B P3 C13 History and Physical Examination: An Evidence-Based Approach Flashcards
Typical angina should satisfy three characteristics:
(1) substernal discomfort
(2) initiated by exertion or stress
(3) relieved with rest or sublingual nitroglycerin.
__________ more commonly present with a less typical clinical picture.
Women, elderly persons, and patients with diabetes
Dyspnea may occur with exertion or in recumbency (orthopnea) or even on standing (_____________).
Platypnea
_______________ of cardiac origin usually occurs 2 to 4 hours after onset of sleep; the dyspnea is sufficiently severe to compel the patient to sit upright or stand and then subsides gradually over several minutes.
Paroxysmal nocturnal dyspnea
A report of a regular, rapid-pounding sensation in the neck or visible neck pulsations associated with palpitations increases the likelihood of this arrhythmia
Atrioventricular nodal reentrant tachycardia (AVNRT)
______________ occurs suddenly, with rapid restoration of full consciousness thereafter.
Cardiac syncope
Patients with ___________________ may experience early warning signs (nausea, yawning), appear ashen and diaphoretic, and revive more slowly, albeit without signs of seizure or a prolonged postictal state.
Neurocardiogenic syncope
__________ is defined as a state of decreased physiologic reserve and vulnerability to stressors.
Frailty
____________ is present with significant right-to-left shunting at the level of the heart or lungs. It also is a feature of hereditary methemoglobinemia
Central cyanosis
________________ of the fingers, toes, nose; characteristic of the reduced blood flow that accompanies small-vessel constriction seen in severe heart failure, shock, or peripheral vascular disease.
Peripheral cyanosis or acrocyanosis
_____________ cyanosis affecting the lower but not the upper extremities occurs with a patent ductus arteriosus (PDA) and pulmonary artery hypertension with ______________ at the level of the great vessel
Differential cyanosis
Right-to-left shunting
Hereditary telangiectases on the lips, tongue, and mucous membranes seen in what syndrome
Osler-Weber-Rendu syndrome
A lace-like purplish dislocation of the skin that imparts a mottled or reticulated appearance
Livedo reticularis
Tanned or bronze discoloration of the skin in unexposed areas can suggest iron overload and _____________.
Hemochromatosis
_______________ often occur with either anticoagulant and/or antiplatelet use, whereas _____________ characterize thrombocytopenia, and _______________ can be seen with infective endocarditis and other causes of leukocytoclastic vasculitis.
Ecchymoses
Petechiae
Purpuric skin lesions
Various lipid disorders can manifest with ___________, located subcutaneously, along tendon sheaths, or over the extensor surfaces of the extremities.
Xanthomas
Xanthomas within the palmar creases are specific for _______________
Type III hyperlipoproteinemia
The leathery, cobblestone, “plucked chicken” appearance of the skin in the axillae and skinfolds of a young person is characteristic of ______________________, a disease with multiple cardiovascular manifestations, including premature atherosclerosis.
Pseudoxanthoma elasticum
Extensive lentiginoses (freckle-like brown macules and café-au-lait spots over the trunk and neck) may be part of developmental delay associated cardiovascular syndromes (_________, ___________, ______________) with multiple atrial myxomas, atrial septal defect (ASD), hypertrophic cardiomyopathy, and valvular stenoses.
LEOPARD, LAMB, and Carney
___________ should be suspected in the presence of lupus pernio, erythema nodosum, or granuloma annulare.
Cardiovascular sarcoid
A high-arched palate is a feature of ________________ disease syndromes.
Marfan and other connective tissue
A large protruding tongue with parotid enlargement may suggest ______________.
Amyloidosis
Patients with _________________ characteristically have a bifid uvula.
