PACES - Cardio Flashcards
What should you look for on inspection from the edge of the bed?
Resting state, oedema, scars, deformities, colour, ECG, O2, GTN, fluids
What should be assessed on examination of the hands
Colour, Temperature, Cap refill, Clubbing
Signs:
Splinter Haemorrhages
Osler Nodes
Janeway Lesions
Tar Staining
Tendon Xanthomata
Quinke’s Sign
What are the main cardiac causes of clubbing?
Cyanotic Congenital HD
Infective Endocarditis
Atrial Myxoma
How would you check for a collapsing pulse?
Any pain in arm/shoulder?
Raise arm above head whilst gripping forearm musculature
+ve = pulsation in forearm in AR, PDA
Causes of raised JVP
CHF/RVF
FLuid Overload
Constrictive Pericarditis
Tamponade
Pericardial Effusion
Which signs might you observe in the eyes?
Conjunctival Pallor (ask pt to pull down eyelid)
Corneal Arcus
Xanthelasma
Jaundice
Which signs might you observe in the face?
Malar Flush
Dysmorphia
De Musset’s Sign (Bobbing in AR)
Which signs might you observe in the mouth?
Cyanosis
Poor Dentition
Muller’s Sign (Bobbing of uvula in AR)
Midline Sternotomy
CABP
Open valve surgery
Cardiac Transplant
Correction of congenital cardiac defects
Anterior Thoracotomy
Lobectomy
Pneumonectomy
Clamshell Incision
Bilateral Lung Transplant
Widespread traumatic chest injury (incl large malignancy/ mediastinal malignancy resection)
Sub-Clavicular
Pacemaker Insertion
What can cause a displaced apex beat?
Cardiomegaly
LV Dilation (MR/AR)
Displacement due to RV Hypertrophy
What if you can’t feel the apex beat?
Ask patient to roll to left and exhale.
Check right in case pt dextrocardic
How do you feel for heaves?
Place the heel of your right hand over the left lower parasternal edge with a straight elbow
How do you assess for thrills?
Palpate over valve areas with pads of fingers
Manoeuvres for MR pansystolic murmur radiation
Ask patient to hold breath in expiration and listen to the axilla for radiation
Manoeuvre for Mitral Regurgitation
Listen at apex with bell
Hold expo
Roll to left lateral side
Manoeuvres for TR
Listen at Tricuspid area with bell, then diaphragm, then ask for inspiration
Auscultation at pulmonary area
Listen mainly to second heart sound
See if radiates to the back
Manoeuvre for listening to ejection systolic murmur (AS)
Louder on expiration,
Check radiation to the carotids
Manoeuvre for AR?
Early diastolic murmur
Sit pt up, lean them forward, listen for murmur when breath held in exp at aortic and tricuspid areas.
Name 4 causes of an ejection systolic murmur
AS
PS
Coarctation of the Aortic
HOCM
Name 3 causes of a pansystolic murmur
MR
TR
VSD
What might cause a late systolic murmur?
Mitral Valve Prolapse
What might cause an early systolic murmur?
Acute severe MR
What can cause an early diastolic murmur?
Aortic Regurgitation
Pulmonary Regurgitation
What can cause a mid-late diastolic murmur?
Mitral Stenosis
Austin Flint Murmur (Severe AR)
Ejection Systolic Murmur, Likely AS
Normal
S4 - Severe LVH, Diastolic HF
Mitral Stenosis
Mitral Regurgitation
What are the peripheral features of AS?
Narrow Pulse Pressure
Whart are the causes of aortic stenosis?
calcific is most common (due to inflammation in the elderly)
Congenital bicuspid 1-2%
Rheumatic fever
Supravalvular AS
When is a valve replacement indicated in AS?
Symptomatic patients
Asymptomatic if EF40%, Need for CABG, Abnormal BP when exercising, VT, small valve area
What are the main indications for a pacemaker?
Persistent symptomatic bradycardia
Complete/Mobitz 2/ Persistent Heart blocks
Resistant tachyarrhythmias
Some cardiomyopathies
What are the different types of pacemaker?
