CVS exam

Question 1

What are abnormal findings in the hands?

Answer 1

Fever is feature of infective endocarditis (IE), pericarditis, may occur after MI (autonomic stimulation hands feel warm and sweaty but with hypotension and shock, may feel cold and clammy)
Splinter haemorrhages: IE, some vasculitic disorders
Petechiae rash: vasculitis (most often present in legs)
Janeway lesions, Osler’s nodes, nail fold infarcts and finger clubbing are uncommon features of endocarditis.
Urinanalysis is necessary to check haematuria (endocarditis, vasculitis), glucose (diabetes) and protein (hypertension and renal disease)
Clubbing: congenital cyanotic heart disease, IE, atrial myxoma (benign tumour) - any disease associated with chronic hypoxia

Question 2

What are you looking for in the face and eyes?

Answer 2

Mouth: central cyanosis, oral hygiene
Eyelids for xanthelasmata (soft yellowish plaques)
At the iris for corneal arcus (creamy yellow discolouration)
At the conjunctival for Petechiae
Central cyanosis may be due to HF or rarely, congenital heart disease associated with R to L shunting and finger clubbing,
Corneal arcus and xanthelasmata are an important predictor for CVD but can occur in normolipidaemic patients,

Question 3

What could radial radial delay and radial femoral delay indicate? What a collapsing pulse indicate?

Answer 3

Radial-femoral delay: coarctation of the aorta (congenital narrowing of the aorta, usually distal to the left subclavian artery)
A collapsing pulse is when the peak of the pulse wave arrives early and is followed by a rapid descent. This rapid fall imparts the collapsing sensation and is exaggerated by raising the patient’s arm above the level of the heart. It occurs in severe aortic regurgitation and is associated with wide pulse pressure.
Radial radial delay suggests coarctation or aortic dissection
Small volume thready pulse - shock

Question 4

What is a narrow and wide pulse pressure associated with?

Answer 4

Narrow: aortic stenosis
Wide: aortic regurgitation

Question 5

What are causes of a fast or slow pulse?

Answer 5

Tachycardia (>100bpm): sinus rhythm (exercise, pain, excitement/anxiety, fever, hyperthyroidism, sympathomimetics e.g. Salbutamol, vasodilator/s), arrhythmia (AF, atrial flutter, supraventricular tachycardia, ventricular tachycardia)
Bradycardia (

Question 6

What are causes of an irregular pulse?

Answer 6

Sinus arrhythmia
Atrial extrasystoles
Ventricular extrasystoles
Atrial fibrillation
Atrial flutter with variable response
Second degree heart block with variable response

Question 7

What are common causes of AF?

Answer 7

Hypertension
Heart failure
Myocardial infarction
Thyrotoxicosis
Alcohol-related heart disease
Mitral valve disease
Infection e.g. Respiratory, urinary 
Following surgery especially cardio thoracic surgery

Question 8

What are causes of increased pulse volume?

Answer 8

Physiological: exercise, pregnancy, advanced age, increased environmental temperature
Pathological: aortic regurgitation, peripheral vascular disease, hypertension, Paget’s disease of bone, fever, peripheral atrioventricular shunt, thyrotoxicosis, anaemia

Question 9

What is pulsus paradoxus

Answer 9

Exaggeration of the normal variability of pulse volume with breathing
Pulse column normally increases in expiration decreased during inspiration due to intrathoracic pressure changes affecting venous return to the heart.
This variability in exaggerated diastolic filling of both ventricles is impeded by increased intrapericardial pressure. This occurs in cardiac tamponade because of accumulation of pericardial fluid and in constrictive pericarditis.

Question 10

What are Korotkoff sounds?

Answer 10

These sounds are produced between systole and diastole because the artery collapses completely and reopens with each heart beat, producing a snapping or knocking sound.
The first appearance of sounds (Phase 1) during cuff deflation indicates systole. As pressure is gradually reduced, the sounds muffle (Phase 4) and then disappear (Phase 5).
Inter observer agreement is better for phase 5 and this is the diastolic BP. Occasionally muffled sounds persist (Phase 4) and do not disappear; in this case, record phase 4 as the diastolic pressure.
Phase 1: a thud
Phase 2: a blowing noise
Phase 3: a softer thud
Phase 4: a disappearing blowing noise
Phase 5: nothing

Question 11

What is implied if the BP is different in each arm?

Answer 11

A difference >10mmHg suggests the presence of subclavian artery disease.
Unequal brachial BP is a marker of increased cardiovascular morbidity and mortality .

Question 12

What happens if you use the wrong cuff size?

