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PBR: Cardiology > Physical Exam > Flashcards

Physical Exam Flashcards

1
Q

Differentiate peripheral from central cyanosis.

A

Peripheral cyanosis can occur with normal oxygen saturation and is due to reduced periperal circulation, which allows tissues to extract more oxygen, leaving the venous ends of the capillaries with more reduced (deoxygenated) hemoglobin. Central cyanosis is the result of arterial desaturation and is best seen in the tongue, oral mucous membranes, and trunk.

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2
Q

What is acrocyanosis?

A

Peripheral cyanosis that occurs most commonly with cold, polycythemia, or in normal newborns and young infants. It is benign.

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3
Q

At what arterial oxygen saturation level can cyanosis usually be appreciated on physical exam?

A

<85%

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4
Q

What is differential cyanosis?

A

Differential cyanosis refers to cyanosis of the lower extremities and toes but not fingers or upper extremities.

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5
Q

What cardiac conditions should be suspected if differential cyanosis is noted on exam?

A

Differential cyanosis can indicate aortic arch obstruction or persistant pulmonary HTN with ductal L>R shunting of desaturated blood.

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6
Q

What is the term for cyanosis that affects the lower extremities but not the upper extremities?

A

Differential cyanosis

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7
Q

What is reverse differential cyanosis?

A

Cyanosis that affects the (preductal) upper extremities but not the (postductal) lower extremities.

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8
Q

What cardiac condition should be suspected if reverse differential cyanosis is noted on exam?

A

Transposition of the great arteries with R>L shunting of saturated blood through the ductus.

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9
Q

What is the term for cyanosis that affects the upper extremities but not the lower extremities?

A

Reverse differential cyanosis

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10
Q

Which nail bed finding is concerning for infective endocarditis?

A

Splinter hemorrhages.

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11
Q

What characteristic skin finding is associated with Neurofibromatosis?

A

Café-au-lait macules ***picture?

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12
Q

What characteristic skin finding is associated with tuberous sclerosis?

A

Ash-leaf spots***picture?

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13
Q

What does significant delay or absence of the femoral pulse compared to the radial pulse indicate?

A

Coarctation of the aorta

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14
Q

What does a rapid rising or bounding pulse indicate?

A

This finding indicates the presence of a large PDA or aortic valve insufficiency.

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15
Q

In what conditions might one note a slow-rising pulse?

A

Aortic stenosis or HTN

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16
Q

What do prominent jugular veins on physical exam indicate?

A

Obstruction, abnormal backflow, or worsened ventricular filling due to poor compliance.

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17
Q

Define the a wave of jugular venous pulse mapping.

A

The a wave is a venous wave that occurs just before the first heart sound and is due to atrial contraction.

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18
Q

What does a large a wave in the jugular venous pulse map indicate?

A

A large a wave typically indicates elevated right ventricular end-diastolic pressures because if the right atrium contracts while there is higher filling pressure in the right ventricle, the blood is going to be pushed back to the neck.

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19
Q

What are cannon a waves in the jugular venous pulse map? Which conditions are associated with this phenomenon?

A

Cannon a waves occur when the right atrium contracts against a closed tricuspid valve, and can occur with AV dissociation (3rd degree heart block or junctional rhythm) or ventricular tachycardia.

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20
Q

Define the v wave of jugular venous pulse mapping.

A

The v wave is due to increasing filling volume and concomitant increasing pressure of the right atrium. It begins late in ventricular systole and into early diastole.

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21
Q

In what situations would you expect to see a large v wave in jugular venous mapping?

A

The v wave is large with states of poor ventricular compliance and severe tricuspid regurgitation.

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22
Q

Draw the jugular venous pulse wave map.***

A

Insert Figure 13-1***

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23
Q

What is the point of maximal impulse (PMI), and where is it typically located?

A

PMI is the portion of the chest where the apex of the heart is nearest to the surface. It is typically located just below the left nipple.

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24
Q

What happens to the PMI with cardiomegaly?

A

The PMI shifts leftward toward the axilla.

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25
Q

What happens to the PMI with left ventricular overload?

A

The impulse is stronger than typical.

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26
Q

What happens to the PMI with right ventricular overload?

A

The impulse can be felt just to the left of the left lower sternal border.

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27
Q

What condition should be suspected if the PMI is located in the right chest?

