Cardiovascular Exam

Question 1

What is this? What causes this?

Answer 1

Janeway lesions
Painless, flat lesions
Haemorrhagic lesions on thenar eminence
Embolic phenomena in Infective Endocarditis

Question 2

What is seen here? What causes this?

Answer 2

Oslers nodes
Painful, raised lesions
Immunological phenomena in Infective Endocarditis

Question 3

What is seen here? List 4 features

Answer 3

Clubbing
Loss of Lovibond’s angle
Increased longitudinal curvature of the nail
Boggy nail bed
Drumsticking of finger nails

Question 4

List 3 cardiovascular causes of clubbing

Answer 4

Atrial myxoma
Congenital cyanotic heart disease e.g. ToF
Infective Endocarditis

Question 5

What is seen here? What causes this?

Answer 5

Tendon xanthomata
Hyperlipidaemia (typically familial hypercholesterolaemia)

Question 6

3 causes of radio-radial delay

Answer 6

Subclavian artery stenosis (e.g. compression by a cervical rib)
Aortic dissection
Aortic coarctation

Question 7

3 causes of collapsing pulse

Answer 7

Normal physiological states: fever, pregnancy
Cardiac lesions: AR, PDA
High output states: anaemia, AV fistula, thyrotoxicosis

Question 8

3 causes of Narrow pulse pressure

Answer 8

AS
Congestive heart failure
Cardiac tamponade.

Question 9

2 causes of wide pulse pressure

Answer 9

Aortic dissection
AR

Question 10

What is seen here? What causes this?

Answer 10

Splinter haemorrhages
Embolic phenomena of infective endocarditis

Question 11

What is Quincke’s pulse? What causes it?

Answer 11

Visible capillary pulsations on compression to fingernail bed
Aortic regurgitation

Question 12

What causes a slow rising pulse?

Answer 12

Aortic stenosis

Question 13

What causes a bounding pulse?

Answer 13

CO2 retention

Question 14

Give 2 features of a CO2 retention flap. What causes this?

Answer 14

Bilateral
Symmetrically timed
Hypercapnia: COPD/ T2 respiratory failure

Question 15

What is pulsus paradoxus? Give 2 causes

Answer 15

varied pulse strength with each inspiration + expiration
Severe asthma
Cardiac tamponade

Question 16

What is pulsus alternans? Name a cause

Answer 16

regular alterations in force of pulse (not varying with respiration)
Severe LVF

Question 17

When may a jerky pulse be felt?

Answer 17

HOCM

Question 18

What is seen here? List 3 causes

Answer 18

Malar flush
Mitral stenosis (CO2 retention causes vasodilation)
SLE
Polycythaemia rubra vera

Question 19

What is seen here? What causes this?

Answer 19

Corneal arcus
If <50: hypercholesterolaemia

Question 20

What is seen here? What causes this?

Answer 20

Xanthelasma
Hypercholesterolaemia

Question 21

What is seen here? What causes this?

Answer 21

Kayser Fleischer Rings
Wilsons disease

Question 22

What is this man suffering from? What clinical sign would be seen?

Answer 22

Superior vena cava obstruction
Raised JVP + absent pulsation

Question 23

What is Kussmauls sign? When is this seen?

Answer 23

Paradoxical JVP rise on inspiration
Impaired ventricular filling
Cardiac tamponade, constrictive pericarditis, restrictive cardiomyopathy

Question 24

What are cannon A waves in the JVP? What causes these?

Answer 24

Large A waves from simultaneous contraction of RA + RV

3rd degree heart block

Question 25

List 4 causes of raised JVP

Answer 25

Fluid overload Cardiac tamponade RHF + Cor pulmonale Constrictive pericarditis

Question 26

What is this? What is it used for?

Answer 26

Hickman line Administer drugs, take blood samples

Question 27

Name the scar. What surgery may have been performed?

