Causes of False Positive and False Negative Tests for Marked Inspiratory Fall in Blood Pressure

Why do some asthmatic patients seem to have a marked inspiratory fall in blood pressure ANS Bronchospasm may raise the intrathoracic pressure very high (similar to a Valsalva maneuver), and inspiration will, by contrast, seem to lower the systolic pressure excessively. Actually, it is an expiratory rise in blood pressure, not an inspiratory fall. 2. When will there be no significant inspiratory fall in blood pressure despite marked tamponade ANS a. If AR is present, the LV can fill from the...

Factors Controlling Loudness of VSD Murmurs

What is the relationship between the size of the VSD and the loudness of the murmur ANS If it is very small (pinhole VSD), the murmur may be very soft. If it is very large, so that there are almost equal pressures in the RV and the LV, the murmur may also be very soft. If, however, it is moderately large, there is usually a very loud murmur. (Some of the loudest murmurs observed in cardiological practice, next to prolapsed valve honks, are caused by moderately large VSDs.) 2. What auscultatory...

Right Ventricular Hypertrophy RVH

What are the characteristics of a normal left parasternal impulse ANS It consists of a tiny inward (posterior) movement throughout most of systole due to the emptying of the RV. In children and in some adults, there is a smaller-amplitude initial outward movement of short duration, probably due to a change in shape of the RV during isovolumic contraction. 2. How does the left parasternal impulse caused by the RVH or pulmonary stenosis (PS) or pulmonary hypertension differ from normal ANS It is...

Other Auscultatory Signs of PDA

What auscultatory signs of the increased flow through the mitral valve and large volume load on the LV may be heard in patients with a PDA ANS There may be an S3 and or a mitral diastolic flow murmur and the S2 split may be paradoxical. 2. What are the multiple clicks or crackles heard at the end of systole and the beginning of diastole called Their significance ANS Eddy sounds. They signify a large flow ductus 11 . PDA with High Pulmonary Artery Pressure 1. What causes differential cyanosis...

The S4 in Myocardial Infarction

What proportion of patients with acute myocardial infarction have an S4 ANS Almost all will have a phonocardiography S4 unless they have MS or atrial infarction. It is heard by auscultation in about half of the patients during the first few days following infarction 2 . Note An infarcted area, whether dyskinetic (bulges out like an aneurysm in systole) or akinetic (no movement during systole), causes loss of compliance of the LV. Presence of excess catecholamines, which is usual in the first...

Ejection Sound in Pulmonary Hypertension

Why is an ejection sound heard in pulmonary hypertension ANS The high pressure in the pulmonary artery may dilate the pulmonary artery root, and the valve ring will be stretched. The tautened cusps, opening at a very rapid rate, probably produce the sound or click. This high-frequency phonocardiogram and simultaneous carotid tracing is from a patient with severe pulmonary hypertension secondary to a VSD (Eisenmenger syndrome). Note that the pulmonary ejection (E J) sound does not diminish with...

Glossary

Skeleton Coloring Pages Printable

Aneurysm Localized dilatation of either a blood vessel or a heart chamber. The most common cause of an arterial aneurysm is atherosclerosis. Anywhere in the aorta atrophy of the media (muscular layer) deep to an atherosclerotic plaque results in either a saccular or a fusiform (spindle-shaped) dilatation. The most common site is the abdomen distal to the renal arteries. Syphilis (lues) used to be the most common cause of thoracic aortic aneurysm, usually in the ascending aorta. When infection...

And The Severity Of Mitral Stenosis

What are the major factors controlling the duration of isovolumic relaxation, or the 2-OS interval ANS a. The pressure at which the aortic valve closes (near systolic pressure). b. The pressure in the LA at the time the mitral valve opens. 2. What is the relationship between the degree of MS and the height of the V wave in the LA ANS The greater the stenosis, the greater the obstruction to flow and thus the slower and more incomplete is the emptying of the LA. Therefore, the greater the MS, the...