A

Dextrocardia

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28
Q

What actions are represented by the 1st heart sound?

A

The 1st heart sound reflects closure of the mitral valve, then the tricuspid valve.

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29
Q

Where is the 1st heart sound best auscultated?

A

You can best hear the 1st heart sound at the apex or LLSB.

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30
Q

Which conditions result in a loud 1st heart sound?

A

Mitral stenosis, increased ventricular contractility, or a short PR interval. All are conditions which cause the valves to come together forcefully at the beginning of systole.

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31
Q

Which condition results in a diminished 1st heart sound?

A

Conditions of decreased contractility, such as myocarditis.

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32
Q

In what conditions might one hear a systolic ejection click?

A

You can hear systolic ejection clicks when there is an enlarged great vessel at the base of the heart or when there is a thickened/abnormal semilunar valve. Examples include: Thickened semilunar valves (aortic stenosis, bicuspid aortic valve, pulmonary stenosis), enlarged aorta (tetralogy of Fallot), and truncus arteriosus (multivalved great vessel).

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33
Q

Differentiate between the physical exam characteristics of a pulmonary ejection click vs an aortic ejection click.

A

Pulmonary ejection clicks occur early in systole at the left heart base and can vary with respiration. Aortic ejection clicks generally present at the apex and do not vary with respiration.

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34
Q

How can palpation of the pulse be used to differentiate between 1st heart sounds and clicks?

A

1st heart sounds precede the pulse, while clicks are usually simultaneous with the pulse.

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35
Q

When do nonejection clicks occur and where are they usually heard best?

A

Nonejection clicks occur later in systole and are heard at the LLSB or the apex.

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36
Q

What condition should be suspected if a midsystolic click is best heard at the apex?

A

Mitral valve prolapse

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37
Q

What actions are represented by the 2nd heart sound?

A

The 2nd heart sound reflects closure of the aortic valve, then the pulmonic valve.

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38
Q

What causes the physiologic splitting of the second heart sound?

A

Physiologic splitting is caused by increased venous return with inspiration. When you inspire deeply, you increase venous return to the right side and decrease pulmonary venous return to the left, so the pulmonary valve closes later and the aortic valve closes earlier.

39
Q

If splitting of the second heart sound is easily heard in an infant, what conditions should be suspected?

A

A large L>R atrial shunt (e.g. ASD) or venous shunt (anomalous pulmonary venous return)

40
Q

In what condition is the aortic valve closure loud and best heard at the LUSB?

A

Transposition of the great arteries, because the aortic valve is anterior and directly under your stethoscope.

41
Q

What condition results in a single 2nd heart sound that is heard loudest at the LLSB?

A

Tetralogy of Fallot, because the aorta is wide and dextroposed, and the pulmonary artery is located anterior and is smaller than usual.

42
Q

In what conditions do you hear fixed splitting of the second heart sound?

A

Fixed splitting of the second heart sound is due to delayed right ventricular emptying and can indicate possible ASD, right bundle branch block, or severe pulmonary stenosis.

43
Q

What is paradoxical splitting of the second heart sound and when does it occur?

A

Paridoxical splitting is when the second heart sound splits during expiration rather than inspiration. It is due to a delay in left ventricular emptying, with the aortic closure sound coming after pulmonic. You hear this in severe aortic stenosis or left bundle branch block.

44
Q

What is the 3rd heart sound?

A

The 3rd heart sound is heard in early diastole when there is rapid, passive filling of a relatively stiff ventricle. It can be normal in children and pregnant women.

45
Q

What are some pathologic conditions that can present with a 3rd heart sound?

A

AV valve regurgitation and left or right ventricular dysfunction/stiffness.

46
Q

What is the 4th heart sound?

A

The 4th heart sound occurs in late diastole when atrial contraction fills the ventricle.

47
Q

What are some pathologic conditions that can present with a 4th heart sound?

A

Aortic stenosis, mitral regurgitation, hypertrophic cardiomyopathy, and HTN with left ventricular hypertrophy.

48
Q

Which is almost always abnormal in a child: a 3rd or 4th heart sound?

A

The presence of a 4th heart sound is almost always abnormal in children. The 3rd heart sound can be normal in children and pregnant women.

