Cardiac and Vascular

Question 1

JVP on inspiration is called

Answer 1

Kussmaul’s Sign

It indicates poor RIGHT ventricular filling, usually due to RIGHT SIDED HEART FAILURE.

Blood backs up into the superior vena cava + into the external jugular. It may even appear as a BULGE in the jugular on inspiration.

Can also indicate restrictive cardiopathologies like pericarditis or tamponade.

Normally on inspiration there is a DECREASE in central venous pressure so Kussamaul’s sign is said to be a PARADOXICAL rise in JVP on inspiration

Question 2

Delayed Femoral Pulse, Brachial fine

Answer 2

Coarctation of the Aorta

Question 3

Pericarditis Pain

Answer 3

Changes with position, specifically it is relieved by leaning forward.

Question 4

Tearing pain that radiates to the back

Answer 4

Aortic Dissection, can be in the chest or in the abdomen but both tend to radiate back.

Question 5

How do we get our patient to qualify dyspnea during history taking?

Answer 5

By asking how much activity precedes it:

1 flight, 2 flights, walking to the kitchen, sitting…

Question 6

Classic Exam Findings in Tamponade

Answer 6

Distended Neck Veins

Muffled Heart Sounds

Pulsus Paradoxis - BIG drop in SBP on inspiration. This occurs because thoracic pressure is about all that’s keeping BP up in tamponade and during inspiration that pressure drops to allow air to rush in. That drop in pressure is usually compensated for by the beating of the heart but in tamponade the heart cannot compensate and the SBP drops precipitously.

On exhalation, SBP and DBP will be close in Tamponade, a condition known as NARROW Pulse Pressure

Question 7

Pain in the calf on ambulation, name it and the #1 Ddx associated with it:

Answer 7

Claudication

DVT

Question 8

Signs of Chronic Venous Insufficiency

Answer 8

Statsis Dermatitis
Bronzing and
ankle/calf Edema

Question 9

Chest Pain worse on inspiration relieved by sitting fwd. Diffuse ST segment elevation on ECG (there can be notching of the R wave as well)

Answer 9

Pericarditis

Question 10

Most Common Cause of Sudden Death in Teens/Athletes?

Answer 10

HyperTrophic Cardiomyopathy or Super-thick
septum (usually only on the left side) and left ventricular wall may also be thicker. This reduces the volume that can be moved by the left ventricle.

Its genetic. If found, test the entire family
South East Asians especially

The murmur sounds similar to AORTIC STENOSIS on auscultation but…
1) Valsalva Increases Murmur Intensity in HTC
but Decreases intensity in AS
2) HTC murmur intensity will DECREASE with
squatting or raising legs above heart

Question 11

Delay between 1st Heart Sound and corresponding Carotid pulse

Ejection CLICK after S1 followed by crescendo-decrescendo murmur best heard at Rt 2nd intercostal space, radiating to carotids

Answer 11

Aortic Stenosis

Question 12

signs of cardiac tamponade

Answer 12

JVD- decreased ventricular capacity backs up the works and the jugulars coming down from the head can’t empty…

Diaphoresis
Shock signs

Question 13

Becks Triad of…

Answer 13

Tamponade

JVD
Distant Heart Sounds
Hypotension

also Narrow Pulse Pressure

Question 14

Pulse Pressure

Answer 14

Normal is 120-80= 40

Wide is over 100 and is normal (briefly) in exercise but if chronic, think atherosclerosis

If WIDE in combo with BRADYcardia and IRREGULAR breathing think INCREASED IntraCranial Pressure

If Narrow (less than 25% of systolic) think Blood Loss first then…Restrictive Cardiomyopathies like Tamponade or anything that restricts filling of the left ventricle.

Question 15

New Diastolic Murmur

Answer 15

Valvular Dz

Question 16

Common lipid drug that is contraindicated if pt also has gout

Answer 16

Niacin

At doses over 3g/day Can precipitate gout even in those who don’t have it

Question 17

superior vena cava syndrome

Answer 17

l

Question 18

pericarditis vs constrictive pericarditis

Answer 18

Chest radiation causes constrictive
JVD
Hx of radiation

Viral pericardidits doesn’t usually progress to constrictive

Question 19

“Corkscrew” arteries at the wrists and ankles on angiogram of a Smoker’s extremities.
Claudication and Hypoxia are additional symptoms

Answer 19

Think Beurger’s Dz
aka Thromoangitis Obliterans

Smoking so damages the arteries (and veins) that blood supply and drainage of the hand
that any use results in claudication. Very painful.

