The cardiac examination

Question 1

Features of down syndrome?

Answer 1

Low set ears, epicanthic folds, brushfield spots, flat nasal bridge

Question 2

Features of Ank Spond

Answer 2

Question mark posture, restricted neck movements

Question 3

Features of Marfans

Answer 3

tall, arachnodactyly, arm span ?heigh. chest wall deformity

Question 4

Features of turners syndrome

Answer 4

Webbed neck, short stature, wide carrying angle , infertility, absence of secondary sexual characteristics, wide small nipples

Question 5

Features of Noonans syndrome

Answer 5

Similar to turners but can be male and are fertile

Question 6

Features of Holt Oram syndrome

Answer 6

Triphalangeal thumb, radial hypoplasia

Question 7

What is a malar flush

Answer 7

Rash present in pulmonary HTN secondary to M.S.

Question 8

Which HS does the metallic valve make

Answer 8

It makes a sound when it closes i.e. AVR would be heard at S2

Question 9

What scars can be present in a cardio exam and what are their indications?

Answer 9

Midline sternotomy - CABG/ Valve replacement/ Transplant
Lateral thoracotomy - MVR, valvotomy, coarctation of aorta fixation, Blalock Tousig shunt insertion
Subclavicular (PPM/ICD)
ACF scar - angiogram
Leg scar - vein harvesting

Question 10

Peripheral signs of IE?

Answer 10

Oslers nodes - painful raised lesions on pulp of fingers
Janeway lesions - Macular lesions, painless on palms/ soles of feet
Clubbing

Question 11

Clubbing in cardiology exam causes

Answer 11

Congenital heart disease (exp cyanotic)
Eisenmenger
IE
Atrial myxoma

Question 12

What can cause an unequal pulse on examination

Answer 12

Blalock Toussig shunt (connection between branch on Subclavian Art and Pulmonary Art to shunt blood to lungs in cyanotic heart disease). can cause unequal underdeveloped limb. done in ToF
Cervical rib
Subclavian stenosis
AV fistula
Coarctation of aorta

Question 13

What signs do you look for in the eyes?

Answer 13

Corneal arcus
Xanthelasma
Anaemia
Jaundice (haemolysis across stenoses valve)
Lens of eye (ectopia lentis - marfans/ homocystinuria)

Question 14

Signs on mouth

Answer 14

Dentition
Central Cyanosis
Uvula bobbing
Head bobbing

Question 15

Signs of pseudoxanthoma elasticum

Answer 15

Plucked chicken skin appearance (neck, chest, shoulders, arm folds)
Retinal angiod streaks
MV prolapse
GI haemorrhage
increased risk of IHD

Question 16

Talk through the JVP waveform

Answer 16

A wave - atrial contraction
C wave - ventricular contraction
X decent - (Part 1) relaxation of atria (part 2) TV closed and heart moves down as ventricular contraction at maximum
V wave - Ventricular passive filling. TV closed.
Y decent - TV opens and passive filling of RV

Question 17

Gynaecomastia in CVS

Answer 17

Digoxin/ spironolactone

Question 18

JVP in AF?

Answer 18

single wave due to absent A wave

Question 19

Causes of giant A waves

Answer 19

Due to atrial contraction against some resistance. occurs every beat
- Pulmonary HTN
- Tricuspid stenosis
- Right Ventricular failure

Question 20

Causes of canon A waves

Answer 20

Contraction of atria against closed TV
- Complete HB
- VT
- ventricular ectopics

Question 21

Causes of large CV wave

Answer 21

Tricuspid regurgitation

Question 22

JVP features of tamponade

Answer 22

Absent Y decent. Prominent X decent.

Question 23

JVP features of constrictive pericarditis

Answer 23

Prominant deep X and Y decent

Question 24

When is kussmauls sign present and why?

Answer 24

Constrictive pericarditis > Tamponade

Inspiration increases JVP (normally it will fall). In constriction inspiration increases venous return to heart. Due to inability for heart to expand against stiff pericardium RV cannot accommodate increase in return of blood. Therefore JVP increases.

Question 25

Explain pulsus paradoxicus

Answer 25

Can occur with tamponade

Fall in BP normal on inspiration due to reduced filling of left heart (typically <10mmHg) and increased filling of rt heart reduced LV size. In tamponade this effect is more pronounced. Bowing of septum into LV impairing stroke volume.

Question 26

What does MS do to apex?

Answer 26

Tapping apex

Question 27

What does a thrusting apex imply?

Answer 27

Volume overload

Question 28

What does a heaving apex imply

Answer 28

Pressure overload

Question 29

As diastolic murmurs are challenging to hear, what might you expect with a patient with AR?

Answer 29

ESM (aortic flow murmur)
Present S2
Collapsing pulse
Displaced apex

Question 30

As diastolic murmurs are challenging to hear, what might you expect with a patient with MS?

Answer 30

AF
Malar flush
tapping apex
loud S1

Question 31

Why does S3 occur and when may it be present?

Answer 31

Passive diastolic filling of LV.
normal if <30. Can occur in LVH/ constrictive pericarditis and MR

Question 32

Why does S4 occur and when may it be present?

Answer 32

Atrial contraction against stiff ventricle

HOCM, LVH, Amyloidosis, Ventricular ischaemia. absent in AF

Question 33

List disorders than influence the volume of S1

Answer 33

Quiet: Mitral regurg
Loud: MLUBS
Mitral stenosis, Left-> Right shunts, hyperdynamic state, ectopic beats (atrial), Short PR

Question 34

List disorders than influence the volume of S2

Answer 34

Loud: pulmonary HTN, ASD
Quiet: AS

Question 35

Disorder that effect the splitting of S2:

Answer 35

Wide: DUBS
Deep inspiration, pUlmonary stenosis, right Bundle branch block, Severe MR

Reverse: DUBS
DUctus arteriosus, LBBB, Severe AS

Fixed: ASD