49
Q

Describe the likelihood that a murmur is pathologic in a neonate <6 hours old vs a neonate >6 hours old.

A

A murmur auscultated during the first 6 hours of life is usually pathologic and caused by a valve defect (aortic/mitral stenosis or tricuspid/mitral regurgitation). After 6 hours, as pulmonary vascular resistance falls, the majority of murmurs are benign and due to normal transition sounds (but if pathologic are most likely caused by circulatory shunts like ASD, VSD, or PDA).

50
Q

What condition should be suspected if a school-aged child presents with a new-onset murmur consistent with mitral regurgitation or aortic stenosis?

A

Rheumatic fever

51
Q

Which physical exam maneuvers decrease venous return?

A

Valsalva and squat-to-stand (listen within 15 seconds of standing from 30 second squat)

52
Q

Which physical exam maneuvers increase venous return?

A

Passive straight leg raise and squatting.

53
Q

Which physical exam maneuvers increase systemic vascular resistance?

A

Handgrip, transient arterial occlusion, and squatting

54
Q

Which (4) maneuvers can be used to differentiate the murmur for hypertrophic cardiomyopathy? ***Table 13-2

A

***Table 13-1 and 13-2

55
Q

Which (3) maneuvers can be used to differentiate the murmur for mitral valve prolapse? ***Table 13-2

A

***Table 13-1 and 13-2

56
Q

Which (2) maneuvers can be used to differentiate the murmur for aortic stenosis? ***Table 13-2

A

***Table 13-1 and 13-2

57
Q

Which (3) maneuvers can be used to differentiate the murmur for VSD? ***Table 13-2

A

***Table 13-1 and 13-2

58
Q

Where is the murmur for tricuspid regurgitation heard loudest?

A

The tricuspid regurgitation murmur is heard best at the LLSB.

59
Q

What abnormality should be suspected if a tricuspid regurgitation murmur is heard in a neonate?

A

Ebstein anomaly (congenitally deformed and displaced tricuspid valve resulting in a giant right atrium and tiny right ventricle, usually with an ASD).

60
Q

What are the classic characteristics of a PDA murmur?

A

PDA murmurs are loudest at the LUSB and left infraclavicular area. They are initially systolic and, as pulmonary vascular resistance drops, become continuous, machine-like, and crescendo-decrescendo.

61
Q

What is the normal progression ductus arteriosus closure in neonates?

A

The ductus closes within 24 hours of birth in 50% of neonates, within 48 hours of birth in 90% of neonates, and within 72 hours for virtually all neonates.

62
Q

What situations might cause delayed closure of the ductus arteriosus?

A

Preterm birth and birth at high altitude

63
Q

What is the most common cause of pathologic murmur?

A

VSD

64
Q

Where are VSDs heard best?

A

VSDs are loudest at the LLSB

65
Q

Differentiate between the characteristic sounds of a small vs a large VSD.

A

Small VSDs have a high-frequency sound and may only occur in early systole. Larger VSDs cause a holosystolic harsh murmur.

66
Q

Characterize a typical pulmonary stenosis murmur.

A

Pulmonary stenosis murmurs are loudest at the LUSB and are typically midsystolic harsh ejection murmurs.

67
Q

Characterize a typical aortic stenosis murmur.

A

Aortic stenosis murmurs are loudest at the RUSB, and they radiate into the carotid arteries. They are midsystolic harsh ejection murmurs with an early systolic click heard best at the apex and a systolic thrill palpable at the suprasternal notch.

68
Q

Where are murmurs caused by coarctation of the aorta heard best?

A

These murmurs are loudest on the upper back in the interscapular area.

69
Q

In what age groups are you most likely to hear a murmur caused by an ASD?

A

ASDs rarely cause a murmur in childhood. Diagnosis is typically made in adolescents or adults.

70
Q

What is the typical ASD murmur?

A

An ASD murmur is normally a soft Grade 1-2 murmur heard best at the LUSB.

71
Q

Where would one expect to hear a mitral regurgitation murmur?

A

Mitral regurgitation murmurs are loudest at the apex and radiate to the axilla.

72
Q

What abnormal heart sound is classically associated with pericarditis?

A

Pericarditis causes a friction rub that can usually be heard in both systole and diastole. It has a harsh sandpaper-on-sandpaper sound.