Amputation is often required.

Smoking cessation, obviously. There really is no great treatment for this.

Question 20

Nifedipine (Procardia)

Answer 20

A DiHydroPyradine CCB, meaning it works more on peripheral vasculature than on myocytes, though it is the #1 for Prinzmetal’s Angina.

Displaced by ACE/ARB for HTN, this is the BP med that you cannot mix with grapefruit juice as it is metabolized by CYP3A4. It remains the drug of choice for HTN in AFRICAN AMERICANS on whom ACES/ARBS don’t seem effective.

Used for Reynaud’s

Extended Release formulations are probably best as it can effect symptomatic swings in BP.

Question 21

Sinus-y Tach with Short PR (less than 0.12) and Delta Waves

Answer 21

WPW Re-Entry Tachycardia

Question 22

COPD - Most common Arrythmia

Answer 22

Multifocal Atrial Tachycardia

Irregularly irregular but d/t different pacemakers so Ps are visible (they’re not distinguishable in AFIB) and there are several different P-Wave morphologies.

Question 23

Left sided heart attack but no lingering arrhythmia? Which med ?

Answer 23

ACE

Mysteriously prevents left ventricular hypertrophy and remodeling and preserves ejection fraction

Question 24

Pt had Rheumatic Fever and still has opening snap murmur (aortic stenosis). What prophylaxis should he have for dental surgury

Answer 24

Amoxacillin 1 hr before dental surgery and 6 hrs after.

Question 25

Free Wall Rupture/Dressler’s syndrome Occurs when?

Answer 25

Usually within 72 hrs of transmural and lateral wall MI

It causes tamponade, which is mainly visible on EKG as smaller/tiny QRS complexes as the blood compresses the ventricles preventing filling.

Your pt becomes abruptly hemodynamically unstable. Bp plummets, SOB

Cardiogenic shock treatment and pericardial centesis are in order. You can remove the blood from the pericardial space and transfuse it back into the pt.

Question 26

Sick Sinus Syndrome

Answer 26

SA Node gone wonky

Brady-Tachy as the SA is nodding off then waking up

paroxsysmal SVT when SA gets irritated followed by a long pause while it calms down.

Utter loss of P-Waves when SA finally gives up the ghost.

Time for a pacemaker

Question 27

Murmur Tips

Answer 27

Right Sided is louder during inspiration

Left Sided is louder during Expiration

Valsalva increases preload and makes Mitral Prolapse and Hypertrophic Cardiomathy louder

Question 28

Ventricular Septal Defect

Answer 28

Hole in the ventricular septum

Pan Systolic Murmur across the pericardium heard at 3/4 intercostal left spaces

Get an Echo

Close it up with the pig skin patch

Question 29

Osteo Secundum

Answer 29

Most Common Atrial Septal Defect usually caused by an enlarged Foramen Ovale that does not completely seal when first breaths reduce pressure in the right atrium and the pressure difference between left and right atria closes the Septum Primum flap.

Few obvious symptoms, especially if the defect is minor and there isn’t much shunt. A left to right shunt can of course precipitate pulmonary hypertension with it’s resultant scarring of lung capillaries and poor gas exchange and the risk of right heart enlargement (aka Eisenmenger’s syndrome) but these are chronic issues.

There may be poor weight gain and mild hypoxia in babies, children.

For some reason, Mitral Valve Stenosis is a common co-anomaly and this will have it’s characteristic S1 Opening Snap followed by a low rumble as blood forces the valve open then is pressed through the smaller Opening. Heard best supine and @ the apex

In adults, there is a stroke risk d/t patent foramen clot passage

Question 30

Lutembacher Syndrome

Answer 30

Osteo Secundum Atrial Septal Defect WITH Mitral Valve Stenosis.

Question 31

Osler’s Nodes

Answer 31

Painful Raised Nodules on the Hands and Feet. They are the sites of Immune Complex Deposition - Immune complexes form when antibodies bind their antigens. They’re usually opsonized or taken out in the liver and spleen by macrophages but when they get lodged in distal vasculature they form osier’s nodes. Characterisitic of:

Infective Endocarditis
Lupus (Systemic Lupus Erythmatosis)
Systemic Gonorrhea

Question 32

Fixed Splitting of S2

Answer 32

Atrial Septal Deviation and Left to Right shunting through it