PE (Lecture 4) Flashcards by Cal Schiller

Lower part of sternum depressed

Pectus Excavatum (Funnel Chest)

compression of heart/vessels may cause murmurs

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Sternum displaced anteriorly (increased AP diameter)

Pectus carinatum (pigeon chest)

costal cartilages are depressed

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increased AP diameter

Seen in aging/COPD

Barrel chest

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Right to left shunt, called? And caused by?

Eisenmenger

This is seen in Ventricular septal defect, Atrial septal defect, and patent ductus arteriosus

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Diastolic HTN…

fatigue for 6 mos… slightly overweight… constipation…

Hypothyroidism

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If PMI enlarged, think?

HTN, HCM, LVH

ATRIAL MYXOMA! (most common benign tumor that can “act like mitral stenosis”)

See Chp. 45

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JVP is normally?

5-9cm

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JVD (not JVP) is associated with?

Volume overload states, such as CHF

probably seen with S3

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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.

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“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”)

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A wave immediately precedes?

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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

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Intermittent prominent “a” waves can be observed in ____ and they are commonly referred to as cannon “a” waves .

complete heart block

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Pericardial knock is seen with?

constrictive pericarditis and tamponade

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Pt has blowing systolic murmur, 4th ICS… is the x wave present?

No, because there’s no x descent present with severe tricuspid regurge

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Prominent “x” descent may be observed in

constrictive pericarditis and pericardial tamponade

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The “x” descent may be eliminated completely in

severe

tricuspid regurgitation

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May be especially prominent in patietns w/ severe tricuspid regurge?

“v” wave

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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

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Ordinarily the JVP falls with ____ due to

reduced pressure in the expanding thoracic cavity.

inspiration

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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 .

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Th e differential diagnosisgenerally associated with Kussmaul sign is _____, as well as with restrictive cardiomyopathy

constrictive pericarditis

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Increased pulse pressure typically observed in ____ and multiple conditions that increase stroke volume or force of contraction

aortic regurgitation

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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?

1. Amyloidosis 2. Sarcoidosis 3. 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