Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

RACP Clinical Short > Cardiac Short Case > Flashcards

Cardiac Short Case Flashcards

1
Q

Right Thoracotomy scar cardiac ddx?

A

1) Pulmonary Artery banding
- to reduce pulmonary blood flow in lesions with left->right shunts or
- to “train” the left ventricle by increase after load (hypoplastic left heart) prior to definitive surgery
2) Shunt

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Left thoracotomy scar cardiac ddx?

A

1) Coarctation of aorta repair
2) patent ductus ateriosis ligation
3) Shunt
4) Pulmonary artery banding

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Median sternotomy scar?

A

All open heart corrections

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Thoracotomy scar differentials?

A

1) Right sided lesions –> PA banding, closed valvotomies
2) Left sided lesions –> CoA, closed valvotomies
3) Connecting lesions –> PDA, shunt formation
4) TO fistula repair
5) Thoracic duct ligation
6) Valvular ring repair

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Steps of Cardiac Exam?

A

1) Unwell or well
2) Breathless or not breathless
3) Cyanotic or not
4) Growth parameters
5) Vitals: BP (ask for 4 limb), Temp, RR, Urinalysis (ask for at end)
6) Iatrogenic: IVs, O2
7) Dysmorphology (Downs, Turners, Noonans etc)
8) Skin –> scars
9) Periphery:
- Hands/Arms: clubbed (look at feet too), SBE (splinter, Osler, Janeway), BP, antecubetal fossa scars
- Pulse (do upper and lower limb) - rate, rhythm, volume, form (lift up to detect hyperdynamic pulsation = aortic incompetence), radio-radial/radio/femoral delay, absent or decreased L) radial pulse (post coarct, post BT shunt)
10) Head:
- JVP (in older child, look at 45degrees, inc w RVF)
- Eyes: Pale conjunctiva, icterus, roth spots
- Mouth: central cyanosis
- Oral dentition state
- Carotids –> volume + form
11) Precordium
- Inspect: symmetry –> L chest prominence = chronic RVH, R chest prominence = dextrocardia with chronic ventricular hypertrophy. Apical pulsation
- Palpate: Apex, LLSE, LUSE, RUSE, supraclavicular. Heaves/thrills (inc suprasternal notch), palpable P2 (closure of pulmonary valve)
- Auscultate: Areas, HS, added sounds, Murmurs + radiation
12) Lungs:
- Feel deep in axilla for collaterals in CoA if suspected
- Auscultate at bases
- Sacral oedema
- Cough (PCD)
13) Abdomen: Hepatomegaly (pulsatile = TRR, Enlarged = RVF), Splenomegaly (SBE)
14) Legs: Pitting oedema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Normal hands w clubbed feet differential?

A

Eisenmengers w PDA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Hyperdynamic pulsation differential?

A

Aortic incompetence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Absent L) brachial pulse differential?

A

1) post CoA repair
2) Post Blalock-Taussig shunt repair (will also have L) thoracotomy scar)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

JVP increased with what?

A

RVF

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Supraclavicular murmur radiation?

A

L) = PDA
R) = Aortic stenosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Carotid murmur radiation?

A

Aortic lesions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Axilla murmur radiation?

A

Mitral valve (roll them away from you)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Radiation of murmur to back?

A

1) Peripheral pulmonary stenosis
2) CoA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Murmur increased with Valsava with which lesions?

A

1) HOCM
2) Mitral valve prolapse (increased intensity and earlier click)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Murmur decreased with valsalva in which lesions?

A

Innocent murmurs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Murmur increased when sitting forward with which lesions?

A

Aortic regurgitation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is an anacrotic carotid pulse and which lesions is it felt in?

A

1) Slow rising pulse/slow upstroke
2) Seen in severe aortic stenosis (small volume + slow upstroke)

AKA Plateau pulse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What is an BISFERIENS carotid pulse and which lesions is it felt in?