Answer 12

The bladder should be approximately 80% of the length and 40% of the width of the upper arm circumference.
If the cuff is too small, it will overestimate the BP
If the cuff is too big, it will underestimate the BP.

Question 13

What is the auscultatory gap?

Answer 13

Up to 20% of elderly hypertension patients have Korotkoff sounds which appear at systolic pressure and disappear for an interval between systolic and diastolic pressure.
If the first appearance of the sound is missed, the systolic pressure will be recorded at a falsely low level
Definition: the period during which Korotkoff sounds indicating true systolicpressure fade away and reappear at a lower pressure point; responsible for errors made in recording falsely low systolic blood pressure, especially in hypertensive patients, of up to 25 mm Hg, and avoided by pumping the cuff 30 mm Hg beyond palpable systolic pressure.

Question 14

How can having patient’s arm at the wrong level and postural change affect the BP?

Answer 14

The patient’s elbow should be level with the heart as hydrostatic pressure causes ~5mmHg change in recorded systolic and diastolic BP for a 7cm change in arm elevation. Arm elevation => increased hydrostatic pressure => increased BP.
Postural change: the pulse increases by about 11 bp , systolic BP falls and diastolic BP rises when a healthy person stands. The BP stabilises after 1-2 minutes. Check the BP after a patient has been standing for two minutes; a drop of 20mmHg on standing is postural hypotension.

Question 15

Why does AF make BP assessment more difficult?

Answer 15

Beat-to-beat variability.

Deflate the cuff at 2 mmHg per beat and repeat measurement if necessary

Question 16

What clinical findings indicate aortic dissection?

Answer 16

The presence of:
Chest pain that is tearing or ripping
A difference in pulse pressure of >20mmHg between arms and
Mediastinal or aortic widening on chest X-day

Question 17

Although the JVP varies with respiration (height), position of patient and rises with abdominal pressure, the carotid artery pulsation is independent of position of patient, abdominal pressure and respiration .
When is the JVP raised?

Answer 17

Elevated in states of fluid overload, notably in heart failure, conditions with right heart dilation e.g. Acute pulmonary embolism and chronic obstructive pulmonary disease (when it is called cor pulmonale).
Mechanical obstruction of the superior vena cava (most often caused by lung cancer) may cause extreme, non-pulsatile elevation of the JVP. Here the JVP no longer reflects right atrial pressure and the abdominojugular test will be negative.
It is elevated in HF, PE, pericardial effusion, pericardial constriction and SVC obstruction

Question 18

When feeling for apex beat, ask patient to roll to left if you can’t feel it initially. What are heaves and thrills?

Answer 18

A thrill is the tactile equivalent of a murmur and is a palpable vibration.
A heave is a palpable impulse that noticeably lifts your hand.
The apex beat may be impalpable in overweight or muscular people or in patients with asthma or emphysema because the lungs are hyper inflated. It may be diffusely displaced inferiorly and laterally in left ventricular dilatation e.g. After myocardial infarction with aortic stenosis, severe hypertension and dilated cardiomyopathy or in chest deformity.
Left ventricular hyper trophy e.g. With hypertension, aortic stenosis produces a forceful undisplaced apical impulse. This thrusting apical heave is quite different from the diffuse impulse of left ventricular dilatation.
Pulsation over the left parasternal area (right ventricular heave) indicates right ventricular hyper trophy or dilatation, most often accompanying pulmonary hypertension.
The tapping apex beat in mitral stenosis represents a palpable first heart sound and is not usually displaced. A double apical impulse is characteristic of hypertrophic cardiomyopathy.
The most common thrill is that of aortic stenosis which may be palpable at the apex, at the lower sternum or in the neck. The thrill caused by a ventricular septal defect is best felt at the left and right sternal edges. Diastolic thrills are very rare.

Question 19

How would you listen for Mitral Regurgitation and Mitral Stenosis murmurs?

Answer 19

MR: roll patient to the left - and listen in the left axilla (pan systolic)
MS: roll patient to the left, listen at the apex using light pressure with the bell to detect the mid-diastolic and pre-systolic murmur.

Question 20

How would you listen for Aortic Regurgitation and Aortic Stenosis murmurs?

