1
Q
Harsh murmur
A
- Mitral regur
- Aortic stenosis
- Pulmonic stenosis
- VSD
- Hypertrophic cardiomyopathy
- PDA
2
Q
Blowing murmur
A
- Tricuspid regurg
- Aortic regurg
3
Q
Rumbling murmur
A
- mitral stenosis
4
Q
Musical murmur
A
- aortic stenosis when heard over apex
5
Q
Midsystolic murmur
A
- flow thru semilunar valves
- Ex. hypertrophic cardiomyopathy
- Assoc w anachrotic pulse (Aortic stenosis)
6
Q
Pansystolic murmur
A
- backflow thru AV valves
7
Q
Late systolic murmur
A
- MVP
8
Q
Early Diastolic murmur
A
- backflow thru semilunar valves
- Ex. Aortic regurg
- Assoc w Waterhammer pulse (rapid & collapsing pulse) & Bisfriens pulse
9
Q
Mid diastolic murmur
A
- obstruction of flow thru semilunar valves
10
Q
Late diastolic murmur
A
- Mitral stenosis
11
Q
Left heart failure
A
- Causes: systemic hypertension, ischemic heart disease, valvular disorders (mitral and aortic stenosis and regurgitation), cardiomyopathy
- Presentation: breathlessness, orthopnea, paroxysmal nocturnal dyspnea
- Findings: tachypnea, tachycardia, S3 gallop rhythm, bibasilar inspiratory lung crepitations. When severe: Cyanosis, pink frothy sputum, extensive crepitations
12
Q
Right heart failure
A
- Causes: secondary to left heart failure, chronic obstructive pulmonary disease, atrial septal defect
- Presentation: due to fluid retention, breathlessness and swelling of legs which may extend to ascites
- Findings; elevated JVP, large liver, ascites, cardiac cachexia (skeletal muscle loss) peripheral edema
13
Q
Cardiac Tamponade
A
Findings: cold extremities, tachycardia, pulsus paradoxus (decrease pulse amplitude or fall in systolic blood pressure greater than 10 mm Hg) with inspiration, low blood pressure, markedly raised JVP, positive Kussmaul sign (JVP elevated further in inspiration), muffled heart sounds, clear lung fields.
14
Q
Aortic stenosis
A
- Causes: congenital, congenital bicuspid vale with premature calcification, calcific calcification in a normal aortic valve, rheumatic aortic stenosis
- Presentation: breathlessness, chest pain dizziness or syncope, all on exertion
- Findings: slow rising pulse, thrusting or heaving apex beat (LVH), harsh loud ejection systolic murmur, heard best left mid parasternal, right second interspace or apex
- A2 maybe soft or absent
- crescendo-decrescendo murmur
15
Q
Aortic Incompetence
A
- Causes: dilated aortic root (hypertension, Marfan‟s, ascending aortic aneurysm), abnormal aortic valve (rheumatic heart disease, endocarditis)
- Presentation: exertional breathlessness
- Findings; collapsing pulse, wide pulse pressure (>90 mm Hg) (Corrigan‟s sign, de Musset‟s sign, Quinke‟s sign, pistol shot femorals, Duroziez‟s murmur), early diastolic decrescendo murmur along the left sternal border or right sternal border
16
Q
Mitral stenosis
A
- Causes: rheumatic heart disease, SLE
- Presentation: gradual onset of progressive breathlessness
- Findings: malar flush, elevated JVP, peripheral edema, atrial fibrillation, left parasternal heave heave, tapping apex beat, low pitched, rumbling mid-diastolic murmur, opening snap
17
Q
Mitral regurg
A
- Causes: intrinsic valve disease (valve or valve related mechanism), secondary to stretched valve ring due to left ventricular dilation
- Presentation: breathlessness, effort intolerance, fatigue
- Findings: displaced diffuse apex beat, loud pan-systolic murmur at apex, radiates up along left sternal border, or left axilla, S1 soft, S3 sometimes, atrial fibrillation
18
Q
Mitral valve prolpase
A
late systolic murmur
19
Q
Common causes of mitral incompetence
A
- Mitral valve prolapse
- Infective endocaditis
- Rheumatic heart disease
- Ruptured papillary muscle or chordae
- Papillary muscle dysfunction
- Left ventricular dilation from any cause- dilated mitral valve
20
Q
Hypertrophic cardiomyopathy
A
- Cause: genetic, resulting in asymmetric hypertrophy of left ventricular myocardium especially the septum
- Presentation: exertional breathlessness, chest pain, dizziness, sudden death due to ventricular arrhythmia
- Findings: double apex beat, bisferiens pulse, S4, crescendo decrescendo murmur at base which becomes more prominent with valsalva or standing and less loud with squatting.
