Pathophysiology and examination

Question 1

Finger clubbing causes

Answer 1

Clubbed fingers is a symptom of disease, often of the heart or lungs which cause chronically low blood levels of oxygen.

Cardiovascular = infective endocarditis, cyanotic congenital heart failure

Respiratory = lung cancer, cystic fibrosis, bronchiectasis, interstitial lung disease

(VEGF increased in response to lack of oxygen to promote angiogenesis which disorts shape of fingers)

Question 2

xanthomata

Answer 2

lipid deposits on the skin - appear as yellow deposits which are cholesterol-enriched.

Could appear in hands, wrists, elbows.

can also appear in eye but known here as xanthelasma.

associated wit hyperlipidemia (risk factor for coronary heart disease, hypertension).

Question 3

Arachnodactyly

Answer 3

abnormally long and slender toes and fingers in contrast to size of palms/foot.

“spider fingers”

characteristic of marfan syndrome (connective tissue disorder) which can cause mitral/aortic valve prolapse and aortic dissection.

Question 4

splinter haemorrhages

Answer 4

can allude to many disorders such as infective endocarditis, congenital heart disease, vasculitis, infection of nail, local trauma

caused due to tiny blood clots which damage capillaries

Question 5

Janeway lesions and Osler nodes

Answer 5

These are strongly associated with infective endocarditis

Janeway lesions = red/purple dots on palms. Non-tender lumps

Osler nodes = red/purple dots on fingers. Tender lumps

Question 6

conjunctival pallor

Answer 6

suggestive of anaemia

Question 7

Kayser-Fleischer rings

Answer 7

dark circle around the iris characteristic of Wilson disease. This refers to a build up of copper due to processing issues within the liver. Wilson disease can lead to cardiac myopathy.

Question 8

Corneal arcus

Answer 8

Lipid deposits that appear as rings on the outer region of the cornea. Usually gray or white and are usually opaque. . They can grow with time, and can eventually form a ring around the entire cornea

usually presented in patients beyond 60 and associated with hypercholesterolemia

Question 9

malar flush

Answer 9

Red discolouration of cheeks. Almost rash-like

Typically associated with mitral valve stenosis (narrowing, and failure to properly open valve)

This causes backup of blood into pulmonary veins which causes CO2 retention (can also cause pulmonary oedema)

(could also be lupus erythematous)

Question 10

cool hands vs cool and clammy/sweaty hands

Answer 10

cool hands = poor perfusion (e.g. congenital heart disease)

cool and sweaty = acute coronary syndrome

Question 11

normal heart rates vs abnormal

Answer 11

normal = 60-100 bpm

abnormal:

Bradycardia (below 60) - could be athletic, atrioventricular block, certain medications (e.g. beta blockers, calcium channel blockers), sick sinus syndrome

Tachycardia (0ver 100) - anxiety, supraventricular tachycardia, hypovolemia, hyperthyroidism.

Question 12

abnormal rhythm

Answer 12

typically atrial fibrillation but could be something like ectopic beats

Question 13

radial -radial delay

Answer 13

non-synchronous beats between radial artery of both arms

can be due to aortic dissection, aortic coarctation, or potentially a compressed subclavian artery due to a broken rib

Question 14

collapsing pulse

Answer 14

This is something that would be tested for.

Ask patient if shoulder pain and avoid if so.

Patient is sitting in reclined position, and arm is vertically lifted upwards and then lifted back down - a stronger pulse can be felt rapidly increasing felt in arm muscle bulk - like woodpecker trying to peck its way out.

causes = physiological states (fever, pregnancy), commonly aortic regurgitation with regards to cardiac causes, but could also be patent ductus arteriousus, may also be high output states (anaemia, thyrotoxicosis, AV fistula).

Question 15

normal vs abnormal blood pressures

Answer 15

hypertension: blood pressure of greater than or equal to 140/90 mmHg if under 80 years old or greater than or equal to 150/90 mmHg if you’re over 80 years old.

Hypotension: blood pressure of less than 90/60 mmHg.

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
.
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.

Question 16

JVP

Answer 16

jugular venous pressure

indirect measure of central venous pressure

internal jugular vein connects to right atrium without any intervening valves meaning it can reflect pressure within the right atrium.

raised JVP is greater than 3cm suggests venous hypertension, including hypovolemia, right heart side failure (commonly due to left from pulmonary hypertension due to conditions like COPD, interstitial lung disease),Tricuspid regurgitation: causes include infective endocarditis and rheumatic heart disease.
Constrictive pericarditis: often idiopathic

Question 17

valve regurgitation vs stenosis vs prolapse

Answer 17

stenosis - narrowing and struggle for valve to open and inappropriate blood flow path

prolapse = valve that has slipped out of place

regurgitation - leaky valve, sometimes due to prolapse, meaning valve doesn’t close properly, meaning blood can flow back the way.

Question 18

hepatojugular reflux test

Answer 18

other means of accessing JVP.

Position the patient in a semi-recumbent position (45º).
Apply direct pressure to the liver.
Closely observe the IJV for a rise.
In healthy individuals, this rise 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 deemed a positive result

causes =suggests the right ventricle is unable to accommodate an increased venous return, but it is not diagnostic of any specific condition. The following conditions frequently produce a positive hepatojugular reflux test:

Constrictive pericarditis
Right ventricular failure
Left ventricular failure
Restrictive cardiomyopathy

Question 19

angular cheilitis

Answer 19

common, non-contagious, inflammatory condition affecting the corners of the mouth or oral commissures.

most commonly due to fungal infection (candida), but can be due to vit B12 and iron deficiency

Question 20

signs on the chest visibly that may point towards a cardiovascular condition

Answer 20

pectus excavatum (sunken appearance of chest)

pectus carinatum (sternum and rib protusion)

visible apex beat could be secondary to ventricular hypertrophy

any thoracic scars :

e.g. median sternotomy scar (valve replacement, coronary artery bypass grafts (CABG).

Left mid-axillary scar: this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-defibrillator (ICD)

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.

Question 21

heaves vs thrills

Answer 21

thrills = vibratory sensations felt on the skin overlying the heart. Reflects turbulent blood flow. Essentially a palpable valve murmur. Accessed over each heart valve.

Heaves = forceful ventricular contractions

Place the heel of your hand parallel to the left sternal edge (fingers vertical) to palpate for heaves.

If heaves are present you should feel the heel of your hand being lifted with each systole.

typically associated with right ventricular hypertrophy.

Question 22

valve locations

Answer 22

tricuspid valve -4th or 5th intercostal space at the lower left sternal edge.

Mitral valve: 5th intercostal space in the midclavicular line.

Pulmonary valve: 2nd intercostal space at the left sternal edge.

Aortic valve: 2nd intercostal space at the right sternal edge.

Repeat auscultation across the four valves with the bell of the stethoscope

Question 23

oedemas at legs

Answer 23

pitting pedal oedema (associated with right ventricular failure).