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225 Cards in this Set
- Front
- Back
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What is pectus excavatum?
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Funnel breath - incavement of breast bone.
May cause abnormal position of heart |
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What is voussure?
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A bulge of precordium, showing the thorax is too small for the heart
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Pulsation of precordium indicates?
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CVS disease & cardiomegaly
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What is a systolic pull in intercostal space?
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Not pathologic, typical young children
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What is precordium?
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Heart region
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What is PMI?
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Point of maximum impulse
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Where is normal PMI?
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1-2 cm medially from midclavicular line in 4th or 5th intercostal space
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What may cause the PMI to move to the left?
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- Pleuropericardial adhesions
- Right sided pneumothorax - Cardiomegaly |
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Typical sign of left ventricular hypertrophy?
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- Apical thrust, located medially from midclavicular line
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What things may we palpate in precordial region?
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- Apical impulse
- Palpable gallop - Systolic thrust - Tactile equivalents of sounds and murmurs - Precordial thrill |
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When may we se a systolic thrust (lift) of the sternum?
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Hypertrophy / dilatation of right ventricle.
Pathology in normosthenic, normal in asthenic |
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Where may we palpate the tactile equivalent of 2nd heart sound?
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Sternal attachment of left 3rd and 4th ribs
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When we may palpate 2nd heart sound, it may mean?
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Pulmonary hypertension
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What may a tactile equivalent of 1st heart sound mean?
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Severe mitral stenosis with membranous valve
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How does a precordial thrill feel like?
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A purring cat
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What does a precordial thrill mean?
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Organical valvular disease
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Stethoscope: Bell listens best? Example?
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Lower frequencies - like 3rd & 4th HS
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Stethoscope: Membrane listens best? Example?
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Higher frequencies - like decrescendo diastolic murmur or aortic insufficiency
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On heart auscultation - what order should we seek for problems?
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1. HS
2. Additional sounds 3. Murmurs |
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Where may we listen for aortic valve?
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Right 2nd interspace parasternally
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Where may we listen for pulmonary valve?
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Left 2nd interspace parasternally
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Where may we listen for tricuspid valve?
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Lower sternum and lower left sternal border
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Where may we listen for mitral valve?
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Area of apex of heart
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Where is the systolic click of the aortic valve best heard?
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Over the apex
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Where may the opening snap of mitral valve be best heard?
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Over the site of pulmonary ausculation - although it originates from bicuspic valve
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Timing of 1st heart sound in cardiac cycle?
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Onset of systole
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Timing of 2nd heart sound in cardiac cycle?
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End of systole
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The time b/w 1st & 2nd heart sound is called?
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Systolic pause
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The time b/w 2nd & 1st heart sound is called?
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Diastolic pause
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How are heart sounds in obese people?
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Softer
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How are heart sounds in patients with pulmonary emphysema?
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Almost inaudible
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What is the cause of 1st HS?
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Closure of atrioventricular valves.
Due to higher pressure in ventricles upon contraction, the valves are pushed back. |
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What are the name of atrioventricular valves?
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Mitral valve (bicuspic)
Tricuspid valve |
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The loudness of 1st HS depends on?
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- Speed of pressure increase
- Anatomic condition of valves - Position of the cusps at the time of ventricular systole |
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How far after beginning of QRS is onset of 1st HS?
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50ms
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How long on ECG does the 1st HS last?
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100ms
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Accentuation of 1st HS may mean?
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- Mitral stenosis (mitral is heard over tricuspid)
- Exertional tachycardia - Fever - Thyrotoxicosis It is also a bit delayed, the stenotic valve holds against the pressure a bit longer and then bam it closes |
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Diminished 1st HS may mean?
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Valvular changes due to:
- Thickening - Fibrosis - Calcification Rheumatic heart disease Acute myocardial infarction |
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Splitting of 1st HS means?
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Asynchronous ventricular contraction (septal defects)
Bundle branch block --> Not important diagnostically -----> But must distinguish from 4th HS & early systolic click |
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What does an early systolic click mean?
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Usually an ejection sound
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What does a late systolic click mean?
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Mitral insufficiency - due to prolapse of the mitral valve into atrium during systole
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Reason behind 2nd HS?
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Closure of the aortic and pulmonary valves due to higher pressures in the outgoing vessels than inside the ventricles
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Which component - pulmonary or aortic - is the most prominent?
