur: An early high pitched diastolic decrescendo blowing murmur heard best along the left sternal border with the patient sitting up, leaning forward, and holding their breath after exhaling.
Wide Pulse Pressure: The difference between systolic and diastolic blood pressure can be large, causing bounding or “water-hammer” pulses.
Corrigan’s pulse: A rapid and forceful distension of the arterial pulse with a quick collapse.
De Musset’s sign: Bobbing of the head in time with the heartbeat.
Austin Flint murmur: A mid-diastolic rumble at the cardiac apex due to the regurgitant flow of blood interfering with the flow of blood into the ventricle from the atrium.
Quincke’s pulse: Capillary pulsations seen on the fingernails when light is shone on them.
Traube’s sign: pistol shot’ femorals, a booming sound heard over the femorals.
Duroziez’s sign: to and fro diastolic murmur heard when compressing the femo-
rals proximally with the stethoscope.
Hill’s sign: A higher systolic blood pressure in the legs compared to the arms.
Müller’s sign—systolic pulsations of the uvula.
Have a wide pulse pressure, bounding pulse, long diastolic murmur
Cardiac tamponade 1
- rapid accumulation of fluid in the pericardium. It is a pathophysiological process whereby elevated intrapericardial pressure from a pericardial effusion causes compression of the heart (especially the right ventricle)
- causes squeezing of the chambers of the right side of the heart more than the left side
- presentation: hypotension, tachycardia, jugular venous distension, muffled heart sounds, pulses paradosus, pallor, cold sweats, left ventricular failure, symptoms of right heart failure, obstructive shock- no venous return , cardiac arrest, dyspneic
Beck’s triad?
Pulses paradoxus: it is a misnomer, it is an exaggerated drop in systolic arterial BP more than 10mmhg which occurs during inspiration
Cardiac tamponade 2
- Unstable patients with suspected tamponade: Do not delay treatment for extensive diagnostic workup; proceed directly with quick pericardial fluid drainage, through either pericardiocentesis or surgery
- In stable patients, confirm the diagnosis with echocardiography (either TTE or FAST). treatment focuses on the underlying disease.
- Aetiology: Hemopericardium: accumulation of blood in pericardial space
Cardiac wall rupture (e.g., complication of post- myocardial infarction)
Chest trauma (traumatic cardiac tamponade)
Aortic dissection
Cardiac surgery (e.g., heart valve surgery, coronary bypass surgery)
Serous or serosanguinous pericardial effusion
Idiopathic
Acute pericarditis (especially viral- coxsackie b virus, novel Covid-19 but also fungal, tuberculous or bacterial)
Malignancy- lymphoma, breast ca, radiation therapy
Postpericardiotomy syndrome
Uremia
Autoimmune disorders such as SLE, rheumatoid arthritis
Hypothyroidism
Right heart failure
Cardiac tamponade 3
Diagnosis: chest X-ray- enlargement of the heart (cardiomegaly)
12 lead ECG:
Transthoracic Echo: pericardial effusion, during diastole right atrium and ventricular collapse, septum bounce, during systole more blood will pass through the tricuspid as compared to the mitral
- Pericardiocentesis which improves a hemodynamically unstable patient is cardiac tamponade
RX: in a haemodynamic ally unstable pt before pericardiocentesis is done
1. An inotrope such as dobutamine can be given to help with the contractility of the heart. Be careful as it can cause bradycardia via vasodilatation
2. Vasopressors: norepinephrine or epinephrine
3. Be careful when giving fluids
4. When pressure is stabilized, pericardiocentesis can be done.
5. If there is an underlying problem then a chest tube can be placed in
Ddx of cyanosis
Lung pathology: intra liminal obstruction such as copd, asthma, pulmonary edema, pulmonary embolism, pneumonia. Solved: when supplementatry oxygen is given
Heart: 5T’s and VSD with Eisenmenger syndrome
Rare: methaemoglobinemia
Skin discoloration Ddx
- Addison’s disease
- ACTH in bronchial carcinoma
- chronic kidney disease (when urea is raised)
- malabsorption
- cholasma (in pregnancy)
- ## haemochromatosis (bronze diabetes)
Obesity
- BMI of over 30kg/m2.
- higher waist to hip ratio, indicating central fat distribution,
- It is associated with diabetes mellitus type 2, ischaemic heart disease, dyslipidemia, osteoarthritis,
Conditions associated with obesity: Cushing syndrome, hypothyroidism,
Lifestyle change is key to treatment, to increase energy expenditure and reduce intake
Medica- tion ± surgery may be considered if the patient fulfils strict criteria
Enlarged lymph nodes
Reactive lymphadenopathy specifically refers to the enlargement of lymph nodes in response to an infection or inflammation.