A

1) A double pulse is felt due to the backflow of blood in early diastole. The first carotid pulse felt is normal systole, while the second is actually early diastolic due to the regurgitating blood.
2) Seen in Aortic regurgitation (with or without aortic stenosis) + severe HOCM
- Small volume, slow upstroke, collapsing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is a collapsing carotid pulse and which lesions is it felt in?

A

1) a pulse that is bounding and forceful, rapidly increasing and subsequently collapsing, as if it were the sound of a water hammer that was causing the pulse.
2) Seen in Aortic Regurgitation, PDA, Peripheral arteriovenous aneurysm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is an Alterans pulse and which lesions is it felt in?

A

1) beat-to-beat variation in the amplitude of the pressure pulse —> alternating weak and strong beats best appreciated at peripheral pulses
2) Loud in: Mitral stenosis, tricuspid stenosis, hyperdynamic circulation
3) Soft in Mitral regurgitation, mitral valve calcification

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

A loud S1 signifies which issues?

A

1) Tricuspid stenosis
2) Mitral stenosis
3) Hyperdynamic circulation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

A loud A2 signifies which issues?

A

1) HTN
2) Aortic stenosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

A loud P2 signifies which lesion?

A

1) Pulm HTN (may also have mid-diastolic murmur)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

An increased split in S2 indicates which pathology?

A

1) RBBB
2) Pulmonary stenosis
3) VSD
4) Mitral regurgitation (earlier A2)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

A fixed split S2 indicates which pathology?

A

ASD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What does an S3 indicate?

A

1) Can be normal in children
2) Volume overload in L or R heart e.g. PDA, VSD, LVF, RVF

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What does S4 indicate?

A

Left or right ventricular hypertrophy
- L) = Aortic stenosis, systemic hypertension, HOCM
- R) = Pulmonary stenosis, pulm HTN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

A soft A2 signifies which pathology?

A

1) Calcified aortic valve
2) Aortic regurgitation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

A soft P2 indicates which pathology?

A

Pulmonary stenosis (soft A2 with loud P2 = PS with PHTN)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What is a reversed split and which lesions is it seen in?

A

P2 is before A2 (how am I supposed to hear this, honestly)
1) LBBB
2) Aortic stenosis
3) CoA
4) PDA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What does an Ejection Systolic Murmur at LLSE indicate?

A

VSD
- Early systolic murmur (if muscular) or pansystolic (if perimembranous) at LLSE
- Assoc with Mid Diastolic Rumble at apex due to relative mitral stenosis
- Asso w decrescendo diastolic murmur at URSE if also have aortic regurgitation

32
Q

Complications of VSD?

A

1) Pulmonary HTN
2) LVH, BVH or RVH depending on shunt direction

33
Q

Ejection systolic murmur at URSE?

A

1) Valvular Aortic Stenosis: carotid radiation +/- ejection systolic click at URSE. May be assoc w decrescendo diastolic murmur at 3rd L) intercostal space if also AR from bicuspid AV.
2) Supravalvular AS –> URSE/ULSE w radiation to neck/apex. R) arm BP >L arm BP + NO ejection click
3) Coarct: ESM at URSE/LLSE radiating to back (L interscapular area) + thrill at suprasternal notch +/- ejection click at apex (UL BP > LL BP)

34
Q

Complications of valvular aortic stenosis?

A

1) narrow pulse pressure
2) anacrotic/plateau pulse
3) thrill at URSE/suprasternal notch
4) reverse splitting of S2 (normalizes with inspiration)
5) S4
6) absent A2
7) increased murmur length
8) late peak of systolic murmur
9) LVF (late)

35
Q

Ejection systolic murmur at ULSE?

A

1) Supravalvular aortic stenosis (URSE or ULSE w radiation to neck/apex. Note: R arm BP > L arm BP and NO ejection click)
2) Pulmonary stenosis –> back radiation +/- systolic click which decreases with inspiration, soft P2, splitting of S2. +/- thrill at ULSE/suprasternal notch. Can get RVF
3) Atrial Septal Defect –> + fixed splitting of S2, mid-diastolic rumble at LLSE (relative mitral stenosis). Can get RVH or RVF (rare)

36
Q

Ejection Systolic Murmur loudest at LLSE?