21
Q
Sx of arterial insufficiency
A
- Pain – initially on activity and relieved by rest (intermittent claudication) due to muscle hypoxia
- Rest pain – progression of disease
- Paresthesia and numbness
- Cool or cold extremity
- Skin color changes – pallor (hypoxia),black means gangrene, red severe insufficiency
- Ulcers
22
Q
Signs of arterial insufficiency
A
- Pallor
- Decrease skin temperature
- Loss of hair distally
- Loss of muscle mass
- Decrease to absent pulses
- Distal ulceration (tips of digit) • Peripheral neuropathy
- Gangrene
23
Q
Special tests for arterial insufficiency
A
- Buerger’s test
- Allen’s test
24
Q
Buerger’s test
A
- Raise both legs to 60 degrees, shoes off
- Patient wiggle feet and toes
- Hold for 60 seconds
- Have patient sit up and swing legs over the side of the bed
- Observe for return of color (10 seconds) and venous filling (15 seconds)
25
Signs of venous insufficiency (stasis dermatitis)
* Edema – dorsum of foot, posterior to medial
* malleolus, lower anterior leg
* Stasis dermatitis
* Ulcers – usually in the area of the medial
* malleolus
* Varicose veins
* Increase warmth due to associated cellulitis
* Cords – thrombosed superficial vein
26
Test for venous insufficency
* Manual compression test
* Trendelenberg's test
27
Manual compression test
* Locate a portion of varicose greater saphenous vein in the leg or preferably bridging the thigh and leg
* Place the index and ring fingers (index finger on the inside) of both hands on the vein approximately 10 cm apart
* Compress with the proximal fingers to fill that portion of the vein with blood
* Compress with the distal fingers while maintaining pressure with the proximal fingers. A column of blood is now trapped.
* Lift the index finger of the distal hand (maintaining pressure with the other fingers) and tap over the vein. A fluid wave should be detected proximally.
* Replace the index finger applying pressure. Lift the index finger of the proximal hand and tap the vein. No fluid wave should be detected distally
28
Trendelenberg test: competency of valves of **saphenous and communicating veins**
* Test one leg at a time
* Raise leg to 90 degrees at the hip and maintain for I minute
* Apply tourniquet to upper thigh to occlude flow in the superficial veins
* Have patient stand on both legs
* Observe for rapid filling of the veins from below
* Wait for 20 seconds and remove tourniquet
* Observe for additional filling from above
29
Signs & sx of DVT
* Pain – usually of a dull ache that may be relieved by elevation of the leg
* Swellingand tightness of the leg
* Erythema
* Increased warmth of affected limb
30
Test for DVT
* Circumference of calf
* Homan
* Pratt
31
Homan's sign
* Dorsiflexion of the foot with the knee extended
* Resultant compression of the soleus plexus of veins
32
Pratt's test
Postero-anterior compression of calf using both hands
33
Fundoscopy changes
Hypertension
* A-V nicking
* Exudates ,hemorrhages
* Papilledema (malignant hypertension)
Endocarditis
* Roth spots
34
Anachrotic
* **slow rising **(small) delayed pulse w a notch or shoulder on ascending limb.
* Ex. Aortic stenosis
35
Waterhammmer (Corrigan's) pulse
* rapid and sudden systolic expansion aka collapsing pulse
* Ex. Aortic regurg
36
Bisfriens pulse
* Double-peaked pulse w midsystolic dip
* Aortic regurg
37
Aternans pulse
* Alternating amplitude of pulse pressure
* Ex. CHF
38
Paradoxical pulse
* Marked systolic hypotension upon inspiration
* Ex. cardiac tamponade, constrictive pericarditis, COPD
39
Leriche's syndrome
* radial-femoral delay
* Aorta or iliac atherosclerosis, Coarctation of aorta after the subclavian artery, etc.
