Short case differentials -Cardiology

Question 1

Pansystolic murmurs

Answer 1

Mitral regurgitation
Ventricular septal defect
Aortopulmonary shunting
(Tricuspid stenosis)

Question 2

Midsystolic murmurs

Answer 2

Aortic stenosis
Hypertrophic cardiomyopathy
Pulmonary flow murmur of ASD
Pulmonary stenosis

Question 3

Late systolic murmur

Answer 3

Mitral valve prolapse

Papillary muscle dysfunction

Question 4

Early diastolic murmurs

Answer 4

Aortic regurgitation

Pulmonary regurgitation

Question 5

Mid-diastolic murmurs

Answer 5

Mitral stenosis
Tricuspid stenosis
Atrial myxoma
Austin Flint murmur of Aortic regurgitation
Carey Coombes murmur of acute rheumatic fever

Question 6

Presystolic (late diastolic) murmurs

Answer 6

Mitral stenosis
Tricuspid stenosis
Atrial myxoma

Question 7

Continuous murmur

Answer 7

Patent ductus arteriosis
Arteriovenous fistula (coronary artery, pulmonary, systemic)
Aortopulmonary connection
Venous hum
Rupture of the sinus of Valsalva into right ventricle or atrium
Mammary souffle

Question 8

Valvular strain phase increases the following murmurs

Answer 8

Hypertrophic cardiomyopathy (louder)
Mitral valve prolapse (longer duration)

Question 9

Valvular strain phase decreases the following murmurs

Answer 9

Aortic stenosis

Mitral regurgitation

Question 10

Squatting increases the following murmurs

Answer 10

Aortic stenosis

Mitral regurgitation

Question 11

Squatting decreases the following murmurs

Answer 11

HCOM (softer)

Mitral valve prolapse (shorter duration)

Question 12

Handgrip decreases the following murmurs

Answer 12

HCOM (softer)
Mitral valve prolapse (shorter)
Aortic stenosis (softer)

Question 13

Handgrip increases the following murmurs

Answer 13

Mitral regurgitation (by increasing afterload)

Question 14

Added sound before S1

Answer 14

S4

Pre-systolic (diastolic murmur MS, atrial myxoma, )

Question 15

Added sound after S1

Answer 15

Ejection click (congential AS or PS)

Question 16

Added sound after S2`

Answer 16

Widely split S2
S3
Opening snap (Mitral stenosis)
Pericardial knock
Tumour plop

Question 17

Soft S2

Answer 17

Calcified severe AS

Aortic regurgitation

Question 18

Loud S2

Answer 18

Systemic hypertension
Congenital AS
Pulmonary hypertension (P2)

Question 19

Increased splitting of S2 on inspiration

Answer 19

RBBB
Pulmonary stenonsis
VSD
Mitral regurgitation
ASD (fixed splitting)

Question 20

Fixed S2 splitting

Answer 20

ASD

Question 21

Increased splitting of S2 on expiration

Answer 21

LBBB
Severe aortic stenosis
Coarctation of aorta
Large PDA

Question 22

Causes of elevated JVP

Answer 22

Fluid overload
Right ventricular failure
Hyperdynamic circulation
Tricuspid stenosis or regurgitation
Pericardial effusion or constrictive pericarditis
Superior vena caval obstruction

Question 23

Cause of cannon a wave (flicker during S1)

Answer 23

Complete heart block

Paroxysmal nodal tachycardia with retrograde atrial conduction

Question 24

Cause of dominant a wave (flicker during S1)

Answer 24

Tricuspid stenosis (slow y descent)
Pulmonary stenosis
Pulmonary hypertension

Question 25

Dominant v wave (flicker during S2)

