PE

Question 1

Parasternal heave

Answer 1

• Precordial impulse visible/palpated on chest wall
• Systolic elevation of L costal cartilages
  o From heart or great vessels => hypertrophy/enlargement of underlying ventricle
  o W cardiac or respiratory diseases

Question 2

Souffle

Answer 2

• Vascular/cardiac murmur w a blowing quality
  o After S1
  o Short to long: mid systolic to S2 or beyond

Question 3

Causes souffle

Answer 3

o Postpartum/lactation: mammary souffle = rapid/incr flow through breast arteries
 Systolic murmur
 Can be abolished by pressure applied lateral to the breast

Question 4

Precordial thrill

Answer 4

• Vibration at point of maximal intensity
  o Loud murmur
  o Location depend on associated lesion

Question 5

Bruit

Answer 5

• Systolic noises

Question 6

Causes of bruit

Answer 6

o Flow turbulence from partial obstruction of artery lumen or high flow
 Heard over large arteries
o Peripheral arteriovenous shunts
 Involved arteries may be dilated
 May have venous pulsation
 Thrill may be present
* Anything incr blood flow can incr bruit (fever, anemia, hyperT4)

Question 7

Pulse deficit

Answer 7

• Irregular pulse rhythm => suggest arrhythmia.
  o Pulse rate not equal HR
  o Difference btw pulse and HR = pulse deficit

Question 8

Cause of pulse deficit

Answer 8

Afib most common

Question 9

Friction rub

Answer 9

 Triphasic
* Systolic: ventricular contraction
* Diastolic: ventricular relaxation and expansion during diastole
* Atrial systolic: atrial contraction at end of diastole
 Scratchy/squishy noise
 Accentuate on inspiration => distorted pericardium pulled by inspiratory expansion

Question 10

Pathology causing friction rub

Answer 10

o Infection, metastatic dz, acute myocardial infacrtion, post cardiac sx

• No correlation btwn qty of pericardial effusion
  o Not associated w small amount of pericardial effusion
  o Pericarditis: fibrin strands caused by inflammation connecting 2 layers
   Acute: viral infection, collagen vascular dz, trauma, uremia, invasive tumors

Question 11

Pericardium anatomy

Answer 11

o 2 layers: parietal (fibrous) and visceral (serous)
o Separated by small amount of fluid (ultrafiltrate plasma)

Question 12

Pulse pressure

Answer 12

• Normal pulse:
  o Smooth, rapid upstroke with smooth dome shape summit
  o Slower downstroke
  o Dicrotic notch after 300ms

Question 13

hypokinetic pulse causes

Answer 13

Decreased pulse pressure

decr SV: CHF/hypovolemia
 Most of the time: ↓ SV → ↑ arterial resistance + ↓ compliance to maintain BP
 Pulse pressure ≠ sensitive to detect ↓SV
 Weak pulse = severely ↓SV or acutely ↓SV
* Severe SAS
o ↓ peripheral vascular resistance
o ↑ arterial compliance

Question 14

hyperkinetic pulse causes

Answer 14

increased pulse pressure

rapid ejection of ↑ volume of blood
o ↑ systolic BP → ↑ SV
o ↓ diastolic BP → shunts/regurgitation
 Run off of blood during diastole
 AI, PDA → bounding pulses
 Arteriovenous fistula
 Severe bradycardia
 Thyrotoxicosis, anemia, fever

Question 15

Pulsus paradoxus

Answer 15

• Expiration: ↑ pulse pressure
• Inspiration: ↓ pulse pressure
  o Secondary to ↓systemic BP >10mmHg
  o Weak pulses may disappear for several beats during inspiration
• Exaggerated w cardiac tamponade

Question 16

Pulsus Bisfierens

Answer 16

• Pulse with double impulse → bifid pulse
• HCM w obstructive component
• Severe AI w SAS

Question 17

Pulsus alternans

Answer 17

Alternating strong and weak pulses
* Higher and lower amplitude pulse → alternating SV
o Extreme cases: lower pulse can become imperceptible
o Regular intervals/height alteration
o No change w respiration
* Sign of myocardial depression and LV failure
o DCM

Question 18

Pulsus bigeminus

Answer 18

• Alternating pulse with arrhythmias
• Ventricular bigeminy most commonly
  o Amplitude of VPC is lower

Question 19

Waterhammer/bounding/Corrigan’s pulse

Answer 19

• Large and strong pulse with normal contours
• PDA, AV fistula
• Corrigan’s pulse → AI

Question 20

Pulsus brevis

Answer 20

• Brisk pulse → shorter pulse w rapid rise in systole
• MR

Question 21

Pulsus parvus & tardus

Answer 21

• Small/weak pulses
• Delayed systolic peak
• Moderate to severe SAS

Question 22

Dicrotic pulse

Answer 22

• Twice peaked pulse
  o Diastolic notch following S2
  o Systolic notch
• Impaired Lv performance → ↓CO, ↑SVR