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120 Cards in this Set

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What are some presenting symptoms of the cardiac patient?
Chest pain
Dyspnoea
Oedema
Palpitations
Syncope/pre-syncope/dizziness
Intermittent claudication
Fatigue
When might patients have silent infarcts?
Atypical Variant
Diabetics (neuropathy)
Patient with a Transplanted heart (denervation)
What is the typical presentation of Angina?
Retrosternal Crushing/heavy (dull, not well localised) pain or discomfort
May radiate to the left shoulder and arm, neck, jaw and back
Stable angina (due to sclerosis of coronary arteries) is typically brought on exertion
Unstable angina (due to clots in the coronary artery) is typically brought on rest
What are 10 risk factors for coronary artery disease?
1. Previous Coronary Disease
2. Smoking
3. Hypertension
4. Hyperlipidaemia
5. Positive family history
6. DM
7. Obesity
8. Male sex
9. Age
10. Raised homocysteine levels
What are the structures associated with chest pain?
Cardiac pain: (MI, ischaemia)
Vascular: (Aortic dissection/aneurysm)
Pleuropericardial pain: (Pericarditis, infective pleurisy, pneumothorax, pneumonia, autoimmune disease, mesothelioma, metastatic tumour)
Chest wall: (Persistant cough, trauma, tietze’s syndrome, rib fracture, herpes zoster, slipping rib syndrome)
Gastrointestinal: (GORD, oesophageal spasm)
Airway pain: (Pulmonary embolism, Intubation, tracheitis, central bronchial carcinoma, inhaled foreign body/aspiration)
Mediastinal pain: (lymphoma, oesophagitis, sarcoid adenopathy)
What is characteristic of pleuritic pain? What is it caused by?
Sharp localised chest pain made worse on inspiration
Often relieved by sitting up and leaning forwards
Usually due to movement of inflamed pleural or pericardial surfaces
What kind of pain is characteristically caused by a dissecting aneurysm of the aorta?
Very severe (tearing) which can radiate to the back
How long does Anginal Pain last and when is Myocardial infaction the likely cause?
Chest pain lasting more than 30 mins is more likely to be caused by MI than Angina.

Also chest pain lasting serval days is unlikely to be either.
What is Dyspnoea and what are possible causes?
It is a unexpected awareness of breathing

DDx:
Acute - PE, ARDS, Panic attack

Pulmonary: Airflow obstruction, pleural effusion, restrictive lung disease, aspiration, pneumonia

Cardiac: MI, congestive heart failure, valvular disease, arrythmia, tamponade

Metabolic: Acidosis, hypercapnia, sepsis

Hematologic : Anaemia, methhemoglobinaemia
What is Orthopnoea and what is the mechanism?
It is dyspnoea that developes when the patient is in the supine position. This is due to the redistribution of fluid to a greater surface area of the lung while supine
What is paroxysmal nocturnal dyspnoea? What is the mechanism?
Severe dyspnoea that wakes the patient from sleep so that he or she is forced to get up gasping for breath.

This occurs because of a sudden failure of left ventricular output with an acute rise in pulmonary venous and capillary pressures; this leads to transudation of fluid into the interstitial tissues, which increases the work of breathing
What are palpitations? what is its mechanism?
Palpitations are an unexpected awareness of the heart beat. This can manifest as a missed beat followed by an abnormally forceful beat (due to increased ventricular diastolic time) but the term is not specific
how might you terminate supraventricular tachycardias without medication?
May be terminated by increasing vagal tone

Valsalva manoeuvre, carotid massage, coughing, swallowing cold water
What is syncope?
It is a transient loss of conciousness resulting from cerebral anoxia
What questions do you ask a patient who presents with a syncopal episode?
Was there dizziness, palpitations or any warning just before?

Were yu doing anything at the time? (passing urine, coughing, under emotional stress)

Was there any witnessess? if so, what happened after you collapsed?

How quickly did you recover? was there any pain on waking?
What is the term for syncope caused by standing up suddenly?
Postural syncope
What is the term for syncope caused by emotional stress?
Vasovagal syncope
What are the typical characteristics of chest wall pain?
Localised sharp pain
Associated with Respiration
Not associated with exertion
Pain from the spine often radiates to the back
What is characteristic of pain associated with PE?
Sharp pleuritic pain or rapid onset
Also associated with collapse, cyanosis and dyspnoea
Can present as anginal pain
how might a person with oesophageal spasm pain present?
Retrosternal chest pain that may be indistinguishable from angina.

