Cardiovascular Symptoms and Signs

Question 1

Chest pain - alarming and increasing over minutes to hours

Answer 1

• angina (new or unstable) or ACS
• STEMI
• NSTEMI
• Oesophagitis and oesophageal spasm
• PE/infarction
• pneumothorax (tension, moderate or mild)
• dissecting thoracic aortic aneurysm
• chest wall pain (eg Tietze’s syndrome)

Question 2

Severe lower chest or upper abdominal pain

Answer 2

• GORD/gastritis
• biliary colic
• pancreatitis
• MI (often inferior)

Question 3

Sudden breathlessness, onset over seconds

Answer 3

• PE/infarction
• pneumothorax (tension, moderate or mild)
• anaphylaxis
• inhalation of foreign body

Question 4

Orthopnoea and paroxysmal nocturnal dyspnoea

Answer 4

• pulmonary oedema
• COPD
• asthma
• cardiac arrhythmia

Question 5

Palpitations

Answer 5

• runs of SVT ?exercise induced due to IHD ?due to electrolyte abnormalities
• episodic heart block
• sinus tachycardia
• AF
• ventricular ectopics
• menopause
• thyrotoxicosis
• phaeochromacytoma (rare)

Question 6

Acute breathlessness, wheeze +/- cough

Answer 6

• exacerbation of asthma
• exacerbation of COPD
• acute viral or bacterial bronchitis
• acute left ventricular failure due to ?cardiac event ?valvular disease ?electrolyte imbalance ?arrhythmia
• anaphylaxis

Question 7

Cough and pink frothy sputum

Answer 7

• acute pulmonary oedema due to left ventricular failure

- mitral stenosis

Question 8

Syncope

Answer 8

• vasovagal attack - simple faint
• postural hypotension
• Stokes-Adams attack
• aortic stenosis
• hypertrophic cardiomyopathy
• micturition syncope
• cough syncope
• carotid sinus syncope
• hypoglycaemia
• cerebrovascular accident
• PE/infarct

Question 9

Leg pain on walking - intermittent claudication

Answer 9

• arterial disease in legs

- spinal claudication

Question 10

Leg pain on standing - relieved by lying down

Answer 10

• peripheral venous disease and varicose veins

- disc protrusion

Question 11

Unilateral calf or leg swelling

Answer 11

• DVT
• ruptured Baker’s cyst
• cellulitis
• abnormal lymphatic drainage
• congenital oedma (Milroy’s syndrome)

Question 12

Bilateral ankle swelling

Answer 12

• right ventricular failure
• poor venous return
• low albumin states
• bilateral cellulitis often associated with diabetes mellitus
• IVC obstruction due to prolonged immobility, carcinoma and oral contraceptive use
• drugs
• bilateral thromboses
• impaired lymphatic drainage

Question 13

Peripheral cyanosis

Answer 13

• Raynaud’s phenomenon
• arterial obstruction
• haemorrhage
• low cardiac output
• septicaemia (commonly due to gram -ve organisms)

Question 14

Central cyanosis

Answer 14

• right to left cardiac shunt
• right to left pulmonary shunt
• haemoglobin abnormalities

Question 15

Pulse rate >120bpm

Answer 15

• fever
• haemorrhage
• hypoxia
• thyrotoxicosis
• severe anaemia
• heart failure
• PE/infarction
• drugs (eg. amphetamines and beta agonists)
• severe electrolyte disturbances

Question 16

Bradycardia

Answer 16

• athletic heart
• drugs
• sinoatrial disease
• ventricular or suraventricular bigemini
• MI
• hypothyroid
• hypothermia
• severe electrolyte disturbances

Question 17

Pulse irregular

Answer 17

• AF
• atrial flutter with variable heart block
• atrial or ventricular ectopics
• Wenkebach heart block

Question 18

Pulse volume high

Answer 18

• aortic incompetence
• arteriosclerosis
• severe anaemia
• bradycardia of any cause with normal myocardium
• hyperkinetic circulation