A

1) Ventral septal defect: early systolic murmur if muscular or pansystolic murmur if perimembranous + mid diastolic rumble at apex (relative mitral stenosis) + decrescendo diastolic murmur at URSE (Aortic regurgitation)
2) Coarct: ESM at URSE/LLSE radiating to back (L interscapular area) + thrill at suprasternal notch +/- ejection click at apex (UL BP > LL BP)

37
Q

DDx for Pansystolic Murmur?

A

1) Mitral regurgitation
2) Tricuspid regurgitation
3) VSD
4) Ebstein’s Anomaly
5) Aorto-pulmonary shunts

Heard loudest BELOW the nipple line

Note all Pansystolic murmurs are ACYANOTIC

38
Q

DDx for ejection systolic murmur?

A

1) Aortic stenosis
2) Pulmonary stenosis (can be cyanotic if critical)
3) Pulmonary flow murmur in ASD
4) HOCM

Heard loudest ABOVE the nipple line

With carotid thrill = Left ventricular outflow tract obstruction
Without carotid thrill = probably right ventricular outflow tract obstruction

39
Q

Late Systolic murmur Ddx?

A

Mitral valve prolapse

40
Q

Early diastolic murmur Ddx?

A

1) Aortic Regurgitation
2) Pulmonary regurgitation

41
Q

Mid-diastolic murmur Ddx?

A

1) Mitral stenosis
2) Tricuspid stenosis

42
Q

Continuous murmur + acyanotic lesion Ddx?

A

1) PDA
2) Aorto-pulmonary connection
3) AV fistula
4) Rupture of sinus valsalva into R) atrium or ventricle
5) Venous hum (loudest over R supra-clavicular fossa –> gone if press internal jugular vein)

43
Q

Continuous murmur and cyanotic lesion?

A

1) MAPCA - Major aortopulmonary collateral arteries
2) BT shunt

44
Q

Syndromes associated with Pulmonary Stenosis?

A

1) Noonans
2) Alagille
3) Williams

45
Q

Signs seen with pulmonary stenosis?

A
  • ↓ pulse volume (if severe and critical)
  • JVP → may be ↑
  • Cyanosis (if severe and critical)
  • Apex → RVH with heave
  • Thrill → pulmonic area
  • Heart sounds: +/- systolic click before murmur (valvular disease), Soft S2, S4, ↑ split
    o ESM
    o Pulmonic area (note also loud in tricuspid area)
    o +/-
45
Q

Signs seen with pulmonary stenosis?

A
  • ↓ pulse volume (if severe and critical)
  • JVP → may be ↑
  • Cyanosis (if severe and critical)
  • Apex → RVH with heave
  • Thrill → pulmonic area
  • Heart sounds: ESM (Pulmonic area (note also loud in tricuspid area) +/- radiate to back (if peripheral pulmonary stenosis), +/- systolic click before murmur (valvular disease), Soft S2, S4, ↑ split
  • +/- RVF

If severe PS: ↓ pulse volume, Cyanosis, RVH with heave, Thrill, S4, ↑ length of murmur

46
Q

Pink with CCF and LVH Ddx?

A

VSD
AVSD
PDA
Hypoplastic (repaired)

47
Q

Pink with CCF and RVH Ddx?

A

ASD
PAPVD
TOF (repaired w residual RVOTO)
PA w VSD

48
Q

Pink with no CCF and LVH Ddx?

A

AS
Coarctation
MR
Myocardial

49
Q

Pink with no CCF and RVH Ddx?

A

PS
MS

50
Q

Previous surgery and pink Ddx?

A

ASD/VSD/AVSD repair
Tetralogy repair (likely PS murmur at ULSE)
Arterial switch
TAPVD repair
Fontan no fenestration

51
Q

Blue with CCF and LVH Ddx?

A

PA w good MAPCAs
TGA/VSD
Truncus

52
Q

Blue with CCF and RVH Ddx?

