Internal Medicine > OHCEPS - Cardiovascular System > Flashcards

OHCEPS - Cardiovascular System Flashcards

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1
Q

MC and most important CV symptom?

A

Chest pain

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2
Q

History for chest pain?

A

Same as for any other pain:

  1. Nature
  2. Site
  3. Any radiation
  4. Severity (1-10)
  5. Mode and rate of onset - What was the patient doing at the time?
  6. Duration (if now resolved)
  7. Exacerbating/Relieving factors
  8. Associated symptoms
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3
Q

True angina - features?

A
  1. Retrosternal
  2. “Crushing”, “Heaviness”,”like a tigh band”.
  3. Worse with physical or emotional exertion, cold weather and after eating.
  4. Relieved by rest and nitrate spray (within a couple of minutes)
  5. Not affected by respiration or movements.
  6. Sometimes associated with breathlessness
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4
Q

In patients with known angina - important?

A

A change in the nature of the symptom is important. How much exercise they can do before feeling the discomofort and whether this has changed.

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5
Q

Pain of MI?

A

Similar to angina but much more severe, persistent (Despite GTN spray) - associated with nausea, sweating, and vomiting.
Patients also, describe a feature of impending doom or death - “angor animi”.

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6
Q

MCCs of pericarditis?

A
  1. Viral/Bacterial infections
  2. MI
  3. Uremia
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7
Q

Pericarditis pain - features?

A
  1. Constant retrosternal “soreness”.
  2. Worse on inspiration (pleuritic).
  3. Relieved slightly by sitting forwards.
  4. Not related to movement or exertion.
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8
Q

Often mistaken for MI or angina?

A

Esophageal spasm.

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9
Q

Esophageal spasm - Features of pain?

A
  1. Severe, retrosternal burning pain.
  2. Onset after eating or drinking.
  3. May be associated with dysphagia
  4. May have a history of dyspepsia
  5. May be relieved by GTN as this is a smooth muscle relaxant (hence the confusion with angina) but GTN will take up to 20min to relieve this pain whereas angina is relieved within a few minutes.
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10
Q

GERD pain?

A
  1. Retrosternal, burning pain.

2. Relieved by antacids, onset after eating.

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11
Q

Aortic dissection - pain?

A
  1. Severe tearing pain.
  2. Felt posteriorly - classically between the shoulderblades.
  3. Persistent, most severe at onset.
  4. Patient is usually hypertensive and “marfanoid”.
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12
Q

Aortic dissection mistaken for MI - Problem?

A

Thrombolysis here may prove fatal.

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13
Q

Pleuritic (respiratory) pain - causes?

A
  1. Pulmonary embolus

2. Pneumothorax

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14
Q

Pleuritic pain - features?

A
  1. Sharp pain, worse on inspiration and coughing.
  2. Not central - may be localized to one side of the chest.
  3. No radiation
  4. No relief from GTN
  5. Associated with breathlessness, cyanosis etc.
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15
Q

Musculoskeletal chest pain - caused?

A

Injury
Trauma
Chondritis etc.

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16
Q

Musculoskeletal chest pain - features?

A
  1. Localized to a spot.
  2. Worsened by movement and respiration.
  3. May be tender to palpation.
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17
Q

Tietze’s syndrome?

A

Costochondritis - inflammation of the costal cartilages at ribs 2,3,4.
Will be associated with tender swelling over the costo-sternal joints.

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18
Q

New York Heart Association classification of breathlessness?

A

I - nil at rest, some on vigorous exercise.
II - nil at rest, breathless on moderate exercise.
III - mild breathlessness at rest, worse on mild exertion.
IV - significant breathlessness at rest and worse on even slight exertion (patient is often bed-bound).

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19
Q

What to ask in order to quantify breathlessness?

A
  1. How far can they walk on the flat before they have to stop? (“march tolerance”)
  2. What about stairs and hills? Can they make it up a flight?
  3. Are they sure that they stop due to breathlessness or is it some other reason (arthritic knees for example)?
  4. Has the patient had to curtail their normal activities in any way?
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20
Q

Orthopnea?

A

Breathlessness when lying flat.

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21
Q

Orthopnea - will patient tell you?

A

NO - should be asked.

How many pillows to sleep?

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22
Q

PND?

A

Episodes of breathlessness occuring at night - usually thought to be due to pulmonary edema.

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23
Q

PND - will the patient tell?

A

NO - Should be asked.

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24
Q

PND - what happens?

A

Sufferers will experience waking in the night spluttering and coughing - they find they have to sit up or stand and many go to the window for “fresh air” in an attempt to regain their normal breathing.

