Clinical Examination - Cardiology Flashcards
List some medical paraphernalia you might see on general inspection suggestive of Cardiovascular disease
- ECG
- Cardiac Monitoring
- GTN spray
- Oxygen supplement
- Blood glucose monitoring
- Insulin or diabetic medications
- Catheter - fluid output measured - Heart failure
- Cigarette packets
- IV furosemide
List some signs you may see on general inspection suggestive of cardiovascular disease
- Status at rest - are they comfortable
- Respiratory distress
- Are they using accessory muscles
- are they tripoding
- Body habitus
- increased - risk fo IHD
- tall and thin - think marfans
- Pallor - anaemia
- Chest - any scars or chest wall deformities
What sign might you see in the hands suggestive of marfans syndrome
Arachnodactyly (‘spider fingers’): fingers and toes are abnormally long and slender, in comparison to the palm of the hand and arch of the foot. Arachnodactyly is a feature of Marfan’s syndrome, which is associated with mitral/aortic valve prolapse and aortic dissection.
What sign in the hands is suggestive of hyperlipidaemia
Xanthomata: raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow. Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension).
What sign in the hands suggests a history of smoking?
Tar staining
What cardiovascular disease are suggested by the presence of finger clubbing?
Finger clubbing is associated with several underlying disease processes, but those most likely to appear in a cardiovascular OSCE station include congenital cyanotic heart disease, infective endocarditis and atrial myxoma (very rare).
What signs in the hands are suggestive of infective endocarditis?
- Splinter haemorrhages: a longitudinal, red-brown haemorrhage under a nail that looks like a wood splinter. Causes include local trauma, infective endocarditis, sepsis, vasculitis and psoriatic nail disease.
- Janeway lesions: non-tender, haemorrhagic lesions that occur on the thenar and hypothenar eminences of the palms (and soles). Janeway lesions are typically associated with infective endocarditis.
- Osler’s nodes: red-purple, slightly raised, tender lumps, often with a pale centre, typically found on the fingers or toes. They are typically associated with infective endocarditis.
What sign in the hands may be suggestive of heart failure?
Swollen fingers and tight rings
What sign in the hands may suggest poor circulation and what cardiovascular disease may casue this?
Cold, pale hands
Prolonged capillary refill time
This may be due to peripheral vascular disease or failure in left ventricular output.
What signs of cardiovascular disease would you look for in the arms on inspection?
- Bruising - suggestive of anticoagulation. Patients with previous ACS and those with mechanical heart valves will likely be on long term anticoagulation
- Tendon xanthomata - suggestive of dyslipidaemia.
- Track marks - IV drug use is a risk factor for infective endocarditis
What is a regularly irregular pulse suggestive of?
A dropped beat associated with second degree heart block.
What can cause a radio-radial delay?
- Subclavian artery stenosis (e.g. compression by a cervical rib)
- Aortic dissection
- Aortic coarctation
What signs would you test for in the arms to evaluate for aortic regurgitation?
- Bounding pulse (associated with aortic regurgitation as well as CO2 retention
- Wide pulse pressure: more than 100 mmHg of difference between systolic and diastolic blood pressure. Causes include aortic regurgitation and aortic dissection.
- A collapsing pulse - a forceful pulse that rapidly increases and subsequently collapses. It is also sometimes referred to as a ‘water hammer pulse’.
What would you look for in the blood pressure of someone with aortic stenosis?
Narrow pulse pressure: less than 25 mmHg of difference between the systolic and diastolic blood pressure. Causes include aortic stenosis, congestive heart failure and cardiac tamponade.
What signs would you look for in the arms that could suggest an aortic dissection?
Wide pulse pressure: more than 100 mmHg of difference between systolic and diastolic blood pressure. Causes include aortic regurgitation and aortic dissection.
Difference between arms: more than 20 mmHg difference in blood pressure between each arm is abnormal and may suggest aortic dissection
What signs of cardiovascular disease are looking for when inspecting the patients eyes?
- Conjunctival pallor: suggestive of underlying anaemia. Ask the patient to gently pull down their lower eyelid to allow you to inspect the conjunctiva.
- Corneal arcus: a hazy white, grey or blue opaque ring located in the peripheral cornea, typically occurring in patients over the age of 60. In older patients, the condition is considered benign, however, its presence in patients under the age of 50 suggests underlying hypercholesterolaemia.
- Xanthelasma: yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia.
- Kayser-Fleischer rings: dark rings that encircle the iris associated with Wilson’s disease. The disease involves abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues (including the heart where it can cause cardiomyopathy).
What sign would you look for in the cheeks of a patient that could suggest a valvular pathology? (name the valve pathology too)
Malar Flush
Seen in mitral stenosis
What sign in the mouth is associated with iron deficiency?
- Angular stomatits
- Atrophic glossitis
What sign in the mouth may be suggestive of infective endocarditis?
Poor dentition
What sign in the mouth may suggest marfans syndrome?
A high arched palate
What sign in the mouth may suggest B12 deficiency?
Beefy Glossitis
What is the normal distance of the JVP?
What cardiovascular disease could cause a raised JVP?