73
Q

What is the most common “innocent” murmur in an infant?

A

In infancy, the most common murmur is physiologic peripheral pulmonary stenosis and, occasionally, a Still’s murmur.

74
Q

What 4 rules must be fulfilled for a murmur to be safely categorized as innocent?

A
  1. The physical exam is normal except for the murmur. 2. The child is asymptomatic. 3. The history has no red flags (such as fever, which could be associated with rheumatic fever or endocarditis). 4. There are no additional abnormal heart sounds such as clicks.
75
Q

What should be the next step for a child with a new murmur that doesn’t meet all the criteria for an innocent murmur?

A

Send the child for an ECHO and/or pediatric cardiology referral.

76
Q

What happens to an innocent systolic murmur when the child is placed in a supine position? With Valsalva maneuvers?

A

The murmur should get louder when the child is placed in a supine position because the stroke volume increases with this maneuver.

77
Q

What are some conditions which may make innocent murmurs louder on exam?

A

Laying supine, exercise, anxiety, anemia, or fever.

78
Q

What happens to an innocent systolic murmur when the child performs Valsalva maneuvers?

A

The murmur can get softer or disappear with Valsalva maneuvers.

79
Q

What conditions should one suspect if a child has a murmur that increases in intensity with Valsalva maneuvers?

A

Hypertrophic cardiomyopathy or obstructive left heart lesions.

80
Q

What distinguishes Still’s murmur from others?

A

It has a musical quality that is not present in other murmurs.

81
Q

What is a Still’s murmur?

A

It is a very common benign systolic ejection murmur with a musical quality and vibratory character.

82
Q

Where is a Still’s murmur best heard and what conditions cause it to decrease in intensity?

A

Still’s murmur is best heard at the LLSB, and it not heard in the back. It decreases in intensity with expiration, positional changes that decrease venous return (like standing), and with faster heart rates.

83
Q

What are the characteristics of right ventricular outflow tract murmurs?

A

They are best heard at the base, are midpitched, and have an ejection character. They do not have a musical component. They are benign murmurs.

84
Q

How might one distinguish between a RVOT murmur and mild pulmonary stenosis?

A

RVOT murmurs do not radiate to the back or axilla. Murmurs due to stenosis are usually harsher and longer and there can be a systolic ejection click if there is an associated dysplastic valve.

85
Q

Describe the murmur of a supraclavicular arterial bruit.

A

Supraclavicular arterial bruits are benign murmurs due to turbulence in the subclavian and carotid arteries, which, in turn, is due to increased acceleration in early systole. It is very short and early, usually ending before the first 3rd of systole. It is easy to diagnose by its shortness and supraclavicular location.

86
Q

What is the underlying cause for the murmur associated with peripheral pulmonary stenosis?

A

PPS is a common benign functional murmur that occurs shortly after birth when there is a large increase in blood flow to the lungs via the pulmonary artery. The murmur arises from the increased pulmonary artery flow hitting the relatively small pulmonary branches, causing turbulence.

87
Q

Where on the thorax do you usually hear peripheral pulmonary stenosis?

A

RUSB with radiation to the back and axilla

88
Q

Describe the typical presentation of a murmur caused by peripheral pulmonary stenosis.

A

It is typically a soft, grade 1-2 midsystolic ejection murmur heard in the RUSB with radiation to the back and axilla.

89
Q

When would you expect the murmur from peripheral pulmonary stenosis to resolve?

A

The murmur usually resolves within 6-12 months of birth as the peripheral pulmonary branches grow bigger.

90
Q

When should one consider referring to cardiology for peripheral pulmonary stenosis?

A

If the murmur is harsh or does not resolve as expected refer to cardiology to rule out true branch pulmonary artery stenosis.

91
Q

What causes a venous hum murmur?

A

Venous hum is caused by blood draining down collapsed jugular veins into dilated intrathoracic veins. The high velocity makes the vein walls “flutter”, resulting in a low-pitched murmur.

92
Q

What happens to a venous hum murmur when the child is placed in a supine position?

A

The hum should disappear because the neck veins are distended and there is no pressure gradient between the two areas.

93
Q

Which maneuvers cause a venous hum murmur to diappear?

A

Supine positioning, Valsalva, turning the head, or compression of the jugular vein.

PBR: Cardiology (20 decks)

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