Loeys-Dietz syndrome
Orange tonsils are typical of ________________
Tangier disease
Ptosis and ophthalmoplegia suggest ___________
Muscular dystrophies
Congenital heart disease often is accompanied by hypertelorism, low-set ears, micrognathia, and a webbed neck, as with __________, __________, ____________
Noonan, Turner, and Down syndromes
Proptosis, lid lag, and stare point to _______________
Graves hyperthyroidism
Patients with _____________ may have blue sclerae, mitral or aortic regurgitation (AR), and a history of recurrent nontraumatic skeletal fractures.
Osteogenesis imperfecta
Lacrimal gland hyperplasia is sometimes a feature of __________.
Sarcoidosis
Pink-purplish patches with telangectasias over the malar eminences in MS
Mitral facies
Extensive varicosities, medial ulcers, or brownish pigmentation from hemosiderin deposition, suggest ____________
Chronic venous insufficiency
Muscular atrophy and the absence of hair in an extremity should suggest ________ or a neuromuscular disorder.
Chronic arterial insufficiency
Redistribution of fat from the extremities to central/abdominal stores (_______________) in some patients with HIV infection may relate to antiretroviral treatment and is associated with insulin resistance and several features of the metabolic syndrome.
Lipodystrophy
Cutaneous venous collaterals over the anterior chest suggest _______, especially in the presence of indwelling catheters or leads from cardiac implantable electrical devices (CIEDs)
Chronic obstruction of the superior vena cava (SVC) or subclavian vein
The severe kyphosis of _______ should prompt careful auscultation for AR and scrutiny of the electrocardiogram (ECG) for first degree atrioventricular (AV) block.
Ankylosing spondylitis
The “straight back syndrome” (loss of normal kyphosis of the thoracic spine) can accompany ____________
Mitral valve prolapse (MVP)
A thrill may be present over well-developed intercostal artery collaterals in patients with ____
Aortic coarctation
Systolic hepatic pulsations signify _______
Severe tricuspid regurgitation
The abdominal aorta normally may be palpated between the _____________ in thin patients and in children.
Epigastrium and the umbilicus
The JVP aids in the estimation of volume status.
The external (EJV) or internal (IJV) jugular vein may be used, although the ______ is preferred
IJV
Because the EJV is valved and not directly in line with the SVC and right atrium.
An elevated left EJV pressure may also signify a persistent _______ or compression of the ________
Persistent left-sided SVC
Compression of the innominate vein
The bedside venous pressure is usually estimated by the vertical distance between the _________, where the manubrium meets the sternum (angle of Louis).
Top of the venous pulsation and the sternal inflection point
A distance of _______ is considered an abnormal JVP
Greater than 3 cm
Venous pulsations above the clavicle with the patient in the sitting position are clearly abnormal, because the distance from the right atrium is at least ___ cm
10 cm
Has an undulating two troughs and two peaks for every cardiac cycle (biphasic); height of column falls and troughs become more prominent
Internal Jugular Vein Pulse
The a wave reflects right ________, occurs just after the _____, and precedes _______
Atrial presystolic contraction
After the electrocardiographic P wave
Precedes the first heart sound (S1)
Cause of prominent a wave
Patients with reduced right ventricular (RV) compliance from any cause
A _______ wave occurs with AV dissociation and right atrial contraction against a closed tricuspid valve.
Cannon a wave
The presence of cannon a waves in a patient with wide complex tachycardia identifies the rhythm as ventricular in origin
The a wave is absent with _____
Atrial fibrillation
The ________ reflects the fall in right atrial pressure after the a wave peak.
x descent
The predominant waveform in the jugular venous pulse in normal individuals
X descent
The x descent follows because of ________ created by ventricular systole pulling the tricuspid valve downward
Atrial diastolic suction
The _____ interrupts the x descent as ventricular systole pushes the closed valve into the right atrium.
c wave
The _____ represents atrial filling, occurs at the end of ventricular systole, and follows just after ____
v wave
S2
Factors that determine v wave height
RA compliance
Volume of blood returning to the RA from all sources
The v wave is smaller than the a wave because of the ________
Normally compliant right atrium
a and v waves in
ASD
TR
ASD - a and v waves may be of equal height
TR - v wave is accentuated
With TR, the v wave will merge with the c wave because retrograde valve flow and antegrade right atrial filling occur simultaneously.