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25
PND - questions?
1. Do they wake up in the night coughing and trying to catch their breath? 2. If so, glean as much detail as you can - including how often and how badly the symptom is disturbing the patient's sleep cycle.
26
Cough in pulmonary edema?
Productive - frothy white sputum - may be flecked with blood (pink) due to ruptured bronchial vessels, but this is not usually a worrying sign in itself.
27
Questions regarding ankle edema?
1. How long? 2. Worse any particular time of day? (cardiac edema worse toward the evening, resolves overnight) 3. Exactly, how extensive is the swelling? 4. Is there evidence of abdominal swelling and ascites?
28
Palpitations?
Awareness of one's own heart beat.
29
Questions for palpitations - difficult topic - difficult to clarify exact nature.
1. When did the sensation start/stop? 2. How long does it last? 3. Did it come on suddenly or gradually? 4. Did the patient blackout? If so, for how long? 5. Was the heart beat felt as fast, slow, or some other pattern? 6. Was it regular or irregular? - Ask to tap out on their knee what felt. 7. What was the patient doing when palpitations started? 8. Any relationship to eating or drinking? (tea, coffe, wine, chocolate?) 9. Could this be from medication? 10. Has this ever happened before? If so, what were the circumstances? 11. Any associated symptoms? (chest pain, shortness of breath, syncope, nausea, dizziness) 12. Did the patient stop their activities or lie down? 13. Was the patient able to stop palpitations somehow?
30
Syncope?
Faint or swoon.
31
Pre-syncope?
The feeling that the patient is about to faint.
32
Questions about syncope?
1. Gradual/sudden onset? 2. How long was the loss of consciousness? 3. What was the patient doing when it happened (standing, urinating, coughing)? 4. Were there any preceding or associated symptoms such as chest pain, palpitations, nausea, sweating? 5. Any medication relationship? (antihypertensives, GTN) 6. When patient came round, were there any other symptoms remaining? 7. Was there any tongue-biting or urinary or fecal incontinence? 8. Was there any motor activity during the episode? 9. How long did it take for the patient to feel "back to normal"?
33
True claudication - what does patient tell?
1. Feels like a tight 'cramp' in the muscle. 2. Usually calf, thigh, buttock, and foot. 3. ONLY in exercise. 4. Disappears at rest. 5. May also be numbness or pins-and-needles on the skin of the foot (blood is diverted from the skin to the ischemic muscle).
34
Claudication - quantify?
If possible, the claudication "distance" - for judging the severity.
35
If very severe leg ischemia (rest pain), what will some patient do to relieve pain at night?
Hang the affected leg off the side of the bed.
36
Cardiac risk factors?
1. Age 2. Gender 3. Obesity 4. Smoking - don't be caught out by the 'ex-smoker' that gave up yesterday! 5. HTN - When it was diagnosed, how treated, monitored? 6. HyperCH - Same. 7. Diabetes - what type? diagnosed? treated? monitored? usual glucose readings? 8. FHx - 1st degree relatives who had CV events before 60.
37
PMH - Cardiac problems?
Ask especially about: 1. Angina - If they have GTN spray how often they need to use it and whether this has changed significantly recently. 2. MI - when? How treated? 3. Ischemic Heart disease? - diagnosed? Any angiograms? Other investigations? 4. Cardiac surgery? - bypass? How many arteries? 5. AF or other cardiac rhythm disturbance - what treatmet? On warfarin? 6. RF 7. Endocarditis 8. Thyroid disease
38
Framework for the cardiovascular examination?
1. General inspection 2. Hands 3. Radial pulse 4. Brachial pulse 5. Blood pressure 6. Face 7. Eyes 8. Tongue 9. Carotid pulse 10. Jugular venous pressure and pulse waveform 11. Inspection of precordium 12. Palpation of the precordium 13. Auscultation of precordium 14. Auscultation of neck 15. Dynamic manoeuvres (if appropriate) 16. Lung bases 17. Abdomen 18. Peripheral pulses (lower limbs) 19. Edema 20. Peripheral veins
39
Positioning of the cardiac patient for examination.
Leaning back to 45 degrees supported by pillows.
40
What must be done if BP standing and seated is intended to be measured?
