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Flashcards in Cardiac Examination Deck (94):
1

What is indicated by a pain that is worse on inspiration?

Pericarditis or pleuritic pain

2

What is indicated by a pain that is relieved within minutes by GTN?

angina

3

What is indicated by a pain that is improved by leaning forwards?

Pericarditis

4

If a patient describes a pain as constricting, what is/are likely cause(s)

Angina
Oesophageal spasm
Anxiety

5

What is characteristic of pain felt due to MI?

Prolonged (>1/4 hour), dull, central crushing pain

6

What is indicated by a sharp pain?

Pleural or pericardial cause

7

How is the pain of aortic dissection classically described?

Instantaneous, tearing interscapular pain (may also be retrosternal)

8

How might you determine whether chest pain was musculo-skeletal?

Look for pain on specific postures or activity

Aim to reproduce the pain by movement and sometimes palpation over the structure causing it

9

What is Tietze's syndrome?

Self-limiting costochondritis with or without costosternal joint swelling

10

What is the likely presenting complaint in Tietze's syndrome?

Chest pain with tenderness

11

What causes pleuritic pain?

Inflammation of the pleura due to pulmonary infection, inflammation or infarction

12

What exacerbates pleuritic pain? How might a patient describe it?

Inspiration. "it causes me to catch my breath"

13

How does cardiac tamponade present?

Shock with raised JVP

14

What might cause dyspnoea?

1. LV failure
2. Pulmonary embolism
3. Any respiratory cause
4. Anxiety

15

What is orthopnoea? What might it indicate? How might you find out if a patient suffers from it?

Shortness of breath when lying flat
Heart failure
How many pillows do you use to sleep at night?

16

What specific symptoms are associated with heart failure?

1. Orthopnoea
2. Paroxysmal nocturnal dyspnoea
3. Peripheral oedema

17

How might a patient who has had a PE present? What should you ask them?

1. Acute onset of dyspnoea with pleuritic chest pain
2. Ask about risk factors for DVT and check if their calves are swollen

18

What might cause palpitations?

Ectopics
Atrial fibrillation
SVT
VT
Thyrotoxicosis
Anxiety
(rarely) phaeochromocytoma

19

Which prodromal (early) symptoms of syncope indicate a cardiac cause?

Chest pain
Palpitations
Dyspnoea

20

Which prodromal (early) symptoms of syncope indicate a CNS cause?

Aura
Headache
Dysarthria
Limb weakness

21

How might you differentiate between a cardiac and CNS siezure if prodromal symptoms are unknown?

Was recovery rapid? Indicates cardiac cause e.g. arrhythmia

Was recovery prolonged with drowsiness? Indicates CNS cause

22

What questions might you ask about the seizure itself?

During the seizure was there:
1. Loss of pulse
2. Limb jerking
3. Tongue biting
4. Urinary incompetence

5. How long did it take the patient to return o normal?
6. How long did the siezure last
7. What was the patient doing at the time
8. Did it come on suddenly or gradually

23

What questions might you ask a patient with palpitations?

When and how did it start/stop
Duration?
Onset sudden or gradual?
Is it associated with black out? If so for how long?
Is it fast or slow?
Is it regular or irregular?
Ask the patient to tap out the rhythm
Is it related to eating/drinking (particular coffee, tea, wine, chocolate

24

What is the NYHA?

New York classification of heart failure

I: Heart disease is present but there is no undue dyspnoea from normal activity
II: Comfortable at rest; dyspnoea activity e.g. walking up stairs
III: Most activity including ADL causes dyspnoea
IV: Dyspnoea at rest

25

What is/are the likely cause(s) of irregular fast palpitations

AF
Atrial flutter with variable block

26

What is/are the likely cause(s) of regular fast palpitations

SVT
VT

27

What is/are the likely cause(s) of slow fast palpitations

Drugs e.g. beta-blockers
Bigeminy

28

What are the cardiovascular causes of clubbing?

Cyanotic congenital heart disease
Endocarditis
Atrial myxoma
Aneurysms
Infected grafts

29

What signs of infective endocarditis can be seen on the hands

Splinter hemorrhaging
Janeway lesions
Osler's nodes

30

What indication(s) of hyperlipdaemia is/are seen round the eyes?

