Examination Flashcards
USE BOOK
Hands - Janeway lesions:
What are they?
Are they painful?
Where do they tend to occur?
Hands - Osler nodes:
Are they painful?
Where do they tend to occur?
What are they both a sign of?
Non-tender maculopapular erythematous palm pulp lesions
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Tender(painful) red nodules on finger pulps/thenar eminence
THINK OSLER NODES MORE PAINFUL AS THEY OCCUR ON THE FINGER TIPS
Infective endocarditis
Hands:
What is the difference between Janeway lesions and Osler nodes?
What might you see on the hands of a smoker?
Osler’s nodes and Janeway lesions are similar and point to the same diagnostic conclusion. The only noted difference between the two is that Osler’s nodes present with tenderness, while Janeway lesions do not.
Tar staining
Arm:
Xanthomata - what is the cause?
Where is it usually found?
Hyperlipidaemia
Tendons of the wrist
Arm:
Radio-radial delay:
- What is the main cause? - THINK ABOUT THE VESSELS COMING OFF OF THE AORTA
- What aortic pathology could cause this?
Subclavian artery stenosis (caused by compression by cervical rib)
Aortic dissection
Arm:
What does a collapsing pulse mean?
Narrow pulse pressure is caused by a drop in left ventricular cardiac output. This leads to diastolic dysfunction as the pressure doesn’t drop.
- What valve disease would cause this?
- What cardiac emergency would cause this? - Think reduced filling of the heart
What is a wide pulse pressure associated aortic regurg?
Aortic regurgitation
Aortic stenosis
Cardiac tamponade
This regurgitant flow causes a decrease in the diastolic blood pressure in the aorta, and therefore a widening of the pulse pressure. - THERE IS LESS BLOOD RUSHING INTO THE CHAMBER SO THERE IS LESS PRESSURE AGAINST THE VALVES AS THEY CLOSE.
Face - Malar flush:
What is it?
What valve disease is this a sign of?
And why does that happen?
Mitral stenosis
Due to back pressure and buildup of carbon dioxide (CO2).
Blood is finding it harder to get through the lungs due to the incompetence of the mitral valve. (Pulmonary HTN)
This leads to carbon dioxide not diffusing to the alveoli as well as oxygen not diffusing into the pulmonary veins.
CO2 is a natural vasodilator - therefore dilation of the superficial vessels of the fsce.
Face:
What signs might you see on the eyes that could indicate hypercholesterolaemia?
What does pale conjunctiva indicate?
What would you see with central cyanosis? - 2 specific places to look
Corneal arcus
Xanthelasma
Anaemia
Bluish discolouration of the lips and/or the tongue
Face:
What is angular stomatitis
What does angular stomatitis indicate?
What does a high arched palate suggest?
Why do you pay attention to their dental hygiene?
Inflammation of the corners of the mouth
Iron deficiency
Marfan’s syndrome which increases your risk of aortic aneurysm or dissection
A possible route for infective endocarditis
Neck:
What does a raised JVP indicate? - 3
What type of carotid pulse will aortic stenosis cause?
Fluid overload
Right ventricular failure
Tricuspid regurgitation
Slow rising
Neck:
What is the hepatojugular reflex?
• Apply pressure to the liver
• Observe the JVP for a rise
• In healthy individuals, this should last no longer than 1-2 cardiac cycles (it should then fall)
• If the rise in JVP is sustained and equal to or greater than 4cm this is a positive result
Chest - Inspection:
What operations would require the following surgical scars:
Look up each one before answering:
- Anterolateral thoracotomy scar
- Mid-sternotomy scar
- Infraclavicular scar
- Left mid-axillary scar is for ICD’s. What does iCD stand for?
https://www.bmj.com/content/354/bmj.i3905
CABG/valve surgery
Minimally invasive valve surgery
Pacemaker
Subcutaneous implantable cardioverter-defibrillator (ICD)
https://www.bmj.com/content/354/bmj.i3905
LOOK AT BOOKLET IN DESKTOP
Chest wall deformities - define the following:
Pectus excavatum
Pectus carinatum
A caved-in or sunken appearance of the chest.
A rare chest wall deformity that causes the breastbone to push outward instead of being flush against the chest. It is also known as pigeon chest or keel chest
Palpation:
What do you palpate first?
Thrills:
- Where do you feel for a thrill?
- What causes a thrill?
- What part of the hand do you use to feel for this?
- Do you place your hand vertically or horizontally across the chest?
- What does a thrill feel like?
Heaves:
- What does a heave feel like?
- What causes a heave?
- What part of the hand do you use to feel for this?
- Parasternal heaves are felt. Where is this felt and what does it suggest?
