PE (Lecture 4) Flashcards
Lower part of sternum depressed
Pectus Excavatum (Funnel Chest)
compression of heart/vessels may cause murmurs
Sternum displaced anteriorly (increased AP diameter)
Pectus carinatum (pigeon chest)
costal cartilages are depressed
increased AP diameter
Seen in aging/COPD
Barrel chest
Right to left shunt, called? And caused by?
Eisenmenger
This is seen in Ventricular septal defect, Atrial septal defect, and patent ductus arteriosus
Diastolic HTN…
fatigue for 6 mos… slightly overweight… constipation…
Hypothyroidism
If PMI enlarged, think?
HTN, HCM, LVH
ATRIAL MYXOMA! (most common benign tumor that can “act like mitral stenosis”)
See Chp. 45
JVP is normally?
5-9cm
JVD (not JVP) is associated with?
Volume overload states, such as CHF
probably seen with S3
The arterial pulse usually exhibits a single upstroke,
whereas (in patients in sinus rhythm) the venous pulse has
two peaks and two troughs per cardiac cycle.
“A” wave: atrial contraction (ABSENT in _____)
“C” wave: ventricular contraction (tricuspid bulges). This technically is a reflection of a Carotid artery pulsation, but I wouldn’t describe it in this manner. (YOU PROBABLY will never SEE THIS IN PRACTICE OR TEST). Either way, both descriptions are technically correct. The ventricle contracts and that sends the blood to the artery that puts pressure on the veins (Technically the C Wave).
“X” descent: atrial relaxation
“V” wave: _____ (occurs at same of time of ventricular contraction)
“Y” descent: ventricular filling (tricuspid opens)
A wave absent in AFIB (also no S4)
V wave = atrial venous filling (V wave = “villing”)
A wave immediately precedes?
S1
Increased “A” waves due to what?
RVH, Pulmonary HTN, TS , AV Dissociation ( complete heart block) All these things affect atrial load so directly affect the “a” wave
Intermittent prominent “a” waves can be observed in ____ and they are commonly referred to as cannon “a” waves .
complete heart block
Pericardial knock is seen with?
constrictive pericarditis and tamponade
Pt has blowing systolic murmur, 4th ICS… is the x wave present?
No, because there’s no x descent present with severe tricuspid regurge
Prominent “x” descent may be observed in
constrictive pericarditis and pericardial tamponade
The “x” descent may be eliminated completely in
severe
tricuspid regurgitation
May be especially prominent in patietns w/ severe tricuspid regurge?
“v” wave
A wave the atria contracting against the tricuspid valve…so “cannon” A waves can be seen contracting against closed tricuspid wave… think about what dz states that would be seen in?
A flutter PAC (or tachy) AV blocks Ventricular ectopics V tach Junctional rhythm
Ordinarily the JVP falls with ____ due to
reduced pressure in the expanding thoracic cavity.
inspiration
Kussmaul’s sign is the observation of a JVP that
___ with inspiration .
rises
Kussmaul’s sign suggests impaired filling of the
right ventricle due t o either fluid in the pericardia !
space or a poorly compliant myocardium or
pericardium .
Th e differential diagnosisgenerally associated with Kussmaul sign is _____, as well as with restrictive cardiomyopathy
constrictive pericarditis
Increased pulse pressure typically observed in ____ and multiple conditions that increase stroke volume or force of contraction
aortic regurgitation
Narrowing pulse pressure typically associated with hypovolemia, severe ____, or severe ____
left ventricular failure, or severe mitral stenosis
aortic stenosis
Bisferiens Pulse (“double tap pulse”)
• A pulse with two palpable beats during systole,
seen in:
- HOCM
- Aortic stenosis and insufficiency.
• Rapid ejection of an increased stroke volume
(e.g., exercise, fever, patent ductus arteriosus)
Variation in pulse amplitude occurring with
alternate beats due to changing systolic pressure, Beats occur at constant intervals but with a regular alternation of the peak of the pressure pulse and/or the rate of rise of the ascending limb .
Name? Seen in?
Pulsus alternans
Systolic HF (accompanied by S3)
LV dysfunction, failure
Pulse with slow rate of pressure increase, small
pulse pressure, late
Associated with SEVERE Aortic Stenosis
Pulsus Parvus et Tardus
Pulsus paradoxicus… Abnormal exaggeration (>10 mm Hg) of the normal decrease in systolic blood pressure during inspiration… seen in?