A

TGA intact septum
TAPVD
HLHS

53
Q

Blue with no CCF and LVH Ddx?

A

PA w poor MAPCAs
Tricuspid Atresia

54
Q

Blue with no CCF and LVH Ddx?

A

Tetralogy
Ebsteins (blue and well)

55
Q

Previous surgery and blue Ddx?

A

“Palliative surgery for cyanotic congenital heart disease, this may be a staged procedure and patient remains blue”

1) Shunted circulations: Tetralogy / Pulmonary atresia, Single ventricle with PS, Norwood procedure, TGA / LVOTO

2) Single ventricle lesions (no shunt): “Many complex heart lesions may lead to single ventricle physiology”: Bidirectional cavopulmonary shunt, Fontan with fenestration

56
Q

Increased pulmonary vascularity in CXR Ddx?

A
  • Truncus arteriosus
  • TAPVD
  • Transposition of great arteries
57
Q

Decreased pulmonary vascularity on CXR Ddx?

A
  • Tricuspid atresia
  • Ebstein’s
  • Pulmonary atresia w MAPCAs
  • Teratology of Fallot
  • Critical pulmonary stenosis with R→ L shunt
58
Q

Normal ECG axis for age?

A

a) Birth → +60 to +180 degrees
b) 1 year → +10 to + 100 degrees
c) 10 years → +30 to +90 degrees
d) Also check p-wave axis (should be ↑ or +ve in avF/II/III)

59
Q

RVH ECG findings + differential:

A

Large R waves in V1 and V3 ( > 5 squares in <1mo, >4 squares in <1yo, > 3 squares in >1yo)

Large S waves in V5 and V6 (> 3 squares in <1mo, >2 squares in <1yo, > 1 squares in >1yo)

Differentials:
1) ↑ RV over-load
2) Pulmonary valve stenosis
3) Tricuspid insufficiency
4) Pulmonary HT
5) VSD (L → R shunt)

60
Q

LVH rules on ECG?

A
  • LAD for the patient’s age
  • QRS voltages in favor of the LV
    o R in I, II, III, aVL, aVF, V5, or V6 (Pressure Overload: II, III, aVF; Volume Overload: V5, V6)
    o S in V1 (> 1 squares in <1m, > 2 squares in <1yo, > 3 squares in >1yo; abnormal R/S ratio in favor of LV)
    o R/S Ratio in V1, V2
    o Q in V5 and V6 > 5 mm coupled with Tall peaked T-waves
  • wide QRS-T Angle with T axis outside normal range
  • flat or inverted T waves in I or aVF
  • severe = inverted t wave in V6 and ST segment depression in lateral leads
61
Q

RVH ECG criteria in children?

A
  • RAD for the patient’s age
  • ↑ rightward and anterior QRS axis: R in V1, V2, aVR, S in I, V6
  • abnormal R/S ratio in favor of right ventricle: R/S ratio in V1, S/R ratio in V4-6 after 1 month of age
  • upright T in V1 (if <6yrs, from 3-5 days of life)
  • with very severe RVH and strain the t wave will flip back in V1 and there may be ST segment depression and small q wave in lead V1
  • q wave in V1 (normal in 10% of neonates)
  • wide QRS-T angle with the T axis outside normal ranges
62
Q

LVH ECG criteria?

A
  • LAD for the patient’s age
  • QRS voltages in favor of the LV: R in I, II, III, aVL, aVF, V5, or V6
    (Pressure Overload: II, III, aVF; Volume Overload: V5, V6), S in V1
  • abnormal R/S ratio in favor of LV: R/S Ratio in V1, V2, Q in V5 and V6 > 5 mm coupled with Tall peaked T-waves
  • wide QRS-T Angle with T axis outside normal range
  • flat or inverted T waves in I or aVF
  • severe = inverted t wave in V6 and ST segment depression in lateral leads
63
Q

LVH ECG criteria?

