B P3 C13 History and Physical Examination: An Evidence-Based Approach

Question 1

Typical angina should satisfy three characteristics:

Answer 1

(1) substernal discomfort
(2) initiated by exertion or stress
(3) relieved with rest or sublingual nitroglycerin.

Question 2

__________ more commonly present with a less typical clinical picture.

Answer 2

Women, elderly persons, and patients with diabetes

Question 3

Dyspnea may occur with exertion or in recumbency (orthopnea) or even on standing (_____________).

Answer 3

Platypnea

Question 4

_______________ of cardiac origin usually occurs 2 to 4 hours after onset of sleep; the dyspnea is sufficiently severe to compel the patient to sit upright or stand and then subsides gradually over several minutes.

Answer 4

Paroxysmal nocturnal dyspnea

Question 5

A report of a regular, rapid-pounding sensation in the neck or visible neck pulsations associated with palpitations increases the likelihood of this arrhythmia

Answer 5

Atrioventricular nodal reentrant tachycardia (AVNRT)

Question 6

______________ occurs suddenly, with rapid restoration of full consciousness thereafter.

Answer 6

Cardiac syncope

Question 7

Patients with ___________________ may experience early warning signs (nausea, yawning), appear ashen and diaphoretic, and revive more slowly, albeit without signs of seizure or a prolonged postictal state.

Answer 7

Neurocardiogenic syncope

Question 8

__________ is defined as a state of decreased physiologic reserve and vulnerability to stressors.

Answer 8

Frailty

Question 9

____________ is present with significant right-to-left shunting at the level of the heart or lungs. It also is a feature of hereditary methemoglobinemia

Answer 9

Central cyanosis

Question 10

________________ of the fingers, toes, nose; characteristic of the reduced blood flow that accompanies small-vessel constriction seen in severe heart failure, shock, or peripheral vascular disease.

Answer 10

Peripheral cyanosis or acrocyanosis

Question 11

_____________ cyanosis affecting the lower but not the upper extremities occurs with a patent ductus arteriosus (PDA) and pulmonary artery hypertension with ______________ at the level of the great vessel

Answer 11

Differential cyanosis

Right-to-left shunting

Question 12

Hereditary telangiectases on the lips, tongue, and mucous membranes seen in what syndrome

Answer 12

Osler-Weber-Rendu syndrome

Question 13

A lace-like purplish dislocation of the skin that imparts a mottled or reticulated appearance

Answer 13

Livedo reticularis

Question 14

Tanned or bronze discoloration of the skin in unexposed areas can suggest iron overload and _____________.

Answer 14

Hemochromatosis

Question 15

_______________ often occur with either anticoagulant and/or antiplatelet use, whereas _____________ characterize thrombocytopenia, and _______________ can be seen with infective endocarditis and other causes of leukocytoclastic vasculitis.

Answer 15

Ecchymoses

Petechiae

Purpuric skin lesions

Question 16

Various lipid disorders can manifest with ___________, located subcutaneously, along tendon sheaths, or over the extensor surfaces of the extremities.

Answer 16

Xanthomas

Question 17

Xanthomas within the palmar creases are specific for _______________

Answer 17

Type III hyperlipoproteinemia

Question 18

The leathery, cobblestone, “plucked chicken” appearance of the skin in the axillae and skinfolds of a young person is characteristic of ______________________, a disease with multiple cardiovascular manifestations, including premature atherosclerosis.

Answer 18

Pseudoxanthoma elasticum

Question 19

Extensive lentiginoses (freckle-like brown macules and café-au-lait spots over the trunk and neck) may be part of developmental delay associated cardiovascular syndromes (_________, ___________, ______________) with multiple atrial myxomas, atrial septal defect (ASD), hypertrophic cardiomyopathy, and valvular stenoses.

Answer 19

LEOPARD, LAMB, and Carney

Question 20

___________ should be suspected in the presence of lupus pernio, erythema nodosum, or granuloma annulare.

Answer 20

Cardiovascular sarcoid

Question 21

A high-arched palate is a feature of ________________ disease syndromes.

Answer 21

Marfan and other connective tissue

Question 22

A large protruding tongue with parotid enlargement may suggest ______________.

Answer 22

Amyloidosis

Question 23

Patients with _________________ characteristically have a bifid uvula.