The S2 Split In Pulmonary Hypertension

What are the three general types of pulmonary hypertension ANS a. Hyperkinetic pulmonary hypertension, i.e., that due to excess volume flow, as in large left-to-right shunts. The pulmonary arterioles can dilate to accommodate up to three times the normal cardiac output before the pulmonary artery pressure must rise. b. Vasoactive pulmonary hypertension, i.e., that due primarily to pulmonary arteriolar constriction, as in response to either hypoxia or to a high left atrial pressure, as in...

The Crescendo Murmur to the Mt in Mitral Stenosis The Presystolic Murmur

Mitral Stenosis Pressure Curves

What is the appearance or shape of a murmur that is produced by atrial contraction forcing blood through a stenotic mitral valve ANS It should follow the curve of atrial pressure rise and fall, i.e., it should be crescendo-decrescendo. 2. What is the actual shape of the diastolic murmur produced by atrial contraction at the end of diastole in MS ANS It is crescendo to the first sound. This murmur is often called presystolic. 3. Does the presystolic crescendo murmur of MS extend to the M1...

The Exaggerated Physiological S3

List the common shunts and the valvular lesion that may cause excessive flow through the mitral valve, therefore exaggerating or bringing back the physiological S3. ANS a. The two left-to-right shunts, ventricular septal defect VSD and persistent ductus arteriosus PDA . Atrial septal defects ASDs do not increase flow through the mitral valve. b. An incompetent mitral valve, i.e., mitral regurgitation MR . Low-frequency phonocardiogram from a 15-year-old girl with severe rheumatic MR. Besides...

And Thyroid Artery Flow Murmurs

What is characteristic of the timing and duration of a physiological non-obstructive vascular murmur ANS They are early in systole and short. 2. What are the characteristics of an arterial murmur due to obstruction ANS If a pressure difference across the obstruction is present in both systole and diastole, the murmur will be continuous, and the systolic murmur is always louder than the diastolic. The murmurs will have a mid- or late systolic peak if the obstruction is severe. 3. What is the...

Causes of a Loud A2 or P2

Hyperkinetic Circulation

What conditions tend to make the aortic component of the second sound louder than normal ANS a. Conditions that raise aortic systolic pressure, e.g., systemic hyper tension, which occasionally produces a drumlike sound or tambour S2. A tambour is a small drum that is covered only on one side. The tambour effect may persist even after the blood pressure has been lowered to normal by medication. b. Conditions that produce a hyperkinetic systemic circulation, e.g., youth, or thyrotoxicosis. The...

The Loudness Of The Opening Snap

Aortic And With Opening Snap

Other than an obese or emphysematous chest and AR, what can cause a soft or absent OS despite significant MS ANS a. The mitral valve may be too calcified for the bellies to snap to their maximal open position. The S1 may still be loud. b. Extremely low flow due to exceptional severity of the stenosis, secondary pulmonary hypertension, concomitant aortic or tricuspid valve disease, or myocardial dysfunction. 2. How often does a mitral commissurotomy eliminate the OS ANS Probably in not more...

Normal Jugular Pulse Contours

Jugular Pulse

What is the difference between the jugular and right atrial pulse contours ANS None for all practical purposes, except when jugular pulse tracings pick up carotid artifacts. Therefore, the right atrial contours will be explained first because it is right atrial events that produce the jugular contours. 2. What is the normal right atrial contour and what are the letters given to the important crests and descents ANS The normal right atrial contours consist of A, C, V, and H waves. However, it...

Right Ventricular Enlargement

Apex Cardiogram

How can you best palpate for movement caused by a large RV ANS a. Since the RV is an anterior structure, its enlargement may produce an increased left parasternal movement. Diffuse left parasternal movements are often best palpated with the proximal part of the palm thenar and hypothenar areas . The movement is then transmitted to the entire arm. The shoulder becomes the fulcrum and this amplifies the hand movements that are at the end of the arm lever. b. Look for systolic downward movement...

Abnormalities of the V Wave

Descent Restrictive Cardiomyopathy

How can you recognize a higher than normal V wave at a glance ANS By recognizing a Y descent of greater amplitude than normal. 2. What are the common causes of a higher than normal jugular V wave ANS a. Excessive right atrial filling either from 1 above the tricuspid valve, as in ASD or anomalous pulmonary venous connection, or 2 below the tricuspid valve as in TR. b. Loss of compliance of the right atrium from either 1 outside the heart, i.e., constrictive pericarditis, or 2 inside the...