Ddx:
- infections:
Bacteria- tb, STIs such as syphyllis
Viral: infective mononucleosis (EBV), HIV, CMV, infectious hepatitis
Others: toxoplasmosis
Non infective: sarcoidosis, amyloidosis,
Dermatology: eczema, psoriasis
Drugs: phenytoin
- autoimmune dx: dx where the body mistakenly attacks itself- rheumatoid arthritis, SLE
Infiltrative lymphadenopathy refers to a condition where lymph nodes are infiltrated by abnormal cells, which could be due to malignancies or certain infectious or inflammatory conditions.
Malignant
Lymphoma or leukemia: ALL, AML, CLL
Metastatic from breast, lung, prostate, kidney
Oedema Ddx
Increased hydrostatic pressure: DVT, right heart failure
Decreased oncotic pressure: low plasma protein such as: protein losing enteropathy, cirrhosis, nephrotic syndrome,
Periorbital edema: the eyelid skin is very thin so periorbital oedema is usually the first sign—think of al- lergies (contact dermatitis, eg from stings), angioedema (can be hereditary, ACEI),
Non- pitting edema: lymphoedema due to poor lymphatic drainage.
Filariasis
Weight loss
- Malnutrition
- Malignancy
- infections such as TB- bronchoscopy samples for ZN stain and TB culture. , HIV,
- diabetes Type 2
- ## hyperthyroidism in cases of increased appetite
Cachexia in cardiac failure
- cardiac cachexia
Chest pain with heart burn
heartburn’ more likely if ‘burning’, onset after eating/drinking, worse lying flat, or associated with dysphagia.
Syncope
- loss of consciousness for a short duration as a result of hypoperfusion. Causes: AV block, aortic stenosis
- how long did it last for
- is there any warning before (pre syncope)
- what was the patient doing (was it gradual or sudden)
- associated with confusion, tongue bites, incontinence , loss of memory pre/post
- any witnesses
Prodromal symptoms: Chest pain, palpitations, or dyspnoea point to a cardiac cause, eg ar- rhythmia.
Aura, headache, dysarthria, and limb weakness indicate CNS causes. During the episode: Limb jerking, tongue biting, or urinary incon- tinence? NB: hypoxia from lack of cerebral perfusion may cause seizures. Recovery: Was this rapid (arrhythmia) or prolonged, with drowsiness (seizure)?
Vertiligo
illusion of rotation of either the patient or their sur- roundings ± difficulty walking/standing, patients may fall over.
Imbalance and faintness
Imbalance, a difficulty in walking straight but without vertigo, from peripheral nerve, posterior column, cerebellar, or other central pathway failure.
Faintness ie ‘light-headedness’, seen in anaemia, BP, postural hypotension, hypoglycaemia, carotid sinus hypersensitivity, and epilepsy.
Intermittent claudication
Pain in the buttock, thigh, calf, foot
How long can patient walk before experiencing the pain
- rest pain
Ddx: DVT
Ischaemic heart disease risk factors
- hypertension
- smoking
- diabetes mellitus
- family history hyperlipidemia
Wide pulse pressure
- aortic regurgitation
- anaemia
- exercise
- pregnancy
- hyperthyroidism
- obstructive sleep apnea
- arteriosclerosis
- septic shock
Narrow pulse pressure
- aortic stenosis
- hypovolemia
- Cardiogenic shock
- cardiac tamponade
- advanced HF
Impalpable heart
- Dextrocardia
- ## COPD
A thrill
Palpable murmur
Polydactyl
Atrial septal defect
Cuff size
- ## Optimal cuff width is 40% of the arm circumference.
Postural hypotension
- This is an important cause of falls and faints in the elderly. It is defined as a drop in systolic BP >20mmHg or diastolic >10mmHg after standing for 3min vs lying.
Ddx: Hypovolaemia (early sign);
drugs, eg nitrates, diuretics, antihypertensives, antipsychotics; Addison’s
; hypopituitarism
; autonomic neuropathy (DM, multisystem atrophy); after a marathon run (peripheral resistance is low for some hours);
idiopathic.
Small volume pulses
- aortic stenosis
- shock
- pericardial effusion
Slow rising (anacrotic) pulse
Also known as parvus et tardus
This causes the pulse to rise to its peak more slowly and less forcefully than normal
- aortic stenosis
Bisferiens pulse
- combination of aortic stenosis and aortic regurgitation , HOCM, patent ductus arteriosus
pulse that feels like a double peak or “two beats” during one cardiac cycle, i.e., with each heartbeat. It is often associated with conditions that cause an irregular flow of blood out of the heart.
Pulsus alterans
alternating strong and weak beats) suggests LVF, cardiomyopathy, or aortic stenosis.
Jerky pulses
Hypertrophic CM