40
Large v waves
Tricuspid regurgitation
41
Giant/cannon a waves
Hepatojugular reflux, Complete heart block
42
Absent a waves
Atrial fib
43
Mumur special techniques
Used to distinguish between Mitral valve prolapse [MVP], Hypertrophic cardiomyopathy [HCOM], & Atrial stenosis [AS] murmurs. [PR=Peripheral resistance VR=Venous return]
i) Squatting
44
Prinzmetal angina
Cause & mechanism not clear [may be due to coronary artery spasm]
Presentation:
* Occurs @ rest & awakens patient from sleep [not associated w/ physical activity]
* Associated w/ ST segment elevation & indicative of transmural ischemia
Relieving: Vasodilators
45
Typical angina
Most common form. Critical stenosis [reduction of coronary artery to fixed stenosis
Presentation:
* Crushing or squeezing substernal pain that may radiate down left arm
* Associated w/ increased demand- physical activity, emotional excitement
Relieving: Rest & Vasodilators
46
Unstable angina
Disruption of plaque w/ superimposed thrombosis & vasospasm [not complete occlusion YET]
Presentation:
* Harbinger of subsequent MI
47
Finger clubbing
* Cardiac causes: Bacterial endocarditis, Cyanotic congenital heart diseases
* Pulmonary causes:Lung cancer, Empyma, Cystic fibrosis, Fibrosing alveolitis
* GI causes: Cirrhosis, Crohn, UC
* Congenital:
* Idiopathic
48
Systemic edema
* RHF
* Renal Failure
* Unregulated secretion of ADH
49
ASD
Left to right shunt, it might switch later forming Eisenmenger’s complex
i) Etiology: Usually congenital
ii) Results in:
(1) Right ventricular enlargement
(2) Pulmonary HTN
Signs:
* wide, fixed splitting
* Pulmonary flow murmur
* ECG show RBBB
50
VSD
Left to right shunt, it might switch later forming Eisenmenger’s complex
i) Etiology: Usually congenital small defect, If large
associated with growth retardation & CHF
ii) Results in:
(1) Right ventricular enlargement
(2) Pulmonary HTN
Signs:
* Loud pansystolic murmur -\> Maladie de Roger
* Forceful apex beat with a thrill
* Mitral diastolic flow murmur
51
Tetralogy of fallot
Right to left shunt Results in:
(1) Cyanosis immediately or soon after birth
(2) Increased feeding & crying
(3) Patient becomes apneic or unconscious
(4) Growth retardation
(5) Clubbing
(6) Polycythemia
52
Eisenmenger's syndrome
Right to left shunt that is due to shunt reversal in large ventricular or atrial septal defects
i) Results in:
(1) Right ventricular hypertrophy
(2) Pulmonary HTN
ii) Signs:
* Clubbing
* Central cynosis
* ECG will reveal RVH
53
Hypertrophic Cardiomyopathy (HCOM)
Obstructive
i) Etiology: 50% of cases autosomal dominant mutation
ii) Results in:
(1) Stiff ventricles impede diastolic filling
(2) Septal hypertrophy causing LV out flow tract obstruction
Signs:
* Angina on exertion
* Dyspnea on effort
* Syncope
* Sudden death in young adults
54
Congestive heart failure
Etiology: Multiple causes
(1) Pressure overload: LVH & then LVE
(2) V olume overload: L VH & L VE occur together
(3) Most common cause of RHF is LHF
ii) LHF results in:
(1) Hypotension -\> BP could be normal due to
increased peripheral resistance
(2) Pulmonary edema -\> SOB & Rales @ base of the lung
iii) RHF results in:
(1) ↑JVP, Pitting edema, ↑Liver congestion, ↓BP
55
Cardiac tamponade
Accumulation of fluid in pericardial space
i) Slow effusion results in:
(1) Right sided heart failure
(2) Severe pitting edema & ascites
(3) Pulsus paradoxus NOT as prominent
ii) Rapid effusion results in: MEDICAL emergency -\> Patient is very ill
(1) ↑Peripheral resistance, Hypotensive, Chest x-ray shows enlarged heart
(2) Pulsus paradoxus
CPD F2014
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