The ______ follows the v wave peak and reflects the fall in right atrial pressure after tricuspid valve opening.
y descent
Resistance to ventricular filling in early diastole blunts the y descent, as is the case with _______ or _______
Pericardial tamponade
Tricuspid stenosis
The y descent will be steep when ventricular diastolic filling occurs early and rapidly, as with
Pericardial constriction
Restrictive cardiomyopathy
Isolated, severe TR
The normal venous pressure should fall by at least ________ with inspiration.
3 mm Hg
A rise in venous pressure (or its failure to decrease) with inspiration
Kussmaul sign
Kussmaul sign is associated with
Constrictive pericarditis
Restrictive cardiomyopathy
Pulmonary embolism
RV infarction
Advanced systolic heart failure
The ______ requires firm and consistent pressure over the upper abdomen, preferably the right upper quadrant, for at least 10 seconds.
Abdominojugular reflux maneuver
Positive abdominojugular reflux maneuver
Rise of more than 3 cm in the venous pressure sustained for at least 15 seconds
A positive abdominojugular reflux sign can predict heart failure in patients with dyspnea, as well as a pulmonary artery wedge pressure higher than ______
15 mm Hg
Important Aspects of Blood Pressure Measurement
Measurement should be done after ___________ of rest, repeated 5 minutes later, and the readings averaged.
Cuff length and width should be _____ and ______ of arm circumference, respectively
5 minutes
80% and 40%
Korotkoff sounds may be heard all the way down to 0 mm Hg with the cuff completely deflated in
Children
Pregnant patients
Chronic severe AR
Large arteriovenous fistula
In these cases, both the phases 4 and 5 pressures should be noted.
Blood pressure should be measured in both arms either in rapid succession or simultaneously; normally the measurements should differ by _________, independent of handedness.
Less than 10 mm Hg
A blood pressure differential of more than 10 mm Hg can be associated with
Subclavian artery disease
Supravalvular aortic stenosis (SVAS)
Aortic coarctation
Aortic dissection
Systolic leg pressures may exceed arm pressures by as much as ________; greater leg-arm systolic blood pressure differences are seen in patients with
20 mm Hg
Severe AR (Hill sign)
Extensive and calcified (noncompressible) lower extremity PAD
Orthostatic hypotension is a fall in blood pressure of more than ______ systolic and/or more than ______ diastolic in response to moving from the supine to the standing position within 3 minutes
20 mm Hg/10 mm Hg
In patients with _____, blood pressure does not usually fall on standing.
Postural orthostatic tachycardia syndrome (POTS)
The carotid artery pulse wave occurs within _____ milliseconds of the ascending aortic pulse and reflects aortic valve and ascending aortic function
40 ms
One of the two pedal pulses may not be palpable in a normal subject because of unusual anatomy (posterior tibial, less than _____%; dorsal pedis, less than __%), but each pair should be symmetric. True congenital absence of a pulse is rare, and in most cases, pulses can be detected with a handheld Doppler device when not palpable.
PTA < 5%
DPA <10%
Simultaneous palpation of the brachial or radial pulse with the femoral pulse should be performed in young patients with hypertension to screen for ____.
CoA
A _______ pulse may occur in hyperkinetic states such as fever, anemia, and thyrotoxicosis, or in pathologic states such as severe bradycardia, AR, or arteriovenous fistula.
Bounding pulse
A _______ is created by two distinct pressure peaks.
Examples
Bifid pulse
Ex:
Chronic severe AR
HCM
Fever/Sepsis
Exercise
IABP
A fall in systolic pressure of more than 10 mm Hg with inspiration
Seen in what conditions?