Usually comes on after drinking hot/cold fluids

May be asscoaited with dysphagia
What are some uncommon causes of dyspnoea
Massive ascites
Pregnancy
Bilateral diaphragmatic paralysis
Large pleural effusion
Severe Pneumonia
What are the common causes of dyspnoea?
Left Ventricular failure
COPD
Restrictive lung diseases
The presence of orthopnoea or paroxysmal nocturnal dyspnoea is more suggestive of what?
Cardiac failure rather than lung disease
Oedema that is bilateral and less severe when lying down is suggestive of what?

What is likely if there if the face is oedematous?
Cardiac failure

Nephrotic syndrome
What are the risk factors for claudication?
Smoking
Reduced caludication distance
Other vascular disease (stroke, IHD)
Roughly how long does it take, after quitting smoking, to drop the risk of disease to that of the normal population?
Risk of MI reduced in 2 years
Risk of developing Angina is reduced in 10 years
What are the risk factors relavent in the family history for coronary artery disease?
1st degree relatives
Diagnosed at 60 yrs old or less
What is the risk of a Diabetic developing MI (without a history of MI's)?
The same risk as a non-diabetic who has had an infarct
(good control of BSL's reducs risk)
What is the most common cause of death for renal failure patients?
IHD (due to high Ca and PO4 products)
What are the risk factors for infective endocarditis?
Damaged or prosthetic valve(s)
Poor dentition
History of Rheumatic Fever/ heart disease
What do you look for in a patient with suspected previous cardiac bypass?
Midline Sternotomy scar
Previous saphenous vein harvesting
What possible symptoms might a patient with previous rhuematic fever have?
'Growing pains'
'Put to bed for long periods as a child'
How much exposure is needed for a cardiovascular examination?
Neck, chest, leg exposure
What is the general sequence of the cardiovascular examination?
1. Handwash
2. Exposure + positioning (45 degs)
3. General appearance
4. Radial Pulse (rate, rhythm)
5. Inspection of the hand
6. Radiofemoral delay
7. Radioradial inequality
8. BP (lying + standing)
9. Eyes, face, mouth
10. JVP (height, character)
11. Carotid pulse (charcter on each side)
12. Inspection of praecordium
13. palpation (apex, heaves, thrills)
14. Auscultation (4 areas + carotids)
15. Reposition (left lateral, sitting)
16. Percuss + auscultate lungs
17. Sacral oedema
18. Reposition lying (hepatomegaly, pulsatile liver, spleenomegaly, aortic aneurysm)
19.Palpation + auscultation of femorals
20, Palpation of peripheral pulses + peripheral oedema
21. Examine Fundi, Urine dipstick, Temperature
What do you look for on general inspection in the cardiovascular examination?
Patients general state of health
Dyspnoea
Cachexia (severe cardiac failure)
Marfans syndrome
Turners syndrome
Down syndrome
What is cardiac cachexia caused by? (3 things)
It is the result of severe cardiac failure and is thought to be due to anorexia (congestive liver enlargement), impaired intestinal absorption (congested intestinal veins) and increased levels of inflammatory cytokines
What do you look for in the hands in the cardiovascular examination?
Clubbing
Splinter haemorrhages (infective endocarditis, or trauma)
Osler's nodes (infective endocarditis)
Janeway lesions (infective endocarditis)
What are the causes of clubbing?
Infective endocarditis
Lung carcinoma
Bronchiectasis
Lung abscess
Empyema
Idiopathic pulmonary fibrosis
Cystic fibrosis
Asbestosis
Cirhosis (esp. biliary cirrhosis)
IBD Coeliac disease
What is the cause of splinter haemorrhages?
Trauma
Infective endocarditis (due to a vasculitis of the nail bed)
Rhuematoid arthritis (vasculitis)
Polyarteritis nodosa
Antiphospholipid syndrome
Sepsis
Haematological malignancy
Profound Anaemia
What is radiofemoral delay diagnostic of?
Coarction of the aorta, where there is a congenital narowing of the aortic isthmus at the level where the ductus arteriousus joins the descending aorta
What does radial-radial inequality suggest?
Usually due to a large arterial occlusion by n atherosclerotic plaque or aneurysm

Can also be due to unilateral subclavian artery stenosis
What does a collapsing (bounding) pulse suggest?
Aortic regurgitation
What is pulsus alternans? What does it suggest?
It is an aternating strong and weak pulse

