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34 Cards in this Set

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  • Back
What are the commonest causes of cardiac tamponade?
E: When the clinical triad of cardiac tamponade was first described by Beck in 1935, it consisted of hypotension, elevated systemic venous pressure, and a small, quiet heart. The condition was commonly due to penetrating cardiac injuries, aortic dissection, or intrapericardial rupture of an aortic or cardiac aneurysm. Today the most common causes are neoplastic disease, idiopathic pericarditis, acute myocardial infarction (MI), and uremia.
A: pericard, uremia,(mi)|(infar), neopl
What are the three findings in cardiac tamponade?
E: * Jugular venous distention: almost universally present except in patients with severe hypovolemia.
* Pulsus paradoxus: defined as a decrease in systolic blood pressure (BP) in excess of 10 mmHg during quiet inspiration. Pulsus paradoxus is difficult to elicit in volume-depleted patients.
* Tachycardia, with a thready peripheral pulse: sometimes severe cardiac tamponade may restrict left ventricle (LV) and right ventricle (RV) filling enough to cause hypotension, but a thready and rapid pulse is almost invariably present.
A: (JV)|(jug), tachy, paradox
What is Kussmaul's sign?
E: Kussmaul's sign, an inspiratory increase in systemic venous pressure, is commonly present in chronic constrictive pericarditis but is rarely detected in acute cardiac tamponade.
When is S3 heard: (after/before) S2?
E: An S3 (or ventricular gallop) is a low-frequency sound that is heard just after the second heart sound (S2). When found in normal young patients, it is called a physiologic S3.
A: after
What is the differential diagnosis of pathologic S3?
E: An S3 is also found in a variety of pathologic conditions (pathologic S3), including congestive heart failure (CHF), mitral valve prolapse, thyrotoxicosis, coronary artery disease (CAD), cardiomyopathies, pericardial constriction, mitral or aortic insufficiency, and left-to-right shunts.
A: CAD, CHF, left, MI, AI, myop, MVP, thyro
What is the differential diagnosis for S4?
E: It is associated with CAD, pulmonic or aortic valvular stenosis, hypertension, and ventricular hypertrophy from any cause.
A: aort, pulm, hypertro, hyperten
What does an S4 represent, in physiological terms?
E:An S4, or atrial gallop, occurs just before S1 and reflects decreased ventricular compliance (a stiff ventricle).
A: complian
What is the grade of a murmur which is strong enough to cause a palpable thrill?
E: 1:Barely audible intensity (only a cardiologist can hear it!)
2: Low-intensity murmur (the upper-level resident can hear it)
3:Loud murmur (everyone can hear it)
4:Loud murmur with palpable thrill
5: Loudest murmur audible (still requires a stethoscope placed on the chest)
6:Murmur loud enough to be heard with the stethoscope off the chest
During inspiration A2 normally occurs slightly after P2. True/False?
E: S2 is normally split into aortic (A2) and pulmonic components (P2) caused by the closing of the two respective valves. The degree of splitting varies with the respiratory cycle (physiologic splitting). With inspiration, the negative intrathoracic pressure leads to increased venous return to the right side of the heart and a decrease to the left side; this causes P2 to occur slightly later and A2 to occur slightly earlier, which leads to a widening of the splitting of S2. With expiration, the negative intrathoracic pressure is eliminated and A2 and P2 occur almost simultaneously.
Physiologic splitting (widens/shortens) with inspiration?
E: Widens with inspiration and almost disappears with expiration.
A: wid
In paradoxical splitting of the second heart sound, expiration appears to (widen/shorten) the splitting.
E: Paradoxical splitting of S2 refers to the situation in which the split of A2 and P2 seems to widen with expiration and shorten with inspiration (the opposite of normal). This paradox is caused by P2 preceding A2 during expiration and is usually due to conditions that delay A2 by delaying ejection of blood from the LV and therefore closure of the aortic valve.
A: widen
What is the differential diagnosis of a paradoxically split S2?
E: Causes include aortic insufficiency, aortic stenosis, hypertrophic obstructive cardiomyopathy, MI, left bundle branch block, or an RV pacemaker.
A: AS, AI, HOCM, LBB, pace
What are the causes of fixed splitting?
E: ASD and right ventricular dysfunction
What is the difference in height between the angle of Louis and the right atrium?
E: The patient's chest should be elevated to the point that the pulsations are maximally visualized (usually 30-45° of elevation). The height of this oscillating venous column above the sternal angle (angle of Louis) can then be measured (Fig. 3-1). Since the sternal angle is about 5 cm from the right atrium (RA) (regardless of elevation angle), central venous pressure can be estimated by adding 5 cm to the measurement.
What is the normal central venous pressure?
E: Normal central venous pressure is 5-9 cmH2O.
What is the a wave in the central venous pressure waveform caused by?
E: The c wave is produced by right atrial contraction and occurs just before S1.
What is the c wave in the central venous pressure waveform caused by?
E: c wave is caused by bulging upward of the closed tricuspid valve during RV contraction (often difficult to see).
A: tric
What is the v wave in the central venous pressure waveform caused by?
E:v wave is caused by right atrial filling just before opening of the tricuspid valve.
A: fill
When can you see irregular cannon waves?
E: Irregular "cannon" a-waves are seen in atrioventricular (AV) dissociation or ectopic atrial beats.
A: dissoc, ectopic
When can you see regular cannon waves?
E: Regular "cannon" a-waves are seen in a junctional or ventricular rhythm in which the atria are depolarized by retrograde conduction.
A: junct, vent
What is the likely cause of a systolic ejection murmur, best heard at the second right intercostal space, in an 82-year-old asymptomatic man?
E: By far, the most common cause in this setting is aortic sclerosis. This valvular abnormality is characterized by thickening and/or calcification of the aortic valve, and unlike valvular aortic stenosis, it is typically not associated with any significant transvalvular systolic pressure gradient.
A: scler
How will you distinguish between aortic sclerosis and aortic stenosis?
E: The following findings are present with aortic stenosis but absent with aortic sclerosis:

* Diminished carotid upstroke
* Diminished peripheral pulses
* Late peaking of systolic murmur
* Loud S4
* Syncope, angina, or heart failure
* Loud systolic murmur and thrill

A:upstr, late, angina, (CHF)|(fail)
How do standing, squatting, and leg-raising affect the intensity and duration of the systolic murmur heard on dynamic auscultation in a patient with idiopathic hypertrophic subaortic stenosis (IHSS)?
E: In IHSS, a decrease in the size of the LV increases the dynamic LV outflow obstruction, leading to an increased intensity of the murmur. A decrease in LV volume occurs on standing. In contrast, leg-raising and squatting increase venous return and thereby increase LV volume, decreasing the dynamic LV obstruction and the murmur intensity.
What is pulsus paradoxus?
E: Pulsus paradoxus was first described by Kussmaul in 1873 as the apparent disappearance of the pulse during inspiration despite persistence of the heartbeat. In fact, pulsus paradoxus is an exaggeration of the normal decline in systolic BP and LV stroke volume on inspiration.
What is the mechanism of pulsus paradoxus
E: The fall in intrathoracic pressure is rapidly transmitted through the pericardial effusion and results in an exaggerated increase in venous return to the right side of the heart. This, in turn, causes bulging of the interventricular septum toward the LV, thereby resulting in a smaller LV volume and LV stroke volume during inspiration.
What is the other principle condition which can cause pulsus paradoxus?
E: Pulsus paradoxus is not a sine qua non of cardiac tamponade. It may also occur in patients with severe chronic obstructive pulmonary disease complicated by the need for large negative intrathoracic pressures on inspiration. Interestingly, pulsus paradoxus is usually absent in chronic constrictive pericarditis.
Name 5 causes of an abnormal early diastolic sound heard at the apex and lower left sternal border?
E:What is the differential diagnosis of an abnormal early diastolic sound heard at the apex and lower left sternal border?
1. Loud P2
2. S3 gallop
3. Opening snap
4. Pericardial knock
5. Tumor plop (atrial myxoma)

An early diastolic sound may be due to wide splitting of S2, with or without a loud pulmonic closure sound. An atrial septal defect (ASD) causes wide and fixed splitting of S2.
A:P2, plop, knock, S3,
Explain the significance of a loud P2.
E: A loud P2 usually indicates the presence of pulmonary hypertension, whether primary or secondary to chronic pulmonary disease.
A: pulm.*hyp
What is the significance of an opening snap?
E: An opening snap may be the only finding in a patient with a mild noncalcified and pliable mitral valve. In such a patient, a loud S1 is also commonly present. A diastolic rumble at the apex confirms the physical diagnosis of mitral stenosis.
A: calci
What is the mechanis behind a pericardial knock?
E: In patients with chronic constrictive pericarditis, the sudden slowing of LV filling in early diastole associated with the restriction of a rigid pericardium acting as "a rigid shell" causes the pericardial knock.
A: slow
The presence of an opening snap indicates severe mitral stenosis. True/False?
E: An opening snap is typically present only when the mitral valve leaflets are pliable, and it is therefore usually accompanied by an accentuated S1. Diffuse calcification of the mitral valve can be expected when an opening snap is absent. If calcification is confined to the tip of the mitral valve, an opening snap is still commonly present. The interval between the aortic closure sound and opening snap (A2-OS) is inversely related to the mean LA pressure. A short A2-OS interval is a reliable indicator of severe mitral stenosis; however, the converse is not necessarily true.
What are the five major Jones criteria for diagnosing rheumatic fever?
E: Carditis, polyarthritis, chorea, erythema marginatum, subcutataneous nodules
A: poly, chor, carditis, erythem, nodu
How many major Jones criteria are needed to fulfill the diagnosis of rheumatic fever?
E: The clinical diagnosis of acute rheumatic fever is made if two major criteria or one major and two minor criteria are present in a patient with a preceding streptococcal infection (as evidenced by recent scarlet fever, positive throat culture for group A streptococci, or increased antistreptococcal antibody or other streptococcal antibody titer).
What are the five minor Jones criteria?
E: Fever, prolonged PR interval, arthralgia, elevated ESR or C-reactive protein, history of rheumatic fever
A: fever, PR, hist, ESR, arthral