Pulsus paradoxus
- Pericardial tamponade
- Pregnancy
- Pulmonary disease (severe) - Massive PE, COPD, Tension pneumothorax
- Hemorrhagic shock
- Obesity
Pulsus paradoxus may be palpable at the brachial artery when the pressure difference exceeds _______
15 mm Hg
Pulsus paradoxus is detected by noting the difference between the systolic pressure at which the Korotkoff sounds are first heard (during expiration) and the systolic pressure at which the Korotkoff sounds are heard with each beat, independent of respiratory phase. Between these two pressures, the sounds will be heard only intermittently (during expiration).
_____ defined by the beat-to-beat variability of the pulse amplitude
Pulsus alternans
Pulsus alternans generally occurs in
Severe heart failure
Severe AR
Hypertension
Hypovolemic states
Pulsus alternans attributed to cyclic changes in intracellular ____ and action potential duration.
Association with electrocardiographic ________ appears to increase arrhythmic risk.
Calcium
T wave alternans
Severe aortic stenosis may be suggested by a _________ pulse and is best appreciated by careful palpation of the carotid arteries
Weak and delayed pulse (pulsus parvus et tardus)
An abrupt carotid upstroke with rapid fall-off characterizes the pulse of chronic AR ( ___________ ).
Corrigan or water-hammer pulse
Abnormal pulse oximetry, defined by a _________ difference between finger and toe oxygen saturation, can also indicate lower extremity PAD and is comparable to the ABI
> 2%
The point of maximal impulse normally is over the left ventricular (LV) apex beat and should be located in the midclavicular line at the fifth intercostal space.
It is smaller than ______ in diameter and moves quickly away from the fingers. It is best appreciated at _______, when the heart is closest to the chest wall.
2 cm
End-expiration
LV cavity enlargement displaces the apex beat _______
A _______ apex beat is a sign of LV pressure overload (as in aortic stenosis or hypertension).
Leftward and downward
Sustained apex beat
A palpable, presystolic impulse corresponds to a ______ and reflects the atrial contribution to ventricular diastolic filling of a noncompliant left ventricle.
Fourth heart sound (S4 )
A prominent, rapid early filling wave in patients with advanced systolic heart failure may result in a palpable ________.
Palpable third sound (S3)
A parasternal lift occurs with RV pressure or volume overload.
Signs of TR (jugular venous ___ waves) and/or pulmonary artery hypertension (loud, single, or palpable __) should be sought.
JV cv waves
P2
HOCM rarely may cause a _________, with contributions from a palpable S4 and the two components of the systolic pulse.
Triple cadence apex beat
Normal splitting of S1 is accentuated with ________
Complete right bundle branch block.
S1 intensity increases in
- Early stages of RMS (leaflets still pliable)
- Hyperkinetic states
- Short P-R intervals (less than 160 milliseconds)
S1 becomes softer in
- Contractile dysfunction
- Late stages of stenosis (leaflets are rigid and calcified)
- Beta-adrenergic receptor blockers
Long P-R intervals (greater than 200 milliseconds)
Mechanical ventilation
Obstructive lung disease
Obesity
Pendulous breasts
Pneumothorax
Pericardial effusion
With normal, or physiologic, splitting, the A2–P2 interval increases during _______ and narrows with _______.
Increases - inspiration
Narrows - expiration
The A2–P2 interval widens with _______ because of delayed pulmonic valve closure, and with _______ because of premature aortic valve closure.
CRBBB
Severe MR
Unusually narrow but physiologic splitting of S2, with an increase in the intensity of P2 relative to A2 , indicates ____________
Pulmonary artery hypertension
With fixed splitting, the A2 –P2 interval is wide and remains unchanged during the respiratory cycle, indicating _______
Ostium secundum ASD
Reverse, or paradoxical, splitting occurs as a consequence of a pathologic delay in aortic valve closure, as may occur with _____.
CLBBB
RV apical pacing
Severe aortic stenosis
HCM
Myocardial ischemia
When both A2 and P2 can be heard at the lower left sternal border or apex, or when P2 can be palpated at the second left interspace __________, present
Pulmonary hypertension
The intensity of A2 and P2 decreases with aortic and pulmonic stenosis, respectively. A ______ S2 may result.
Single S2
__________ high-pitched, early systolic sound that coincides in timing with the upstroke of the carotid pulse and usually is associated with congenital bicuspid aortic or pulmonic valve disease, or sometimes with aortic or pulmonic root dilation and normal semilunar valves.
Ejection sound
The only right sided ejection sound that decreases in intensity with inspiration
Pulmonic valve disease
Nonejection clicks, which occur after the upstroke of the carotid pulse, are related to _______ .
MVP
Effects of standing and squatting with MVP
With standing, ventricular preload and afterload decrease and the click and murmur move _______ to S1.
With squatting, ventricular preload and afterload increase, the prolapsing mitral valve tenses ______ in systole, and the click and murmur move ______ from S1
Closer
Later/Away
The high-pitched __________ of mitral stenosis occurs a short distance after S2
Opening snap (OS)
The A2–OS interval is _______ proportional to the height of the left atrial (LA)-LV diastolic pressure gradient.
Inversely proportional
The intensity of both S1 and OS decreases with progressive calcification and rigidity of the anterior mitral leaflet.
A ______________ is a high-pitched early diastolic sound, which corresponds in timing to the abrupt cessation of ventricular expansion after AV valve opening and to the prominent y descent seen in the jugular venous waveform in patients with constrictive pericarditis.
Pericardial knock (PK)
________ low-pitched sound sometimes only heard in certain positions that arises from the diastolic prolapse of the tumor across the mitral valve.
Tumor plop
A third heart sound (S3) occurs during the rapid filling phase of ventricular diastole.
An S3 may be normally present in _______, but indicates systolic heart failure in older adults and carries important prognostic weight
Children, adolescents, and young adults
A left-sided S3 is a low-pitched sound best heard over the LV apex with the patient in the _______ position
A right-sided S3 is usually heard at the lower left sternal border or in the subxiphoid position with the patient ________, and may become louder with inspiration
Left lateral decubitus
Supine
A ______ occurs during the atrial filling phase of ventricular diastole and is thought to indicate presystolic ventricular expansion.
This finding is especially common in patients with accentuated atrial contribution to ventricular filling (e.g., LV hypertrophy).
Fourth heart sound (S4)
Examples of Early Systolic Murmurs
Mitral—acute MR
VSD
Muscular
Nonrestrictive with pulmonary hypertension
Tricuspid—TR with normal pulmonary artery pressure
Examples of Midsystolic murmurs
Aortis stenosis
Pulmonic stenosis
Examples of Late Systolic murmurs
MVP
TVP
Examples of Holosystolic murmurs
Atrioventricular valve regurgitation (MR, TR)
Left-to-right shunt at ventricular level (VSD)
___________ results in a decrescendo, early systolic murmur because of the steep rise in pressure within the noncompliant left atrium
Acute severe MR
Radiation of posterior mitral leaflet prolapse? Anterior mitral leaflet prolapse?
Severe MR associated with posterior mitral leaflet prolapse or flail radiates anteriorly and to the base; MR caused by anterior leaflet involvement radiates posteriorly and to the axilla.
In patients with normal pulmonary artery pressures, an early systolic murmur, which increases in intensity with inspiration, may be audible at the lower left sternal border, and regurgitant cv waves may be visible
Acute TR
Midsystolic murmurs begin after S1 and end before S2 ; they usually are _________ in configuration.
Crescendo-decrescendo
Midsystolic murmurs begin after S1 and end before S2 ; they usually are _________ in configuration.
Crescendo-decrescendo
An isolated grade ______ murmur in the absence of symptoms or other signs of heart disease is a benign finding that does not warrant further evaluation, including echocardiography.
Grade 1 or 2 midsystolic murmur
Mid-to-late, apical systolic murmur usually indicates ____; one or more nonejection clicks may be present.