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Aortic, pulmonary lags behind
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Which ventricle expels more blood?
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Right ventricle - it has better filling due to suction effect of thorax
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What is the physiological splitting of 2nd HS?
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That the pulmonary component lags a bit behind
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Which HS has the higher pitch?
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2nd
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Longest time difference between the 2 HS?
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0.04 s (at hight of inspiration)
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Accentuation of pulmonary component may mean?
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- Pulmonary hypertension (mitral stenosis)
- Some congenital heart diseases - Pulmonary embolism - Left heart failure |
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Weakening of pulmonary component may mean?
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Fibrotic or calcified leaflets of the valve
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A fixed splitting of 2nd heart sound is?
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A splitting where both components are clearly splitted and it does not change with breathing
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Fixed splitting of 2nd heart sound indicates?
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Atrial septal defect
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Cause of 3rd HS?
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Sudden ending of ventricular distention in initial phase of diastole
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Pith of 3rd HS? Bell or membrane?
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Low - bell
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Pathologic 3rd HS found in?
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Mitral incompetence
Ventricular septal defect LEFT VENTRICULAR FAILURE (40+y) Constrictive pericarditis |
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What is pulsus alternans?
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An alternating strong and weak pulse
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What indicates pulsus alternans?
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Left ventricular systolic impairment
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When may we hear 3rd HS?
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Quick after 2nd HS, like: lub dub (dub)
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What is the cause of 4th HS?
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Distention of the ventricle caused by atrial systole (active filling)
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When may we hear 4th HS?
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Just before 1st HS
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4th HS may indicate?
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Myocardial infarction
Longstanding hypertension Increased mean atrial pressure |
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What is a gallop?
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Usually tachycardia combined with 3rd or 4th HS
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Gallop rhythm is typical (but not conclusive) for?
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Left ventricular failure
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Cause of diastolic opening snap of the mitral valve?
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Rheumatic heart disease
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What does it mean that a valve is stenotic?
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It cannot open properly, so the leaflets vibrate and create a snapping sound
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What is the pericardial knock?
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1 HS, 2 HS + early 3rd HS
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What is the early systolic (ejection) click?
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A click due to stenosis of either aortic or pulmonary valve - the valve cannot open properly, and like a rope holding the door suddenly tightens, this is what makes the sound
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When does early systolic click appear?
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Quick after 1st HS
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What is the late systolic click?
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Either:
- Pathologic prolapse of mitral valve into left atrium - Pericarditis |
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What is the source of a murmur?
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When the flow velocity of blood exceed a certain critical limit in a place where heart cavity or vessels are narrowed or have an uneaven surface
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High-pitched murmurs are found where?
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In areas with high velocity of blood flow - aortic insufficiency where blood regurgitate through a narrow opening
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Low-pitched murmurs are found where?
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In areas with lower blood velocity - like mitral stenosis
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2 types of systolic murmurs?
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Ejection murmur
Regurgitation murmur |
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When does ejection murmur occur?
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In stenosis of aortic or pulmonary valves
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What is relative stenosis?
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Valves are fine, but either blood flow velocity or the amount of blood (thus velocity) are greater - creating the murmur (like wind through a tunnel)
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Shape of ejection murmurs on phonocardiography?
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Diamond, introduced by an early systolic click
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Where is the murmur heard in aortic stenosis?
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2nd right interspace parasternally
Transmit --> Jugular and carotids (more to the right) |
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Where is the murmur heard in pulmonary stenosis?
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Left of the sternum and under clavicles
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How may we determine that a murmur is functional and not organic valvular?
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Functional is not loud (3 or less) and do not spread
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Different types of regurgitation murmurs?
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- Decrescendo (weakening in systole)
- Crescendo-decrescendo (similar to ejection (diamond)) - Crescendo (Increasing during systole) |
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What may cause systolic murmurs?
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Mitral valve
Tricuspid valve Ventricular septal defects |
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PMI of mitral incompetence?
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Apex, spreading to axilla, intensify by squatting
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Late systolic murmurs are mostly caused by?
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Degenerative changes of elastic valvular structures
--> Leading to prolapse of mitral valve |
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PMI of tricuspid insufficiency?
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Lower sternum, no spread
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Very loud murmur, means how severe of organic insufficiency?
