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OSCE II > CVB Clinical Medicine (except MDM) > Flashcards

CVB Clinical Medicine (except MDM) Flashcards

1
Q

What pathologies are possible if a patient has high jugular venous pressure?

A

Hypevolumemia

Heart failure (right side)

Pulmonary edema

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2
Q

What is the grade of a pulse that is absent, or that you are unable to palpate?

A

0+

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3
Q

Where should you find the point of maximum impulse of the heart?

A

The apex of the left ventricle

(5th intercostal space, left of the sternum but medial to the mid-clavicular line)

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4
Q

What symptoms would make aortic dissection a more likely diagnosis?

A
  • Tearing pain
  • Sudden onset (Acute)
  • Very severe
  • History of hypertension
  • Radiates to the back
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5
Q

What are the 5 characteristics that we use to describe murmurs?

A
  • Timing
  • Shape (crescendo? decrescendo?)
  • Location of maximum intensity
  • Radiation
  • Quality
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6
Q

How would you find a Right Ventricle Heave on physical exam?

If you found one, what pathology might be present?

A

Palpate with the heel of your hand along the left parasternal area

Normal = you don’t feel anything

RV heave = you can feel the RV contracting. This indicates pulmonary hypertension or RV hypertorphy

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7
Q

What strategy would you use to hear S3, if it is present?

A

With the patient in LLD, use light pressure to listen with the bell at the apex of the heart (5th intercostal space, between the left sternal boarder and mid-clavicular line)

If present, you would hear S3 early in every diastole (right after S2)

“WHAT THE hell” pattern

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8
Q

What is the grade of an “increased” pulse?

A

3+

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9
Q

Which symptoms would make coronary ischemia a less likely diagnosis?

A
  • Pain is sharp
  • Exercise does not make the pain worse
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10
Q

What strategy would you use to hear S4, if it is present?

A

With the patient in LLD, use light pressure to listen with the bell at the apex of the heart (5th intercostal space, between the left sternal boarder and mid-clavicular line)

If present, you would hear S4 late in every diastole (right before the next S1)

It will sound like a “gallop”

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11
Q

Why is it important to test for dyslipidemia in the clinic?

A

Dyslipidemia is a risk factor for CVD, and correcting it leads to treatment, and subsequently reduced CVD risk

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12
Q

Which cardiac pathology causes a murmer that is characterized as a…

Holosystolic murmur that does not change in intensity throughout systole

A

Mitral regurgitation

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13
Q

What is pulsus paradoxus?

How is it diagnosed?

A

If SBP on expiration is >10 mmHg higher than SBP on inspiration

  • Basically, you are taking blood pressure but letting the air out slower (2 mmHg/second)
    • Inflate the cuff
    • Gradually deflate until Korotkoff sounds are heard, but only on expiration (this is SPB on expiration)
    • Keep deflating until Korotkoff sounds are heard continuously (this is SBP on inspiration)
    • If there is >10 mmHg difference between these two numbers, pulsus paradoxus is present
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14
Q

What pathologies are indicated by S4?

A

S4 is always pathologic

It indicates forceful atrial contraction, ejecting blood in to a stiff left ventricle

This indicates hypertension or aortic stenosis with LV hypertrophy

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15
Q

Which symptoms would make aortic dissection a less likely diagnosis?

A
  • Gradual onset
  • Dull pain
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16
Q

Which cardiac pathology causes a murmer that is characterized by…

Crescendo-decrescendo during systole that can be heard diffusely

A

Aortic stenosis

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17
Q

What are the major organs that, when diseased, could cause a patient to present with chest pain?

A

In the chest: HALPP

  • Heart
  • Aorta
  • Lungs
  • Pericardium
  • Pleura

Related to digestion: SPEG (sounds like spaghetti)

  • Stomach
  • Pancreas
  • Esophagus
  • Gallbladder

Other

  • Muscle
  • Bone
  • Skin
  • Psycogenic
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18
Q

What symptoms would make a diagnosis of GERD more likely?

A
  • Pain is episodic
    • After meals
    • When lying down
  • Radiation to throat
  • Leaves sour taste in the mouth
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19
Q

Where would you palpate the popliteal artery?

A

Behind the knee

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20
Q

Where would you palpate the dorsalis pedis artery?

A

The top of the foot

(UCSD Practical Guide to Clinical Medicine)

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21
Q

List the systolic murmurs

A

Aortic stenosis

Mitral regurgitation

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22
Q

Which symptoms would make pulmonary embolism a more likely diagnosis?

A
  • Sharp pain
  • Pain is worse with inspiration
  • May have hemoptysis (coughing up blood)
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23
Q

What are the 6 life-threatening “can’t miss” diagnosis that present with chest pain?

