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Finals osce > 2. Cardio examiantion > Flashcards

2. Cardio examiantion Flashcards

1
Q

general inspection cardio

A

(colour, breathing, comfort, position,
build)

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2
Q

cardiac signs in the hands

A
  • Tar staining
    o Vasodilatation/constriction, temperature
    o Sweating (suggests increased sympathetic drive)
    o Pallor of palmar creases
    o Peripheral cyanosis
    o Clubbing
    o Splinter haemorrhages
    o Osler’s nodes and Janeway lesions
    o Tendon xanthomas
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3
Q

what does sweating suggest cardiac

A
  • pain –> sympathetic drive
  • HF/MI - inadequate circualtion –> sympathetic drive
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4
Q

what does pallor of palmar crease suggest

A

anaemia

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5
Q

causes of clubbing

A

Causes of clubbing can be divided into: cardiac, repsiratory and other

Cardiac causes:
cyanotic congenital heart disease (Fallot’s, TGA)
bacterial endocarditis

Respiratory causes
interstitial pulmonary fibrosis
lung cancer
cystic fibrosis, bronchiectasis
lung abscess, empyema, tuberculosis
asbestosis, mesothelioma
fibrosing alveolitis

Other causes
Crohn’s, to a lesser extent UC
cirrhosis,
Graves’ disease

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6
Q

examination findings infective endocarditis

A

inspection:
- splinter haemorrhages
- janeway lesions
- oslers nodes
- finger clubbing in long standing disease

auscultation:
- new or changing murmur

to complete:
- fundoscopy - roth spots

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7
Q

what are janeway lesions

A

painless red flat macules on the palms of the hands and soles of the feet

suggestive of infective endocarditis

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8
Q

what are oslers nodes

A

tender red/purple nodules on the pads of the fingers and toes

O = Ow

suggestive of infective endocarditis

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9
Q

what are roth spots

A

haemorrhages on the retina seen during fundoscopy

suggestive of infective endocarditis

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10
Q

what are tendon xanthomas

A

They commonly affect the tendons of the dorsal surface of the hands

Tendon xanthomas are cholesterol deposits in tendons.

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11
Q

what is the waterhammer pulse

A

testing the brachial pulse for ‘collapsing pulse’ associated with aortic regurgitation

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12
Q

cardiac signs in the eyes

A

o Subconjunctival pallor
o Corneal arcus
o Xanthelasmata

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13
Q

what is corneal arcus

A

Corneal arcus is characterized by a white or grey opaque ring around the iris. Most often this affects both eyes (i.e., bilateral)

can be benign in older adults

however in ppl <40 arcus juvenilis may occur due to a lipid metabolism disorder, such as familial hyperlipidemia (i.e., elevated blood lipid levels), hypercholesterolemia (i.e. elevated cholesterol levels), or dyslipidemia (i.e., atypical lipid levels).

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14
Q

cardiac face sign

A

o Malar flush (mitral stenosis)

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15
Q

cardiac signs in the mouth/lips

A

o Central cyanosis (under tongue or on mucous membranes inside lips)
o High-arched palate (Marfan’s)
o Dental caries (may predispose to infective endocarditis)

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16
Q

what vein is best to look at as a proxy fir central venous pressure

A

internal jugular vein

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17
Q

how to distinguish between jvp and carotid pulsation

A

Number of pulses: the JVP has a double waveform pulse (i.e. 2 pulses) whereas the carotid artery has a single pulsation for each cardiac cycle.

Palpability: the pulse of the JVP is not easily palpable, whereas the carotid pulse is typically easy to feel.

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18
Q

how to emasure the jvp? what is normal?

A

the vertical distance between the sternal angle and the top of the pulsation point of the IJV (in healthy individuals, this should be no greater than 3cm).

19
Q

what is the hepatojugular reflex?

A

apply pressure to the liver - if there is a sustained rise in JVP equal to or greater than 4cm this is deemed a positive result for raised JVP

In healthy individuals, this rise should last no longer than 1-2 cardiac cycles (it should then fall).

20
Q

causes of raised JVP?

A

hypervolemia
right sided heart failure
tricuspid regurgitation
obstructive shock
- consrrictive pericarditis
- pneumothorax
- superior vena cava obstruction

21
Q

JVP wave form and corresponding things:

A

A wave: atrial contarction

x wave 1 : atrial relaxation

c wave: tricuspid valve closure

x wave 2: (opposite as x1)- last part of ventricualr contraction

v wave : venous filling

y wave: eptying of right atrium into right ventricle

22
Q

what is a thoracotomy scar? where may it be? indications

A

A thoracotomy is a surgical procedure in which a cut is made between the ribs to see and reach the lungs or other organs in the chest or thorax.

  • posterolateral thoracotomy: pulmonary resections (pneumonectomy/lobectomy/wedge)
  • anterolateral thoracotomy:
    left sided = open chest massage
  • axillary thoracotomy : pulmonary resections, pneumpthorax, pleurectomy
  • mini-thoractotomy: right anterior mini thoractomy = accessing the aortic valve
    right lateral mini thoractomy = accessing mitral valve
23
Q

posterolateral thoracotomy indications

A

pulmonary resections (pneumonectomy/lobectomy/wedge)

24
Q

what is a midline sternotomy scar? indications?