Make patient stand for 3 min before measuring - it may be wise to do this at the beginning of the examination.
41
General inspection of cardiac patient.
1. Do they look ill? If so, in which way? 2. Are they short of breath at rest? 3. Is there any cyanosis 4. What is their nutritional state? - Are they overweight? - Are they cachectic? 5. Other syndrome: Marfan, Turner, Down?
42
Cardiac patient - exam of the hand.
1. Temperature - may be cold in CHF. 2. Sweat 3. State of nails - blue discoloration if peripheral blood flow is poor/ splinter hemorrhages (small streak-like bleeds in the nail bed) - especially in bacterial endocarditis, but may also be seen in RA, vasculitis, trauma, sepsis from any source. 4. Finger clubbing - IE, cyanotic CHD. 5. Xanthomata - often on tendons at the wrist. 6. Osler's nodes - rare manifestation in IE - Red, tender nodules on the finger pulp or thenar eminence. 7. Janeway lesions - non-tender macular-papular erythematous lesions seen on the palm or finger pulps as a rare feature of bacterial endocarditis.
43
How many rhythm patterns are there for the pulse?
1. Regular 2. Irregularly irregular 3. Regularly irregular 4. Regular with ectopics
44
Regular pulse increase or decrease with inspiration?
Decrease.
45
Regular pulse increase or decrease with expiration?
Increase.
46
Example of irregularly irregular pulse?
A-fib
47
Example of regularly irregular pulse?
1. Pulsus bigeminus --> regular ectopic beats resulting in alternating brief gaps + long gaps between pulses. 2. In Wenkenbach's phenomenon --> Incr. time between each pulse until one is missed and then the cycle repeats.
48
Chracter/waveform of pulse - Aortic stenosis?
Slow rising pulse, maybe with a palpable shudder - sometimes called "anacrotic" or a "plateau" phase.
49
Character/Waveform of pulse - Aortic regurgitation?
A collapsing pulse which feels as those it suddenly hits your fingers and falls away just as quickly - "Waterhammer" pulse.
50
Pulsus bisferiens?
Waveform with 2 peaks, found where aortic stenosis and regurgitation co-exist.
51
HCM pulse?
May feel normal at first but peters out quickly - often described as jerky.
52
Pulsus alternans?
An alternating strong and weak pulsation - synonymous with severely impaired left ventricle in a failing heart.
53
Pulsus paradoxus?
Pulse is weaker during inspiration.
54
Causes of pulsus paradoxus?
1. Cardiac tamponade 2. Status asthmaticus 3. Constrictive pericarditis
55
Radio-radial pulse delay?
Pulses should occur simultaneously - pathology include: 1. Aneurysm of the aortic arch 2. Subclavian artery stenosis
56
Radio-femoral pulse delay?
If exist --> aortic coarctation (radial and femoral of the SAME side).
57
CV exam - face:
Eyes - Mouth - Neck. Be sure to ask: 1. Look up --> conjunctiva. 2. "Open wide" --> inside mouth and tongue.
58
CV exam --> especially look for:
1. Jaundice 2. Anemia 3. Xanthelasma 4. Corneal arctus 5. Mitral facies 6. Cyanosis 7. High arched palate 8. Dental hygiene
59
Corneal arcus??
Yellow ring seen overlying the iris - significant in patients <40 but not in older persons.
60
High arched palate suggests?
Marfan
61
Centre of the RA in relationship to the sternal angle?
5cm below.
62
Normal JVP?
3cm above the sternal angle (8cm of blood).
63
Standard position for JVP measurement?
Tilted at 45.
64
Features of jugular pulsation?
1. 2 peaks (in sinus rhythm) 2. Impalpable 3. Obliterated by pressure 4. Moves with respiration
65
Carotid pulsation - features?
1. 1 peak 2. Palpable 3. Hard to obliterate 4. Little movement by respiration
66
Hepatojugular reflex?
1. Watch the neck pulsation 2. Exert pressure over the liver with the flat of your right hand. JVP should RISE approx. 2cm, the carotid pulse will not.
67
Character of the jugular venous pulsation?
Jugular pulsation has 2 main peaks --> establish the timing of the peaks in the cardiac cycle by palpating the carotid pulse at the SAME time.
68
Key features of jugular venous pulsation?
1. a wave --> atrial contraction. 2. c point --> slight A-V-ring bulge during ventric. contraction. 3. x decent --> atrial relaxation. 4. v wave --> tricuspid closure + atrial filling. 5. y decent --> ventricular filling as tricuspid opens.