Answer 20

AR: ask patient to sit up and lean forwards, then to breathe out fully and hold breath. Listen over the right second intercostal space and over the left sternal edge (best heard over left sternal edge) with the diaphragm for the murmur. High pitched descrendo that lasts all or part of diastole
AS: listen over the carotid arteries (ejection systolic) - with breath held

Question 21

Describe the third heart sound. Is it normal or pathological?l

Answer 21

Low pitched early diastolic sound best heard with the bell at the apex. It coincides with rapid ventricular filling immediately after opening of the AV valves. ‘Lub-dub-dum’.
Normal finding in children, young adults and during pregnancy
Usually pathological after the age of 40 years. The most common causes are left ventricular failure, when it is an early sign and mitral regurgitation, due to volume loading of the ventricle. In heart failure, S3 occurs with a tachycardia, referred to as a ‘gallop rhythm’ and S1 and S2 are quiet. Other useful signs, if present, are raised jugular venous pressure, peripheral oedema and basal lung crackles.

Question 22

What is 4th heart sound?

Answer 22

Less common than S3. Soft and low pitched.
It occurs just before S1 (da-lub-dub).
It is always pathological and is caused by forceful atrial contraction against a non-compliant or stiff ventricle.
An S4 is most often heard with left ventricular hypertrophy due to hypertension, aortic stenosis or hypertrophic cardiomyopathy. It cannot occur when there is atrial fibrillation.
Both an S3 and S4 cause a triple or gallop rhythm.

Question 23

What are causes of ejection systolic murmurs?

Answer 23

Increased flow through normal valves:
Innocent systolic e.g. Fever, athletes (bradycardia => large stroke volume), pregnancy (CO output maximum at 15 weeks
ASD (pulmonary flow murmur)
Severe anaemia
Normal or reduced flow through a stenosis valve
Aortic stenosis
Pulmonary stenosis
Other causes of flow murmurs
Hypertrophic cardiomyopathy (obstruction at sub valvular level)
Aortic regurgitation (aortic flow murmur)

Question 24

What are pansystolic murmurs called?

Answer 24

All caused by a systolic leak from a high- to lower- pressure chamber
Mitral regurgitation
Tricuspid regurgitation
Ventricular septal defect
Leaking mitral or tricuspid prosthesis

Question 25

Give an example of an early diastolic murmur

Answer 25

Term is misleading; usually the murmur lasts throughout diastole but is loudest in early systole. It is typically caused by AR .
Since the regurgitant blood volume must be ejected during the subsequent systole, significant aortic regurgitation leads to increased stroke volume and is almost always associated with a systolic flow murmur.
Pulmonary regurgitation is uncommon. May be caused by pulmonary artery dilatation in pulmonary hypertension or a congenital defect of the pulmonary valve.

Question 26

Give an example of a mid-diastolic murmur

Answer 26

Usually caused by mitral stenosis.
Low pitched, rumbling sound which may follow an opening snap ‘lap-ta-ta-Ruu ‘ (ruu the mid diastolic murmur).
The murmur is accentuated by exercise.
If the patient is in sinus rhythm, left atrial contraction increases the blood flow across the stenosis valve, leading to presystolic accentuation of the murmur.
The murmur of tricuspid stenosis is similar but rare.

Question 27

Give an example of a continuous murmur?

Answer 27

Rare in adults
The most common cause is a patent ductus arteriosus
The murmur is best heard at the upper left sternal border and radiates over the left scapula.
It’s continuous character is machinery-like.

Question 28

What are you looking for in the face, mouth and eyes?

Answer 28

Face
Mitral facies - associated with mitral stenosis

Eyes

Conjunctival pallor – anaemia – ask patient to gently pull down lower eyelid
Corneal arcus – yellowish/grey ring surrounding the iris – hypercholesterolaemia
Xanthelasma – yellow raised lesions around the eyes – hypercholesterolaemia

Mouth

Central cyanosis – bluish discolouration of lips / underneath tongue
Angular stomatitis – inflammation of corners of the mouth – iron deficiency
High arched palate – suggestive of Marfans – ↑ risk of aortic aneurysm/dissection
Dental hygiene – important if considering sources for infective endocarditis

Question 29

What signs do you look for in the hands and skin?

Answer 29

Tobacco staining
Peripheral cyanosis
Feel the temperature
Clubbing
Splinter haemorrhages (linear, reddish-brown marks along the axis of the finger and toenails, thought to be due to circulating immune complexes). One or two normal, due to trauma
Look at the palmar aspect for Janeway lesions (painless red spots which blanch on ensure, on the thenar or hypo thenar eminences), Osler's nodes (painful raised erythematous lesions which are rare)
Xanthomata
Petechiae

Question 30

How would you get the 2nd heart sound to split?

Answer 30

Ask to breathe in and then hold (deep inspiration)
You would hear the aortic valve first and then the pulmonary valve second
Can also accentuate right-sided murmurs