Answer 23

Loeys-Dietz syndrome

Question 24

Orange tonsils are typical of ________________

Answer 24

Tangier disease

Question 25

Ptosis and ophthalmoplegia suggest ___________

Answer 25

Muscular dystrophies

Question 26

Congenital heart disease often is accompanied by hypertelorism, low-set ears, micrognathia, and a webbed neck, as with __________, __________, ____________

Answer 26

Noonan, Turner, and Down syndromes

Question 27

Proptosis, lid lag, and stare point to _______________

Answer 27

Graves hyperthyroidism

Question 28

Patients with _____________ may have blue sclerae, mitral or aortic regurgitation (AR), and a history of recurrent nontraumatic skeletal fractures.

Answer 28

Osteogenesis imperfecta

Question 29

Lacrimal gland hyperplasia is sometimes a feature of __________.

Answer 29

Sarcoidosis

Question 30

Pink-purplish patches with telangectasias over the malar eminences in MS

Answer 30

Mitral facies

Question 31

Extensive varicosities, medial ulcers, or brownish pigmentation from hemosiderin deposition, suggest ____________

Answer 31

Chronic venous insufficiency

Question 32

Muscular atrophy and the absence of hair in an extremity should suggest ________ or a neuromuscular disorder.

Answer 32

Chronic arterial insufficiency

Question 33

Redistribution of fat from the extremities to central/abdominal stores (_______________) in some patients with HIV infection may relate to antiretroviral treatment and is associated with insulin resistance and several features of the metabolic syndrome.

Answer 33

Lipodystrophy

Question 34

Cutaneous venous collaterals over the anterior chest suggest _______, especially in the presence of indwelling catheters or leads from cardiac implantable electrical devices (CIEDs)

Answer 34

Chronic obstruction of the superior vena cava (SVC) or subclavian vein

Question 35

The severe kyphosis of _______ should prompt careful auscultation for AR and scrutiny of the electrocardiogram (ECG) for first degree atrioventricular (AV) block.

Answer 35

Ankylosing spondylitis

Question 36

The “straight back syndrome” (loss of normal kyphosis of the thoracic spine) can accompany ____________

Answer 36

Mitral valve prolapse (MVP)

Question 37

A thrill may be present over well-developed intercostal artery collaterals in patients with ____

Answer 37

Aortic coarctation

Question 38

Systolic hepatic pulsations signify _______

Answer 38

Severe tricuspid regurgitation

Question 39

The abdominal aorta normally may be palpated between the _____________ in thin patients and in children.

Answer 39

Epigastrium and the umbilicus

Question 40

The JVP aids in the estimation of volume status.

The external (EJV) or internal (IJV) jugular vein may be used, although the ______ is preferred

Answer 40

IJV

Because the EJV is valved and not directly in line with the SVC and right atrium.

Question 41

An elevated left EJV pressure may also signify a persistent _______ or compression of the ________

Answer 41

Persistent left-sided SVC

Compression of the innominate vein

Question 42

The bedside venous pressure is usually estimated by the vertical distance between the _________, where the manubrium meets the sternum (angle of Louis).

Answer 42

Top of the venous pulsation and the sternal inflection point

Question 43

A distance of _______ is considered an abnormal JVP

Answer 43

Greater than 3 cm

Question 44

Venous pulsations above the clavicle with the patient in the sitting position are clearly abnormal, because the distance from the right atrium is at least ___ cm

Answer 44

10 cm

Question 45

Has an undulating two troughs and two peaks for every cardiac cycle (biphasic); height of column falls and troughs become more prominent

Answer 45

Internal Jugular Vein Pulse

Question 46

The a wave reflects right ________, occurs just after the _____, and precedes _______

Answer 46

Atrial presystolic contraction

After the electrocardiographic P wave

Precedes the first heart sound (S1)

Question 47

Cause of prominent a wave

Answer 47

Patients with reduced right ventricular (RV) compliance from any cause

Question 48

A _______ wave occurs with AV dissociation and right atrial contraction against a closed tricuspid valve.

Answer 48

Cannon a wave

The presence of cannon a waves in a patient with wide complex tachycardia identifies the rhythm as ventricular in origin

Question 49

The a wave is absent with _____

Answer 49

Atrial fibrillation

Question 50

The ________ reflects the fall in right atrial pressure after the a wave peak.

Answer 50

x descent

Question 51

The predominant waveform in the jugular venous pulse in normal individuals

Answer 51

X descent

Question 52

The x descent follows because of ________ created by ventricular systole pulling the tricuspid valve downward

Answer 52

Atrial diastolic suction

Question 53

The _____ interrupts the x descent as ventricular systole pushes the closed valve into the right atrium.