69
a wave - when?
Seen JUST BEFORE the carotid pulse.
70
Raised JVP - means?
1. RVF 2. Tricuspid stenosis 3. Tricuspid regurgitation 4. SVC obstruction 5. Pulm. embolus 6. Fluid overload
71
Large a waves - means?
Hypertrophied RA: 1. Pulm. HTN 2. Pulm. stenosis 3. Tricuspid stenosis
72
Absent a wave - means?
A-fib
73
Cannon a waves - means?
Large, irregular waves caused by contraction of the atrium against a closed tricuspid valve --> Seen in COMPLETE HEART BLOCK.
74
Large v waves - means?
Regurgitation of blood through an incompetent TV.
75
Sharp y decent - means?
Constrictive pericarditis.
76
Sharp x decent - means?
Cardiac tamponade
77
JVP will decrease or increase during inspiration in the normal state?
Decrease.
78
Kussmaul's sign?
JVP RISES during inspiration in the presence of: 1. Pericardial constriction 2. RV infarction 3. Cardiac tamponade - rarely
79
Inspection of the precordium?
1. Scars 2. Any abnormal chest shape or movements 3. Pacemaker or implantable defibrillator 4. Any visible pulsations
80
Scars on the precordium?
1. Sternal split --> CABG 2. Left lateral thoracotomy may be evidence of previous closed mitral valvotomy. 3. Resection of coarctation 4. Ligation of PDA
81
General palpation of the precordium?
1. Explain what you doing - particularly to female patients. 2. Place the flat of your right hand on the chest wall - to the left/right of the sternum - Any pulsations? 3. "Heave" - this is sustained, thrusting pulsation usually felt at the left sternal edge indicating RV enlargement. 4. "Thrill" - Palpable murmur - severe valvular disease.
82
Palpating the apex beat?
Usually at the 5th intercostal space in the mid-clavicular line.
83
Palpation of the precorium - Findings?
1. Abnormal position of the apex beat - usually more lateral than expected. 2. No apex beat felt - usually caused by heavy padding with fat or internal padding with an over-inflated emphysematous lung. 3. Sometimes can be felt by asking the patient to lean forwards or laterally.
84
Character of the apex beat?
1. Stronger, more forceful 2. Sustained 3. Double impulse 4. Tapping 5. Diffuse 6. Impalpable
85
Stronger, more forceful apex beat?
Hyperdynamic circulation - sepsis, anemia.
86
Sustained apex beat?
1. LVH 2. AV stenosis 3. HCM 4. Hyperkinesia
87
Double impulse (apex beat)?
Palpable atrial systole - characteristic of HCM.
88
Tapping apex beat?
Description given to a palpable S1 in SEVERE MITRAL STENOSIS.
89
Diffuse apex beat?
Poorly localized beat caused by LV aneurysm.
90
Impalpable apex beat?
1. Emphysema 2. Obesity 3. Pericardial effusion 4. Death
91
Apex beat - what should be kept in mind?
Beware of DEXTROCARDIA. If no beat is felt - check the right side.
92
CV exam - Percussion?
Not useful - not included.
93
MV area?
5th intercostal space in the mid-axillary line (the apex)
94
TV area?
5th intercostal space
95
PV area?
2nd intercostal space at the left sternal edge.
96
AV area?
2nd intercostal space at the right sternal edge.
97
If unsure about the S1 and S2, or where the murmur is occuring?
You can palpate one carotid pulse while listening to the heart - enabling you to feel systole. Carotid pulse occurs with S1.
98
S1?
MV closure is the main component of S1.
99
Loud S1?
Forceful closing: 1. MV stenosis 2. TV stenosis 3. Tachycardia
100
Soft S1?
Prolonged ventr. filling or delayed systole: 1. Left bundle branch block 2. AV stenosis 3. AV regurgitation
101
Variable S1?
Variable ventr. filling: 1. A-fib 2. Complete heart block
102
Soft S2?
DECR. mobility of AV (AV stenosis) OR if leaflets fail to close properly (AV regurgitation).
103
Loud S2?
1. Aortic component loud in HTN or congenital AV stenosis (here the valve is narrowed but mobile). 2. Pulmonary component loud in pulmonary HTN.
104
Splitting of S2 - Exaggerated normal splitting?
Caused by DELAY in RV emptying: 1. Right bundle branch block 2. PV stenosis 3. VSD 4. MV regurgitation
105
Splitting of S2 - Fixed splitting?
No difference in the extent of splitting between inspiration and expiration. Usually due to ASD.
106
Splitting of the S2 - Reversed splitting?
``` Pulmonary component comes before aortic component. Caused by a delay in LV emptying: 1. Left bundle branch block 2. AV stenosis 3. AV regurgitation ```
