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Short case clinical skills > Short case differentials -Cardiology > Flashcards

Short case differentials -Cardiology Flashcards

1
Q

Pansystolic murmurs

A

Mitral regurgitation
Ventricular septal defect
Aortopulmonary shunting
(Tricuspid stenosis)

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2
Q

Midsystolic murmurs

A

Aortic stenosis
Hypertrophic cardiomyopathy
Pulmonary flow murmur of ASD
Pulmonary stenosis

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3
Q

Late systolic murmur

A

Mitral valve prolapse

Papillary muscle dysfunction

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4
Q

Early diastolic murmurs

A

Aortic regurgitation

Pulmonary regurgitation

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5
Q

Mid-diastolic murmurs

A

Mitral stenosis
Tricuspid stenosis
Atrial myxoma
Austin Flint murmur of Aortic regurgitation
Carey Coombes murmur of acute rheumatic fever

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6
Q

Presystolic (late diastolic) murmurs

A

Mitral stenosis
Tricuspid stenosis
Atrial myxoma

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7
Q

Continuous murmur

A

Patent ductus arteriosis
Arteriovenous fistula (coronary artery, pulmonary, systemic)
Aortopulmonary connection
Venous hum
Rupture of the sinus of Valsalva into right ventricle or atrium
Mammary souffle

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8
Q

Valvular strain phase increases the following murmurs

A 
Hypertrophic cardiomyopathy (louder)
Mitral valve prolapse (longer duration)
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9
Q

Valvular strain phase decreases the following murmurs

A

Aortic stenosis

Mitral regurgitation

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10
Q

Squatting increases the following murmurs

A

Aortic stenosis

Mitral regurgitation

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11
Q

Squatting decreases the following murmurs

A

HCOM (softer)

Mitral valve prolapse (shorter duration)

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12
Q

Handgrip decreases the following murmurs

A 
HCOM (softer)
Mitral valve prolapse (shorter)
Aortic stenosis (softer)
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13
Q

Handgrip increases the following murmurs

A

Mitral regurgitation (by increasing afterload)

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14
Q

Added sound before S1

A

S4

Pre-systolic (diastolic murmur MS, atrial myxoma, )

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15
Q

Added sound after S1

A

Ejection click (congential AS or PS)

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16
Q

Added sound after S2`

A 
Widely split S2
S3
Opening snap (Mitral stenosis)
Pericardial knock
Tumour plop
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17
Q

Soft S2

A

Calcified severe AS

Aortic regurgitation

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18
Q

Loud S2

A

Systemic hypertension
Congenital AS
Pulmonary hypertension (P2)

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19
Q

Increased splitting of S2 on inspiration

A 
RBBB
Pulmonary stenonsis
VSD
Mitral regurgitation
ASD (fixed splitting)
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20
Q

Fixed S2 splitting

A

ASD

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21
Q

Increased splitting of S2 on expiration

A

LBBB
Severe aortic stenosis
Coarctation of aorta
Large PDA

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22
Q

Causes of elevated JVP

A 
Fluid overload
Right ventricular failure
Hyperdynamic circulation
Tricuspid stenosis or regurgitation
Pericardial effusion or constrictive pericarditis
Superior vena caval obstruction
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23
Q

Cause of cannon a wave (flicker during S1)

A

Complete heart block

Paroxysmal nodal tachycardia with retrograde atrial conduction

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24
Q

Cause of dominant a wave (flicker during S1)

A

Tricuspid stenosis (slow y descent)
Pulmonary stenosis
Pulmonary hypertension

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25
Q

Dominant v wave (flicker during S2)

A

Tricuspid regurgitation

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26
Q

Exaggerated x descent

A

acute pericardial tamponade

constrictive pericarditis

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27
Q

Sharp y descent

A

severe tricuspid regurgitation

Constrictive pericarditis

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28
Q

Anacrotic pulse

A

Small volume, slow uptake, notched wave on upstroke

Aortic stenosis

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29
Q

Plateau pulse

A

Slow upstroke

Aortic stenosis

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30
Q

Bisferens pulse

A

Anacrotic pulse and collapsing

Aortic stenosis and regurgitation combined

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31
Q

Collapsing pulse

A

Aortic regurgitation
Hyperdynamic circulation
Patent ductus arteriosis
Peripheral arteriovenous fistula (haemodialysis)