Question 19

Pulse volume low

Answer 19

• poor cardiac contractility
• hypovolaemia
• relative hypovolaemia due to poor vascular tone
• aortic stenosis

Question 20

Hypertension

Answer 20

• temporary hypertension with no risk factors
• essential hypertension (95% of cases)
• hypertension of pregnancy
• obstructive sleep apnoea
• renal hypertension
• endocrine hypertension
• vascular hypertension
• drug-induced hypertension due to NSAIDs, oestrogen pill, steroids, erythropoeitin

Question 21

Blood pressure very low

Answer 21

• cardiogenic - low output
• low circulating blood volume
• loss of vascular tone
• Addison’s disease
• spinal cord injuries/disease

Question 22

Postural fall in blood pressure

Answer 22

• drug-induced due to excessive dose of antihypotensive agent
• autonomic neuropathy
• idiopathic orthostatic hypotension
• cardiogenic - low output
• low circulating blood volume
• loss of vascular tone
• CNS diseases eg. MS, Parkinson’s

Question 23

BP/pulse difference between arms

Answer 23

• old or acute thrombosis in atheromatous artery or aneurysm or dissection of ascending aorta
• supravalvular aortic stenosis (congenital)
• subcalvian steal syndrome
• thoracic inlet syndrome
• aortic arch syndrome, Takayasu’s syndrome

Question 24

BP/pulse difference between arms and legs

Answer 24

• old or acute thrombosis in atheromatous artery
• aneurysm or dissection of descending thoracic or abdominal aorta or iliac arteries, especially in diabetics
• coarctation of aorta

Question 25

Prominent leg veins +/- unilateral leg swelling

Answer 25

- varicose veins +/- competent communicatng valves - thrombophlebitis - DVT

Question 26

Unilateral leg and ankle swelling

Answer 26

- DVT - ruptured Baker's cyst - cellulitis - unilateral varicose veins - chronic venous insufficiency from old DVTs - venous insufficiency from obstruction by tumour or lymph node - immobility - abnormal lymphatic drainage caused by lymphoma or malignant infiltration - congenital oedema (Milroy's syndrome) - acute lymphatic obstruction due to streptococcal lymphangitis

Question 27

Bilateral leg and ankle swelling

Answer 27

- bilateral varicose veins or old DVTs - low albumin - congestive cardiac failure - cor pulmonale - immobility - abnormal lymphatic drainage caused by lymphoma or malignant infiltration - congenital oedema (Milroy's syndrome) - acute lymphatic obstruction due to streptococcal lymphangitis

Question 28

Raised JVP

Answer 28

- fluid volume overload - congestive cardiac failure - cor pulmonale - AF - complete heart block - tricuspid regurgitation - pericardial effusion - constrictive pericarditis - jugular vein obstruction

Question 29

Abnormal apex pulse

Answer 29

- fat, fluid or air between the apex and palpating hand - dextrocardia - large left ventricle - hypertrophied left ventrile - hypertrophic cardiomyopathy - ventricular aneurysm - mitral stenosis - right ventricular hypertrophy due to pulmonary hypertension or pulmonary stenosis

Question 30

Extra heart sounds

Answer 30

- normal young heart | - heart failure, cardiomyopathy, constrictive pericarditis

Question 31

Diastolic murmur

Answer 31

- mitral stenosis - mitral stenosis with pliable valve - aoritc incompetence

Question 32

Mid-systolic murmur

Answer 32

- aortic stenosis - hypertrophic cardiomyopthy - aortic sclerosis - pulmonary high flow - ASD causing high pulmonary flow (rare) - pulmonary stenosis

Question 33

Pansystolic murmur

Answer 33

- mitral incompetence - tricuspid incompetence - VSD

Question 34

Murmurs not entirely in systole or diastole

Answer 34

- patent ductus arteriosus | - pericarditis with pericardial friction rub