As The Cause Of A Split S

How long after the Mj does the aortic ejection sound Al occur in normal subjects ANS The usual AJ occurs at the end of isovolumic contraction i.e., about 40-60 ms 0.04 -0.06 s after the Ml . To help you judge this normal split of the first sound interval, a 40-ms split takes as long as it does to say pa-da moderately quickly. The 60-ms split can be imitated by saying pa-ta as quickly as possible. A 40- to 60-ms split is a moderately wide split. 2. Which valvular abnormalities are the usual...

Measurement Of Venous Pressure

Forensic Pathology Images Enapure

How can you detect jugular pulsations that are difficult to perceive ANS a. Shine a light tangentially from behind or in front of the neck to throw a jugular shadow. b. The most accurate way of finding the top level of pulsations is to examine the silhouette of the neck. When you are examining the right side of the neck, you must lean over to the left side of the patient or stand on the left side of the bed temporarily to obtain a good view of the silhouette of the skin overlying the right...

Differential Diagnosis Of The Fixed Split

What may mimic a wide fixed split of the S2 ANS a. The A2 followed by an opening snap. b. A very wide split in which normal movements of the A2-P2 are difficult to perceive by auscultation. 2. Why does the split S2 in the normal subject tend to narrow on sitting or standing ANS This happens because when both ventricles receive less blood due to pooling in the abdomen and the legs , the RV responds by ejecting its blood relatively faster than does the LV 5 . The RV responds more to changes in...

Triple Ripple Hocm

Apex Cardiogram

With which abnormality do you often find a mid-systolic dip in the presence of LVH ANS Hypertrophic obstructive cardiomyopathy HOCM . 2. What kind of impulse may be imparted to the apex beat of a patient with severe HOCM if an A wave is also present ANS A triple outward movement known by some as a triple ripple . This is almost pathognomonic of HOCM . 3. Which valvular abnormality may have a mid-systolic dip without LVH ANS A prolapsed mitral valve. An S4 or a click and murmur quickly...

Arterial Pulses and Pressures

Arterial Tracings Water Hammer Pulse

Why is palpating both brachial and radial arteries simultaneously an efficient method of palpating the arm pulses, besides speeding up the palpation of the pulses ANS It allows you to estimate the systolic blood pressure without a stethoscope or blood pressure cuff. This procedure is described later in this chapter. Since the brachial artery is a medial vessel, it should be approached medially. The radial artery is a lateral vessel and therefore should be approached laterally. 2. Where are...

Hepatojugular Reflux

Hepatojugular Reflex

What is the cause of a high venous pressure in a person with low cardiac output ANS a. Increase of venous tone due to sympathetic outflow and catecholamines. b. Increased blood volume due to salt and water retention, probably at least partly due to the increased sympathetic outflow effect on the kidneys. One may therefore characterize a high venous pressure in heart failure as due to an increase in tone volume. 2. What can cause a patient with heart failure to have an apparently normal...

Capillary Pulsation

How do you elicit capillary pulsation Quincke's sign ANS Compress the skin of the face or hands with a glass slide, or exert slight pressure on the nail beds and watch for intermittent flushing. You can also transilluminate the nail bed with a flashlight against the pad of the patient's finger while shading the finger with the other hand. 2. What is the mechanism of capillary pulsations and what noncardiac conditions can cause it ANS The mechanism is the transmission of the arterial pulse...

Leg Pulses and Blood Pressure in Coarctation of the Aorta

Anacrotic Shoulder

When should you suspect coarctation of the aorta ANS In any patient with hypertension. 2. What are the characteristics of the pulses proximal to and beyond an aortic coarctation ANS The proximal pulses, i.e., the carotid and brachial pulses, are large, bounding pulses. The parts of the body beyond the coarctation i.e., usually beyond the left subclavian artery receive blood through enlarged collaterals that do not transmit the percussion wave well. Therefore, not only do the lower extremity...