It suggests advanced left ventricular failure
What does the systolic BP represent?
It is the peak pressure that occurs in the artery following ventricular systole
What does the diastolic BP represent?
The level to which arterial blood falls during ventricular diastole
What is the typical anatomical position of the brachial artery?
Located in the anticubital fossa, 1/3 of the way over from the medial epicondyle
What are the different Korotkoff sounds?
Phase 1: thud
Phase 2: blowing noise
Phase 3: softer thud
Phase 4: Disappearing blowing noise
Phase 5: Absent sound
Systolic and diastolic BP are measured from which korotkoff sounds?
Systolic = beginning of phase 1
Diastolic = beginning of phase 5 or phase 4 for people with severe aortic regurgitation
how much higher is the BP in the legs than it is in the arms?
About 20mmHg higher
What is pulsus paradoxus? Why is it a paradox?
What are the causes?
During inspiration there is a normal drop in BP (due to negative intrathoracic pressure blood pools in pulmonary vessels so left heart filling is reduced)

Pulsus paradoxus is when reduction in BP is exaggerated on inspiration (greater than 10mmHg)

Its paradoxical as there is rise in heart rate

Severe asthma, constrictive pericarditis, pericardial effusion
What are the cardiovascular causes of jaundice?
Severe right heart failure leading to hepatic congestion
Prosthetic heart valve induced hemolysis
Hemolytic anaemias
What do you look for on inepction of the face in the cardiovascular examination?
Jaundice
Xanthalasmata (intracutaneous yellow cholesterol deposists)
Mitral facies (rosy cheeks + bluish tinge due to malar capillary dialation, associated with pulmonary hypertension and low cardiac output)
High arched palate (marfans)
Dentition
Tongue + lips (central cyanosis)
Mucosa (petechiae, from infective endocarditis)
What cardiac diseases is Marfans syndrome associated with?
Congenital heart disease including
- Aortic regurgitation secondary to aortic root dialation
- Mitral regurgitation due to mitral valve prolapse
What is the typical anatomical location of the carotid arteries?
Medial to the sternomastoid muscles
How do you tell apart the JVP from the carotid?
JVP
- is visible, not palpable
- Has a more prominent inward movement than the artery
- Complex wave form (double flicker if in sinus rhythm)
- Moves on respiration (decreases on inspiration)
- Obliterated when partial pressure is applied to base of neck, but then fills from above
What are the different phases of the JVP pulse? what do the phases represent?
1. 'a' wave (+) = RA systole
2. 'c' point (+) = tricuspid valve closure
3. 'x' descent (-) = RA diastole
4. 'v' wave (+) = atrial filling while tricuspid valve is closed during ventricular systole
5. 'y' descent = tricuspid valve opens (ventricular filling)
What is Kausmal's sign? what position is it best obtained?
Raise in JVP during inspiration (opposite of what should happen). Due to Right ventricular filling impairment (contrictive pericarditis, cardiac tamponade, RV infarction)

Best obtained 90 degrees, with patient breathing through the mouth
What constitutes as a positive abdominojugular reflex?
Elevated JVP (>4cm) while pressure is applied over the midline of the abdomen for more than 10s
What are some causes of a raised JVP?
RV failure
Tricuspid stenosis/regurgitation
Fluid Overload
Pericardial effusion/constrictive pericarditis
SVC obstruction
Hyperdynamic circulation
What are some causes of a dominant 'a' wave (JVP)?
Tricuspid stenosis (+ slow y descent)
Pulmonary stenosis
Pulmonary hypertension
What are some causes of cannon 'a' waves (JVP)?
Complete Heart Block
Paroxysmal nodal tachycardia with retrograde atrial conduction
Atrioventricular dissociation
What could cause a dominant v wave (JVP)?
Tricuspid regurgitation
When might the x descent (JVP) be absent or exaggerated?
Absent: AF
Exaggerated: Acute cardiac tamponade, constrictive pericarditis
When might the y descent (JVP) be sharp or slow?
Sharp: Severe tricuspid regurgitation, constrictive pericarditis
Slow: Tricuspid stenosis, RA myxoma
When inspecting the praecordium during the cardiovascular examination, what should you look for?
Scars (previous operations, trauma)
Skeletal abnormalities (pectus excavatum, kyphoscoliosis)
Pace-maker, Defib + associated hiccups from loose RA lead
Apex beat
Where should the apex beat be palpable?
You shouldnt be able to palpate the anatomical apex of the heart, the palpable beat is just superior to the anatomical apex

Left midclavicular line
5th intercostal space
What could a displaced apex beat mean?
Cardiomegaly
Pleural/pulmonary disease
Chest wall deformaties
What is a pressure loaded apex beat? What could cause it?
Its a forceful and sustained impulse