A
  • LAD for the patient’s age
  • QRS voltages in favor of the LV: R in I, II, III, aVL, aVF, V5, or V6
    (Pressure Overload: II, III, aVF; Volume Overload: V5, V6), S in V1
  • abnormal R/S ratio in favor of LV: R/S Ratio in V1, V2, Q in V5 and V6 > 5 mm coupled with Tall peaked T-waves
  • wide QRS-T Angle with T axis outside normal range
  • flat or inverted T waves in I or aVF
  • severe = inverted t wave in V6 and ST segment depression in lateral leads
64
Q

Left Atrial Hypertrophy ECG finding + differential?

A

Bifid P wave

Differential:
* MR or MS
* Cardiomyopathy
* Large VSD/PDA

65
Q

Right Atrial Hypertrophy ECG finding + differential?

A

Tall + tented p wave

Differential:
- ASD
- TR
- TA
- PA
-Pulm HTN
-ToF
- TAPVR/PAPVR
- severe PS

66
Q

LVH differentials?

A

↑ LV overload
Aortic stenosis
Mitral insufficiency
VSD
PDA

67
Q

RVH differentials?

A

↑ RV over-load
Pulmonary valve stenosis
Tricuspid insufficiency
Pulmonary HT
VSD (L → R shunt)

68
Q

Left axis deviation ECG criteria + differentials?

A

↓ in III, evident when ↓ in II

DDx:
 Tricuspid atresia
 ASD (primum)
 PS in Noonan’s esp if HCM
 Endocardial cushion defect
 Single ventricle
 LVH esp with volume overload
 Ebsteins
 WPW
 L-TGA

69
Q

Right axis deviation ECG criteria + DDx?

A

↓ in III, ↓ in I

DDx:
 ASD (secundum)
 RBBB

70
Q

Heart Block on ECG differentials?

A

 L-TGA (corrected TGA)
 Polysplenia syndrome
 AVSD
 Ebstein’s
 Acute rheumatic fever
 Congenital heart block with maternal SLE

71
Q

Q wave normal in which leads?

A

II
III
AVF
V5 and V6

If noted in R) chest leads then: LBBB, RVH, L-TGA, HOCM, Infarction

72
Q

RBBB differentials?

A

Partial
 ASD
 Ebstein’s anomaly

Complete
 Post right-ventriculotomy (repair of VSD, tetralogy of Fallot)
 Coarctation of the aorta (in infants<6mo)
 Endocardial cushion defects
 PAPVR
 Occasionally in normal children

With left axis deviation → ostium primum ASD
With R axis deviation → ostium secundum ASD
With R atrial hypertrophy + delta waves → Ebstein’s
Complete RBBB → post-ventriculotomy

73
Q

How to Dx protein losing enteropathy?

A

A1 anti-trypsin present in faeces

74
Q

Post cardiac surgery operative complications?

A

o RLN palsy → voice changes, poor cough
o Horner’s syndrome (30% with BT shunts)
o Diaphragm
o Scar

75
Q

Steps of post cardiac surgery examination?

A
  • Unwell or well
  • Growth and puberty and nutritional status
  • Vitals → BP, temperature, urinalysis
  • IQ
  • Dysmorphic
  • Lesions of skin: Acne, Bruising

CVS EXAMINATION
* Hands: Polycythaemia, Gout, Signs of SBE
* Wrist → HR → regular or irregular, ↓ pulse on side
* Eyes → polycythaemia, Horner’s, fundoscopy (retinal bleeds)
* Mouth: Cyanosis, Cough and speak → RLN palsy
* Chest: Inspect respiration → diaphragmatic palsy, Palpate for pace maker, Scars → healed or not, Apex displaced, Shunt murmur, Stenotic or regurgitant murmurs
* Back chest: Kyphoscoliosis, Any crackles
* Hepatomegaly → CHF

CNS EXAMINATION
* Gait examination (stroke)

76
Q

Complication of Fontan?

A
  • Chylothorax and pleural effusions are very common complications.
  • Protein losing enteropathy common (and is an indication for transplant)
  • Strokes – post-fontan all patients are on warfarin to prevent paradoxical embolus and stroke
  • Cerebral abscesses

RACP Clinical Short (11 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions