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Cardiology Examination Flashcards

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1
Q

What are pulse and BP findings in AS?

A

1) plateau or anacrotic pulse
2) late peaking - tardus
3) small volume - parvus
4) reduced pulse pressure

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2
Q

What are palpation findings in AS?

A

1) diffuse apex beat, may be displaced

2) systolic thrill at base of heart

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3
Q

What are auscultation findings in AS?

A

1) Narrowly split or reverse splitting of S2
2) Harsh ESM radiating to carotids, loudest on sitting forwards on full expiration
3) Commonly associated with AR
4) ejection click preceding murmur in congenital AS

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4
Q

What are signs of severe AS? (7)

A
  1. plateau pulse
  2. narrow pulse pressure
  3. thrill in aortic area
  4. soft S2, reversed splitting of S2
  5. S4
  6. long, late peaking murmur
  7. LVH (pre-terminal)
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5
Q

What are causes of AS?

A
  1. calcification of congenital bicuspid valve (40-60yrs), assoc with coarctation
  2. Progressive calcific disease of trileaflet valve
  3. Childhood rheumatic fever (invariably associated with mitral involvement)
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6
Q

What are investigations in AS?

A
  1. ECG - LVH, LV strain, LAH
  2. CXR - post stenotic diltation of ascending aorta
  3. TTE
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7
Q

What are echocardiographic findings of severe AS?

A

Valve area less than 1cm^2
Mean gradient >40mmHg
Aortic jet velocity >4m/sec

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8
Q

What monitoring is appropriate in AS?

A

Surveillance TTE

  • Q1y for severe 0Sx AS
  • Q2y for moderate
  • Q3y for mild
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9
Q

What are indications for surgery in AS?

A
  1. When symptomatic and severe

2. Severe AS w LVEF

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10
Q

What are findings on general examination in AR?

A

1) Marfan’s syndrome
2) Ankylosing spondylitis
3) Argyll robertson pupils

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11
Q

What are pulse and BP findings in AR?

A

Collapsing pulse, wide pulse pressure

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12
Q

What are findings on the neck in AR?

A

Corrigan’s sign - prominent carotid pulsation

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13
Q

What are findings on palpation in AR?

A

Apex beat displaced and diffuse

Diastolic thrill at LLSE when pt sits forwards in full expiration

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14
Q

What are findings on auscultation in AR?

A

Soft A2
Early decrescendo diastolic high pitched murmur at LLSE, increased w expiration.
Systolic ejection murmur also present (AS or torrential flow)
Austin flint murmur - rumbling mid-disatolic murmur at apex

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15
Q

What are signs of severe AR?

A
  1. collapsing pulse
  2. wide pulse pressure
  3. long decrescendo diastolic murmur
  4. Left ventricular S3
  5. Soft A2
  6. Austin flint murmur
  7. Signs of LVF
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16
Q

What are causes of AR?

A 
Valvular:
- congenital bicuspid AV
- rheumatic (rarely only AR)
- endocarditis
- dehiscence of prosthetic
Aortic root dilatation/disease:
- Marfans
- Ank spon
- Aortitis
- Dissecting aortic aneurysm
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17
Q

What are investigations in AR?

A

ECG - normal or LVH

CXR - normal, enlarged cardiac silhouette with LV contour, ascending aorta prominent, APO if acute

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18
Q

What are TTE findings of severe AR?

A

A regurgitant fraction 50%
Regurgitant volume 60ml/beat
Vena contracta width >6mm

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19
Q

What monitoring is indicated in AR?

A

Yearly TTE as LVEF and dilation my precede symptoms in 20% - high risk of SCD

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20
Q

When is surgery indicated in AR?

A

Severe symptomatic AR
Severe AR with LVEF less than 50% or FS less than 29
Severe AR with EDD >75mm or ESD >55mm
Moderate or severe AR in pts who require CAGS or other cardiac surgery
Severe AR - abnormal response to exercise

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21
Q

What is the place of vasodilator therapy in AR?

A

Short term bridge to surgery with elimination of congestive Sx
Where AVR is not possible
for LV dysfunction post AVR

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22
Q

What are examination findings in ASD?

A

Palpation - normal or RV enlargement

Auscultation - fixed split S2, low pitched diastolic TV flow murmur, pulmonary systolic ejection murmur

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23
Q

What are examination findings in VSD?

A

Palpation - diffuse displaced apex beat, thrill at LSE

Auscultation - harsh pansystolic murmur, maximal at and confined to LLSE, S3 + S4, sometimes assoc with MR

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24
Q

What are causes of VSD?

A
  1. congenital

2. Acquired - septal MI

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25
What are indications for surgery in VSD?
Mod-large VSD with pulm to systemic flow ratio of >1.5:1 | Lack of v. high pulmonary pressures
26
What are examination findings in PDA?
Pulse and BP - collapsing pulse with sharp upstroke, low diastolic BP Palpation - diffuse apex beat Auscultation - reversed split S2, loud continuous machinery murmur at L1stICS, mitral mid-diastolic murmur
27
what are features of tetralogy of fallot?
1. Large VSD 2. Overriding Aorta 3. Pulmonary stenosis 4. Resultant RV hypertrophy ECG shows RVH, RAD, tall peaked T-waves
28
What conditions are associated with eisenmenger syndrome?
ASD or VSD PDA Complex congenital abnormalities - single ventricle, ToF
29
What are features on Ex in Eisenmenger syndrome?
1. Polycythaemia 2. Clubbing - upper and lower limbs 3. Central cyanosis (any cause of severe pulm HTN will lead to VQ-MM and central cyanosis 4. 2nd heart sound - loud with pHTN, fixed split in ASD, single with VSD 5. Pulmonary HTN 6. Evidence of RHF (hepatomegaly, peripheral oedema, ascites)
30
What are investigations in eisenmenger syndrome?
1. ECG - R or bi-v hypetrophy, RA abnormality 2. CXR - dilation of central pulmonary arteries, peripheral pulmonary artery pruning, neovascularity, right heart enlargement
31
What are echo findings in eisenmenger's syndrome?
increased RV wall thickness, septal bulging to L) with systole RV dilatation and hypokinesis RA dilatation and tricuspid and pulmonic regurgitation Underlying abnormality may be difficult to see due to equalisation of pressures across chambers
32
What is management of eisenmenger's syndrome?
1. pulmonary vasodilator theray - epoprostenol 2. avoidance of volume depletion, pregnancy, isometric exercise, vasodilatation, high altitude (death due to TEmbo, hypovolemia, preeclampsia) 3. extreme caution w non-cardiac surgery 4. haematologic issues 5. surgical options - Heart/lung transplan
33
What are examination findings in HCM?
``` Pulse - sharp, rising, jerky JVP - prominent a-wave Palpation - double or triple impulse Auscultation: - late systolic murmur at the LLSE, and apex - Pansystolic murmur at apex (MR) - S4 Dynamic manoeuvre - increase with valsalva, reduced with isometric exercise ```
34
What are causes of HCM?
1. AD 2. idiopathic 3. Fredreich's ataxia
35
What are ECG findings in HCM?
LAD LVD anterolat ST depression
36
What are general examination findings in MR?
tachypnoea | mitral facies - malar flush
37
What are findings on examination of the pulse in MR?
Normal or sharp upstroke | a-wave lost in AF
38
What are findings on palpation in MR?
apex beat displaced and diffuse pansystolic thrill at apex parasternal impulse (LA enlargement)
39
What are findings on auscultation in MR?
soft or absent S1 (MV leaflets fail to close properly) LV S3 - rapid LV filling in early diastole or S4 (only in SR) Pansystolic murmur at apex radiating to axilla (immediatley after S1, may obscure S2)
40
What are signs of severe MR?
1. small volume pulse (very severe) 2. displaced apex, enlarged LV 3. Soft S1, split S2, S3 4. Early diastolic rumble 5. Pulmonary hypertension 6. LVD
41
What are causes of MR?
1. valvular apparatus abnormalities - IHD with pap muscle rupture - myxomatous degeneration - infective endocarditis - rheumatic heart disease - carcinoid syndrome - CTD - Ank spon, RA 2. Functional/ventricular abnormalities - dilatation due to CM
42
What are Ix in MR?
ECG - LA enlargement, may also see LVH +/- RVH Echo - VC width, regugitant fraction, slow reversal in pulmonary veins - prominent flail MV leaflet or ruptured pap muscle
43
What Mx is required in MR?
Surgery - MV repair preferable to replacement - symptomatic (Class III/IV) and severe MR - severe MR with LVEF 30-60% - Severe MR with pulmonary hypertension, systolic PAP >50mmHg at rest, or 60mmHg w exercise
44
What are aspects of medical management in MR?
Vasodilators - ISMN, hydralazine, ACEi - afterload reduction is beneficial if fluid overload states - preload reduction can help loading abnormalities - revascularisation if ischaemia suspected
45
What are examination findings in MVP?
Auscultation - systolic click (usually mid-diastolic), systolic murmur, high pitched, late systolic Dynamic auscultation - valvasla, murmur and click louder and earlier isometric - later and softer
46
What are causes of MVP?
1. myxomatous degeneration of mitral valve | 2. associated with ASD (secundum) HCM or marfans
47
What are general findings in Mitral stenosis?
tachypnoea mitral facies peripheral cyanosis
48
What are pulse/bp findings in MS?
