Questions on examination of cardiovascular system


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Pulse

What are the normal examination routine of pulse?

Normal routine:

  1. Rate
    • Resting heart rate is normally 60–90 bpm.
    • Bradycardia is a pulse rate <60 bpm; tachycardia is a rate of >100 bpm.
  2. Rhythm
    • Sinus rhythm originates from the sinoatrial node and produces a regular rhythm.
  3. Volume
    • Volume refers to the perceived degree of pulsation and reflects the pulse pressure.
  4. Character
    • Character refers to the waveform or shape of the arterial pulse.
  5. Condition of the vessel wall
  6. Radiofemoral delay and radioradial delay or inequality

Compare other pulses simultaneously ( carotid pulse should not be seen simultaneously). Volume and char­acter of pulse are better seen in brachia! and carotid artery. Collapsing pulse in AR and pulsus alternans in L VF are better seen in radial.

* Macleod’s Clinical Examination, 13th Edition Page: 109, 110; Short Cases in Clinical Medicine, ABM Abdullah Page: 69
Describe normal and abnormal rate of pulse.

Rate:

  • Tachycardia: When the pulse rate is >100/min.
  • Bradycardia: When the pulse rate is <60/min.

Causes of tachycardia and bradycardia – see Atrial fibrillation.

What is sinus tachycardia?

Sinus rate >100 beats per minute (bpm) is sinus tachycardia.

Related reading Atrial fibrillation

* Pre-exam preparation for medicine, HN Sarker
What is sinus bradycardia?

Sinus rate

* Pre-exam preparation for medicine, HN Sarker
Tell some common causes of sinus tachycardia?

Some common causes of sinus tachycardia are:

  • Anxiety
  • Fever
  • Anemia
  • Heart failure
  • Thyrotoxicosis
  • Phaeochromocytoma
  • Drugs—e.g. β -agonists (salbutamol).

Related reading at Atrial fibrillation

* Pre-exam preparation for medicine, HN Sarker; Davidson’s Principles and Practice of Medicine, 22nd edition Page: 563

* Davidson’s Principles and Practice of Medicine, 22nd edition Page: 563
Tell some common causes of sinus bradycardia?

Some common causes of sinus bradycardia are:

  • MI (especially inferior MI)
  • Sinus node disease (sick sinus syndrome)
  • Hypothermia
  • Hypothyroidism
  • Obstructive jaundice
  • Raised intracranial pressure.
  • Drugs—e.g. β -blockers, digoxin, and verapamil.
* Pre-exam preparation for medicine, HN Sarker; Davidson’s Principles and Practice of Medicine, 22nd edition Page: 563
Describe normal and abnormal rhythm of pulse.

It is the interval between successive pulses.

Types:

  1. Regular
  2. Irregular
    • Irregularly irregular
    • Regularly irregular.

Causes of irregular pulse:

  1. Regularly irregular (follows a definite pattern of regular rhythm followed by irregular rhythm). It occurs in:
    • Sinus arrhythmia (pulse rate increases on each inspiration, decreases on each expiration). It is abolished by exercise.
    • Occasional ectopics. Second-degree heart block (Mobitz type I, Wenckebach type).
  2. Irregularly irregular means irregular in rhythm and volume. Its causes are:
    • Atrial fibrillation.
    • Multiple ectopics.
    • Atrial flutter with variable block
    • Paroxysmal atrial tachycardia with variable block.
 * Short Cases in Clinical Medicine, ABM Abdullah Page: 71
What is pulse deficit?

It is the difference between the heart rate and the pulse rate. It is commonly found in atrial fibrillation and multiple ectopic beats.

The pulse deficit (difference between heart beats and pulsations at the periphery) is determined by simultaneous palpation at the radial artery and auscultation at the PMI, near the heart apex.

Read more at medicosnotes.com, Wikipedia

Describe volume of pulse.

Causes of high-volume pulse:

  • AR
  • Hyperdynamic circulation due to any cause
  • PDA
  • Hypertension

Causes of low-volume pulse:

  • Shock
  • AS
  • MS
  • Chronic constrictive pericarditis
  • Pericardial effusion
  • Pulmonary hypertension
 * Short Cases in Clinical Medicine, ABM Abdullah Page: 71
Describe different character of pulse.
  1. Anacrotic pulse is a slow-raising, small-volume pulse (notch on upstroke). It is caused due to AS.
  2. Plateau pulse is of small volume with slow upstroke. It is caused due to AS.
  3. Bisferiens pulse is the double peak of pulse, which is felt better in carotid ( due to combination of slow raising and collapsing). Caused due to combined AS and AR.
  4. Water hammer pulse is typically found in AR.
  5. Pulsus alternans is an alternate strong and weak beat (suggestive of LVF).
  6. Jerky pulse is seen in carotid artery. It is caused due to hypertrophic cardiomyopathy (HCM).
  7. Pulsus paradoxus: When volume of pulse reduces on inspiration and increases on expiration, it is called pulsus paradoxus (also systolic BP falls during inspiration, normally <10 mmHg). It is the exaggeration of normal phenomenon ( normally present in children). It is better detected by sphygmomanometer. Abnormal, if > 10 mmHg.
  8. Collapsing pulse: There is a rapid upstroke and descent of pulse, seen by raising the arm above the head.