Can be caused by Aortic stenosis or hypertension
What is a thrusting apex beat? What could cause it?
Its a forceful nonsustained apex beat

Can occur with mitral regurgitation or dialated cardiomyopathy
What is a double impulse apex beat characteristic of?
Hypertrophic Cardiomyopathy
What is a tapping apex beat? What could cause it?
Its a palpable first heart sound and indicates Mitral or Tricuspid Stenosis
What is Dextrocardia?
It is an congenital abnormality resulting in the inversion of the heart and great vessels
What is a thrill?
Its a palpable murmur (caused by turbulent flow)
What are the different areas of auscultation (heart)
Mitral Area: 4th intercostal space, midclavicular line
Tricuspid Area: 5th intercostal space, left of the sternum
Pulmonary Area: 2nd intercostal space, left of the sternum
Aortic Area: 2nd intercostal space, right of the sternum
What is the order in which the valves in the heart close?
(S1) mitral then tricuspid
(S2) Pulmonary then aortic
What could cause a loud S1 heart sound?
Mitral Stenosis
Tachycardia or any cause of short AV conduction time
What could cause a soft S1 Heart sound?
Any cause or prolonged diastolic filling time (e.g. 1st degree heart block, LBBB, mitral regurgitation)
What could cause a loud S2 heart sound?
Loud A2 in patients with systemic hypertension or congenital aortic stenosis

Loud P2 in pulmonary hypertenion
What could cause a soft S2 heart sound?
Aortic valve calcification, reduced leaflet movement, aortic regurgitation
What could potentially cause splitting of S1 heart sound?
Complete RBBB
When might you get an increase in the normal splitting of S2?
Due to any delay in Right Ventricular emptying or Early Left ventricular emptying

(e.g RBBB, pulmonary stenosis, Ventricular septal defect, mitral regurgitation)
What is fixed splitting (heart sounds) and what might cause it?
It is a split in S2 that doesnt change with respiration

This occurs in Atrial septal defect (the two chambers are connected so the volumes/pressures tend to equalise)
What is reverse splitting and what could cause it?
This is when P2 occurs first and splitting occurs in expiration

Can be caused by LBBB, severe aortic stenosis, coarction of aorta, large patent ductus arteriousus)
What is a third heart sound? (S3)
Its a low pitched mid-diastolic sound (can be physiological as in young peopled due to rapid diastolic filling or pathological due to reduced ventricular compliance). Left ventricular S3 is loudest at the apex and is a sign of left ventricular failure and dialatation, but may occur with mitral/aortic regurgitation
What might cause a Right ventricular S3 sound?
Right ventricular Failure
Constrictive pericarditis
What is an S4 heart sound?
It is a late diastolic sound due to a high pressure atrial wave reflected back from a poorly compliant ventrical (absent in AF)
What is a summation gallop?
It is when S3 and S4 are superimposed when heart rates exceed 120bpm

Present S3 and S4 is associated with severe Left ventricular dysfnction
What is an opening snap (heart sounds)?
High pitched sound occuring after S2 due to the sudden opening of the mitral valve (as in mitral stenosis). Is usually followed by the diastolic murmur or MS
What is a systolic ejection click? what can cause it?
Early systolic click over aortic/pulmonary areas due to aortic/pulmonary stenosis
What possible lesions could produce a pansystolic murmur?
Mitral regurgitation
Tricuspid regurgitation
VSD
Aorto pulmonary shunts
What possible lesions could produce a midsystolic murmur?
Aortic stenosis
Pulmonary stenosis
Hypertrophic cardiomyopathy
ASD (pulmonary flow murmur)
What possible lesions could produce a late systolic murmur?
Mitral valve prolapse
Papillary muscle dysfunction
What possible lesions could produce a early diastolic murmur?
Aortic Regurgitation
Pulmonary regurgitation
What possible lesions could produce a mid-diastolic murmur?
Mitral stenosis
Tricuspid stenosis
Austin flint murmur (aortic regurg)
Carey coombs murmur (Acute rheumatic fever)
What possible lesions could produce a presystolic murmur?
Mitral stenosis
Tricuspid stenosis
What possible lesions could produce a continuous murmur?
Patent ductus arteriousus
AV fistula
Blalock shunt (aortopulmonary connection)
Rupture of sinus of valsalva into right ventricle/atrium
Mammary souffle (pregnancy)
Where does AS, MR, AR, PR radiate to? (others dont radiate)
AS: 1200
MR: 1000 and 0200
AR: 0500
PR: 0700
Define Levine's Grading system
1/6: very soft and not heard at first
2/6: Soft
3/6: Moderate, no thrill
4/6: loud, thrill just palpable
5/6: Very loud, thrill easily palpable
6/6 can be heard without stethoscope

