Chapter 267 - Physical Examination of the Cardiovascular System

Question 1

Clinical performance improves predictably as a function of experience.
True or False?

Answer 1

False.

“Despite popular perceptions, clinical performance does not improve predictably as a function of experience.”

Question 2

Which clinical signs can be used to predict the prognosis of systolic heart failure?

Answer 2

Jugular venous pressure and third heart sound (S3).

Question 3

Which clinical and objective signs can be used to predict the prognosis of acute coronary syndrome?

Answer 3

“Heart rate, blood pressure, signs of pulmonary congestion and the presence of mitral regurgitation.”

Question 4

Which of the following might aggravate periphereal cyanosis? Beta-blockers, alpha-blockers or both?

Answer 4

Beta-blockers.
“Peripheral cyanosis (…) can be aggraated by the use of beta-adrenegic blockers with unopposed alpha-mediated constriction.”

Question 5

Which condition is associated with differential cyanosis?

Answer 5

“Large patent ductus arteriosus and secondary pulmonary hypertension with right-to-left shunting at the great vessel level.”

Question 6

The localization of telangiectasias might suggest some diagnosis. Where do you expect to find them and in doing so, which diagnosis would you suspect?

Answer 6

“Hereditary telangiectasias on the lips, tongue, and mucous membranes, as part of the Osler-Weber-Rendu syndrome”.
“Malar telangiectasias also are seen in patients with advanced mitral stenosis and scleroderma.”

Question 7

Palmar crease xanthomas are specific for type III hyperlipoproteinemia.
True or False?

Answer 7

True.

Question 8

Arcus senilis is specific of risk for coronary heart disease.
True or False?

Answer 8

False.

“An arcus senilis pattern lacks specificity as an index of coronary heart disease risk.”

Question 9

Name two diseases associated with saddle-nose deformity and heart disease.

Answer 9

Wegener’s vasculitis (granulomatosis with polyangiitis).

Relapsing polychondritis.

Question 10

Which valvulopathy is associated with hepatomegaly and hepatic pulsations?

Answer 10

Tricuspid regurgitation.

Question 11

How to differentiate Janeway lesions from Osler’s nodes?

Answer 11

“Janeway lesions of endocarditis are nontender, slightly raised hemorrhages on the palms and soles, whereas Osler’s nodes are tender, raised nodules on the pads of the fingers or toes.”

Question 12

“A Homan’s sign (posterior calf pain on active dorsiflexion of the foot against resistance) is neither specific nor sensitive for deep venous thrombosis.”

True or False?

Answer 12

True.

Question 13

What is the correlation between centimeters of water and milimeters of mercury?

Answer 13

1,36cmH2O = 1,0mmHg

Question 14

The a wave of the venous waveform might have a cannon shape transiently in which disease?

Answer 14

Auriculoventricular dissociation, especifically when the right atrium contracts against a closed tricuspid valve. It is also observed in broad complex ventricular tachycardia.

Question 15

The fall in venous pressure is expected to be in the magnitude of how many mmHg during inspiration?

Answer 15

3mmHg

Question 16

How do you define and what conditions can be associated with Kussmaul’s sign?

Answer 16

“Kussmaul’s sign is defined by either a rise or a lack of fall of the JVP with inspiration and is classicaly associated with constrictive pericarditis, although it has been reported in patients with restrictive cardiomyopathy, massive pulmonary embolism, right ventricular infarction, and advanced left ventricular systolic heart failure. It is also a common, isolated finding in patients after cardiac surgery wihout other hemodynamic abnormalities.”

Question 17

The prognostic value of elevated jugular venous pressure is significant in symptomatic patients with heart failure aswell as in asymptomatic patients with left ventricular systolic dysfunction.
True or False?

Answer 17

True.

Question 18

Which conditions can be associated with a differential >10mmHg in the measurement of blood pressure between the two superior limbs?

Answer 18

“A blood pressure differential that exceeds this threshold may be associated with atherosclerotic or inflammatory subclavian artery disease, supravalvular aortic stenosis, aortic coarctation, or aortic dissection.”.

Question 19

What conditions can precipitate orthostatic hypotension?

Answer 19

“It can be exacerbated by advanced age, dehydration, certain medications, food, deconditioning, and ambient temperature.”

Question 20

Pulsus paradoxus can be observed in which conditions?

Answer 20

Pericardial tamponade, massive pulmonary embolism, hemorrhagic shock, severe obstructive lung disease, and tension pneumothorax.