107
S3?
Low freq sound (can be JUST heard with the bell) occurring AFTER S2. --> Triple or gallop rhythm.
108
S3 mechanism?
At the end of rapid ventricular filling, early in diastole and is caused by tautening of the papillary muscles or ventricular distention.
109
Physiological S3?
Soft sound heard only at the apex, normal in children and fit adults up to 30.
110
Pathological S3?
--> Some impairment of LV function or rapid ventricular filling: 1. DCM 2. AV regurgitation 3. MV regurgitation 4. Constrictive pericarditis May be associated with a high-pitched pericardial knock.
111
S4?
1. Late DIASTOLIC (just before S1) caused by DECR. compliance - or INCR. stiffness - of the ventr. myocardium. 2. Coincides with abnormally forceful atrial contraction and raised end diastolic pressure in the LV.
112
S4 - physiological?
NEVER
113
S4 etiology?
1. HCM | 2. Systemic HTN
114
For each murmur determine?
1. Timing 2. Site and radiation (where is it heard the loudest?) 3. Loudness and pitch 4. Relationship to posture and respiration
115
Particularly essential in establishing the sound's origin?
The TIMING of the murmur.
116
How to determine if the murmur occurs during systole or diastole?
By feeling the carotid pulse.
117
Systolic murmurs?
1. Pansystolic 2. Ejection systolic 3. Late systolic
118
Pansystolic murmur mechanism?
Tends to be due to BACKFLOW of blood from the ventricle to an atrium.
119
Pansystolic murmur etiology?
1. TV/MV regurgitation | 2. VSD
120
Ejection systolic murmur mechanism?
1. Start quietly at the beginning of systole, quickly rise to a crescendo and decrescendo creating a "whoosh" sound. 2. Caused by turbulent flow of blood out of a ventricle.
121
Ejection systolic murmur etiology?
1. PV/AV stenosis 2. HCM 3. Also if flow is fast - fever, fit young adults.
122
Late systolic murmur mechanism?
1. Audible gap between S1 and the start of the murmur which then continues until S2. 2. Typically, due to TV/MV regurgitation through a prolapsing valve.
123
Diastolic murmurs?
1. Early 2. Mid-diastolic 3. Austin-Flint 4. Graham-Steele
124
Early diastolic murmur - mechanism?
Usually due to backflow through incompetent AV or PV. Starts loud at S2 and decrescendos during diastole. Like whispering the letter "R".
125
Mid-diastolic murmur - mechanism?
Usually due to flow through a narrowed MV or PV. Begin later in diastole - may be brief or continue up to S1. Lower pitched than early diastolic murmurs.
126
Austin-Flint murmur - mechanism?
Audible vibration of the MV during diastole as it is hit by flow of blood due to SEVERE AORTIC REGURGITATION.
127
Graham-Steele murmur - mechanism?
Pulmonary regurgitation secondary to pulmonary artery dilatation caused by INCR. pulmonary artery pressure in MV stenosis.
128
Continuous murmurs - etiology?
1. PDA | 2. AV fistula
129
Murmur radiation?
The murmur will tend to radiate in the direction of the blood flow that is causing the sound.
130
Example - murmur of AV stenosis will radiate where?
Up to the carotids.
131
Grading the volume of a murmur?
1-6 according to loudness.
132
Position - affects murmurs?
Some will become LOUDER - gravity aid the flow of blood creating the sound.
133
AV regurgitation - affected by position?
Louder if the patient sits up, leans forward.
134
MV stenosis - affected by position?
Louder if you ask the patient to lie on their left-hand side.
135
Respiration - affects murmurs?
1. Right-sided murmurs (PV stenosis) tend to be LOUDER during INSPIRATION - Due to incr. venous return. 2. Left-sided murmurs are LOUDER during EXPIRATION.
136
Valvalva manoeuvre - affects murmurs?
``` Decr. CO --> soften most murmurs. EXCEPT: 1. HCM 2. MV regurgitation 3. MVP murmurs that will get louder on release of Valsalva. ```
137
Extra sounds - Opening snap?
MV normally opens immediately after S2. In MV stenosis --> sudden opening of the stiffened valve can cause an audible high-pitched snap. --> May be followed by the murmur of MV stenosis.
138
Extra sounds - opening snap - best heard?
Over the LEFT sternal edge with the diaphragm of the stethoscope.
139
Extra sounds - ejection click?