A
  1. Coronoary ishemia
  2. Aortic dissection
  3. Pulmonary embolism
  4. Pneumothorax
  5. Esophageal rupture
  6. Pericarditis
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24
Q

Which heart sound is louder at the apex of the heart?

A. S1

B. S2

A

A. S1

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25
Q

Why is the Allen Test performed?

A

To test for ulnar artery patency; do this before puncturing the radial artery for an IV or blood draw

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26
Q

If the patient’s heart rate is <120, which is longer?

A. Diastole

B. Systole

A

A. Diastole

(S1 will occur “first” after the longer pause)

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27
Q

Which cardiac pathology causes a murmer that is characterized by…

An opening snap that is followed by a low-pitched decrescendo-crescendo rumble

A

Mitral stenosis

28
Q

What symptoms would make coronary ischemia a more likely diagnosis?

A
  • Dull pain
  • Increased pain with exercise
  • Radiation to…
    • Jaw
    • Shoulder/back
    • Angina
  • Episodic, lasting minutes to hours
29
Q

What strategy would you use to hear aortic regurgitation, if it is present?

What are you listening for?

A

Listen in the aortic area (2nd intercostal space, right of the sternum) with the patient sitting upright

  • Occurs early in diastole (after S2)
  • Woosh that decrescendos
  • Associated with wide pulse pressure
  • Heard diffusely; heart throughout the heart area
30
Q

What is the grade of a normal pulse?

A

2+

31
Q

Where would you palpate the posterior tibeal artery?

A

Under/cupping the medial malleolus

(http://lsu32.nodusstudios.com/pulses.html)

32
Q

On physical exam, you notice that the abdominal aorta is enlarged.

What is your next step?

Why?

A

Order prompt imaging (ultrasound or CT) to exclude an abdominal aortic aneurysm;

If present, risk of rupture should be assessed

33
Q

What are the markers of a positive treadmill stress test?

A
  • Significant ST depression or elevation

AND/OR

  • Patient develops angina symptoms during the test
34
Q

What is the normal range for jugular venous pulse height?

A

5-9 centimeters total

(so 0-4 cm above the Angle of Louis)

35
Q

What signs of cardiac pathology can be seen on inspection of general appearance?

A

Cyanosis

Clubbing (vasodilation of capillaries in nail beds)

Peripheral edema

36
Q

What strategy would you use to hear mitral stenosis, if it is present?

What are you listening for?

A

With the patient in LLD, use light pressure to listen with the bell at the apex of the heart (5th intercostal space, between the left sternal boarder and mid-clavicular line)

  • Occurs in mid-diastole
  • Crescendo right before S1
  • Opening snap followed by a low-pitched rumble
    • The valve begins to open, but stops
37
Q

What pathology is implicated if the point of maximal impulse of the heart is lateral to its normal position?

A

Normal position: apex of left ventricle

(5th intercostal space, left of the sternum but medial to the mid-clavicular line)

If the PMI is lateral to this, it indicates cardiomegaly

38
Q

What is the grade of a “bounding” pulse?

A

4+

39
Q

When you are listening to the heart, what are you most likely to hear (if it is present) when the patient is seated upright, leaning forward slightly?

A

Aortic regurgitation

(Listen at the left sternal border

40
Q

What strategy would you use to hear mitral regurgitation, if it is present?

What are you listening for?

A

Listen at the apex of the heart, in the mitral area (5th intercostal space, left of the sternum, medial to the mid clavicular line)

  • Occurs at the beginning of systole, continues through end of systole (holosystolic)
    • May obscure both S1 and S2
  • No change in intensity throughout duration
  • Radiates to the axilla
41
Q

If you hear bruits in the carotid arteries, how should you modify the rest of the physical exam?

A

If you hear bruits in the carotid arteries, you should not palpate

(If a plaque is present, palpation could cause it to rupture)

42
Q

Should annual stress cardiac imaging or advanced non-invasive imaging be included as part of routine follow-up in asymptomatic patients?

A

No!

May lead to unnecessary invasive procedures, excess radiation exposure if these screening tests are falsely positive

[Exception: Bypass patients >5 years after operation]

43
Q

With the patient in LLD, you use light pressure to listen with the bell at the apex of the heart

What sounds (if present) would you hear in this position?

A

S3, S4 and/or mitral regurgitation

44
Q

Does the carotid pulse occur during systole or diastole?

A

Systole

45
Q

What strategy would you use to hear aortic stenosis, if it is present?

What are you listening for?

A

Listen in the aortic area (2nd intercostal space, right of the sternum)

  • Occurs during systole
  • Crescendo-Decrescendo
  • Radiates to the carotid arteries (heard diffusely)
  • Severe
    • S2 may be absent
46
Q

How is the Allen test performed?