Answer 53

c wave

Question 54

The _____ represents atrial filling, occurs at the end of ventricular systole, and follows just after ____

Answer 54

v wave

S2

Question 55

Factors that determine v wave height

Answer 55

RA compliance

Volume of blood returning to the RA from all sources

Question 56

The v wave is smaller than the a wave because of the ________

Answer 56

Normally compliant right atrium

Question 57

a and v waves in

ASD
TR

Answer 57

ASD - a and v waves may be of equal height

TR - v wave is accentuated

With TR, the v wave will merge with the c wave because retrograde valve flow and antegrade right atrial filling occur simultaneously.

Question 58

The ______ follows the v wave peak and reflects the fall in right atrial pressure after tricuspid valve opening.

Answer 58

y descent

Question 59

Resistance to ventricular filling in early diastole blunts the y descent, as is the case with _______ or _______

Answer 59

Pericardial tamponade
Tricuspid stenosis

Question 60

The y descent will be steep when ventricular diastolic filling occurs early and rapidly, as with

Answer 60

Pericardial constriction
Restrictive cardiomyopathy
Isolated, severe TR

Question 61

The normal venous pressure should fall by at least ________ with inspiration.

Answer 61

3 mm Hg

Question 62

A rise in venous pressure (or its failure to decrease) with inspiration

Answer 62

Kussmaul sign

Question 63

Kussmaul sign is associated with

Answer 63

Constrictive pericarditis
Restrictive cardiomyopathy
Pulmonary embolism
RV infarction
Advanced systolic heart failure

Question 64

The ______ requires firm and consistent pressure over the upper abdomen, preferably the right upper quadrant, for at least 10 seconds.

Answer 64

Abdominojugular reflux maneuver

Question 65

Positive abdominojugular reflux maneuver

Answer 65

Rise of more than 3 cm in the venous pressure sustained for at least 15 seconds

Question 66

A positive abdominojugular reflux sign can predict heart failure in patients with dyspnea, as well as a pulmonary artery wedge pressure higher than ______

Answer 66

15 mm Hg

Question 67

Important Aspects of Blood Pressure Measurement

Measurement should be done after ___________ of rest, repeated 5 minutes later, and the readings averaged.

Cuff length and width should be _____ and ______ of arm circumference, respectively

Answer 67

5 minutes
80% and 40%

Question 68

Korotkoff sounds may be heard all the way down to 0 mm Hg with the cuff completely deflated in

Answer 68

Children
Pregnant patients
Chronic severe AR
Large arteriovenous fistula

In these cases, both the phases 4 and 5 pressures should be noted.

Question 69

Blood pressure should be measured in both arms either in rapid succession or simultaneously; normally the measurements should differ by _________, independent of handedness.

Answer 69

Less than 10 mm Hg

Question 70

A blood pressure differential of more than 10 mm Hg can be associated with

Answer 70

Subclavian artery disease
Supravalvular aortic stenosis (SVAS)
Aortic coarctation
Aortic dissection

Question 71

Systolic leg pressures may exceed arm pressures by as much as ________; greater leg-arm systolic blood pressure differences are seen in patients with

Answer 71

20 mm Hg

Severe AR (Hill sign)
Extensive and calcified (noncompressible) lower extremity PAD

Question 72

Orthostatic hypotension is a fall in blood pressure of more than ______ systolic and/or more than ______ diastolic in response to moving from the supine to the standing position within 3 minutes

Answer 72

20 mm Hg/10 mm Hg

Question 73

In patients with _____, blood pressure does not usually fall on standing.

Answer 73

Postural orthostatic tachycardia syndrome (POTS)

Question 74

The carotid artery pulse wave occurs within _____ milliseconds of the ascending aortic pulse and reflects aortic valve and ascending aortic function

Answer 74

40 ms

Question 75

One of the two pedal pulses may not be palpable in a normal subject because of unusual anatomy (posterior tibial, less than _____%; dorsal pedis, less than __%), but each pair should be symmetric. True congenital absence of a pulse is rare, and in most cases, pulses can be detected with a handheld Doppler device when not palpable.

Answer 75

PTA < 5%

DPA <10%

Question 76

Simultaneous palpation of the brachial or radial pulse with the femoral pulse should be performed in young patients with hypertension to screen for ____.

Answer 76

CoA

Question 77

A _______ pulse may occur in hyperkinetic states such as fever, anemia, and thyrotoxicosis, or in pathologic states such as severe bradycardia, AR, or arteriovenous fistula.

Answer 77

Bounding pulse

Question 78

A _______ is created by two distinct pressure peaks.