Similar to the opening snap of MV stenosis --> high-pitched click heard EARLY in systole --> due to opening of stiffened AV (AV stenosis). --> Associated with BICUSPID AV valves.
140
Extra sounds - ejection click - best heard?
At the aortic or pulmonary areas and down the left sternal edge.
141
Extra sounds - mid-systolic click?
Usually by MVP - Sound of the valve leaflet flicking backward (prolapsing) mid-way through ventricular systole. --> Followed by the murmur of MV regurgitation.
142
Extra sounds - Mid-systolic click - best heard?
At the mitral area.
143
Extra sounds - tumor plop?
A very rare finding due to atrial myxoma.
144
Pericardial rub - when louder?
Louder as the patient is sitting up, leaning forward, and heard best in expiration.
145
AV stenosis - primary site of murmur?
Aortic area + apex.
146
AV stenosis - radiation?
To carotid arteries.
147
AV stenosis - timing?
Ejection systolic.
148
AV stenosis - added sounds?
Ejection click (bicuspid).
149
AV regurgitation - primary site of murmur?
Left sternal edge.
150
AV regurgitation - Radiation?
Towards apex.
151
AV regurgitation - timing?
Early diastolic
152
AV regurgitation - Added sounds?
Austin-Flint murmur.
153
MV stenosis - primary site of murmur?
Apex
154
MV stenosis - radiation?
Nil
155
MV stenosis - timing?
Mid-diastolic
156
MV stenosis - added sounds?
Opening snap
157
MV regurgitation - primary site of murmur?
Apex
158
MV regurgitation - radiation?
Toward left axilla or base of left lung.
159
MV regurgitation - timing?
Pansystolic
160
MV regurgitation - added sounds?
Mid-systolic click (if prolapsing).
161
TV regurgitation - primary site of murmur?
Lower left sternal edge
162
TV regurgitation - radiation?
Lower right sternal edge, liver!.
163
TV regurgitation - timing?
Pansystolic
164
TV regurgitation - added sounds?
No added sounds.
165
PV stenosis - primary site of murmur?
Upper left sternal edge.
166
PV stenosis - radiation?
Left clavicular region.
167
VSD - primary site of murmur?
Left sternal edge.
168
VSD - radiation?
Whole of the precordium.
169
VSD - timing?
Pansystolic
170
Rest of the body - lung bases?
Look especially for crackles or signs of effusion.
171
Rest of the body - The abdomen?
Look for: 1. Hepatomegaly - Is the liver pulsatile (severe TV regurgitation) 2. Splenomegaly 3. Ascites 4. AAA 5. Renal bruits - Renal artery stenosis 6. Enlarged kidneys
172
Varicosities - appearance?
Visible, dilated, tortuous, subcutaneous veins caused by backflow of blood from the deep veins - usually a branch of the long saphenous vein.
173
Varicose veins - how to examine?
1. Patient in standing position with the legs fully exposed. | 2. Note any surrounding edema, eczema, brown pigmentation, or ulcers.
174
Palpation of varicose veins?
1. Gently feel the varicose veins - hard veins may contain thrombus. 2. Ask patient to cough - If there is palpable pulsation in the varicosity, there may be valvular incompetence at the long saphenous vein in the groin.
175
Percussion of varicose veins?
1. Apply fingers of one hand to the upper part of the varicose vein. 2. Gently flick the lower part of the vein with the other hand. - If there is a palpable wave sent up the vein, there are incompetent valves between those 2 points.
176
Trendelenburg test?
1. Ask patient to lie down and raise their leg so as to drain the veins. 2. Apply a tourniquet over the saphenous vein (upper half of thigh). 3. Ask patient to stand. - -> You can determine the site of the incompetent perforating vein...do the varicose veins fill above or below the tourniquet? 4. Repeat the procedure until you are able to pin-point the exact location of the incompetence and, by applying localized pressure, prevent the varicose veins from filling at all.
177
MV stenosis - symptoms?
1. Dyspnea 2. Cough of frothy (pink?) sputum 3. Palpitations (often associated with a-fib and resultant emboli)
178
MV stenosis - signs?
1. Palmar erythema 2. Malar flush 3. "Tapping" apex beat 4. Left parasternal heave 5. Loud S1 6. Mid-diastolic murmur +/- opening snap
179
MV regurgitation - symptoms?
1. Acute dyspnea | 2. Pulmonary congestion
180
MV regurgitation - signs?