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32
Q

Small volume pulse

A

Aortic stenosis

Pericardial effusion

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33
Q

Alternans pulse

A

Alternating strong and weak pulses

Left ventricular failure

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34
Q

Types of pulses common to aortic stenosis

A

Plateau pulse
Anacrotic pulse
Small volume pulse
(Bisferens pulse)

35
Q

Causes of postural drop (HANDI)

A

Hypovolaemia
Hypopituitarism
Addison’s disease
Neuropathy - autonomic (DM, amyloidosis Shy-Drager)
Drugs - vasodilators and other anti-hypertensives, TCAs, diuretics, antipsychotics
Idiopathic

36
Q

Pressure loaded apex beat

A

Heaving, hyperdynamic or systolic overloaded

ddx

  • Aortic stenosis
  • Systemic hypertension
37
Q

Volume loaded apex beat

A

Thrusting, displaced, diffuse, non-sustained

ddx

  • Mitral regurgitation
  • Dilated cardiomyopathy
38
Q

Double impulse apex beat

A

Hypertrophic cardiomyopathy

39
Q

Tapping apex beat

A

Palpable S1

Mitral stenosis

40
Q

Unpalpable apex beat

A 
Obesity
Emphysema
Pericardial effusion
Shock
Dextrocardia
41
Q

Palpable P2

A

Pulmonary hypertension

42
Q

Parasternal heave

A

Pulmonary hypertension

43
Q

Neck bruit

A

Aortic stenosis
Carotid stenosis
Thyrotoxicosis

44
Q

Local causes of leg ulcers

A 
Venous stasis ulcer
Ischaemic ulcer
Malignant ulcer
Infection
Neuropathic ulcer
Underlying systemic disease
45
Q

Systemic causes of leg ulcers

A 
Diabetes mellitus - vascular disease, neuropathy or necrobiosis lipoidica
pyoderma gangrenosum
Rheumatoid arthritis
Lymphoma
Haemolytic anaemia
46
Q

Severity of aortic stenosis

A 
Late peaking murmur
Apical impulse sustained
Long murmur
Delayed carotid upstroke
Decreased A2
Diminished carotid pulse
47
Q

Severity of aortic regurgitation

A

Pulse pressure >80mmHg
Grade 3+ murmur
Sustained or displaced apex beat

48
Q

Clinical signs of left ventricular failure

A

Tachypnoea, cyanosis
Chenyne stokes breathing
Low pulse pressure
Pulsus alternans
Displaced apex beat
S3, palpable gallop rhythm
Middle to late inspiratory crackles and wheeze
Positive abdominojugular reflux test (highest positive LR)
Abnormal Valvsalva response (by listening to Korokoff sounds during Valsalva)

49
Q

Causes of LVF

A

Myocardial disease - IHD, cardiomyopathy
Volume overload - aortic regurgitation, mitral regurgitation, patent ductus arteriosus
Pressure overload - aortic stenosis, systolic hypertension

50
Q

Clinical signs of right ventricular failure

A 
Low volume pulse
Raised jugular venous pressure
Right ventricular heave
Right ventricular S3
Tender hepatomegaly
Pulsatilve liver, large JVP v waves (tricuspid regurgitation)
Ascites
Ankle or sacral oedema
51
Q

Causes of RVF

A

Cor pulmonale
LVF
Myocardial disease (IHD, cardiomyopathy)
Volume overload (atrial septic defect, primary tricuspid regurgitation)
Pressure overload (idiopathic pulmonary hypertension, pulmonary stenosis)