Figure: Pulse waveforms
 * Short Cases in Clinical Medicine, ABM Abdullah Page: 71, 72; Figure: Macleod’s Clinical Examination, 13th Edition Page: 111
What are the causes of pulsus paradoxus?
  1. Pericardial effusion ( especially, cardiac tamponade).
  2. Chronic constrictive pericarditis.
  3. Acute severe asthma and chronic obstructive pulmonary disease (COPD).
  4. Massive pulmonary embolism
 * Short Cases in Clinical Medicine, ABM Abdullah Page: 71
What is the mechanism of pulsus paradoxus?

During inspira­tion, intrathoracic pressure falls, blood pools in pulmonary vessels and hence left heart fill­ing is reduced with reduction of cardiac output. Therefore, the pulse volume is low, which is reverse on expiration.

 * Short Cases in Clinical Medicine, ABM Abdullah Page: 72
What is collapsing pulse?

In collapsing pulse, there is rapid upstroke and descent of pulse, seen by raising the arm above the head.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 191
What are the causes of collapsing pulse?
  1. AR (the commonest cause).
  2. Hyperdynamic circulation due to any cause
  3. PDA
  4. Rupture of sinus of Valsalva.
  5. Large arteriovenous communication.
 * Short Cases in Clinical Medicine, ABM Abdullah Page: 72
If collapsing pulse is present, what else do you want to see?

Then it is essential to see the signs of AR:

  1. BP: High systolic, low diastolic and wide pulse pressure.
  2. Neck: Dancing carotid pulse.
  3. Heart: EDM
* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 101
What are the causes of high volume pulse?

As follows:

  • Aortic regurgitation
  • Hypertension
  • Hyperdynamic circulation due to any cause (severe anemia, thyrotoxicosis, arteriovenous fistula, fever, etc.)
  • PDA
* Long Cases in Clinical Medicine, ABM Abdullah Page: 191
What is the difference between high-volume pulse and collapsing pulse?

Collapsing pulse is always a high-volume pulse, but all the high-volume pulses are not necessarily collapsing.

 * Short Cases in Clinical Medicine, ABM Abdullah Page: 72
What is the type of pulse in AS?

Anacrotic or plateau pulse – low volume slow rising pulse, may be –

  • small-volume pulse (pulsus parvus) or
  • late peaking (pulsus tardus ).
* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 82; Short and Long Cases in Clinical Medicine, HN Sarker Page: 46
Why this is called water hammer pulse?

The name originated from a Victorian toy, consisted of a sealed tube, half filled with water and half being vacuum. Inversion of the tube causes the fluid to fall rapidly without air resistance and strike the end like hammer blow.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 191
What are the causes of wide pulse pressure?

As follows:

  • AR
  • PDA
  • A-V fistula
  • Hyperdynamic circulation (thyrotoxicosis, anemia, beriberi, pregnancy).
* Long Cases in Clinical Medicine, ABM Abdullah Page: 192

JVP

What is the mechanism of cannon waves?

Due to loss of AV synchrony (/AV dissociation), when atria contracts against closed tricuspid valve, backward pressure produces a giant ‘a’ wave that is found in JVP and is called cannon wave.

Short Cases in Clinical Medicine, ABM Abdullah Page: 104; Short and Long Cases in Clinical Medicine, HN Sarker Page: 70
What are the causes of cannon waves?
  • Complete heart block
  • Ventricular tachycardia
  • Junctional rhythm.
Short and Long Cases in Clinical Medicine, HN Sarker Page: 70

Heart sound

Why does variable intensity of first heart sound occur in CHB?

Variable intensity of first heart sound is due to loss of AV synchrony.

Short Cases in Clinical Medicine, ABM Abdullah Page: 104

See more about Complete heart block.

What is wide and fixed splitting of 2nd sound?

Wide means that gap between A2 and P2 is wider than usual and fixed splitting means no variation during respiratory cycle, i.e. it remainins same in inspiration and expiration.

See more about heart sound at ASD.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 55

Why does wide and fixed splitting occur in ADS?
  • Wide: Because of delay in right ventricular ejection (increased stroke volume and right bundle branch block) and
  • Fixed: Because the septal defect equalises left and right atrial pressures throughout the respiratory cycle.

Note:

Normally, there is wide splitting during inspiration due to delay of closure of pulmonary valve.

