Physical Exam Flashcards
5 ways to differentiate from MS and Austin Flint murmur
-MS has opening snap
-MS can worsen with amyl nitrate (with reflex tachycardia)
-MS does not have S3
-Soft S1 (if severe, loud if mild) ; Soft A2 if valvular AR
-Associated early diastolic decrescendo murmur of AR
5 ways to differentiate PS from AS?
-PS located at left upper sternal border
-PS has widened S2
-PS associated with right sided S4
-PS murmur increased on inspiration
-Post Valsalva causes an immediate return in loudness of the PS murmur but a delay in the return of AS murmur
3 ways to tell difference between A2-P2 and S2-OS
-OS: Associated MS murmur
-OS: Widened ‘split’ on standing
-OS: 2nd component widens with inspiration where as OS interval will become wider with expiration
-OS: 2nd component of split S2 is as loud at the apex as at the LSB
-Inspiration will make PS louder and OS softer
-OS heard loudly in the Apex/LLSB whereas P2 heard loudest in the LUSB
-OS associated with a loud S1 (MS)
3 ways to tell the difference between s3 versus OS?
-Shorter time interval from S2-OS
-OS is higher pitched (better heard with diaphragm)
-OS is associated with sharp loud S1
-Upon standing, OS will lengthen from S2 whereas S3 distance doesn’t change
Review changes in Mitral Stenosis with increasing severity
Review PR without Pulm HTN vs. Graeme Steele murmur
Describe the 4 phases of Valsalava?
-Onset: Increased BP and increased intrathoracic pressure
-Sustained: Decreased venous return and blood pressure
-Release: Brief decreased blood pressure
-Overshoot: Increased venous return, blood pressure and reflex bradycardia and decreased SVR
Describe the physical exam for an ASD? (5)
-Systolic murmur from increased flow across the pulmonic valve
-Wide split and Fixed S2
-Holosystolic murmur from TR
-RV enlargement -> RV heave
-Signs of RV failure (Wide split S2, Right sided S3, Elevated JVP, Kussmaul’s, Palpatile Liver, Ascits, Edema)
What do you expect on physical for restrictive VSD? (4)
What happens as VSD becomes more significant? (2)
-Restrictive: Holosystolic murmur in left parasternal murmur (3rd/4th left intercostal spaces) with spokewheel radiation and palpable thrill
-As VSD worsens: Progressive LA/LV dilation, pulmonary hypertension -> Eisenmengers, loss of murmur
Name 4 physical exam findings on PDA?
-Continuous machine like murmur heard in left 2-3rd intercostal space
-LV dilation
-Progressive pulmonary hypertension
-Wide pulse pressure, other signs of increased cardiac output
Name 3 physical exam findings of supravalvular aortic stenosis
-Crescendo-decrescendo murmur heard radiating to carotids
-Loud A2
-Blood pressure in right arm > left arm
Name 4 physical exam findings of Aortic coarctation
-Crescendo-decrescendo murmur heard at scapula. (If collaterals: continuous murmur)
-Upper extremity hypertension (>20mmhg)
-Radial-femoral delay
-Signs of LVH/S4
Name 4 findings of TOF post repair
-Singular S2
-PR murmur
-RV heave +/- signs of RV failure
-Systolic murmur (RVOT re-obstruction OR residual VSD)
Name 4 fundoscopy findings in hypertension
-AV knicking
-Cotton wool spots
-Papilledema
-Exudates and heomorrhages
What part of hand to palpate apex? Thrill?
-Apex: Finger tips
-Thrill: Palm at level of MCP
3 causes of variable intensity S1?
-AV dissociation
-Tamponade
-AFib
3 causes of split S1?
-RBBB
-ASD
-Ebsteins
5 causes of Paradoxical splitting of S2?
-Aortic Stenosis
-Aortic Regurgitation
-LVOT-O/HoCM
-Paced Rhythm
-LBBB
4 causes of wide splitting of RBBB?
-RBBB
-Mitral Regurgitation
-VSD
-Pulmonary Stenosis/RVOT Obstruction
3 causes of increased intensity of A2?
-Hypertension
-Aortic Coarctation
-Ascending Aortic Aneurysm
2 causes of decreased intensity of A2?
-Aortic Regurgitation
-Aortic Stenosis
What are 3 ways to tell if P2 is loud?
-Its louder than A2 in left upper sternal border
-Heard at apex
-Palpable
2 causes of Loud P2?
-Pulmonary Hypertension
-Supravalvular RVOT obstruction
What are 4 causes of systolic ejection click?
-BAV
-Pulmonary stenosis
-PA dilation
-Aortic dilation
How to tell difference between AS and PS?
-PS murmur decreases on inspiration
How to differentiate right sided extra heart sounds to the left?
-Right: Left parasternal (not apical), and increases with inspiration
What are 3 causes of early diastolic murmur?
-Aortic regurgitation
-Graham Steel
-PR without PHtn
What are 4 causes mid-diastolic murmur?
-MS
-TS
-Austin flint murmur
-Myxoma
Name 9 causes of continuous murmur?
-PDA
-Lutembacher’s syndrome
-Aortopulmonary window
-Ruptured sinus of valsalva aneurysm
-Coronary AV fistula
-Pulmonary AV fistula
-Mammary murmur of pregnancy
-Cervical venous hum
-Bronchial collateral murmur
How to define A wave (in JVP) temporally?
- With S4
- Before S1 (V is after and before S2)
-Prior to Carotid pulse (V is after)
What are two ways to define sustained Apex?
-All throughout systole
-During all of carotid pulse or after
List 5 causes of late opening snap other than mild MS
-Bradycardia
-Impaired Relaxation of LV
-Severe AR
-Low atrial pressure
-High Aortic pressure
Is narrow or wide S2-OS interval more specific for MS?
-Narrow (no mimickers where was there are mimickers for wide)
What S2-OS interval indicates severe MS?
< 50 msec
What are three ways to make an S4 softer or disappear altogether?
-Firm pressure with the diaphragm
-Listening to the patient supine (decreased venous return)
-Listening at sites away from the apex