Examples

Answer 78

Bifid pulse

Ex:
Chronic severe AR
HCM
Fever/Sepsis
Exercise
IABP

Question 79

A fall in systolic pressure of more than 10 mm Hg with inspiration

Seen in what conditions?

Answer 79

Pulsus paradoxus

• Pericardial tamponade
• Pregnancy
• Pulmonary disease (severe) - Massive PE, COPD, Tension pneumothorax
• Hemorrhagic shock
• Obesity

Question 80

Pulsus paradoxus may be palpable at the brachial artery when the pressure difference exceeds _______

Answer 80

15 mm Hg

Pulsus paradoxus is detected by noting the difference between the systolic pressure at which the Korotkoff sounds are first heard (during expiration) and the systolic pressure at which the Korotkoff sounds are heard with each beat, independent of respiratory phase. Between these two pressures, the sounds will be heard only intermittently (during expiration).

Question 81

_____ defined by the beat-to-beat variability of the pulse amplitude

Answer 81

Pulsus alternans

Question 82

Pulsus alternans generally occurs in

Answer 82

Severe heart failure
Severe AR
Hypertension
Hypovolemic states

Question 83

Pulsus alternans attributed to cyclic changes in intracellular ____ and action potential duration.

Association with electrocardiographic ________ appears to increase arrhythmic risk.

Answer 83

Calcium

T wave alternans

Question 84

Severe aortic stenosis may be suggested by a _________ pulse and is best appreciated by careful palpation of the carotid arteries

Answer 84

Weak and delayed pulse (pulsus parvus et tardus)

Question 85

An abrupt carotid upstroke with rapid fall-off characterizes the pulse of chronic AR ( ___________ ).

Answer 85

Corrigan or water-hammer pulse

Question 86

Abnormal pulse oximetry, defined by a _________ difference between finger and toe oxygen saturation, can also indicate lower extremity PAD and is comparable to the ABI

Answer 86

> 2%

Question 87

The point of maximal impulse normally is over the left ventricular (LV) apex beat and should be located in the midclavicular line at the fifth intercostal space.

It is smaller than ______ in diameter and moves quickly away from the fingers. It is best appreciated at _______, when the heart is closest to the chest wall.

Answer 87

2 cm

End-expiration

Question 88

LV cavity enlargement displaces the apex beat _______

A _______ apex beat is a sign of LV pressure overload (as in aortic stenosis or hypertension).

Answer 88

Leftward and downward

Sustained apex beat

Question 89

A palpable, presystolic impulse corresponds to a ______ and reflects the atrial contribution to ventricular diastolic filling of a noncompliant left ventricle.

Answer 89

Fourth heart sound (S4 )

Question 90

A prominent, rapid early filling wave in patients with advanced systolic heart failure may result in a palpable ________.

Answer 90

Palpable third sound (S3)

Question 91

A parasternal lift occurs with RV pressure or volume overload.

Signs of TR (jugular venous ___ waves) and/or pulmonary artery hypertension (loud, single, or palpable __) should be sought.

Answer 91

JV cv waves

P2

Question 92

HOCM rarely may cause a _________, with contributions from a palpable S4 and the two components of the systolic pulse.

Answer 92

Triple cadence apex beat

Question 93

Normal splitting of S1 is accentuated with ________

Answer 93

Complete right bundle branch block.

Question 94

S1 intensity increases in

Answer 94

• Early stages of RMS (leaflets still pliable)
• Hyperkinetic states
• Short P-R intervals (less than 160 milliseconds)

Question 95

S1 becomes softer in

Answer 95

• Contractile dysfunction
• Late stages of stenosis (leaflets are rigid and calcified)
• Beta-adrenergic receptor blockers
  Long P-R intervals (greater than 200 milliseconds)

Mechanical ventilation
Obstructive lung disease
Obesity
Pendulous breasts
Pneumothorax
Pericardial effusion

Question 96

With normal, or physiologic, splitting, the A2–P2 interval increases during _______ and narrows with _______.

Answer 96

Increases - inspiration

Narrows - expiration

Question 97

The A2–P2 interval widens with _______ because of delayed pulmonic valve closure, and with _______ because of premature aortic valve closure.

Answer 97

CRBBB

Severe MR

Question 98

Unusually narrow but physiologic splitting of S2, with an increase in the intensity of P2 relative to A2 , indicates ____________

Answer 98

Pulmonary artery hypertension

Question 99

With fixed splitting, the A2 –P2 interval is wide and remains unchanged during the respiratory cycle, indicating _______

Answer 99

Ostium secundum ASD

Question 100

Reverse, or paradoxical, splitting occurs as a consequence of a pathologic delay in aortic valve closure, as may occur with _____.