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 633; Long Cases in Clinical Medicine, ABM Abdullah Page: 246

Murmur

Why does systolic flow murmur occur in CHB?

Systolic flow murmur is due to increased stroke volume.

Short Cases in Clinical Medicine, ABM Abdullah Page: 104

See more about Complete heart block.

What do you mean by ‘ejection systolic murmur’?

It is a crescendo-decrescendo murmur starting after the first heart sound, peak in mid systole and ends before the second heart sound.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 46
Where the murmur of aortic stenosis heard?

The murmur of aortic stenosis is heard throughout the precordium, but is usually loudest in the aortic area.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 46
Why there is ESM in AR?

Due to increased flow through aortic valve without aortic stenosis (or may be associated with AS).

* Long Cases in Clinical Medicine, ABM Abdullah Page: 192
What are the causes of EDM?

As follows:

  • Aortic regurgitation
  • Pulmonary regurgitation (evidence of pulmonary hypertension is present and other peripheralsigns of AR are absent).
* Long Cases in Clinical Medicine, ABM Abdullah Page: 192
May mid-diastolic murmur be heard in AR?

Yes, it is called Austin Flint murmur.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 49
Why there is MDM in AR (Austin Flint murmur)?

It is due to regurgitant flow from aortic valve causing vibration of the anterior leaflet of mitral valve.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 192
What is the mechanism of Austin Flint murmur?

Austin Flint murmur is caused by

  • the aortic regurgitation jet impinging on the anterior mitral valve leaflet leading to functional mitral stenosis,
  • the left ventricular diastolic pressure rising more rapidly than the left atrial pressure.
* Short and Long Cases in Clinical Medicine, HN Sarker Page: 49
How can you differentiate Austin Flint murmur from MDM due to MS?

In MS, following features are present along with MDM

  • Tapping apex beat
  • Loud first heart sound
  • Opening snap
  • MDM is associated with presystolic accentuation.
* Short and Long Cases in Clinical Medicine, HN Sarker Page: 49
What are the murmurs in ASD?

Two murmurs:

  • ESM
    • It is due to increased flow through pulmonary valve
    • ESM is typical of ASD
    • It does not occur due to septal defect
  • MDM
    • MDM in left parasternal area is due to increased flow through tricuspid valve
    • Its presence indicates hemodynamically significant shunt.

Note:

No murmur is due to ASD. Because there is equal pressure between left and right atrium.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 246; Short and Long Cases in Clinical Medicine, HN Sarker Page: 56
Why no murmur due to ASD itself?

There is no murmur due to ASD, because of equal pressure between left and right atrium.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 56
What is continuous murmur?

The continuous murmur begins after the first heart sound and peaks at the second heart sound, after which it trails off, i.e. Murmur can span the whole of systole and diastole, obscuring second heart sound.

Read more at PDA

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 60
What are the causes of continuous murmur?

As follows:

  • PDA
  • Arteriovenous fistula (coronary, pulmonary or systemic)
  • Aortopulmonary fistula (may be congenital or Blalock-Taussig shunt)
  • Venous hum
  • Rupture of sinus of Valsalva to the right ventricle or atrium.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 250
Which murmurs may mimic continuous murmur?

The following murmurs may mimic continuous murmur (to and fro murmur)

  • Mitral regurgitation and aortic regurgitation
  • Ventricular septal defect and aortic regurgitation.
* Short and Long Cases in Clinical Medicine, HN Sarker Page: 60
How would you differentiate PAD murmur from that of pulmonary stenosis when only systolic component is heard?

The murmur of PDA is heard loudest below the left clavicle and is equally loud posteriorly. This is not the case for pulmonary stenosis.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 50
What happens to the murmur of VSD as Eisenmenger’s complex develops?

With the development of pulmonary hypertension, left- to-right shunting decreases, murmur becomes shorter and soft and when pressure equalizes, then murmur disappears.

See more at Eisenmenger’s syndrome

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 62
Why there is no murmur of VSD in TOF?

Why there is no murmur of VSD in TOF, because VSD is large and there is equal pressure in right and left ventricles.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 238
Why murmur in coarctation of aorta?

Murmur in coarctation of aorta is due to:

  • Usually due to increased flow through collateral vessels.
  • Also may be due to associated congenital bicuspid aortic valve.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 254
What are the murmurs heard in coarctation of aorta?

The murmurs heard are as follows

  • A systolic murmur at the site of coarctation – best heard posteriorly
  • An ejection systolic murmur of aortic stenosis due to bicuspid aortic valve
  • An early diastolic murmur of aortic regurgitation due to bicuspid aortic valve
  • Systolic bruits over the collaterals.
* Short and Long Cases in Clinical Medicine, HN Sarker Page: 67
Andy Tran

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