Answer 25

Tricuspid regurgitation

Question 26

Exaggerated x descent

Answer 26

acute pericardial tamponade | constrictive pericarditis

Question 27

Sharp y descent

Answer 27

severe tricuspid regurgitation | Constrictive pericarditis

Question 28

Anacrotic pulse

Answer 28

Small volume, slow uptake, notched wave on upstroke Aortic stenosis

Question 29

Plateau pulse

Answer 29

Slow upstroke Aortic stenosis

Question 30

Bisferens pulse

Answer 30

Anacrotic pulse and collapsing Aortic stenosis and regurgitation combined

Question 31

Collapsing pulse

Answer 31

Aortic regurgitation Hyperdynamic circulation Patent ductus arteriosis Peripheral arteriovenous fistula (haemodialysis)

Question 32

Small volume pulse

Answer 32

Aortic stenosis | Pericardial effusion

Question 33

Alternans pulse

Answer 33

Alternating strong and weak pulses Left ventricular failure

Question 34

Types of pulses common to aortic stenosis

Answer 34

Plateau pulse Anacrotic pulse Small volume pulse (Bisferens pulse)

Question 35

Causes of postural drop (HANDI)

Answer 35

Hypovolaemia Hypopituitarism Addison's disease Neuropathy - autonomic (DM, amyloidosis Shy-Drager) Drugs - vasodilators and other anti-hypertensives, TCAs, diuretics, antipsychotics Idiopathic

Question 36

Pressure loaded apex beat

Answer 36

Heaving, hyperdynamic or systolic overloaded ddx - Aortic stenosis - Systemic hypertension

Question 37

Volume loaded apex beat

Answer 37

Thrusting, displaced, diffuse, non-sustained ddx - Mitral regurgitation - Dilated cardiomyopathy

Question 38

Double impulse apex beat

Answer 38

Hypertrophic cardiomyopathy

Question 39

Tapping apex beat

Answer 39

Palpable S1 Mitral stenosis

Question 40

Unpalpable apex beat

Answer 40

``` Obesity Emphysema Pericardial effusion Shock Dextrocardia ```

Question 41

Palpable P2

Answer 41

Pulmonary hypertension

Question 42

Parasternal heave

Answer 42

Pulmonary hypertension

Question 43

Neck bruit

Answer 43

Aortic stenosis Carotid stenosis Thyrotoxicosis

Question 44

Local causes of leg ulcers

Answer 44

``` Venous stasis ulcer Ischaemic ulcer Malignant ulcer Infection Neuropathic ulcer Underlying systemic disease ```

Question 45

Systemic causes of leg ulcers

Answer 45

``` Diabetes mellitus - vascular disease, neuropathy or necrobiosis lipoidica pyoderma gangrenosum Rheumatoid arthritis Lymphoma Haemolytic anaemia ```

Question 46

Severity of aortic stenosis

Answer 46

``` Late peaking murmur Apical impulse sustained Long murmur Delayed carotid upstroke Decreased A2 Diminished carotid pulse ```

Question 47

Severity of aortic regurgitation

Answer 47

Pulse pressure >80mmHg Grade 3+ murmur Sustained or displaced apex beat

Question 48

Clinical signs of left ventricular failure

Answer 48

Tachypnoea, cyanosis Chenyne stokes breathing Low pulse pressure Pulsus alternans Displaced apex beat S3, palpable gallop rhythm Middle to late inspiratory crackles and wheeze Positive abdominojugular reflux test (highest positive LR) Abnormal Valvsalva response (by listening to Korokoff sounds during Valsalva)

Question 49

Causes of LVF

Answer 49

Myocardial disease - IHD, cardiomyopathy Volume overload - aortic regurgitation, mitral regurgitation, patent ductus arteriosus Pressure overload - aortic stenosis, systolic hypertension

Question 50

Clinical signs of right ventricular failure

Answer 50

``` Low volume pulse Raised jugular venous pressure Right ventricular heave Right ventricular S3 Tender hepatomegaly Pulsatilve liver, large JVP v waves (tricuspid regurgitation) Ascites Ankle or sacral oedema ```

Question 51

Causes of RVF

Answer 51

Cor pulmonale LVF Myocardial disease (IHD, cardiomyopathy) Volume overload (atrial septic defect, primary tricuspid regurgitation) Pressure overload (idiopathic pulmonary hypertension, pulmonary stenosis)

Question 52

Clinical signs of chronic constrictive pericarditis

Answer 52