MVP
Holosystolic murmurs, which are ______ in configuration, derive from the continuous and wide pressure gradient between two cardiac chambers
Examples?
Plateau
Left ventricle and left atrium with chronic MR (cardiac apex)
Right ventricle and right atrium with chronic TR (left lower SB)
Left ventricle and right ventricle with membranous ventricular septal defect (VSD) without pulmonary hypertension (mid-left sternal border, where a thrill is palpable)
Examples of Early Diastolic murmurs
Aortic regurgitation
Pulmonic regurgitation
__________ causes a high-pitched decrescendo early to mid-diastolic murmur.
Chronic AR
With primary aortic valve disease, the murmur is best heard along the _____, whereas with root enlargement and secondary AR, the murmur may radiate along the ______
Left sternal border
Right sternal border
The diastolic murmur is both softer and of shorter duration in __________ AR, as a result of the rapid rise in LV diastolic pressure and the diminution of the aortic-LV diastolic pressure gradient.
Acute AR
Additional features of acute AR include tachycardia, a soft S1, and the absence of peripheral findings of significant diastolic run-off
The murmur of pulmonic regurgitation (PR) is heard along the left sternal border and most often is due to annular enlargement from chronic pulmonary artery hypertension. This murmur is also known as _______ murmur.
Graham-Steele murmur
_________ is the classic cause of a mid- to late diastolic murmur.
The stenosis also may be “silent”—for example, in patients with low cardiac output or large body habitus.
The murmur is best heard over the apex with the patient in the left lateral decubitus position, is low-pitched (rumbling), and is introduced by an _____ in the early stages of the disease.
Mitral stenosis
OS
_______________ (an increase in the intensity of the murmur in late diastole following atrial contraction) occurs in patients with MS in sinus rhythm.
Presystolic accentuation
Functional mitral stenosis or tricuspid stenosis refers to mid-diastolic murmurs created by increased, accelerated ______, without valvular obstruction, in the setting of severe MR or TR, respectively, or ASD with a large left-to- right shunt.
Increased, accelerated transvalvular flow
The low-pitched mid- to late apical diastolic murmur sometimes associated with AR (________) can be distinguished from mitral stenosis on the basis of its response to vasodilators and the presence of associated findings.
Austin Flint murmur
The presence of a _______ implies a pressure gradient between two chambers or vessels during both systole and diastole. These murmurs begin in systole, peak near S2 , and continue into diastole.
Continuous murmur
Examples:
* PDA
* Ruptured sinus of Valsalva aneurysm
* Coronary, great vessel, or hemodialysis-related arteriovenous fistulas.
* Cervical venous hum and mammary soufflé of pregnancy are two benign variants.
Right-sided events, except for the ______, increase with inspiration and decrease with expiration; left-sided events behave oppositely (100% sensitivity, 88% specificity).
Pulmonic ejection sound
Aortic stenosis or MR?
A change in the intensity of a systolic murmur in the first beat after a premature beat, or in the beat after a long cycle length in patients with AF
Aortic stenosis
Particularly in an older patient, in whom the murmur of aortic stenosis is well transmitted to the apex (Gallavardin effect).
Systolic murmurs that are due to LV outflow obstruction, including those caused by aortic stenosis, will increase in intensity in the beat following a premature beat because of the combined effects of enhanced LV filling and post-extrasystolic potentiation of contractile function. Forward flow accelerates, causing an increase in the gradient and a louder murmur.
The intensity of the murmur of MR does not change in the post-premature beat, because relatively little further increase occurs in mitral valve flow or change in the LV-LA gradient.
Patients with heart failure prefer sleeping on their ________ side
Right side
________, which is dyspnea or discomfort experienced in the lateral decubitus position, also may be present
Trepopnea
Shortness of breath may be particularly noticeable when bending forward, termed _________.