A

open heart surgery

  • valve surgery (aortic, mitral most common)

congenital heart defect correction

CABG (if seen, ask to look for vein harvesting scar on legs)

25
Q

cardiac signs inspection of the chest wall

A

sternotomy scars
thoractotomy scars
pectus excavatum
kyphoscoliosis

26
Q

heaves vs thrills

A

heaves = abnormally large pulsation of the heart felt on palpation

thrills = palpable murmur (vibrations/buzzing feeling)

27
Q

what do heaves indicate?

A

right ventricular enlargement, or. rarely, severe left atrial enlargement which pushes the right ventricle forwards.

28
Q

what grade murmur does a palpable thrill indicate

A

grade 4

29
Q

SCRIPT examination of a murmur

A

S – Site: where is the murmur loudest?
C – Character: soft / blowing / crescendo (getting louder) / decrescendo (getting quieter) / crescendo-decrescendo (louder then quieter)
R – Radiation: can you hear the murmur over the carotids (aortic stenosis) or left axilla (mitral regurgitation)?
I – Intensity: what grade is the murmur?
P – Pitch: is it high-pitched or low and rumbling? Pitch indicates velocity.
T – Timing: is it systolic or diastolic?

30
Q

grades of murmurs

A

Grade I: Difficult to hear
Grade II: Quiet
Grade III: Easy to hear
Grade IV: Easy to hear with a palpable thrill
Grade V: Audible with stethoscope barely touching the chest
Grade VI: Audible with stethoscope off the chest

31
Q

stenosis and hypertrophy?

A

When pushing against a stenotic valve, the muscle has to try harder, resulting in hypertrophy:

Mitral stenosis causes left atrial hypertrophy
Aortic stenosis causes left ventricular hypertrophy

32
Q

regurgitation and dilatation

A

When a leaky valve allows blood to flow back into a chamber, it stretches the muscle, resulting in dilatation:

Mitral regurgitation causes left atrial dilatation
Aortic regurgitation causes left ventricular dilatation

33
Q

o/e aortic stenosis

A

ass bump

murmur: ejection-systolic crescendo-decrescendo murmur

radiation: to carotids

pulse: slow rising pulse

other: narrow pulse pressure, thrill in aortic area

34
Q

o/e arotic reguargitation

A

ard fall

murmur: early diastolic Switch back to the diaphragm, sit the patient forward and auscultate at the 4th/5th
intercostal space to the left of the sternum on held expiration

pulse: collapsing pulse (waterhammer),

other: wide pulse pressure

35
Q

o/e mitral stenosis

A

msd u

murmur: mid- diastolic low pitched rumbing
Switch to the bell and auscultate the apex with the patient rolled 45° to the left

pulse: may have irregularly irregualr pulse (AF)

other: tapping apex beat, malar flush, atrial fibrilation

36
Q

o/e mitral regurgitation

A

mrs through

murmur: pan-systolic high pitched whistling murmur, radiate to axilla. third heart sound

pulse: Atrial fibrillation (irregularly irregular pulse)

37
Q

o/e tricuspid regurgitation

A

mumur: pan-systolic murmur

other: prominent/giant V waves in JVP, pulsatile hepatomegaly, left parasternal heave

38
Q

o/e marfans cardio exam

A

inspection:
- hands: arachnodactyly
- mouth : high arched palate
- chest: pectus excavatum

auscultation:
aortic regurgitation (due to dialtion of aortic root)
murmur: early diastolic Switch back to the diaphragm, sit the patient forward and auscultate at the 4th/5th
intercostal space to the left of the sternum on held expiration
pulse: collapsing pulse (waterhammer),

OR mitral valve prolapse –> mitral regurgitation
murmur: pan-systolic high pitched whistling murmur, radiate to axilla. third heart sound

39
Q

o/e HOCM

A

can be normal

murmur: Late ejection systolic murmur exacerbated by valsalva manoeuvre, reduced when squatting
Does NOT radiate to the neck
Best heard at left sternal edge, 3rd-4th intercostal space

pulse: atrial fibrilation Occurs in 20% of patients

other: prominent JVP a wave, abnormal blood pressure response to exercise, foreceful apex beat

40
Q

what to examine if ? coarctation

A

auscultate to the left of the spine in the 3rd/4th intercostal space

Check the femoral pulses. Check synchrony with the radial pulse (radiofemoral delay
in coarctation). (In the OSCE, you should state that you would do this).

41
Q

if there is pitting oedema at the ankles, what else should you test?

A

If this is present, you should always also check
for ascites (see test for shifting dullness above).

42
Q

to complete cardiac examination

A
  • Check the blood pressure in both arms and lying and standing in one arm.
    ● Perform ophthalmoscopy for hypertensive retinopathy
    ● Obtain a 12-lead ECG (In the OSCE, you should state that you would do this).
43
Q

Presenting cardiac examination

A

Today I completed a cardiac examination on xyz

On inspection there was xyz / there were no signs of cardiovascular disease. The pulse rate was x with a regular rhythm.

On palpation there was xyz / there were no heaves or thrills and no lateral displacement of the apex beat

On auscultation there was xyz/ normal heart sounds with no additional sounds. The lung bases were clear

There were no other positive findings

In summary this examination is most consistent with…

44
Q
A

Finals osce (11 decks)

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