Corneal arcus (can be normal in >60 years)
Xanthelasma

31

What is the cause of a heave?

RV enlargement e.g. due to pulmonary stenosis, ASD or cor pulmonale

32

What is a thrill?

A palpable murmur felt as a vibration beneath your hand

33

What is indicated by a pansystolic murmur radiating to the axilla? Where is this best heard? Should the bell or diaphragm of the stethoscope be used?

Mitral regurgitation
The apex
Diaphragm

34

What is indicated by a rumbling mid-diastolic murmur heard best with the bell of the stethoscope?

Mitral stenosis

35

Where should you listen if you suspect a right sided murmur? How can you enable yourself to hear these murmurs better?

Lower left sternal edge; fourth intercostal space (tricuspid area)
Left of the manubrium in the 2nd intercostal space (pulmonary valve murmur)

Ask the patient to take a deep breath in and hold it

36

Where would you listen for aortic stenosis? What does it sound like?

Right of manubrium in 2nd intercostal space
Ejection systolic murmur- crescendo de-crescendo- radiating to the carotids

37

If I had more time I would...

Check for sacral and ankle oedema
Check oxygen saturations
Feel for an AAA
Check peripheral pulses

NB SOAP

38

What past surgical procedure(s) may be indicated by a median sternotomy?

CABG
Valve replacement
Congenital heart disease surgery

39

What should you look for round the bed in a cardiac examination?

Oxygen
GTN spray
Cardiac monitoring devices

40

How do you check for radio femoral delay? What does this indicate?

Check for radio-femoral delay by palpating both the radial and femoral pulses on one side of the body at the same time. The pulsation should occur at the same time, any delay may suggest coarctation of the aorta

41

What does radio-radial delay indicate?

Aortic arch aneurysm

42

In what conditions is pulse pressure narrow?

Aortic stenosis
Hypovolaemia

43

In which conditions is pulse pressure wide?

Aortic regurgitation
Septic shock

44

What is the definition of postural hypotension?

A drop in systolic BP of 10mmHg on standing

45

What is indicated by malar flush?

Mitral stenosis
Low cardiac output

46

What might cause bruit in a) elderly patients and b) young patients

a) atherosclerosis
b) vasculitis

47

What indications of right sided heart failure would be seen on examination of the abdomen?

Heptaomegaly
Ascites

48

What cardiac condition may be indicated by splenomegaly?

Infective endocarditis

49

Where are Roth spots seen? What cardiac condition do these indicate?

Fundus during fundoscopy
Infective endocarditis

50

What will be the effect of a too small cuff on BP reading?

Reading will be falsely raised

51

What is indicated by a BP differential >10mmHg?

Peripheral vascular disease
Aortic aneurysm
Aortic dissection

52

What are the causes of postural hypotension

1. Old age
2. Hypovolaemia
3. Drugs: nitrates, diuretics, antihypertensives, antipsychotics
4. Addison's
5. Hypopituitarism
6. Idiopathic

53

What causes the a wave in the JVP wave form?

Atrial systole

54

What causes the c wave in the JVP wave form?

Closure of the tricuspid valve, not normally visible

55

What causes the x descent in the JVP wave form?

Fall in atrial pressure during ventricular systole (as the atria are no longer contracting)

56

What causes the v wave in the JVP wave form?

Atrial filling against a closed tricuspid valve

57

What causes the y descent in the JVP wave form?

Opening of the tricuspid valve

58

What is the cause of a raised JVP with a normal waveform?

Fluid overload; right heart failure

59

What is the cause of a fixed, raised JVP with absent pulsation?

SVC obstruction

60

What is the cause of a large a wave?

Pulmonary hypertension; pulmonary stenosis

61

What is a cannon a wave?

A large a wave caused by contraction of the right atrium against a closed tricuspid valve

62

What is the cause of a large a wave?

Complete heart block
Single chamber ventricular pacing
Ventricular arrhythmias/ectopics

63

What is the cause of an absent a wave?