normal or reduced volume | AF
49
What is the character of the JVP in MS?
prominent a-wave if pHTN present, loss of a-wave in AF
50
What are findings on palpation in MS?
tapping, palpable S1 RV heave and palpable P2, pulmonary hypertension diastolic thrill (pt in LL position)
51
What are findings on auscultation in MS?
loud S1 loud P2, pulmonary hypertension opening snap low pitched diastolic murmur accentuated with exercise
52
What are signs of severe MS?
(valve area
53
What are causes of MS?
1. rheumatic heart disease 2. infective endocarditis 3. progressive annular calcification in ESRF 4. congenital parachute valve
54
What are investigations in MS?
ECG - AF, p-mitrale (bifid p-waves), changes of pulmonary HTN and RVH CXR - LA enlargement - double shadow
55
What are echocardiographic signs of severe MS?
mean gradient >10, valve area less than 1cm^2, systolic PAP >50
56
What are management considerations in MS?
Medical - secondary prevention of rheumatic fever, prevention of endocarditis, prevention of thromboembolism. Surgery when symptomatic and mod-severe MS moderate severe MS with systolic PAP >50 moderate or severe MS in pts requring other CTS severe MS with abnormal response to exercise
57
What are examination findings in pulmonary stenosis?
peripheral cyanosis normal or reduced pulse JVP: giant a-waves due to RA hypertrophy, may be elevated RV heave, thrill over pulmonary area Ejection click preceding harsh ESM at pulmonary area, RV S4 (RA hypertrophy) Presystolic pulsation of the liver
58
What are signs of severe PS?
1. ESM peaking late in systole 2. Absence of ejection click 3. Presence of S4 4. Signs of RV failure
59
What are causes of Pulmonary stenosis?
1. congenital | 2. carcinoid syndrome (rare)
60
What are examination findings in pulmonary regurgitation?
Decrescendo, diastolic high pitched murmur (graham-steel murmur) signs of pulmonary hypertension Causes: pulmonary hypertension, infective endocarditis, congenital absence of the pulmonary valve
61
What are core clinical signs of pulmonary hypertension?
1. signs of pulmonary hypertension: - palpable and loud pulmonary component of S2 with splitting - right ventricular heave - pulmonary ejection flow murmur (mid-systolic) - prominent a-wave (forceful atrial contraction) 2. signs of RHF - RV chamber dilatation resulting in tricuspid regurgitation - pulmonary artery dilatation, leading to pulmonary regurgitation - increased JVP and peripheral oedema PLUS - tachypnoea, low CO, peripheral cyanosis, low volume pulse, S4
62
What are the 5 classes of pulmonary hypertension?
1. Pulmonary artery hypertension 2. Pulmonary hypertension due to left heart disease 3. PH due to hypoxic respiratory disease 4. Chronic thromboembolic PH 5. Miscellaneous
63
What are causes of pulmonary arterial hypertension?
1. idiopathic PAH 2. Associated PAH - CTD - scleroderma, RA - Eisenmenger syndrome - Portopulmonary hypertension - Haematological malignancies - HIV infection - Anorexigens, drugs and toxins
64
What are causes of pulmonary hypertension due to left heart disease?
LV dysfunction - hypoxaemia, pulmonary oedema, sleep disordered breathing Mitral and aortic valve disease Restrictive cardiomyopathy or constrictive pericarditis
65
What are causes of PHTn due to hypoxic disease?
COPD ILD OSA
66
What are examination findings in TR?
JVP - large v waves, elevated if RVF palpation - RV heave Auscultation - pansystolic murmur at LLSE, maximal on inspiration Abdomen - pulsatile, large tender liver, asctes
67
What are causes of TR?
``` Functional (RVF) Valvular - IHD with Rv pap muscle infarction - Myxomatous degeneration - TV prolapse - Rheumatic (usually in combo with MR) - Infective endocarditis (IVDU) - Congenital (ebstein's) - Trauma ```
68
What are features of ebstein's anomaly?
- tricuspid leaflets displaced down towards the RV - atrialised RV portion - deficient or absent leaflets - often assoc with ASD ECG shows large P waves and prolonged PR interval. RBBB, WPW. Mx with TV replacement and closure of ASD
69
What are examination features of TS?
JVP - giant a-waves, with slow y-descent Auscultation - diastolic murmur at LLSE, maximal with inspiration TR and MS often also present No signs of pulm HTN pre-systolic pulsation of liver (forceful atrial systole) Causes - rheumatic heart disease
70
What are fundoscopic changes of hypertension?
stage 1 - silver wiring stage 2 - silver wiring + AV nipping stage 3 - silver wiring AV nipping, haemorrhages and hard/soft exudates Grade 4 - silver wiring, av nipping, haemorrhages, exudates and papilledema

Clinical Examination (3 decks)

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