Not useful in estimating severity of disease, helpful in observing progress of disease
How does pitch vary with the type of lesions?
Low pitch = low flow (stenosis)
High pitch = high flow (regurgitation)
At what point does a carotid stenosis become clinicaly undetectable?
Generally those greater than 50% stenosis is difficult to hear
What are the causes of Unilateral Leg Oedema?
DVT
Compression of a large vein by tumour or lymph nodes
What are some causes of non-pitting Oedema?
Hypothyroidism
Lymphoedema (infection, malignancy, congenital, allergy)
What are the most reliable signs of peripheral vascular disease?
1. Absent dorsalis pedis and posterior tibial pulses
2. Limb bruit
3. Sores/ulcers
4. Absent femoral pulse
5. One foot cooler than the other
6. Capillary refill >20 seconds
7. Absent hair
What are the 4 P's of arterial occlusion?
Painful
Pulseless
Pale
Paralysed limb
What are the differences between venous, arterial and diabetic leg ulcers?
Venous: Irregular margin, pale surrounding (neo-epithelium), pink base of granulation tissue, skin warm, oedematous, generally located around malleoli

Arterial: Regular margin, punched out appearance, skin is cold, peripheral pulses absent, usually on lateral side of leg

Diabetic: Neuropathic ulcers are painless, decreased sensation around surrounding skin
What are the risk factors of DVT?
Stasis (immobilisation, cardiac failure)
Vessel wall disease (trauma)
Blood changes (disseminated intravascular coagulation, contraceptive pill, factor V leiden, Antithrombin III deficiency)
What are some diseases that may predispose a patient to developing ulcers?
Diabetes
Rheumatoid arthritis
Inflammatory Bowel Disease (pyoderma gangrenosum)
Lymphoma
Haemolytic anaemia
What are some good signs of cardiac failure?
1. Abdominojugular reflex test positive
2. Valsalva manoeuvre abnormal
3. Apex displaced
4. S3 heart sound
5. HR >100bpm at rest
What is pheocromocytoma?
It is a neuroendocrine tumor of the medulla of the adrenal glands (originating in the chromaffin cells), or extra-adrenal chromaffin tissue that failed to involute after birth and secretes excessive amounts of catecholamines, usually adrenaline and noradrenaline
What are some complications of Hypertension?
Left ventricular failure
Stroke
Renal Failure
Retinopathy (blindness)
IHD
PVD (aneurysms, arterial dissections)
What are the 4 Auscultatory signs of Mitral stenosis?
Loud S1
Opening snap
Rumbling diastolic murmur
Presystolic accentuation (only in sinus rhythm)
What are some symptoms of Mitral stenosis?
Increased LA pressures = Dyspnoea, orthopnoea, paroxysmal noctunal dyspnoea

Ruptured bronchial veins = haemoptysis

Pulmonary hypertension = Oedema, fatigue
What are some causes of Acute Mitral regurgitation?
Myocardial infarction (rupture of papillary muscles)
Infective endocarditis
Trauma, surgery
What are the 3 Auscultatory signs of Chronic Mitral Regurgitation?
Soft S1
Left Ventricular S3
Pansystolic murmur (maximal at apex)
What are some causes of chronic mitral regurgitation?
Mitral valve prolapse
degenerative valve changes
Rheumatic Valve
Papillary muscle dysfunction
Hypertrophic, dialated or restrictive cardiomyopathy
Connective tissue disease (marfans, rhuematoid, ankylosing spondylitis)
What are the 2 Auscultatory signs of Mitral valve prolapse?
Systolic Click
High pitched late systolic murmur
What are the symptoms of Aortic stenosis?
Exertional chest pain, exertional dyspnoea, exertional syncope (IHD must be excluded),
What kind of pulse is present in someone with aortic stenosis?
Anacrotic pulse (plateu) OR the pulse may be late peaking (tardus) and of small volume (parvus)
What are the causes of hypotension and tachycardia?
Shock
Anything to cause reduced stroke volume (to maintain CO)
What is the order in which you assess a chest x-ray?
1. Name, date, projection
2. Rotation
3. Exposure
4. Mediastinum
5. Hila
5. Heart (borders, valve calcification is better on lateral view)
6. Diaphragm
7. Lung fields
8. Bones + soft tissue