Answer 100

CLBBB
RV apical pacing
Severe aortic stenosis
HCM
Myocardial ischemia

Question 101

When both A2 and P2 can be heard at the lower left sternal border or apex, or when P2 can be palpated at the second left interspace __________, present

Answer 101

Pulmonary hypertension

Question 102

The intensity of A2 and P2 decreases with aortic and pulmonic stenosis, respectively. A ______ S2 may result.

Answer 102

Single S2

Question 103

__________ high-pitched, early systolic sound that coincides in timing with the upstroke of the carotid pulse and usually is associated with congenital bicuspid aortic or pulmonic valve disease, or sometimes with aortic or pulmonic root dilation and normal semilunar valves.

Answer 103

Ejection sound

Question 104

The only right sided ejection sound that decreases in intensity with inspiration

Answer 104

Pulmonic valve disease

Question 105

Nonejection clicks, which occur after the upstroke of the carotid pulse, are related to _______ .

Answer 105

MVP

Question 106

Effects of standing and squatting with MVP

With standing, ventricular preload and afterload decrease and the click and murmur move _______ to S1.

With squatting, ventricular preload and afterload increase, the prolapsing mitral valve tenses ______ in systole, and the click and murmur move ______ from S1

Answer 106

Closer

Later/Away

Question 107

The high-pitched __________ of mitral stenosis occurs a short distance after S2

Answer 107

Opening snap (OS)

Question 108

The A2–OS interval is _______ proportional to the height of the left atrial (LA)-LV diastolic pressure gradient.

Answer 108

Inversely proportional

The intensity of both S1 and OS decreases with progressive calcification and rigidity of the anterior mitral leaflet.

Question 109

A ______________ is a high-pitched early diastolic sound, which corresponds in timing to the abrupt cessation of ventricular expansion after AV valve opening and to the prominent y descent seen in the jugular venous waveform in patients with constrictive pericarditis.

Answer 109

Pericardial knock (PK)

Question 110

________ low-pitched sound sometimes only heard in certain positions that arises from the diastolic prolapse of the tumor across the mitral valve.

Answer 110

Tumor plop

Question 111

A third heart sound (S3) occurs during the rapid filling phase of ventricular diastole.

An S3 may be normally present in _______, but indicates systolic heart failure in older adults and carries important prognostic weight

Answer 111

Children, adolescents, and young adults

Question 112

A left-sided S3 is a low-pitched sound best heard over the LV apex with the patient in the _______ position

A right-sided S3 is usually heard at the lower left sternal border or in the subxiphoid position with the patient ________, and may become louder with inspiration

Answer 112

Left lateral decubitus

Supine

Question 113

A ______ occurs during the atrial filling phase of ventricular diastole and is thought to indicate presystolic ventricular expansion.

This finding is especially common in patients with accentuated atrial contribution to ventricular filling (e.g., LV hypertrophy).

Answer 113

Fourth heart sound (S4)

Question 114

Examples of Early Systolic Murmurs

Answer 114

Mitral—acute MR

VSD
Muscular
Nonrestrictive with pulmonary hypertension

Tricuspid—TR with normal pulmonary artery pressure

Question 115

Examples of Midsystolic murmurs

Answer 115

Aortis stenosis
Pulmonic stenosis

Question 116

Examples of Late Systolic murmurs

Answer 116

MVP
TVP

Question 117

Examples of Holosystolic murmurs

Answer 117

Atrioventricular valve regurgitation (MR, TR)

Left-to-right shunt at ventricular level (VSD)

Question 118

___________ results in a decrescendo, early systolic murmur because of the steep rise in pressure within the noncompliant left atrium

Answer 118

Acute severe MR

Question 119

Radiation of posterior mitral leaflet prolapse? Anterior mitral leaflet prolapse?

Answer 119

Severe MR associated with posterior mitral leaflet prolapse or flail radiates anteriorly and to the base; MR caused by anterior leaflet involvement radiates posteriorly and to the axilla.

Question 120

In patients with normal pulmonary artery pressures, an early systolic murmur, which increases in intensity with inspiration, may be audible at the lower left sternal border, and regurgitant cv waves may be visible

Answer 120

Acute TR

Question 121

Midsystolic murmurs begin after S1 and end before S2 ; they usually are _________ in configuration.

Answer 121

Crescendo-decrescendo

Question 122

Midsystolic murmurs begin after S1 and end before S2 ; they usually are _________ in configuration.