Unipolar - Cases where AV conduction is likely to return
Dual-Chamber - RA/RV, Allows paced heart to follow rate increase with exercise
Dual site Atrial - RA, Coronary SInus, RV
Biventricular - RA, RV, LV, Severe HF
ICD - Directly treats cardiac tachyarrhythmias
What do pacemaker codes mean?
1st Letter = chamber paced
2nd Letter = chamber sensed
3rd letter = response to sensed event
4th letter = rate-responsive features (exercise responsive)
5th Letter = Anti-tachycardia facilities
What can cause heart failure?
Cardiac = Preload (Fluid overload), Cardiac muscle damage (MI, cardiomyopathy, infection, CHD etc), Afterload (HTN, PE, Dissection) High output (anaemia, thyrotoxicosis, haemochromatosis, sepsis)
non-Cardiac - ARDS, PE, PHTN, Renal failure/Artery stenosis
How do you treat Heart Failure?
Conservative - Weight, restrict salt, fluid restrict, bed rest and exercise in balance.
Medication - +ve prognosis = ACEi, BBs, Statin, Aspirin, Spironolactone
Symptomatic - Digoxin? Diuretics
Name some causes of AF
Cardiac - Mitral/Aortic valve disease, MI, Pericarditis/Myocarditis
Resp - PE, Pneumonia
Metabolic - thyrotoxicosis, Alcohol, stimulant drugs
Other - Idiopathic, Post surgery, sepsis
How do you do a cardio exam?
Inspect
Hands - Temp, CRT
Radial Pulse, RR Delay
Collapsing Pulse
OFFER BP both arms lying standing
Face, eyes, mouth
Neck - JVP, HJR, Carotid (Bruit)
Inspect chest with arms up, look for chest wall deformities and scars
Palpation - Heaves, Thrills, Apex beat
Auscultate all valves
Mitral area, roll onto bell breathe out
Aortic area, sit forwards, breathe out
Lung bases
Sacral Oedema
Legs
What causes a collapsing pulse?
Aortic regurg
Thyrotoxicosis
Anaemia
Pregnancy
What might cause an absent radial pulse?
Unusual anatomy
Trauma
Coarctation of the aorta
Artherosclerosis
Ecchymoses from anticoagulation
Malar Flush - Mitral Stenosis
High arched palate - Marfan’s, associated with Mitral valve prolapse and aortic regurgitation
What can cause a raised JVP
CCF, RHF, Cor Pulmonale
Constrictive Pericarditis
Tricuspid regurgitation
Which other signs would help diagnosis in a pt with a midline sternotomy?
Metallci click - metallic valve
Murmur - Tissue valve
Vein harvest on legs - CABG
Young - Congenital repair
Immunosuppressed = Heart transplant
Nothing = tamponade?
How do pacemakers work?
Usually for bradyarrhythmias
Either inhibit early contractions or pace late ones.
Pectus Excavatum
Pectus Carinatum
What does a displaced apex beat indicate?
Dilated cardiomyopathy
Regurgitation
What does a heaving apex beat indicate?
Pressure overload
Stenosis
Signs of AS?
Slow rising pulse (feel with four fingers across the pulse)
Heaving apex
ESM, quiet S2, radiates to carotid
Signs of MR?
L Parasternal heave
Displaced Apex
PSM, Soft S1, Quiet S2, Radiates to axilla
Signs of AR?
Aortic thrill
Displaced apex
EDM at LLSE
Collapsing pulse, wide PP, LVF
De Musset’s (Head bobbing)
Muller’s (Uvula)
Quincke’s Sign (Pulsating nail beds)
MS Signs
L Parasternal heave
Malar flush
MDM, Loud S1, early diastolic opening snap
How would you check a valve replacement is functioning properly?
INR and Hb check (MAHA)
Echo
Endocarditis advice
CABG scar from vein harvest
Likely greater saphenous vein
DVT
How would you present a cardio exam?