52
Q

Clinical signs of chronic constrictive pericarditis

A 
Cachexia
Pulsus paradoxus >10mmHg
Low blood pressure
Raised jugular venous pressure
Kussmaul's sign - lack of JVP fall or rise on inspiration
Prominent x and y descents on JVP (brisk collapse during diastole)
Impalpable apex beat
Distant heart sounds
Early S3
Early pericardial knock
Hepatosplenomegaly
Ascites
Peripherial oedema
53
Q

Causes of chronic constrictive pericarditis

A 
Cardiac operation or trauma
Cancer
Tuberculosis
Histoplasmosis or pyogenic infection
Connective tissue disease
End stage renal failure
54
Q

Signs of systemic hypertension and PVD

A

Retinal changes for hypertension - silver wiring 1, AV nipping 2, haemorrhages 3, papilloedema 4
S4 if BP > 180/110
Systolic-diastolic epigastric renal bruit (renal artery stenosis)
Aortic aneurysm
Reduced lower limb pulses bilaterally
Femoral bruits
Carotid bruits

55
Q

Causes of secondary systemic hypertension

A 
Renal disease
Endocrine disease - Conn's, Cushing' syndrome, acromegaly, phaechromocytoma, thyrotoxicosis, hypothyroidism, hyperparathyroidism
Coarctation of aorta
Sleep apnoea
OCP
Polycythemia rubra vera
Pre-eclampsia
56
Q

Signs of pulmonary hypertension

A 
Low volume pulse
prominent a wave on JVP
Right ventricular heave
Loud and palpable P2
Systolic ejection click
S4
Pulmonary ejection murmur
Signs of right ventricular failure
57
Q

Signs of mitral stenosis

A 
Mitral facies
Atrial fibrillation, low volume pulse
Tapping apex beat
Loud S1
Opening snap
Low pitched diastolic murmur
Late diastolic murmur (if not in AF)
Signs of pulmonary hypertension
58
Q

Signs of mitral regurgitation

A 
Normal or sharp upstroke pulse
AF
Displaced apex beat
Pansystolic thrill
Soft/absent S1
S3
Pansystolic murmur radiating to axilla
59
Q

Causes of mitral stenosis

A 
Rheumatic heart disese
Congenital parachute valve
Carcinoid
ergot derivatives
Anorexic medications
60
Q

Causes of mitral regurgitation

A 
Papillary muscle dysfunction from IHD
Cardiomyopathy
Mitral valve prolapse
Rheumatic heart disease
Connective tissue disease
Marfan's syndrome
Congenital
61
Q

Signs of mitral valve prolapse

A

Midsystolic click, changes with position
High pitched late systolic murmur - louder with on standing and Valsalva
Reduced in squatting and isometric exercise

62
Q

Causes of mitral valve prolapse

A

Myxomatous degeneration of the mitral valve

Associated with atrial septal defect, hypertrophic cardiomyopathy, Marfans

63
Q

Clinical signs of aortic stenosis

A

Plateau, late peaking or anacrotic pulse
Hyperdynamic displaced apex beat
Systolic thrill at base of heart (right upper sternal edge, RUSE)
Narrow split or reversed S2
Harsh mid systolic murmur at the RUSE over the carotid area, loudest on expiration
Preceded ejection click
Early decrescendo diastolic murmur (if associated aortic regurgitation)

64
Q

Differential diagnoses for left ventricular outflow obstruction

A

Aortic stenosis - Calcified, congential bicuspid/unicuspid, tetracuspid, rheumatic
Supravalvular obstruction
Subvalvular obstruction
Hypertrophic cardiomyopathy

65
Q

Clinical signs of supravalvular obstruction

A

Broad forehead, widely set eyes and chin
Loud A2
Thrill in sternal notch

66
Q

Clinical signs of subvalvular obstruction

A

Associated aortic regurgitation

67
Q

Clinical signs of aortic regurgitation

A

General signs of Marfan’s syndrome, ankylosing spondylitis or Argyll Robertson pupils
Water hammer pulse - chronic AR only
(bisferens pulse if aortic stenosis is also present)
Wide pulse pressure
Prominent carotid pulsitations
Displaced, hyperkinetic apex beat
Diastolic thrill at left sternal edge sitting up in expiration
Soft A2
Decresendo murmur after second heart sound between 3rd and 4th ribs, with patient sitting forward on expiration
Austin flint murmur - mid diastolic rumble at apex in lateral position