Atrial fibrillation

64

What is the cause of a large v wave?

Tricuspid regurgitation

65

What is the cause of an absent JVP?

When lying flat the jugular vein should be filled. If there is reduced circulatory volume e.g. dehydration or haemorrhage the JVP may be absent

66

What is/are the cause(s) of a bounding pulse?

CO2 retention
Liver failure
sepsis

67

What is/are the cause(s) of a collapsing pulse?

Aortic incompetence
AV malformations
Patent ductus arteriosus

68

What is pulsus paradoxus?

Systolic pressure weakens on inspiration by >10mmHg

69

What causes pulsus paradoxus?

Severe asthma
Pericardial constriction
Cardiac tamponade

70

What is the cause of S1?

Mitral/tricuspid valve closure

71

What causes a loud S1?

Mitral stenosis

72

What is the cause of the second heart sound?

Aortic and pulmonary valve closure

73

How is a 3rd heart sound best heard and at what point in the cycle is it heard?

With the bell of the stethoscope. Just after S2

74

At what age does a third heart sound become pathological

Over 30

75

What is/are the cause(s) of a third heart sound?

Mitral regurgitation
VSD
Post MI
Dilated cardiomyopathy
Constrictive pericarditis (early and more high pitched- 'pericardial knock)
Restrictive cardiomyopathy (early and more high pitched- 'pericardial knock)

76

When does a 4th heart sound occur?

Just before the first heart sound

77

What causes a 4th heart sound?

Always pathological. Represents atrial contraction against a ventricle made stiff by any cause, e.g. aortic stenosis or hypertensive heart disease

78

When is a gallop rhythm heard?

Sinus tachycardia

79

What is the cause of an ejection systolic murmur? What does it sound like

Normal- esp. in children and high output states e.g. pregnancy and tachycardia
Aortic stenosis
Pulmonary stenosis

Crescendo-decrescendo 'whoosh dub'

80

What causes a pansystolic murmur. What does it sound like?

Mitral or tricuspid regurgitation
VSD
Of uniform intensity throughout systole and merges with S2 'whoosh whoosh'

81

What is the cause of an early diastolic murmur? What does it sound like? How is it best heard?

Aortic regurgitation
High pitched and easy to miss. Listen for "absence of silence" in early diastole

Ask the patient to lean forward, take a deep breath in, out and then hold it. Listen with the bell of the stethoscope

82

What is the cause of an early diastolic murmur? What does it sound like? How is it best heard?

Mitral stenosis

Low pitched and rumbling

Ask the patient to roll on to there left side and place stethoscope just beneath the axilla on the left side
Ask the patient to take a deep breath in, then a big breath out and hold it (left sided murmurs are louder on expiration)

83

Where do mitral murmers tend to be loudest?

Apex

84

Where does the ESM of aortic stenosis radiate?

The carotids

85

Where does the PSM of mitral regurgitation radiate?

The axilla

86

When might a pericardial rub be heard? What are its characteristics?

Pericarditis
A superfical scratching sound not confined to systole or diastole

87

How might you make a mitral stenosis or regurgitation murmur more audible?

1. Ask the patient to roll on to there left side and place stethoscope just beneath the axilla on the left side

2. Ask the patient to take a deep breath in, then a big breath out and hold it (left sided murmurs are louder on expiration)

88

How might you make an aortic regurgitation murmur more audible?

1. Ask the patient to lean forward

2. Ask the patient to take a deep breath in, then a big breath out and hold it (left sided murmurs are louder on expiration)

89

Which murmurs are best heard which the bell of the stethoscope?

1. Mitral stenosis
2. Aortic regurgitation
3. Third heart sound

90

How might you confirm your suspicion of an aortic systolic murmur?

Strong and forceful apex beat upon palpation- due to LV hypertrophy

91

How might you confirm your suspicion of a mitral regurgitation murmur?

Displaced apex beat due to enlarged LV

92

Which murmur is pan-systolic?

Mitral regurgitation

93

Which murmur is ejection systolic?

Aortic stenosis

94

Which murmurs are diastolic?

Mitral stenosis
Aortic regurgitation