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Not so much. If no murmur at all it is very severe, cause there is almost no resistance in the valve
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PMI of ventricular septal defect murmurs?
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Left 4th interspace parasternally
Lower sternum --> VERY LOUD = Not significant |
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2 types of diastolic murmurs?
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1. Inflow related: Coarse
2. Regurgitant: Decrescendo |
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When does flow-related murmurs develop?
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In stenosis or relative stenosis of an AV valve (M / T)
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When does tricuspid stenosis most often occur?
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In atrial septal defects - 4x more blood goes through
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Why does not inflow related diastolic murmur start just after 2nd HS?
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Due to isometric relaxation phase. Here ventricular pressure is still higher than atrial
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When does inflow related diastolic murmur start?
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At opening of AV valves, when pressure in atrium are higher than ventricular
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Is murmur more or less audible in calcified leaflets?
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Less
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What usually accompany the inflow-related diastolic murmurs?
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Diastolic opening snap - since the valve´s opening is limited by adhesions, and the sudden tension and vibration of the valve causes the snap
Presystolic crescendo - loudness increase towards end of systole |
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How is stenosis and relative stenosis different in inflow-related diastolic murmurs?
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Relative stenosis there are no opening snap & no presystolic crescendo
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In mitral stenosis, how is pitch and thus what end of stetoschope?
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Low - bell
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What is the murmur of Austin Flint?
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Aortic insufficiency --> Regurgitation. A small stream of regurgitant blood hits mitral valve.
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How to distinguish between murmur of mitral and tricuspid stenosis?
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Need slow, deep breathing - but not easy to distinguish
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Mitral stenosis often leads to?
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Pulmonary hypertension
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Regurgitant decrescendo murmurs occurs in?
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Aortic insufficiency
Pulmonary artery insufficiency |
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When may we hear the regurgitant murmur of aortic insufficiency?
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Right after 2nd HS - due to higher pressure in aorta than LV
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Where is PMI of aortic insufficiency?
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Right and left 2nd intercostal space parasternally
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What side of stethoscope is aortic insufficiency best heard?
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Diaphragm - high pitch
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How can mitral valve dysfunction lead to pulmonary valve insufficiency?
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1. Mitral valve dysfunction
2. Leads to pulmonary congestion 3. Increased pulmonary vascular resistance 4. Secondary dilatation of valvular anulus of pulmonary artery 5. Pulmonary valve insufficiency!! :) |
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What is the diastolic murmur of Graham Steell?
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Murmur of pulmonary valve insufficiency secondary to pulmonary hypertension (thus also usually mitral insufficiency)
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Where does continuous murmurs originate?
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Places where high pressure vasculature communicates with low pressure systems
E.g. Arteries --> systemic veins |
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Where do we hear continuous murmur in patients with PDA? (Patent ductus arteriosus of Botallo)
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Below left clavicle
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What type of murmur do we hear over arteriovenous shunts / fistulas?
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Continuous murmur
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Function of arteriovenous shunts / fistulas?
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In relation du hemodialysis
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What is bruit de diable = devil´s murmur?
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Murmur created by pressure of the stethoscope causing venous compression.
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Pericardial friction rub usually originates from?
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Pericarditis
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What does pericardial friction rub sound like?
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Like walking on frozen snow
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If there is fluid in pericardial sac - how is the pericardial friction rub changed?
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It dissapears
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A louder murmur on squatting indicates?
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Regurgitant murmur of mitral valve
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Why are murmurs heard worse in standing position?
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Since arteriolar resistance decrease
And venous return worsens |
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When can physical exercise be beneficial to hear a murmur?
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In mitral valve stenosis
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What is the valsava maneuver?
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You push internally like trying to have a bowel movement
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What does the valsava maneuver help on the heart?
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Increase the pressure in chest
-- Tells the blood not to come back to the heart --- "Decreasing of preload to the heart" ----- So less stretching of heart muscle, and less efficiency of the heart |
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What does the valsava maneuver help to discover?
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Decrease of all murmurs except:
- Murmur of hypertrophic obstructive cardiomyopathy - Murmur of mitral valve prolapse |
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What is, according to the book, recognized as hypertension?
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Any over 165/90 mmHg
(over 140/90 is not recommended) |
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What is regarded as hypotension?
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Below 100 mmHg
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Systolic BP in lower extremities are how much lower/higher than arms?