``` Cachexia Pulsus paradoxus >10mmHg Low blood pressure Raised jugular venous pressure Kussmaul's sign - lack of JVP fall or rise on inspiration Prominent x and y descents on JVP (brisk collapse during diastole) Impalpable apex beat Distant heart sounds Early S3 Early pericardial knock Hepatosplenomegaly Ascites Peripherial oedema ```

Question 53

Causes of chronic constrictive pericarditis

Answer 53

``` Cardiac operation or trauma Cancer Tuberculosis Histoplasmosis or pyogenic infection Connective tissue disease End stage renal failure ```

Question 54

Signs of systemic hypertension and PVD

Answer 54

Retinal changes for hypertension - silver wiring 1, AV nipping 2, haemorrhages 3, papilloedema 4 S4 if BP > 180/110 Systolic-diastolic epigastric renal bruit (renal artery stenosis) Aortic aneurysm Reduced lower limb pulses bilaterally Femoral bruits Carotid bruits

Question 55

Causes of secondary systemic hypertension

Answer 55

``` Renal disease Endocrine disease - Conn's, Cushing' syndrome, acromegaly, phaechromocytoma, thyrotoxicosis, hypothyroidism, hyperparathyroidism Coarctation of aorta Sleep apnoea OCP Polycythemia rubra vera Pre-eclampsia ```

Question 56

Signs of pulmonary hypertension

Answer 56

``` Low volume pulse prominent a wave on JVP Right ventricular heave Loud and palpable P2 Systolic ejection click S4 Pulmonary ejection murmur Signs of right ventricular failure ```

Question 57

Signs of mitral stenosis

Answer 57

``` Mitral facies Atrial fibrillation, low volume pulse Tapping apex beat Loud S1 Opening snap Low pitched diastolic murmur Late diastolic murmur (if not in AF) Signs of pulmonary hypertension ```

Question 58

Signs of mitral regurgitation

Answer 58

``` Normal or sharp upstroke pulse AF Displaced apex beat Pansystolic thrill Soft/absent S1 S3 Pansystolic murmur radiating to axilla ```

Question 59

Causes of mitral stenosis

Answer 59

``` Rheumatic heart disese Congenital parachute valve Carcinoid ergot derivatives Anorexic medications ```

Question 60

Causes of mitral regurgitation

Answer 60

``` Papillary muscle dysfunction from IHD Cardiomyopathy Mitral valve prolapse Rheumatic heart disease Connective tissue disease Marfan's syndrome Congenital ```

Question 61

Signs of mitral valve prolapse

Answer 61

Midsystolic click, changes with position High pitched late systolic murmur - louder with on standing and Valsalva Reduced in squatting and isometric exercise

Question 62

Causes of mitral valve prolapse

Answer 62

Myxomatous degeneration of the mitral valve | Associated with atrial septal defect, hypertrophic cardiomyopathy, Marfans

Question 63

Clinical signs of aortic stenosis

Answer 63

Plateau, late peaking or anacrotic pulse Hyperdynamic displaced apex beat Systolic thrill at base of heart (right upper sternal edge, RUSE) Narrow split or reversed S2 Harsh mid systolic murmur at the RUSE over the carotid area, loudest on expiration Preceded ejection click Early decrescendo diastolic murmur (if associated aortic regurgitation)

Question 64

Differential diagnoses for left ventricular outflow obstruction

Answer 64

Aortic stenosis - Calcified, congential bicuspid/unicuspid, tetracuspid, rheumatic Supravalvular obstruction Subvalvular obstruction Hypertrophic cardiomyopathy

Question 65

Clinical signs of supravalvular obstruction

Answer 65

Broad forehead, widely set eyes and chin Loud A2 Thrill in sternal notch

Question 66

Clinical signs of subvalvular obstruction

Answer 66

Associated aortic regurgitation

Question 67

Clinical signs of aortic regurgitation

Answer 67

General signs of Marfan's syndrome, ankylosing spondylitis or Argyll Robertson pupils Water hammer pulse - chronic AR only (bisferens pulse if aortic stenosis is also present) Wide pulse pressure Prominent carotid pulsitations Displaced, hyperkinetic apex beat Diastolic thrill at left sternal edge sitting up in expiration Soft A2 Decresendo murmur after second heart sound between 3rd and 4th ribs, with patient sitting forward on expiration Austin flint murmur - mid diastolic rumble at apex in lateral position

Question 68

Causes of aortic regurgitation

Answer 68