Answer 122

Crescendo-decrescendo

Question 123

An isolated grade ______ murmur in the absence of symptoms or other signs of heart disease is a benign finding that does not warrant further evaluation, including echocardiography.

Answer 123

Grade 1 or 2 midsystolic murmur

Question 124

Mid-to-late, apical systolic murmur usually indicates ____; one or more nonejection clicks may be present.

Answer 124

MVP

Question 125

Holosystolic murmurs, which are ______ in configuration, derive from the continuous and wide pressure gradient between two cardiac chambers

Examples?

Answer 125

Plateau

Left ventricle and left atrium with chronic MR (cardiac apex)
Right ventricle and right atrium with chronic TR (left lower SB)
Left ventricle and right ventricle with membranous ventricular septal defect (VSD) without pulmonary hypertension (mid-left sternal border, where a thrill is palpable)

Question 126

Examples of Early Diastolic murmurs

Answer 126

Aortic regurgitation
Pulmonic regurgitation

Question 127

__________ causes a high-pitched decrescendo early to mid-diastolic murmur.

Answer 127

Chronic AR

Question 128

With primary aortic valve disease, the murmur is best heard along the _____, whereas with root enlargement and secondary AR, the murmur may radiate along the ______

Answer 128

Left sternal border

Right sternal border

Question 129

The diastolic murmur is both softer and of shorter duration in __________ AR, as a result of the rapid rise in LV diastolic pressure and the diminution of the aortic-LV diastolic pressure gradient.

Answer 129

Acute AR

Additional features of acute AR include tachycardia, a soft S1, and the absence of peripheral findings of significant diastolic run-off

Question 130

The murmur of pulmonic regurgitation (PR) is heard along the left sternal border and most often is due to annular enlargement from chronic pulmonary artery hypertension. This murmur is also known as _______ murmur.

Answer 130

Graham-Steele murmur

Question 131

_________ is the classic cause of a mid- to late diastolic murmur.

The stenosis also may be “silent”—for example, in patients with low cardiac output or large body habitus.

The murmur is best heard over the apex with the patient in the left lateral decubitus position, is low-pitched (rumbling), and is introduced by an _____ in the early stages of the disease.

Answer 131

Mitral stenosis

OS

Question 132

_______________ (an increase in the intensity of the murmur in late diastole following atrial contraction) occurs in patients with MS in sinus rhythm.

Answer 132

Presystolic accentuation

Question 133

Functional mitral stenosis or tricuspid stenosis refers to mid-diastolic murmurs created by increased, accelerated ______, without valvular obstruction, in the setting of severe MR or TR, respectively, or ASD with a large left-to- right shunt.

Answer 133

Increased, accelerated transvalvular flow

Question 134

The low-pitched mid- to late apical diastolic murmur sometimes associated with AR (________) can be distinguished from mitral stenosis on the basis of its response to vasodilators and the presence of associated findings.

Answer 134

Austin Flint murmur

Question 135

The presence of a _______ implies a pressure gradient between two chambers or vessels during both systole and diastole. These murmurs begin in systole, peak near S2 , and continue into diastole.

Answer 135

Continuous murmur

Examples:
* PDA
* Ruptured sinus of Valsalva aneurysm
* Coronary, great vessel, or hemodialysis-related arteriovenous fistulas.
* Cervical venous hum and mammary soufflé of pregnancy are two benign variants.

Question 136

Right-sided events, except for the ______, increase with inspiration and decrease with expiration; left-sided events behave oppositely (100% sensitivity, 88% specificity).

Answer 136

Pulmonic ejection sound

Question 137

Aortic stenosis or MR?

A change in the intensity of a systolic murmur in the first beat after a premature beat, or in the beat after a long cycle length in patients with AF

Answer 137

Aortic stenosis

Particularly in an older patient, in whom the murmur of aortic stenosis is well transmitted to the apex (Gallavardin effect).

Systolic murmurs that are due to LV outflow obstruction, including those caused by aortic stenosis, will increase in intensity in the beat following a premature beat because of the combined effects of enhanced LV filling and post-extrasystolic potentiation of contractile function. Forward flow accelerates, causing an increase in the gradient and a louder murmur.

The intensity of the murmur of MR does not change in the post-premature beat, because relatively little further increase occurs in mitral valve flow or change in the LV-LA gradient.

Question 138

Patients with heart failure prefer sleeping on their ________ side

Answer 138

Right side

Question 139

________, which is dyspnea or discomfort experienced in the lateral decubitus position, also may be present

Answer 139

Trepopnea

Question 140

Shortness of breath may be particularly noticeable when bending forward, termed _________.