Bendopnea
Four signs are commonly used to predict elevated filling pressures:
- JVD/abdominojugular reflux sign
- Presence of an S3 and/or S4
- Rales
- Pedal edema
The _______ provides the readiest bedside estimate of LV filling pressure.
JVP
Identify the phase of Valsalva
Decrease in stroke volume and pulse pressure and reflex tachycardia with continued strain due to decrease in venous return and increase in vascular resistance
Phase II
Identify the phase of Valsalva
Overshoot of systolic pressure and reflex bradycardia due to increased venous return and decreased systemic vascular resistance
Phase IV
Identify the phase of Valsalva
Overshoot of systolic pressure and reflex bradycardia due to increased venous return and decreased systemic vascular resistance
Phase IV
Two abnormal responses to the Valsalva maneuver in heart failure are recognized:
(1) absence of the phase IV overshoot
(2) the square-wave response
The absent overshoot pattern indicates __________;
The square-wave response indicates ___________ and appears to be independent of ejection fraction
Decreased systolic function
Elevated filling pressures
In a cohort of patients with chronic systolic heart failure, the ____ ([systolic − diastolic]/systolic) correlated well with cardiac index
Proportional pulse pressure
Using a proportional pulse pressure of 25%, the cardiac index could be predicted: if the value was lower than 25%, the cardiac index was ______
Less than 2.2 L/min/m2
Severe mitral stenosis is suggested by
(1) a long or holodiastolic murmur, indicating a persistent LA-LV gradient
(2) a short A2 -OS interval, consistent with higher LA pressure;
(3) a loud P2 (or single S2 ) and/or an RV lift, suggestive of pulmonary hypertension
(4) elevated JVP with cv waves, hepatomegaly, and lower extremity edema
In _________, the LV impulse usually is neither enlarged nor displaced, and the systolic murmur is early in timing and decrescendo in configuration
Acute MR
occurs with papillary muscle rupture or infective endocarditis usually results in sudden and profound dyspnea from pulmonary edema.
Several findings suggest chronic severe MR:
(1) an enlarged, displaced, but dynamic LV apex beat
(2) an apical systolic thrill (murmur intensity of grade 4 or greater)
(3) a mid-diastolic filling complex comprising an S3 and a short, low-pitched murmur, indicative of accelerated and enhanced diastolic mitral inflow
(4) wide but physiologic splitting of S2 caused by early aortic valve closure;
(5) a loud P2 or RV lift
The murmur associated with secondary MR in patients with reduced LV systolic function is often of ______ unless specifically sought.
Low intensity and can be difficult to hear
Findings in AS
Slowly rising carotid upstroke (pulsus tardus), reduced carotid pulse amplitude (pulsus parvus)
Reduced intensity of A2
Mid to late peaking of the systolic murmur
Distinguishing features of the ffg conditions vs AS
HOCM
Subaortic stenosis
Supravalvar stenosis
The presence of an ejection sound indicates a valvular cause.
HOCM can be distinguished on the basis of the response of the murmur to the Valsalva maneuver and standing or squatting.
DMSS will commonly have a diastolic murmur indicative of AR but not an ejection sound
Patients with SVAS, the right arm blood pressure is more than 10 mm Hg greater than the left arm blood pressure.
Patients with _______ present with pulmonary edema and symptoms and signs of low forward cardiac output.
Tachycardia is invariably present; systolic blood pressure is not elevated, and the pulse pressure may not be significantly widened.
S1 is soft because of ______
Acute severe AR
Premature closure of the mitral valve.
A decrescendo diastolic blowing murmur suggests ________
Chronic AR
Little evidence supports the historical claims of the importance of almost all the eponymous peripheral signs of chronic AR, which number at least 12.
The ______ (brachial- popliteal systolic blood pressure gradient higher than 20 mm Hg) may be the single exception (sensitivity of 89% for moderate to severe AR), although its supporting evidence base also is weak.
Hill sign
An elevated JVP together with a delayed y descent, abdominal ascites, and edema suggests ______
Severe tricuspid stenosis.