``` Type A aortic dissection Infective endocarditis Marfan's syndrome Ankylosing spondylitis Syphilic aortitis ```

Question 69

Signs of tricuspid stenosis

Answer 69

Elevated JVP Large a waves with slow y descent on JVP Mid-diastolic rumble at left sternal edge, on inspiration Pre-systolic pulsitation of liver

Question 70

Signs of tricuspid regurgitation

Answer 70

``` Elevated JVP Large v waves Right ventricular heave ?Pansystolic murmur at lower end of sternum accentuated on inspiration Tender hepatomegaly Pulsatile liver Dilated, pulsatile leg veins ```

Question 71

Causes of tricuspid regurgitation

Answer 71

``` RVF Rheumatic Infective endocarditis (IVDU) Tricuspid valve prolapse Right papillary muscle infarction Trauma - steering wheel to sternum Ebstein's anomaly ```

Question 72

Signs of pulmonary stenosis

Answer 72

``` Normal or reduced pulse Giant a waves on JVP Right ventricular heave Harsh ejection murmur loudest on inspiration radiating to left clavicle Ejection click after S1 Presystolic pulsitation of liver Right ventricular S4 ```

Question 73

Causes of pulmonary stenosis

Answer 73

Congenital - Noonan's syndrome | Carcinoid syndrome

Question 74

Signs of pulmonary regurgitation

Answer 74

High pitched decrescendo diastolic murmur that increases on inspiration (Graham steel murmur)

Question 75

Differentials for right ventricular heave

Answer 75

``` Pulmonary hypertension Tricuspid regurgitation Atrial septal defect Pulmonary stenosis Isolated pulmonary regurgitation ```

Question 76

Signs of hypertrophic cardiomyopathy

Answer 76

Sharp, rising, jerky pulse Prominent a wave on JVP Double or triple impulse Late systolic murmur at the lower left sternal edge Pansystolic murmur at apex S4 Murmurs increased by Valsalva, standing and isotonic exercise

Question 77

Causes of hypertrophic cardiomyopathy

Answer 77

Congenital - autosomal dominance with variable expressitivity Friedrich's ataxia

Question 78

Causes of dilated cardiomyopathy

Answer 78

``` Alcohol Beri-Beri Viral infection - coxsackie Anthracycline chemotherapy Dystrophica myotonica haemochromatosis ```

Question 79

Causes of restrictive cardiomyopathy

Answer 79

Infiltrative disease - amyloid, sarcoid Eosinophilic endomyocardial disease Endomyocardial fibrosis

Question 80

Signs of ventricular septal defect

Answer 80

Hyperkinetic displaced apex beat Thrill at left sternal edge Harsh pansystolic murmur at lower left sternal edge between 3rd and 4th rib, loudest on expiration palpable systolic thrill

Question 81

Signs of atrial septal defect

Answer 81

Right ventricular heave Fixed splitting S2 Pulmonary ejection systolic murmur loudest on inspiration

Question 82

Signs of patent ductus arteriosus

Answer 82

``` Collapsing pulse with sharp upstroke Low diastolic pressure Hyperkinetic apex beat Continuous loud machinery murmur in systole and diastole at first intercostal space Mitral mid-diastolic flow murmur Reversed splitting S2 if severe ```

Question 83

Signs of coactation of aorta

Answer 83

Radiofemoral delay Weak femoral pulses hypertension in arms but not legs midsystolic murmur over praecordium and back

Question 84

Signs of repaired tetralogy of Fallot

Answer 84

Median sternotomy scar Long diastolic murmur of pulmonary regurgitation Signs of tricuspid regurgitation