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10-20 mmHg higher - due to help of gravity
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How is BP in lower extermities in patients with coarctation of aorta?
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Lower than arms
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What is pulsus paradoxus?
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A significant decrease in systolic BP during inspiration - exceeding 10 mmHg - called pp when over 20
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Pulsus paradoxus exceeding 20 mmHg may indicate?
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Cardiac failure
Pulmonary emphysema Constrictive / exudative pericarditis |
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What is pulsus alternans?
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Alternating strong and weak pulse pressure (peak of systolic BP)
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What does pulsus alternans indicate?
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Chronic left ventricular myocardial dysfunction
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What is extrasystolic bigeminy?
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Cardiac arrhytmia where the abnormal heart beat occur every other concurrence
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What is definition of a pulse?
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A volume change of the artery
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What is pulse pressure?
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Difference between systolic and diastolic BP
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Less than 25mmHg in PulsePressure on the arm indicates?
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Low cardiac output
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High reading of pulse pressure (>50% of systolic BP) can mean?
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Decreased HR
Decreased peripheral resistance Large stroke volume of LV Decreased elasticity of arterial wall |
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Shape of carotid pulse curve in aortic insufficiency?
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"Celer et altus"
- Sharp upstroke - High pulse pressure - Rapid downstroke |
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What is the Musset´s sign?
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The bouncing of patients head in aortic insufficiency
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What may be the cause of the Musset´s sign?
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The high pulse curve (water-hammer) or corrigan pulse.
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How is the carotid pulse curve in valvular aortic stenosis?
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- Slow upstroke with a few downers before slow increase (thrills)
- Pulse reaches peak slowly |
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How is the carotid pulse curve in subvalvular aortic stenosis with hypertrophic obstructive cardiomyopathy?
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- Very rapid upstroke
- Short downstroke before a second upstroke - Called dicrotic pulse |
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What is hypertrophic obstructive cardiomyopathy?
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Thickening of the LV wall without any appearent reason
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What is pulsus bisferiens?
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Pulse striking twice, like in the obstructive hypertrophic cardiomyopathy
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What is the capillary pulse of Quincke?
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When pressing lightly on patients fingernail, one see pink (good perfusion) and pale (low perfusion) parts.
If tissue under nail pulsate in rhythm of heartbeat - this is positive sign (what next q) |
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What does the capillary pulse of Quinke mean?
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Low peripheral vascular resistance
High systolic ejection output - Aortic incompetence - Thyrotoxicosis - Severe anemia |
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MItral stenosis in adults is always from?
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Rheumatic origin
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Consequence of blood flow due to mitral stenosis?
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Inhibits blood flow from left atrium to ventricle
--> Congestion in left atrium ---> Pulmonary veins ----> Pulmonary capillaries -----> Pulmonary artery (p.hypertension) ------> Transudate of blood plasma to interalveolar septa and alveoli (p. edema) -------> Impedes breathing ==> Dyspnea |
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Auscultatory signs of mitral stenosis?
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- Opening snap of mitral valve
- Coarse inflow related diastolic murmur |
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When does acute mitral incompetence develop?
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- Rupture of chordae tendinae (idiopathic or due to endocarditis)
- Ischemic damage to papillary muscle |
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How are lung findings in mitral insufficiency?
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Congested: Crackling rales over lung bases, pulmonary edema
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Chronic mitral incompetence is caused by usually?
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- Chronic dilatation leading to bad attachment of valve to anulus. "Dilated cardiomyopathy"
- Impairment of papillary muscle function (MI) |
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Consequence of mitral insufficiency?
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More blood to ventricle - volume overload. But a lot is ejected back to atrium - which enlarges greatly
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Auscultatory signs of mitral insufficiency? PMI & spread?
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Regurgitant systolic murmur, PMI at apex, transmit to axilla
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What are greatly enlarged LV & LA clinical signs of?
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Heart failure
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Physical examination findings of combined mitral stenosis & insufficiency?
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VALVULAR STENOSIS
- Opening snap - Inflow related diastolic murmur INCOMPETENCE - Apical systolic murmur |
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Isolated aortic stenosis is usually congenital or acquired?
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Congenital
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Aortic stenosis cause what in LV?
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Hypertrophy - due to more work against the resistance of the narrowed aortic ostium
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First symptom of aortic stenosis may be?