A
  • Ask pt to make a fist
  • Compress the radial and ulnar artery (2-3 seconds)
  • Ask pt to open their hand
    • Palm will be pale
  • Release ulnar artery only
  • If the ulnar artery is patent, the palm will return to normal color in 3-5 seconds
47
Q

If present, what pathology does pulsus paradoxus suggest?

A

Cardiac tamponade (most likely)

Pulsus paradoxus is also present in…

  • Constrictive pericarditis
  • Severe asthma
  • COPD
48
Q

Which symptoms would make pneumothorax a more likely diagnosis?

A
  • Sharp pain
  • Severe dyspnea
  • Acute onset
  • No breath sounds on one side
  • May be caused by recent trauma or spontaneous rupture
49
Q

What is the grade of a diminished, or weaker than expected pulse?

A

1+

50
Q

List some of the common components of Point of Care Tests

A
  • Minimal sample required
  • Consumable reagent cartridte
  • Easy to use operating protocol
    • Few steps, does not require laboratory expertise
  • Internal calibration, QC
  • Results available in 5-10 min or less
  • Data is printed on a screen or on paper
  • Results are documented in the patient chart
51
Q

Which heart sound is louder at the base of the heart?

A. S1

B. S2

A

B. S2

52
Q

What are the markers of a positive stress echocardiogram?

A

ECG evidence of ischemia

Wall motion abnormality (difference between rest and stress)

53
Q

How can you distinguish S1 and S2?

A

Palpate the carotid artery: The pulse occurs during systole, between S1 and S2

54
Q

Why isn’t calculated LDL cholesterol reported when TG >400 mg/dL?

A

The calculation is not accurate since TG > 400/dL indicates the presence of chylomicrons (the patient was not fasted)

55
Q

What pathologies are implicated by auscultation of S3?

A

Distended or incompliant ventricle (the sound is the rapid deceleration of blood as it hits the ventricle)

Note: S3 may be physiologic in healthy patients

56
Q

What are some of the symptoms of esophageal rupture?

A
  • Severe chest and upper abdominal pain
  • Acute onset
  • Severe vomiting and/or retching
57
Q

What is the “first line” test that can reasonably be given to anyone witt worrisome chest pain?

A

ECG

58
Q

How can you distinguish the carotid artery from the jugular vein?

A
  • Palpable?
    • Carotid is palpable
    • Jugular is not
  • Pulsations?
    • Carotid has 1 puslation
    • Jugular has 2 peaks and 2 troughs per cycle (it flickers)
  • Changes?
    • Carotid pulse does not change with respiratory cycle
    • Height of jugular flicker will change with the patient’s position and decrease with inspiration
59
Q

What does a split S2 indicate?

A

No pathology!

Splitting of S2 occurs physiologically upon inspiration.

Inspiration -> More right sided filling -> takes longer to empy -> Pulmonary valve takes longer to close than aortic valve

60
Q

List the diastolic murmurs

A

Mitral stenosis

Aortic regurgitation

61
Q

What is true about a disease that we would NOT want to screen for?

A

We would not screen for a disease that…

  • Does not have a high burden of suffering
  • Is extremely rare
  • Does not have a latent/asymptomatic period
62
Q

What 3 positions should the patient be in when you asuscultate heart sounds?

A
  • Supine
    • Majority of auscultation
  • Left lateral Decubitus (LLD)
    • 3rd and 4th heart sounds
    • Mitral stenosis murmur
  • Seated upright, leaning forward
    • Aortic regurgitation murmur: listen at left sternal border
63
Q

When you are listening to the heart, what are you most likely to hear (if it is present) when the patient is in the left lateral decubitus position (LLD)?

A

3rd and 4th heart sounds

Mitral stenosis murmur

(listen with bell)

64
Q

Which cardiac pathology causes a murmer that is characterized by…

Blowing decrescendo along the sternal boarder that begins right after S2

A

Aortic regurgitation

65
Q

What symptoms would make pericarditis a more likely diagnosis

A
  • Changing position = changing pain
    • Relief with leaning forward
    • More severe when leaning back/lying down
  • Radiation to the back
  • ECG changes are often present
  • History of virus/fever
66
Q

When you palpate with the heel of your hand along the left parasternal area, what are you looking for?

A

RV heave

Normal = you don’t feel anything

RV heave = you can feel the RV contracting. This indicates pulmonary hypertension or RV hypertorphy

67
Q

Which murmurs (systolic vs. diastolic) are always pathologic?

A

Diastolic murmurs; any sound heard during diastole is pathogenic

  • Aortic regurgitation
  • Mitral stenosis

OSCE II (4 decks)

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