- 3cm above the sternal angle
- It is suggestive of increased right atrial pressure, this may be due to:
- Right-sided heart failure: commonly caused by left-sided heart failure. Pulmonary hypertension is another cause of right-sided heart failure, often occurring due to chronic obstructive pulmonary disease or interstitial lung disease.
- Tricuspid regurgitation: causes include infective endocarditis and rheumatic heart disease.
- Constrictive pericarditis: often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying causes.
What sign may be seen in the JVP when there is severe cardiac dysfunction?
Cannon A waves.
Heart block may lead to cannon A waves, in particular, third-degree (complete) heart block. It may be seen with ventricular tachycardia (VT) as a result of the underlying atrioventricular (AV) dissociation. Another cause is Pacemaker syndrome without proper synchronization of atria and ventricles
What is the sign seen in the JVP when a patient is in atrial fibrilliation?
Loss of A waves
Which valvular conidition clasically radiates to the carotids?
Aortic Stenosis
What scars may you see on the chest suggestive of previous cardiac surgery? What does each scar suggest?
- Median sternotomy scar: located in the midline of the thorax. This surgical approach is used for cardiac valve replacement and coronary artery bypass grafts (CABG)
- Anterolateral thoracotomy scar: located between the lateral border of the sternum and the mid-axillary line at the 4th or 5th intercostal space. This surgical approach is used for minimally invasive cardiac valve surgery.
- Infraclavicular scar: located in the infraclavicular region (on either side). This surgical approach is used for pacemaker insertion.
- Left mid-axillary scar: this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-defibrillator (ICD).
- A
- Sternotomy (midline)Most cardiac surgery, esp. CABG
- B
- Anterior thoracotomy (submammary)Lung biopsy, pericardial surgery
- C
- Posterolateral thoracotomy (axillary)Most non-cardiac thoracic procedures
- D
- Clamshell (bilateral subpectoral)Lung transplantation
- E
- Left subclavicular - Pacemaker insertion
What signs can you palpate for in the chest suggestive of left ventricular hypertrophy?
Displacement of the apex beat
Parasternal heaves.
An ejection systolic murmur suggests?
Aortic stenosis
A pansystolic mumur suggests?
Mirtal regurgitation
An early diastolic murmur suggests?
Aortic regurgitation
A rumbling mid diastolic murmur suggests?
mitral stenosis
What is this murmur?
Ejection systolic - aortic stenosis
What is this murmur?
Early diastolic - aortic regurgitation
What is this murmur?
Mid diastolic - mitral stenosis
What is this murmur?
Pan-systolic - mitral regurgitation
When can a S3 be considered normal?
- Young adults and children
- Pregnancy
- Athletes
What can cause the following heart sounds?
The sound is displays heart sounds I +II + III. This can be caused by:
- Severe mitral or tricuspid regurgitation
- Cardiomyopathies
- Heart failure
What can cause the following heart sounds?
These are heart sounds I+II+IV
This is caused by blood striking a non-compliant ventricle. seen in left ventricular hypertrophy and diastolic heart failure.
What is the following sign and what pathology does it suggest?
splinter haemorrhage
what is the following clinical sign and what pathology does it suggest?
Janeway lesions
Infective endocarditis
What clinical sign is this and what disease is it associated with?
Aracnodactilia
Marfans syndrome
What clinical sign is this and what pathology is it associated with?
Oslers node
infective endocarditis
What clinical sign is this and what is it associated with?
Angular stomatitis
iron deficiency
What sign is this and what is it associated with?
Normal in older people
In those under 50 years old it can suggest hypercholesterolaemia
What scar is denoted by B? What surgeries are typically performed using this incision?
Anterior thoracotomy (submammary) - Lung biopsy, pericardial surgery
- A
- Sternotomy (midline)Most cardiac surgery, esp. CABG
- B
- Anterior thoracotomy (submammary)Lung biopsy, pericardial surgery
- C
- Posterolateral thoracotomy (axillary)Most non-cardiac thoracic procedures
- D
- Clamshell (bilateral subpectoral)Lung transplantation
- E
- Left subclavicularPacemaker insertion
Which incision would you use for the placment of a pacemaker?
E
Patient has a murmur - provisional diagnosis?
Tissue valve replacement
What are the cardiac causes of clubbing?
Infective Endocarditis
Congenital Heart Defects
Atrial Myxoma
What are some differentials for a collapsing pulse?
Aortic Regurgitation
Thyrotoxicosis
Pregnancy
Anaemia
What are the features of pulmonary hypertension
- Raised JVP
- Parasternal heave
- Loud P2
- Pulsatile hepatomegaly
- Ascites/peripheral oedema
*
What are the features of pulmonary hypertension
- Raised JVP
- Parasternal heave
- Loud P2
- Pulsatile hepatomegaly
- Ascites/peripheral oedema
*
You see this scar, what should you focus on examination to find the diagnosis?
- look at the legs - vein harvesting due to CABG
- Auscultate the precordium - metallic heart sound/murmur = valve replacement
- Age of patient - if young then congenital heart defect
- Signs of immunosuppression secondary to tissue valve replacement e.g. skin lesions.
What are the features are suggestive of severe aortic stenosis?
A quiet S2 or absent S2
A narrow pulse pressure
S4 - blood hitting a hypertrophied ventricle
LVF: Decompensation