1. Collapsing pulse 2. Sustained apex beat displaced to the left 3. Left parasternal heave 4. Soft S1 5. Loud S2 (pulmonary component) 6. Pansystolic murmur heard at the apex radiating to left axilla +/- mid-systolic click 7. S3
181
AV stenosis - symptoms?
1. Angina 2. Syncope 3. Dyspnea 4. Sudden death
182
AV stenosis - signs?
1. Slow rising pulse 2. Low BP 3. Narrow pulse pressure 4. Sustained and powerful apex beat 5. Ejection systolic murmur radiating to carotids 6. Soft S2 +/- ejection click
183
AV regurgitation - symptoms?
Similar to AV stenosis.
184
AV regurgitation - signs?
1. Collapsing pulse 2. Wide pulse pressure 3. Sustained and displaced apex beat 4. Soft S2 5. Early diastolic murmur at the left sternal edge (decrescendo) 6. +/- ejection systolic murmur (Incr. volume) 7. May also hear a "pistol shot" sound over the femoral artery with severe aortic regurgitation.
185
TV stenosis - signs?
1. Auscultation similar to that of MV stenosis 2. Hepatomegaly 3. Pulsatile liver 4. Venous congestion
186
TV regurgitation - signs?
1. Dilated neck veins 2. Prominent v wave in JVP which may, rarely, cause the earlobe to oscillate !! 3. Pansystolic murmur louder on inspiration with a loud pulmonary component of S2 4. Left parasternal heave 5. Pulsatile liver 6. Peripheral and sacral edema 7. Ascites 8. May also hear a S3 and evidence of a-fib
187
PV stenosis - signs?
1. Normal pulse with an ejection systolic murmur radiating to lung fields often with a palpable thrill over the pulmonary area. 2. Other signs of RH strain or failure.
188
PV regurgitation - signs?
1. Loud S2 which may be palpable | 2. Early diastolic murmur heard at the pulmonary area and high at the left sternal edge.
189
Corrigan's sign?
Sign of AV regurgitation: | Prominent carotid pulsation.
190
De Musset's sign?
Sign of AV regurgitation: | Head-nodding in time with the heartbeat.
191
Mueller's sign?
Sign of AV regurgitation: | Pulsation of the uvula in time with the heartbeat.
192
Hill's sign?
Sign of AV regurgitation: | Higher BP in the legs than in the arms.
193
Quincke's sign?
Sign of AV regurgitation: | Nailbed capillary pulsation.
194
VSD - symptoms?
1. Children often asymptomatic. | 2. If large --> patient may suffer CHF with dyspnea and fatigue.
195
VSD - signs?
1. There may be cyanosis and clubbing. 2. Heart sounds usually appear normal but if pulmonary HTN develops, may hear a loud pulmonary component of S2 with RV heave. 3. May also be a pansystolic murmur heard at the left sternal edge often accompanied by a palpable thrill. 4. Signs may settle with time, the right heart pressure increases causing less shunting and a softer murmur.
196
ASD - symptoms of secondum defect?
1. Asymptomatic if small. 2. Fatigue 3. Dyspnea 4. Palpitations (atrial arrhythmias) 5. Recurrent pulmonary infections 6. Other symptoms of HF 7. Also associated with migraine and paradoxical emboli.
197
ASD - symptoms of primum defect?
1. Symptoms of HF in childhood with a failure to thrive. 2. Chest infections and poor development. 3. In adults there may be a syncope (heart block) and symptoms suggestive of endocarditis.
198
ASD - signs?
1. Fixed splitting of S2 2. Incr. flow over the normal pulmonary valve may give an ejection systolic murmur. 3. Left parasternal heave with a normal or diffuse apical impulse. 4. Particularly in ostium primum defects (endocardial cushion defects), you may hear the pansystolic murmur of MV regurgitation or co-existant VSD (or both). 5. Look for signs of pulmonary HTN.
199
PDA - symptoms?
1. Often asymptomatic | 2. Severe - dyspnea on exertion.
200
PDA - signs?
1. Collapsing pulse 2. Heaving apex beat 3. "Machinery" (continuous) murmur heard all over the precordium 4. S2 not heard. 5. Systolic or diastolic thrill in the 2nd intercostal space on the left.
201
Coarctation of the aorta - symptoms?
1. Usually asymptomatic 2. Headache 3. Epistaxis 4. Dizziness 5. Palpitations 6. Claudication 7. Leg fatigue 8. May also give symptoms of CHF
202
Coarctation of the aorta - signs?
1. Incr. BP in the upper limbs. 2. Radio-femoral delay 3. Ejection systolic murmur at the left sternal edge 4. Sometimes palpable collateral arteries over the scapulae with interscapular bruits. 5. May also have underdeveloped lower limbs.
203
Coarctation of the aorta - associations?