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Syncope
Angina pectoris |
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Auscultatory signs of aortic stenosis?
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Systolic click over apex
Long ejection murmur - transmission to carotids |
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What may cause aortic insufficiency?
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Rheumatic heart disease
Syphilis (mesaortitis) Marfan syndrome Valvular damage of bact. endocarditis Long standing systemic hypertension |
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What is mesaortitis?
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Inflammation of middle layer of aorta - due to syphilis
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Consequences in heart & flow due to aortic insufficiency?
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Ejected blood flows back
-> Increase EDV --> Increase systolic output |
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Inspective sign of aortic insufficiency?
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Musset´s sign
Carotid pulsation |
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Auscultatory signs of aortic insufficiency?
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- Diastolic decrescendo murmur right after 2nd HS
- PMI in 3rd interspace left/right of sternum (rather than valve area) |
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What is Flint´s coarse diastolic murmur?
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In patients with aortic insufficiency - the regurgitating blood hits the mitral valve
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Combined aortic stenosis and insufficiency is heard as?
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1. Systolic ejection murmur
2. Diastolic decrescendo murmur |
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Most common cause of tricuspid insufficiency (thus regurgitation)?
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Dilation of right ventricle in heart failure - thus the valvular leaftlets fail to adjust
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What happens in tricuspid insufficiency?
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Blood is ejected back to RV during systole
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What happens in atrial septal defect? (ASD)
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Blood from LA goes to RA
-> RA gets volume overloaded --> Over time it becomes dilated ---> Pulmonary component will lag behind aortic component of 2nd HS ---> SPLITTING OF 2nd HS |
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Typical auscultatory signs of ASD?
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Splitting of 2nd HS
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What is the Eisenmenger syndrome?
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Congenital ventricular septal defect (VSD) causing L-->R shunt
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What does the Eisenmenger VSD cause?
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More blood in the pulmonary circulation - causing pulmonary hypertension and cyanosis
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Inspection signs of Eisenmenger syndrome?
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Voussure & systolic thrust
Cyanosis (Right ventricular hypertrophy) |
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Auscultatory signs of Eisenmenger syndrome?
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None - silent (!!)
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Causes of VSD?
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1. Congenital (usually)
2. Perforation post MI |
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What is Roger´s disease?
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A hemodynamically uncomplicated VSD with loud systolic murmur
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Auscultatory sounds of VSD?
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Loud systolic murmur, depending on the size of the hole. The smaller the larger sound
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What is patent ductus arteriosus? (PDA)
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Incomplete closure of the duct - leading to shunt of blood from aorta --> pulmonary circulation ("L-->R")
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Auscultatory signs of PDA? PMI & transmitted? (diagnostics!)
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Continuous systolic-diastolig murmur. PMI in 2nd left interspace parasternally. Transmit to under left clavicle
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Cause of valvular stenosis of pulmonary artery?
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Congenital
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Consequences of pulmonary stenosis?
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Hypertrophied RV due to more work against more resistance
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Inspectious signs of pulmonary stenosis?
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Systolic heaving
Presystolic pulsation of neck veins due to forceful contraction of RA |
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Auscultatory signs of pulmonary stenosis?
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Long systolic ejection murmur
PMI over pulmonary valve Transmitted under both clavicles Pulmonary comp. lag after aortic comp. |
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Cause of coarctation of aorta?
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Congenital
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What is coarctation of aorta? Consequences?
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Narrowing of aorta just after left subclavian artery branch. Leading to increased pressure mechanically and also via activation of RAAS (since kidney is hypoperfused)
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Palpatory signs of COA?
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Poor pulse in lower extermities - femoral pulse delayed after radial.
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Auscultatory signs of COA?
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Late systolic murmur, PMI between scapulas
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Most important diagnostics of COA?
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Pressure difference upper and lower extremities
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Where is the pain during angina pectoris?
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Behind sternum
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Where may anginal pain radiate?
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To upper extremities (more left) and to the back
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How is the pain in angina pectoris described?
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Heavy pressure or squeezing
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What releaves the anginal pain?
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Nitroglycerin spray sublingually
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Characters of MI pain?
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Same as anginal - but last longer (+20min)
Not releaved by nitroglycerin! |
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How is pain in dissecting aneurism of aorta?