Answer 140

Bendopnea

Question 141

Four signs are commonly used to predict elevated filling pressures:

Answer 141

• JVD/abdominojugular reflux sign
• Presence of an S3 and/or S4
• Rales
• Pedal edema

Question 142

The _______ provides the readiest bedside estimate of LV filling pressure.

Answer 142

JVP

Question 143

Identify the phase of Valsalva

Decrease in stroke volume and pulse pressure and reflex tachycardia with continued strain due to decrease in venous return and increase in vascular resistance

Answer 143

Phase II

Question 144

Identify the phase of Valsalva

Overshoot of systolic pressure and reflex bradycardia due to increased venous return and decreased systemic vascular resistance

Answer 144

Phase IV

Question 145

Identify the phase of Valsalva

Overshoot of systolic pressure and reflex bradycardia due to increased venous return and decreased systemic vascular resistance

Answer 145

Phase IV

Question 146

Two abnormal responses to the Valsalva maneuver in heart failure are recognized:

Answer 146

(1) absence of the phase IV overshoot
(2) the square-wave response

Question 147

The absent overshoot pattern indicates __________;

The square-wave response indicates ___________ and appears to be independent of ejection fraction

Answer 147

Decreased systolic function

Elevated filling pressures

Question 148

In a cohort of patients with chronic systolic heart failure, the ____ ([systolic − diastolic]/systolic) correlated well with cardiac index

Answer 148

Proportional pulse pressure

Question 149

Using a proportional pulse pressure of 25%, the cardiac index could be predicted: if the value was lower than 25%, the cardiac index was ______

Answer 149

Less than 2.2 L/min/m2

Question 150

Severe mitral stenosis is suggested by

Answer 150

(1) a long or holodiastolic murmur, indicating a persistent LA-LV gradient
(2) a short A2 -OS interval, consistent with higher LA pressure;
(3) a loud P2 (or single S2 ) and/or an RV lift, suggestive of pulmonary hypertension
(4) elevated JVP with cv waves, hepatomegaly, and lower extremity edema

Question 151

In _________, the LV impulse usually is neither enlarged nor displaced, and the systolic murmur is early in timing and decrescendo in configuration

Answer 151

Acute MR

occurs with papillary muscle rupture or infective endocarditis usually results in sudden and profound dyspnea from pulmonary edema.

Question 152

Several findings suggest chronic severe MR:

Answer 152

(1) an enlarged, displaced, but dynamic LV apex beat
(2) an apical systolic thrill (murmur intensity of grade 4 or greater)
(3) a mid-diastolic filling complex comprising an S3 and a short, low-pitched murmur, indicative of accelerated and enhanced diastolic mitral inflow
(4) wide but physiologic splitting of S2 caused by early aortic valve closure;
(5) a loud P2 or RV lift

Question 153

The murmur associated with secondary MR in patients with reduced LV systolic function is often of ______ unless specifically sought.

Answer 153

Low intensity and can be difficult to hear

Question 154

Findings in AS

Answer 154

Slowly rising carotid upstroke (pulsus tardus), reduced carotid pulse amplitude (pulsus parvus)
Reduced intensity of A2
Mid to late peaking of the systolic murmur

Question 155

Distinguishing features of the ffg conditions vs AS

HOCM
Subaortic stenosis
Supravalvar stenosis

Answer 155

The presence of an ejection sound indicates a valvular cause.

HOCM can be distinguished on the basis of the response of the murmur to the Valsalva maneuver and standing or squatting.

DMSS will commonly have a diastolic murmur indicative of AR but not an ejection sound

Patients with SVAS, the right arm blood pressure is more than 10 mm Hg greater than the left arm blood pressure.

Question 156

Patients with _______ present with pulmonary edema and symptoms and signs of low forward cardiac output.

Tachycardia is invariably present; systolic blood pressure is not elevated, and the pulse pressure may not be significantly widened.

S1 is soft because of ______

Answer 156

Acute severe AR

Premature closure of the mitral valve.

Question 157

A decrescendo diastolic blowing murmur suggests ________

Answer 157

Chronic AR

Question 158

Little evidence supports the historical claims of the importance of almost all the eponymous peripheral signs of chronic AR, which number at least 12.

The ______ (brachial- popliteal systolic blood pressure gradient higher than 20 mm Hg) may be the single exception (sensitivity of 89% for moderate to severe AR), although its supporting evidence base also is weak.