Answer 27

Midline sternotomy CABG, aortic valve replacement, mitral valve replacement

Question 28

Name the scar. What surgery may have been performed?

Answer 28

Anterolateral thoracotomy scar Minimally invasive cardiac valve surgery

Question 29

Name the scar. What surgery may have been performed?

Answer 29

Posterolateral thoracotomy scar Mitral valve replacement, Blalock-Taussig shunt, coarctation repair

Question 30

Name the scar. What surgery may have been performed?

Answer 30

Mid-axillary scar ICD insertion

Question 31

Name the scar. What surgery may have been performed?

Answer 31

Subclavicular Pacemaker/ ICD insertion

Question 32

Parasternal heave cause

Answer 32

RV hypertrophy

Question 33

S4 cause

Answer 33

Atrial contraction against a stiff ventricle

Question 34

S3 cause

Answer 34

turbulent ventricular filling

Question 35

AR manoeuvre

Answer 35

lean forward + listen to the left 3rd ICS parasternal

Question 36

MS manoeuvre

Answer 36

roll onto the left side + listen to 5th ICS MCL with the bell

Question 37

Distinguish between aortic stenosis and aortic sclerosis

Answer 37

listen to the carotids with the bell stenosis radiates a crescendo-decrescendo murmur whilst sclerosis will not

Question 38

Aortic stenosis murmur

Answer 38

Ejection systolic, crescendo-decrescendo Radiates to carotids Soft/ absent S2 S4 Slow rising pulse Narrow pulse pressure

Question 39

4 causes of AS

Answer 39

Degenerative calcification (most common >65) Bicuspid aortic valve (most common <65) Rheumatic heart disease HOCM

Question 40

Mx of AS

Answer 40

Asymptomatic: observe Symptomatic: valve replacement Asymptomatic but valvular gradient > 40 mmHg + features e.g. LV systolic dysfunction: consider surgery

Question 41

Aortic regurgitation murmur

Answer 41

Early diastolic High pitch, blowing Quinckes sign De Musset's sign Collapsing pulse Wide pulse pressure

Question 42

5 causes of AR

Answer 42

Rheumatic heart disease Infective endocarditis CTDs: Marfans, EDS Aortic dissection Bicuspid aortic valve

Question 43

Mx of AR

Answer 43

Medical Mx of any associated HF Indications for surgery: symptomatic patients with severe AR asymptomatic patients with severe AR who have LV systolic dysfunction

Question 44

What is De Musset's sign?

Answer 44

Head bobbing

Question 45

What is an Austin flint murmur?

Answer 45

Mid diastolic 'rumbling' murmur Due to severe AR

Question 46

Mitral stenosis murmur

Answer 46

Mid diastolic 'rumbling' Loud S1 Opening snap Low volume pulse AF

Question 47

1 cause of MS

Answer 47

RHEUMATIC FEVER

Question 48

Mx of MS

Answer 48

If mod-severe MS + AF require anticoagulation with Warfarin Asymptomatic: regular echos Symptomatic: Percutaneous mitral balloon valvotomy or mitral valve surgery (commissurotomy, or valve replacement)

Question 49

Mitral regurgitation murmur

Answer 49

Pansystolic High pitched, blowing Soft S1 If severe: widely split S2

Question 50

3 causes of MR

Answer 50

Post-MI papillary muscle rupture Infective endocarditis Rheumatic fever

Question 51

MR Mx

Answer 51

Acutely: nitrates, diuretics, positive inotropes + an intra-aortic balloon pump to increase cardiac output If in HF: ACEi, b-blockers + spironolactone Acute, severe regurgitation: surgery Degenerative MR: Repair (over replacement) If not possible: valve replacement

Question 52

If a patient has a midline sternotomy scar but no leg vein harvest scars, what is the likely explanation?

Answer 52

Interior mammary artery graft

Question 53

Where can vessels be harvested from for CABG?

Answer 53

Leg (saphenous vein) Inside chest (internal mammary artery) Arm (radial artery)