Question 21

Pulsus alternans associated with T-wave alternans might be associated with increased risk for arrythmic events.
True or False?

Answer 21

True.

Question 22

Epigastric cardiac impulse might occur in patients with healthy hearts.
True or False?

Answer 22

True.
“In thin, tall patients and patients with advanced obstructive lung disease and flattened diaphragms, the cardiac impulse may be visible in the epigastrium and should be distinguished from a pulsatile liver edge.”

Question 23

S1 splitting might be a normal finding in auscultating a young patient’s heart.
True or False?

Answer 23

True.
“Nomal spliting can be appreciated in young patients and those with right bundle branch block, in whom tricuspid valve closure is relatively delayed.”

Question 24

Name three conditions associated with loud S1.

Answer 24

“S1 is classically loud in the early phases of rheumatic mitral stenosis (MS) and in patients with hyperkinetic circulatory states or short PR intervals.”

Question 25

Which medication is associated with softening of S1?

Answer 25

Beta-adrenegic blockers.

Question 26

Name the mechanisms that might explain pathological widened splitting of S2.

Answer 26

S2 might be splitten because of late P2 or early A2. P2 becomes delayed with right bundle branch block, while A2 becomes premature with mitral regurgitation.

Question 27

The septal defect associated with fixed splitting of S2 is ostium secundum.
True or False?

Answer 27

True.

Question 28

What are the conditions associated with reversed or paradoxical splitting of S2?

Answer 28

“Reversed or paradoxical splitting (…) occurs in patients with left bundle branch block, right ventricular pacing, severe aortic stenosis, hypertrophic obstructive cardiomyopathy, and acute myocardial infarction.”

Question 29

Name the situations in which you can hear an ejection sound.

Answer 29

“An ejection sound (…) usually is associated with congenital bicuspid aortic or pulmonic valve disease; however, ejection sounds are also sometimes audible in patients with aortic or pulmonary root dilation and normal semilunar valves.”

Question 30

What is the only sound from right cardiac origin that decreases with inspiration?

Answer 30

Pulmonic ejection sound.

Question 31

Squatting is a maneuver that changes the timing of a heart sound. Which one is it?

Answer 31

Meso-sistolyc click with or wihtout meso-systolic murmur from regurgitant mitral valve.
“This click-murmur complex will move away from the first heart sound with maneuvers that increase ventricular preload, such as squatting.”

Question 32

In constrictive pericarditis, what clinical sounds can be found in heart auscultation? Is it accompanied with any alteration in the jugular venous waveform?

Answer 32

Pericardial knock.

Rapid y descent wave.

Question 33

What is the cardiovascular semiology in severe aortic stenosis?

Answer 33

“parvus et tardus carotid upstrokes, a late-peaking grade 3 or greater midsystolic murmur, a soft A2, a sustained LV apical impulse, and an S4.”

Question 34

Name possible conditions that result in midsystolic murmurs, besides the classic aortic stenosis.

Answer 34

“Other causes of midsystolic heart murmur include pulmonic valve stenosis (with or wihtout an ejection sound), hypertrophic obstructive cardiomyopathy, increased pulmonary blood flow in patients with a large atrial septal defect and left-to-right shunting, and several states associated with accelerated blood flow in the absence of structural heart disease, such as fever, thyrotoxicosis, pregnancy, anemia, and normal childhood/adolescence.”

Question 35

Distinguish between the murmurs of aortic stenosis and hypertrophic obstructive cardiomyopathy.

Answer 35

“The murmur of hypertrophic obstructive cardiomyopathy (HOCM) has features of both obstruction to left ventricle (LV) outflow and mitral regurgitation (…). The systolic murmur of HOCM usually can be distinguished from other causes on the basis of its response to bedside maneuvers (…). In general, maneuvers that decrease LV preload (or increase LV contractility) will cause the murmur to intensify, wheares maneuvers that increase LV preload or afterload will cause a decrease in the intensity of the murmur. (…) The murmur of aortic stenosis is typically loudest in the second right interspace with radiation into the carotids, wheares the murmur of HOCM is best heard between the lower left sternal border and the apex.”

Question 36

Which murmurs are more intense in the mid-left sternal border?

Answer 36

Midsystolic murmur from a large atrial septal defect with enhaned pulmonic blood flow and holosystolic murmur from a ventricular septal defect.