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Similar to MI, but very sudden, sharp, intensive, radiates to back or abdomen. "Like a truck drove you in the chest"
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Pain in pericarditis?
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Dull precordial pain. Longlasting (days)
Relief in sitting, worse in supine. Stabbing pain during cough (like pleuritis pain) |
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Pain in pulmonary embolization?
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Not usually painful. If so - discomfort and dyspnea.
Pain of pleuritis character may develop. |
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Other causes of pain in precordial area?
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- Diseases of cervical spine column
- Diseases of mediastinum and pleura - Hiatal hernias - Esophagitis - Diseases of the bony chest walls |
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What is dyspnea?
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Shortness of breath
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2 types of dyspnea?
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Exertional (during exercise)
Paroxysmal (sudden) |
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Exertional dyspnea may be early sign of?
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MItral stenosis
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What is the purpose of the orthopneic position?
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Reduce venous return
Allow usage of auxillary respiratory muscles |
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What is paroxysmal nocturnal dyspnea?
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Wakes up suddenly by shortness of breath - usually same hour every night
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How is the paroxysmal nocturnal dyspnea usually described?
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Feel like choking or that they have to breathe faster
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How is pulmonary edema described by patient?
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Severe dyspnea, orthopnea, moist, foamy sputum
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What is syncope?
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Loss of consciousness due to low cerebral blood perfusion
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What is "blackout" syncopes?
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Syncope due to short bradyarrhythmia or brief cardiac standstill
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What is vasocagal syncope?
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The most common syncope - caused by:
- Longtime standing in hot poorly ventilated area - Pain - Anxiety - Sight of blood - Stimulation of carotid sinus (hypersensitive) |
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What is exertional syncope? Why is it a serious symptom?
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Fainting due to exercise - may be severe heart disease
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What may causes of exertional syncope be?
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Aortic stenosis
Pulmonary artery stenosis Severe pulmonary hypertension |
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What is cyanosis?
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Bluish hue of skin & mucous membranes
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Cause of cyanosis?
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When reduced hemoglobin in capillary blood exceeds 50g/L
1. Stagnation cyanosis 2. Oxygen saturation fall below 85% |
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Why does stagnation of blood cause cyanosis?
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1. More oxygen delivery to tissues
2. Hence more amount of reduced Hb in capillaries |
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What is the mitral facies?
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The cyanotic face developing in mitral valvular disease due to blood stagnation due to increased systemic venous pressure
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What is acrocyanosis?
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Cyanosis of acral parts like earlobes, nose, fingertips
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Normal value of oxygen saturation?
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96%
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How does fall in oxygen saturation below 85% cause cyanosis?
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1. Blood contains less oxygen
2. Normal oxygen extraction from tissues 3. Leads to more reduced Hb, basically. |
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Difference in peripheral and central cyanosis?
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Peripheral: Stagnation of blood
Central: Low oxygen saturation |
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How does heart compensate for low oxygen saturation?
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Increased cardiac output
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How mange g/l of sulfhemoglobin may cause cyanosis?
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5g/L
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How many g/l of methemoglobin may cause cyanosis?
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15g/L
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Can cyanosis occur in patients with anemia?
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No, since all Hb is used for oxygen
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Can cyanosis occur in patients with polycythemia?
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Yes very easily, because there is a lot of Hb´s free and 50g/L limit is easily exceeded
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Cause of local edemas?
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- DVT
- Venous valve incompetence |
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Causes of generalized edema?
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- Hypoalbuminemia
- Increased capillary permeability - Increased filtration pressure in capillaries |
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Another word for generalized edema?
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Anasarca
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What is hemoptysis?
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Coughing up bloody sputum or blood
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Causes of hemoptysis?
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Diseases of pulmonary parenchyma
- TB - Lung cancer - Bronchiectases - Lung abcess Pulmonary congestion - Usually with mitral valve disease Pulmonary embolism Pulmonary hypertension |
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Rusty sputum may mean?
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- Change of erythrocytic Hb to hemosiderin in chronic pulmonary congestion
- Pneumococcal pneumonia |
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Other symptoms to look for other than hemoptysis in pulmonary embolization?
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- Dyspnea
- Pleuritic pain - EKG changes - Thrombophlebitis |
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What is hemoptoe?
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Massive expectoration of blood
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Usualy cause of hemoptoe?
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Broncho-pulmonary disease
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