Observed in cases of cardiac tamponade,
constrictive pericarditis, restrictive cardiomyopathy, hypotensive shock, severe obstructive pulmonary disease, large pulmonary embolism
Causes of restrictive cardiomyopathy?
- Amyloidosis
- Sarcoidosis
- Hemachromatosis
The ___ is better for picking up the
relatively high-pitched sounds of S1 and S2, the murmurs of aortic and mitral regurgitation,and pericardial friction rubs.
diaphragm
The ___ is more sensitive to the low-pitched sounds of
S3 and S4 and the murmur of mitral stenosis.
bell
Defined as palpable, low frequency
vibrations … “ palpable murmur”
• Most commonly associated with cardiac murmurs of
grade IV to VI
Thrill
Movement of the precordium
Associated with large ventricle Heart Failure
Heave/lift
I: very faint
Il: heard immediately when stethoscope placed onto the chest
III: moderately loud
IV: loud with _____
V: Very loud with thrill
VI: VERY LOUD with thrill , may be heard without stethoscope
palpable thrill
S1 best heard at?
Apex
S1 accenuated by?
Shortened PR interval (e.g., WPW)
other stuff too but…
S1 diminished in?
Lengthened PR interval (e.g., 1º degree heart block)
Mitral regurge
SEVERE mitral stenosis
LVH (stiffness)
Widened splitting of S2… seen in?
RBBB
Pulmonic stenosis
Variable splitting of S2 that persists during
expiration along with continued delayed P2
closure and early A2 closure during inspiration
Fixed splitting seen in?
ASD
possibly RBBB as well
Paradoxical splitting of S2 seen in?
**LBBB
Aortic stenosis
Chronic HTN
Splitting that occurs when aortic valve closure is so delayed that P2 occures before A2
Early systolic ejection sounds are related to forceful opening of the aortic or pulmonic valve. These sounds are common in congenital aortic stenosis, with a mobile valve; in hypertension, with forceful opening of the aortic valve; and in healthy young individuals, especially when cardiac output is increased. Midsystolic or late systolic clicks are caused most commonly by ___
mitral valve prolapse
The opening snap of ___ stenosis occurs at the beginning of mechanical diastole, before the onset of the rapid phase of ventricular filling.
mitral and, less commonly, tricuspid
pulsus bisferiens, with percussion and tidal waves occurring during systole. this type of carotid pulse contour is observed most frequently in patients with hemodynamically significant ____
aortic regurgitation or combined aortic stenosis and regurgitation with dominant regurgitation.
____ is a cardinal manifestation of right-sided heart failure
Edema
The intensity of S3 may be increased by?
Increasing the venous return to the heart (e.g., leg raise)
Increasing arterial pressure/CO (e.g., hand grip)
(pro tip… for syncope, increase venous return w/ a leg raise)
Mid diastolic, low-pitch rumble murmur best heard at the apex w/ the patient leaning foward and breathing out
Austin Flint murmur
Opening snap is an early diastolic sharp, high pitched sound most commonly attributable to?
mitral stenosis
Early systolic ejection clicks attributable to?
Aortic stenosis (and pulmonic stenosis)
MID-systolic ejection sounds are usually attributable to?
MVP
sudden opening/regurge of mitral (or less commonly triscuspid) valves during systole
Continuous murmurs?
PDA
venous hum
“blowing” murmurs typically associated w/?
“rumbling” murmurs?
blowing = regurge
rumbling = diastolic (e.g., Austin Flint)
Decrescendo murmur (i.e., reducing in intensity)?
aortic regurge
Crescendo-decrescendo (“diamond-shaped”)
aortic stenosis****
The valsalva initially ____ blood pressure, then ____ BP
increases, then decreases
Standing does what to the heart’s blood volume?
Squatting does what to the heart’s blood volume?
Standing = decreases
Squatting = increases
What maneuver increases intensity of MVP and HOCM?
Standing/valsalva
squatting decrease their intensity
What reduces the intensity of MVP and HOCM?
squatting
Handgrip increases the intensity of MR/MVP, AR, and ____
Handgrip reduces the intensity of AS and ____?
Handgrip increases the intensity of MR/MVP, AR, and VSD
Handgrip reduces the intensity of AS and HCM