Start with flat part of fingers then move to tips of fingers until you can pinpoint it with one finger
Apex beat - feel for displacement suggestive of cardiomegaly.
Over the 4 valve areas
Due to a palpable murmur
Flat part of fingers
Horizontally
Feels like a forward pushing from the chest.
A forward motion generalised by hypertrophy of the underlying cardiac tissue.
The heel part of the hand
Each side of the sternum - RVH
Auscultation:
Why do you auscultate the carotid arteries while the patient holds their breath?
Why may it be good to start at the apex beat as you palpate the carotid pulse?
You listen to all the valves with the diaphragm and bell!
Accentuates aortic stenosis murmur
To determine first heart sound - It allows you to determine S1
Auscultation:
There are 2 types of murmurs, systolic and diastolic murmurs.
Knowing the 4 types of murmurs (left side of the heart ONLY), what 2 are systolic and what 2 are diastolic?
Aortic stenosis and mitral regurgitation **
Aortic regurgitation and mitral stenosis (ARMS)
TIP:
RILE: Right Inspiration, Left Expiration.
Systolic murmurs:
Aortic Stenosis and Mitral Regurgitation are the most common.
Between what heart sounds do these 2 occur between?
Aortic stenosis:
- What type of murmur does aortic stenosis cause?
- Why is it high pitched?
- Why is it called a crescendo-decrescendo?
Accentuating the murmur:
- How do you do this?
- Do they need to hold their breath in expiration or inspiration?
You can always have a listen to the carotids for bruits to confirm:
- Diaphragm or bell?
- What else must you get the patient to do?
Mitral regurgitation:
- It is called a pan-systolic murmur. What does pan-systolic mean?
- Where would you listen into for radiation? Do you use the diaphragm or the bell?
- How do you accentuate this murmur?
- Do you use the diaphragm or bell?
- Do they hold their breath after expiration or inspiration?
Listen to carotids using diaphragm (high velocity) - hold breath
Between S1 and S2 i.e. systolic
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An ejection systolic murmur - have a good time
Due to the high velocity
Gets louder then quieter
Sit patient forward and auscultate over the aortic area during expiration to listen for a murmur
It is present throughout systole
Left side - hold breath on expiation
Into the axilla using the diaphragm - BECAUSE IT IS HIGH VELOCITY AND PITCH SO THE DIAPHRAGM IS USED.
Diastolic murmurs:
Aortic regurgitation and mitral stenosis (think mitral valve needs to be open so blood can leak into the left ventricle before systole) are diastolic murmurs.
Between what heart sounds do these 2 occur between?
Aortic regurgitation:
- What type of murmur does this cause?
- What do you ask the patient to do to accentuate it?
- Do they hold their breath on expiration or inspiration?
- Do you use the D or B?
Mitral stenosis:
- What type of murmur does this cause?
- The accentuation is the same as mitral regurg for systolic murmurs. What should you do differently?
- Why is it low pitched and rumbling?
- Causes for mitral stenosis cause a loud S1 - LUB. Why?
SO FOR ALL ACCENTUATIONS, YOU GET THEM TO BREATH OUT AND HOLD THEIR BREATH!!!
Using the diaphragm
Between S2 and S1 i.e diastolic
Early diastolic (soft) murmur
Lean forward
Hold the breath in expiration
Mid-diastolic murmur
Using the bell
Due to low velocity
Due to thickened valves requiring more systolic pressure to close
Finishing exams:
Why do you inspect the back before listening to the base?
Coarse crackles suggest pulmonary oedema. What may suggest pleural effusion on examination? - 2
Why do you inspect the legs before feeling for oedema?
Looking for scars - posterior thoracotomy
Absent air entry and stony dullness on percussion are suggestive of an underlying pleural effusion
Scars from saphenous vein harvest for Coronary Artery Bypass Graft (CAGB)
The bell of the stethoscope is more effective at detecting low-frequency sounds, including the mid-diastolic murmur of mitral stenosis.
The diaphragm of the stethoscope is more effective at detecting high-frequency sounds, including the ejection systolic murmur of aortic stenosis, the early diastolic murmur of aortic regurgitation and the pansystolic murmur of mitral regurgitation.
The bell of the stethoscope is more effective at detecting low-frequency sounds, including the mid-diastolic murmur of mitral stenosis.
The diaphragm of the stethoscope is more effective at detecting high-frequency sounds, including the ejection systolic murmur of aortic stenosis, the early diastolic murmur of aortic regurgitation and the pansystolic murmur of mitral regurgitation.
https://www.youtube.com/watch?v=wYZbMoWjLEg
https://www.youtube.com/watch?v=dBwr2GZCmQM
https://www.youtube.com/watch?v=wYZbMoWjLEg
https://www.youtube.com/watch?v=dBwr2GZCmQM
