Differential Diagnosis

Question 1

Define Bisferiens pulse

Answer 1

2 palpable beats during systole; Hypertrophic Cardiomyopathy

Best felt in the carotid

Question 2

Define Pulsus Alternans

Answer 2

Alternating strong and weak pulses by >20 mmHg.

LV dysfunction; Best felt radial or femoral

Question 3

Pulses Paradoxus

Answer 3

Abnormal increase in systolic BP >10mmHg;

Cardiac tamponade

Question 4

Bigeminal Pulse

Answer 4

Regular coupling of two beats.

Ventricular bigeminy

Question 5

Discuss the first heart sound

Answer 5

1. Best heard over mitral/tricuspid region.

2. Identifies onset of systole

Question 6

What can cause a split first heart sound?

Answer 6

RBBB

Question 7

Discuss the second heart sound

Answer 7

Best heard along the upper and middle left sternal border.

Question 8

Discuss the physiologic splitting of the second heart sound

Answer 8

1. Delay of pulmonic valve closure.
2. On inspiration, venous return is augmented, delaying closure.
3. Close together on expiration

Question 9

Discuss persistent splitting of S2

Answer 9

Both components audible during inhalation and exhalation.

Question 10

Discuss Fixed Splitting of S2

Answer 10

Interval between A2 and P2 is wide and unchanged during respiratory cycle.
Atrial Septal Defect and Right ventricular failure

Question 11

Discuss paradoxical splitting of S2

Answer 11

Pulmonic valve closes before aortic valve; LBBB and aortic stenosis

Question 12

Discuss S3

Answer 12

Caused by blood from the left atrium slamming into an overfilled ventricle during filling

Question 13

Where can you best hear S3?

Answer 13

Pt is in left lateral decubitus position.

Question 14

Discuss the S4 sound

Answer 14

Blood trying to enter a stiff left ventricle during atrial contraction

Question 15

Discuss opening snap

Answer 15

Due to Calcified valve; AV valve opening

Question 16

Discuss friction rubs

Answer 16

Caused by inflammation of visceral and parietal pericardium; Heard when pt leans forward

Question 17

How can you tell a murmur is pathologic?

Answer 17

1. Loud

2. Diastolic

Question 18

Murmur grading scale

Answer 18

1/6: Heard w/ careful listening
2/6: Audible as soon as stethoscope is applied to the chest.
3/6: Louder than previous
4/6: As loud as previous but w/ thrill
5/6: Audible when only edge of scope on chest
6/6: Audible to naked ear

Question 19

Discuss the properties of Aortic Stenosis murmur

Answer 19

1. Radiates to carotids

2. Later the peak, worse the stenosis

Question 20

Discuss Pulmonic Stenosis murmur

Answer 20

Radiates to left side of neck, usually with thrill

Question 21

Discuss mitral regurgitation murmur

Answer 21

radiates to axila, best heard in left lateral decubitus position

Question 22

Discuss patent ductus arteriosus

Answer 22

Machine like murmur; left to right shunting