Answer 158

Hill sign

Question 159

An elevated JVP together with a delayed y descent, abdominal ascites, and edema suggests ______

Answer 159

Severe tricuspid stenosis.

Question 160

_________ causes elevated JVP with prominent cv waves, a parasternal lift, pulsatile liver, ascites, and edema.

The intensity of the holosystolic murmur of TR increases with inspiration (____________).

Answer 160

Severe TR

Carvallo sign

Question 161

Pulmonic stenosis may cause exertional fatigue, dyspnea, lightheadedness, and chest discomfort (“_______”).

Answer 161

Right ventricular angina

Question 162

With severe pulmonic stenosis, the interval between S1 and the pulmonic ejection sound narrows, and the murmur peaks in late systole and may extend beyond A2. ______ becomes inaudible.

Answer 162

P2

Question 163

The diastolic murmur of secondary PR (______________) can be distinguished from that caused by AR on the basis of its increase in intensity with inspiration, its later onset (after A2 and with P2), and its slightly lower pitch.

Answer 163

Graham Steell

Question 164

The first clue that prosthetic valve dysfunction may be present often is a ______

Answer 164

Change in the quality of the heart sounds or the appearance of a new murmur.

Question 165

A bioprosthesis in the mitral position usually may be associated with a grade 1- 2 midsystolic murmur (from turbulence created by systolic flow across the valve struts that project into the LV outflow tract) and a soft, mid-diastolic murmur that occurs with normal LV filling.

A high-pitched or holosystolic apical murmur signifies ______

Answer 165

Para- or transvalvular regurgitation

Question 166

A bioprosthesis in the aortic position is invariably associated with a midsystolic murmur at the base usually of grade 1-2 intensity.

A _______ is abnormal under any circumstance and merits additional investigation.

Answer 166

Diastolic murmur of AR

Question 167

A high-pitched apical systolic murmur in patients with a mechanical mitral prosthesis, or a decrescendo diastolic murmur in patients with a mechanical aortic prosthesis, indicates _____ or _____

Answer 167

Paravalvular regurgitation or prosthetic dysfunction.

Question 168

A ______ rub is almost 100% specific for the diagnosis of pericarditis, although its sensitivity is not as high, because the rub may wax and wane over the course of an acute illness or may be difficult to elicit.

This leathery or scratchy, typically two- or three-component sound also may be monophasic.

Answer 168

Pericardial friction

Question 169

The most common associated symtom of tamponade is _____ (sensitivity, 87% to 88%)

Answer 169

Dyspnea

Question 170

The diagnosis of CP most often is first suspected after inspection of the JVP and waveforms, with

Answer 170

Elevation and inscription of the classic M or W contour caused by prominent x and y descents
Kussmaul sign

Question 171

_____ murmurs generally increase with inspiration. Left- sided murmurs usually are louder during expiration.

Answer 171

Inspiration: Right-sided murmurs

Expiration: Left-sided murmurs

Question 172

Effect of Valsalva maneuver on murmurs

Answer 172

Most murmurs: Decrease in intensity

HCM: Louder

MVP: Longer and louder

After valsalva:
Right sided: return to baseline intensity earlier than left sided murmurs

Question 173

Effect of exercise on murmurs

Answer 173

Normal or obstructed:
Isotonic & Isometric: louder

Hand-grip: MR, VSD, AR

Question 174

Effect of positional changes on murmurs

Answer 174

Standing: Most murmurs diminish
Except in:
HCM: Louder
MVP: longer and louder

Squatting: most murmurs become louder
HCM: soften and may disappear
MVP: soften and may disappear

Question 175

This maneuver usually produced same results as squatting

Answer 175

Passive leg raising

Question 176

Effect of post-ventricular premature beat or AF on murmurs

Answer 176

Normal/Stenotic semilunar valves:
PVC: Increase in intensity (Cardiac cycle after premature beat)
AF: increase in intensity (after long cycle length)

Systolic murmurs by AV valve regurgitaiton: No change
Papillary muscle dysfunction: Diminish
MVP: shorter after premature beat

Question 177

Effect of pharmacologic interventions on murmurs

Answer 177

Amyl nitrate inhalation
* Initial relative hypotension:
MR, VSD, AR - decrease in intensity
AS: increase in intensity (increase in SV)

• Later tachycardia phase:
  MS, right-sided murmurs: louder

MVP: softer then louder (Biphasic)

Question 178

Transient external compression of both brachial arteries by bilateral cuff inflation to 20 mm Hg or greater than peak systolic pressure augments the murmurs of _____.

Answer 178

MR
VSD
AR