Physical Examination of the Heart

Question 1

Pulsus tardus

Answer 1

Delayed upstroke (aortic stenosis)

Question 2

Bounding (hyperkinetic) pulse

Answer 2

Hyperkinetic circulation, aortic regurgita-
tion, patent ductus arteriosus, marked vasodilatation

Question 3

Pulsus bisferiens

Answer 3

Double systolic pulsation (aortic regurgitation, hypertrophic cardiomyopathy)

Question 4

Pulsus alternans

Answer 4

Regular alteration in pulse pressure amplitude (severe LV dysfunction)

Question 5

Pulsus paradoxus

Answer 5

Exaggerated inspiratory fall (>10 mmHg) in systolic bp (pericardial tamponade, severe obstructive lung disease)

Question 6

Jugular venous distention develops in…

Answer 6

right-sided heart failure, constrictive pericarditis, pericardial tamponade, obstruction of superior vena cava.

Question 7

JVP normally falls with inspiration but may rise (Kussmaul sign) in…

Answer 7

constrictive pericarditis.

Question 8

Pulsus parvus

Answer 8

Weak upstroke due to decreased stroke volume (hypovolemia, LV failure, aortic or mitral stenosis)

Question 9

Large “a” wave

Answer 9

Tricuspid stenosis (TS), pulmonic stenosis, AV dissociation (right atrium contracts against closed tricuspid valve)

Question 10

Large “v” wave

Answer 10

Tricuspid regurgitation, atrial septal defect

Question 11

Steep “y” descent

Answer 11

Constrictive pericarditis

Question 12

Slow “y” descent

Answer 12

Tricuspid stenosis

Question 13

Cardiac apical impulse is normally localized at the…

Answer 13

fifth intercostal space, midclavicular line.

Question 14

Forceful apical thrust

Answer 14

Left ventricular hypertrophy

Question 15

Lateral and downward displacement of apex impulse

Answer 15

Left ventricular dilatation

Question 16

Prominent presystolic impulse

Answer 16

Hypertension, aortic stenosis, hypertrophic cardiomyopathy

Question 17

Double systolic apical impulse

Answer 17

Hypertrophic cardiomyopathy

Question 18

Sustained “lift” at lower left sternal border

Answer 18

Right ventricular hypertrophy

Question 19

Dyskinetic (outward bulge) impulse

Answer 19

Ventricular aneurysm, large dyskinetic area post MI, cardiomyopathy

Question 20

Loud S1

Answer 20

Mitral stenosis, short PR interval, hyperkinetic heart, thin chest wall

Question 21

Soft S1

Answer 21

Long PR interval, heart failure, mitral regurgitation, thick chest wall, pulmonary emphysema

Question 22

Describe S2.

Answer 22

Normally A2 precedes P2 and splitting increases with inspiration.

Question 23

Widened splitting of S2

Answer 23

Right bundle branch block, pulmonic stenosis, mitral regurgitation

Question 24

Fixed splitting of S2 (no respiratory change in splitting)

Answer 24

Atrial septal defect

Question 25

Narrow splitting of S2

Answer 25

Pulmonary hypertension

Question 26

Paradoxical splitting of S2 (splitting narrows with inspiration)

Answer 26

Aortic stenosis, left bundle branch block, heart failure

Question 27

Loud A2

Answer 27

Systemic hypertension

Question 28

Soft A2

Answer 28

Aortic stenosis (AS)

Question 29

Loud P2

Answer 29

Pulmonary arterial hypertension

Question 30

Soft P2

Answer 30

Pulmonic stenosis (PS)

Question 31

Describe S3.

Answer 31

Low-pitched, heard best with bell of stethoscope at apex, following S2; normal in children; after age 30–35, indicates LV failure or volume overload.

Question 32

Describe S4.

Answer 32

Low-pitched, heard best with bell at apex, preceding S1; reflects atrial contraction into a noncompliant ventricle; found in AS, hypertension, hypertrophic cardiomyopathy, and coronary artery disease (CAD).

Question 33

Describe an opening snap (OS).

Answer 33

High-pitched; follows S2 (by 0.06–0.12 s), heard at lower left sternal border and apex in mitral stenosis (MS); the more severe the MS, the shorter the S2–OS interval.

Question 34

What is an ejection click?

Answer 34

High-pitched sounds following S1; observed in dilatation of aortic root or pulmonary artery, congenital AS (loudest at apex) or PS (upper left sternal border); the latter decreases with inspiration.

Question 35

Ejection-type (systolic) murmurs

Answer 35

Aortic outflow tract 1) Aortic valve stenosis 2) Hypertrophic obstructive cardiomyopathy 3) Aortic flow murmur Pulmonary outflow tract 1) Pulmonic valve stenosis 2) Pulmonic flow murmur

Question 36

Holosystolic murmurs

Answer 36

Mitral regurgitation Tricuspid regurgitation Ventricular septal defect

Question 37

Late-systolic murmurs

Answer 37

Mitral or tricuspid valve prolapse

Question 38

Early diastolic murmurs

Answer 38

Aortic valve regurgitation Pulmonic valve regurgitation

Question 39

Mid-to-late diastolic murmurs

Answer 39

Mitral or tricuspid stenosis Flow murmur across mitral or tricuspid valves

Question 40

Continuous diastolic murmurs

Answer 40

Patent ductus arteriosus Coronary AV fistula Ruptured sinus of Valsalva aneurysm