_________ causes elevated JVP with prominent cv waves, a parasternal lift, pulsatile liver, ascites, and edema.
The intensity of the holosystolic murmur of TR increases with inspiration (____________).
Severe TR
Carvallo sign
Pulmonic stenosis may cause exertional fatigue, dyspnea, lightheadedness, and chest discomfort (“_______”).
Right ventricular angina
With severe pulmonic stenosis, the interval between S1 and the pulmonic ejection sound narrows, and the murmur peaks in late systole and may extend beyond A2. ______ becomes inaudible.
P2
The diastolic murmur of secondary PR (______________) can be distinguished from that caused by AR on the basis of its increase in intensity with inspiration, its later onset (after A2 and with P2), and its slightly lower pitch.
Graham Steell
The first clue that prosthetic valve dysfunction may be present often is a ______
Change in the quality of the heart sounds or the appearance of a new murmur.
A bioprosthesis in the mitral position usually may be associated with a grade 1- 2 midsystolic murmur (from turbulence created by systolic flow across the valve struts that project into the LV outflow tract) and a soft, mid-diastolic murmur that occurs with normal LV filling.
A high-pitched or holosystolic apical murmur signifies ______
Para- or transvalvular regurgitation
A bioprosthesis in the aortic position is invariably associated with a midsystolic murmur at the base usually of grade 1-2 intensity.
A _______ is abnormal under any circumstance and merits additional investigation.
Diastolic murmur of AR
A high-pitched apical systolic murmur in patients with a mechanical mitral prosthesis, or a decrescendo diastolic murmur in patients with a mechanical aortic prosthesis, indicates _____ or _____
Paravalvular regurgitation or prosthetic dysfunction.
A ______ rub is almost 100% specific for the diagnosis of pericarditis, although its sensitivity is not as high, because the rub may wax and wane over the course of an acute illness or may be difficult to elicit.
This leathery or scratchy, typically two- or three-component sound also may be monophasic.
Pericardial friction
The most common associated symtom of tamponade is _____ (sensitivity, 87% to 88%)
Dyspnea
The diagnosis of CP most often is first suspected after inspection of the JVP and waveforms, with
Elevation and inscription of the classic M or W contour caused by prominent x and y descents
Kussmaul sign
_____ murmurs generally increase with inspiration. Left- sided murmurs usually are louder during expiration.
Inspiration: Right-sided murmurs
Expiration: Left-sided murmurs
Effect of Valsalva maneuver on murmurs
Most murmurs: Decrease in intensity
HCM: Louder
MVP: Longer and louder
After valsalva:
Right sided: return to baseline intensity earlier than left sided murmurs
Effect of exercise on murmurs
Normal or obstructed:
Isotonic & Isometric: louder
Hand-grip: MR, VSD, AR
Effect of positional changes on murmurs
Standing: Most murmurs diminish
Except in:
HCM: Louder
MVP: longer and louder
Squatting: most murmurs become louder
HCM: soften and may disappear
MVP: soften and may disappear
This maneuver usually produced same results as squatting
Passive leg raising
Effect of post-ventricular premature beat or AF on murmurs
Normal/Stenotic semilunar valves:
PVC: Increase in intensity (Cardiac cycle after premature beat)
AF: increase in intensity (after long cycle length)
Systolic murmurs by AV valve regurgitaiton: No change
Papillary muscle dysfunction: Diminish
MVP: shorter after premature beat
Effect of pharmacologic interventions on murmurs
Amyl nitrate inhalation
* Initial relative hypotension:
MR, VSD, AR - decrease in intensity
AS: increase in intensity (increase in SV)
- Later tachycardia phase:
MS, right-sided murmurs: louder
MVP: softer then louder (Biphasic)
Transient external compression of both brachial arteries by bilateral cuff inflation to 20 mm Hg or greater than peak systolic pressure augments the murmurs of _____.
MR
VSD
AR