1. Often with AV stenosis 2. Aortic aneurysms 3. Bicuspid AV 4. Turner
204
Tetralogy of Fallot?
1. PV stenosis 2. VSD (infundibular) 3. RV hypertrophy 4. Overriding aorta (5. If associated with an ASD also --> Fallot's pentalogy)
205
Tetralogy of Fallot - symptoms?
1. Syncope 2. Squatting relieves breathlessness 3. Growth retardation
206
Tetralogy of Fallot - signs?
1. Finger clubbing 2. Central cyanosis with superadded paroxysms (spells). 3. Murmurs of PV stenosis or the VSD may be heard along with a systolic thrill and left parasternal heave.
207
Pericarditis - causes?
1. Collagen diseases 2. TB 3. Post-infarction 4. Idiopathic
208
Pericarditis - symptoms?
1. Constant retrosternal "soreness" WORSE on inspiration (pleuritic). 2. Relieved slightly by sitting forwards. 3. NOT related to movement or exertion.
209
Pericarditis - if chronic, constrictive, may cause?
1. Kussmaul's sign 2. Impalpable apex beat 3. S3 4. Hepatomegaly 5. Splenomegaly 6. Ascites (pseudo-cirrhosis)
210
Pericardial effusion - signs?
1. Pulsus paradoxus 2. Incr. JVP 3. Impalpable apex beat 4. Soft heart sounds 5. Hepatomegaly 6. Ascites 7. Peripheral edema
211
LVF - symptoms?
1. May include shortness of breath on exertion 2. Orthopnea 3. Paroxysmal nocturnal dyspnea 4. Cough with pink frothy sputum 5. Fatigue 6. Weight loss 7. Muscle wasting 8. Anorexia
212
LHF - signs?
1. May appear tired 2. Pale 3. Sweaty 4. Clammy 5. Tachycardic 6. Thready pulse 7. Low BP 8. Narrow pulse pressure 9. Displaced apex beat 10. (murmur of an underlying valvular abnormality?) 11. S3, S4 12. Tachypnea 13. Crepitations at the lung bases
213
RVF - symptoms?
As above with peripheral edema and facial swelling.
214
RVF - signs?
1. Raised JVP 2. Hepatomegaly 3. Ascites 4. Peripheral (sacral?) edema 5. Pulsatile liver (if tricuspid regurgitation).
215
HCM - symptoms?
1. Often none | 2. If present - shortness of breath, angina, syncope.
216
HCM - signs?
1. Sharp rising (jerky) pulse 2. Prominent JVP a wave 3. Double apex beat 4. Late systolic murmur at left sternal edge which increases with Valsalva maneuvre.
217
Peripheral vascular disease - symptoms?
Claudication
218
Peripheral vascular disease - signs?
1. Shiny, pale, cold limb 2. Hair loss 3. Absent pulse 4. If severe --> ischemic ulceration and gangrene.
219
DVT - often confused with?
1. Cellulitis | 2. Ruptured popliteal cyst
220
DVT - symptoms?
1. Calf pain 2. Swelling 3. Loss of use
221
DVT - signs?
1. Warm 2. Tense 3. Swollen limb 4. Erythema 5. Dilated supreficial veins 6. Cyanosis 7. May be palpable thrombus in the deep veins. 8. Often pain on palpating the calf.
222
The acutely ischemic limb:
Rule of Ps: 1. Painful (at first becoming...) 2. Painless (numb) 3. Pale 4. Paralyzed 5. Pulseless
223
Elderly patient - angina?
1. Presents in multitude of ways. 2. Avoid labeling symptom as pain (which can irritate many patients) 3. "Discomfort", "twinges", "aches" are equally common. 4. Many have few symptoms - may present with sweating or breathlessness - ask if related to exertion.
224
Elderly patients - orthopnea:
Ask WHY extra pillows --> Often due to other symptoms such as arthritis. Do they sleep upright in a chair.
225
Elderly patients - breathlessness:
1. Relates to LOW-OUTPUT - NOT necessarily pulm. edema. | 2. Fatigue is common - should NOT be overlooked.
226
Elderly patients - examination:
1. General - look for clues (GTN sprays, patient returning from the bathroom) 2. Auscultate and think - especially for valve lesions. 3. Edeme --> careful with palpation --> Painful! 4. Check peripheral pulses
227
Elderly patients - additional point:
Respiratory illnesses often OVERLAP - Pulmonary fibrosis and LVF. If things don't add up, or there is little response to treatment --> revisit your diagnosis.
228
Mechanism of splitting of 2nd HS?
Inspiration --> Intrathoracic pressure drops --> Drawing blood into the chest --> Incr. delivery to the right side of the heart --> Decr. delivery to the left as it pools in the pulmonary veins --> SV greater on the right side --> RV contraction takes longer --> PV will close very slightly later than the AV (lub da-dub).
Internal Medicine
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