68
Q

Causes of aortic regurgitation

A 
Type A aortic dissection
Infective endocarditis
Marfan's syndrome
Ankylosing spondylitis
Syphilic aortitis
69
Q

Signs of tricuspid stenosis

A

Elevated JVP
Large a waves with slow y descent on JVP
Mid-diastolic rumble at left sternal edge, on inspiration
Pre-systolic pulsitation of liver

70
Q

Signs of tricuspid regurgitation

A 
Elevated JVP
Large v waves
Right ventricular heave
?Pansystolic murmur at lower end of sternum accentuated on inspiration
Tender hepatomegaly
Pulsatile liver
Dilated, pulsatile leg veins
71
Q

Causes of tricuspid regurgitation

A 
RVF
Rheumatic
Infective endocarditis (IVDU)
Tricuspid valve prolapse
Right papillary muscle infarction
Trauma - steering wheel to sternum
Ebstein's anomaly
72
Q

Signs of pulmonary stenosis

A 
Normal or reduced pulse
Giant a waves on JVP
Right ventricular heave
Harsh ejection murmur loudest on inspiration radiating to left clavicle
Ejection click after S1
Presystolic pulsitation of liver
Right ventricular S4
73
Q

Causes of pulmonary stenosis

A

Congenital - Noonan’s syndrome

Carcinoid syndrome

74
Q

Signs of pulmonary regurgitation

A

High pitched decrescendo diastolic murmur that increases on inspiration (Graham steel murmur)

75
Q

Differentials for right ventricular heave

A 
Pulmonary hypertension
Tricuspid regurgitation
Atrial septal defect
Pulmonary stenosis
Isolated pulmonary regurgitation
76
Q

Signs of hypertrophic cardiomyopathy

A

Sharp, rising, jerky pulse
Prominent a wave on JVP
Double or triple impulse
Late systolic murmur at the lower left sternal edge
Pansystolic murmur at apex
S4
Murmurs increased by Valsalva, standing and isotonic exercise

77
Q

Causes of hypertrophic cardiomyopathy

A

Congenital - autosomal dominance with variable expressitivity
Friedrich’s ataxia

78
Q

Causes of dilated cardiomyopathy

A 
Alcohol
Beri-Beri
Viral infection - coxsackie
Anthracycline chemotherapy
Dystrophica myotonica
haemochromatosis
79
Q

Causes of restrictive cardiomyopathy

A

Infiltrative disease - amyloid, sarcoid
Eosinophilic endomyocardial disease
Endomyocardial fibrosis

80
Q

Signs of ventricular septal defect

A

Hyperkinetic displaced apex beat
Thrill at left sternal edge
Harsh pansystolic murmur at lower left sternal edge between 3rd and 4th rib, loudest on expiration
palpable systolic thrill

81
Q

Signs of atrial septal defect

A

Right ventricular heave
Fixed splitting S2
Pulmonary ejection systolic murmur loudest on inspiration

82
Q

Signs of patent ductus arteriosus

A 
Collapsing pulse with sharp upstroke
Low diastolic pressure
Hyperkinetic apex beat
Continuous loud machinery murmur in systole and diastole at first intercostal space
Mitral mid-diastolic flow murmur
Reversed splitting S2 if severe
83
Q

Signs of coactation of aorta

A

Radiofemoral delay
Weak femoral pulses
hypertension in arms but not legs
midsystolic murmur over praecordium and back

84
Q

Signs of repaired tetralogy of Fallot

A

Median sternotomy scar
Long diastolic murmur of pulmonary regurgitation
Signs of tricuspid regurgitation

Short case clinical skills (5 decks)

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