| What seven historical features of chest pain must be identified to differentiate cardiac pain from noncardiac pain? | Think PQRST: Precipitating factors, Quality, Radiation and location, Relief, Risk factor, Symptoms, and Time and duration |
Physical Examination
| What causes an S1? | Closure of the mitral and tricuspid valves |
| What causes a loud S1? | Sometimes with MVP, sometimes MS and ASD |
| What causes a soft S1? | MR (rheumatic or calcific), severe acute AI (valve closes prematurely) |
| What causes a widely split S1? | TS, Ebstein's anomaly, VT, RBBB, LV pacing |
| What causes an S2? | Closure of the aortic and pulmonic valves |
| What is the first sound of a split S2? | Aortic valve closure |
| What is on the differential of paradoxical splitting? | Pulmonary hypertension, LBBB, aortic stenosis, HOCM, patent ductus arteriosus (left-to-right shunt), TR |
| What causes a single S2? | Either absence of A2 or P2 (i.e., single ventricle, pulmonary atresia), or very soft P2 (Tetralogy of Fallot), or fusion in VSD or PA HTN |
| What causes a loud A2? | Thin chest wall, systemic HTN, aortic coarctation, and corrected TGA |
| What causes a soft A2? | Either AS (decreased mobility) or AI (fails to coapt) |
| What causes a loud P2? | PA HTN |
| What causes a soft P2? | Valvular or infundibular PS |
| What is in the differential when an S4 is noted? | LVH (HTN, AS, HOCM), RVH, IHD, hyperdynamic circulation, acute valvular regurgitation, and restrictive cardiomyopathy |
| When is the click heard in MVP? | Usually midway through systole |
| What maneuvers can affect the click? | Things that shrink the ventricle push the click closer to S2 (sitting up, part of Valsalva). |
| What is an ejection click? | A click usually heard during systole due to a congenitally abnormal aortic or pulmonic valve |
| What is an opening snap? | An early diastolic sound associated with abnormal mitral or tricuspid valve opening. Heard with MS or TS. |
| When does cyanosis occur? | When the concentration of deoxyhemoglobin in the blood is >5 mg/dL |
| What are the two main categories of cyanosis? | Central and peripheral |
| What are the general causes of central cyanosis? | Decreased arterial oxygen saturation caused by right-to-left shunting, impaired ability of hemoglobin to bind oxygen (e.g., in methemoglobinemia or abnormal hemoglobin variants), or impaired pulmonary function |
| What causes peripheral cyanosis? | Cutaneous vasoconstriction due to low CO or exposure to cold |
| What are the causes of peripheral edema? | Chronic venous insufficiency Venous obstruction Lymphatic obstruction Thrombosis Heart failure (high- and low-output) Constrictive pericarditis Nephrotic syndrome Hepatic cirrhosis Angioneurotic edema Myxedema |
| What is the formula for converting cm H2O to mm Hg? | cm H2O × 0.75 = mm Hg |
| In the jugular venous tracing below,* identify the various numbered waveforms. |
|
Passive ventricular filling | |
| What is the abdominal–jugular (also called hepatojugular) reflux? | An increase in JVP of >3 cm H2O with 10 to 30 seconds of periumbilical pressure |
| When does abdominal–jugular reflux occur? | It is associated with RV or LV failure, TR, or any cause of elevated CVP or PCWP. |
| How high is the JVP if the earlobes have a bobbing motion while the patient is sitting? | >15 cm H2O |
| What is the differential diagnosis of Kussmaul's sign? | Constrictive pericarditis, restrictive cardiomyopathy, RV infarction or failure |
| What is the differential diagnosis of pulsus paradoxus? | Pericardial tamponade, constrictive pericarditis, restrictive cardiomyopathy, COPD (exacerbation), asthma (exacerbation), superior vena cava obstruction, pulmonary embolus, hypovolemic shock, pregnancy, and obesity |
| What is the differential diagnosis of pulsus alternans? | Severe HF, anything causing rapid respiratory rates, pericardial tamponade |
| What is a bisferiens pulse? | A pulse waveform with two upstrokes |
| List five causes of a bisferiens pulse. | AI, HOCM, exercise, fever, PDA |
| With what are the following findings associated? | |
| Pulsus tardus | Obstruction to LV outflow (valvular AS or nonvalvular AS) |
| Pulsus parvus | Reduced LV stroke volume |
| Pulsus parvus et tardus | Severe AS |
| Bisferiens pulse (both peaks in systole) | Conditions in which a large stroke volume is ejected rapidly from the LV (aortic regurgitation, combined AS and AI), hypertrophic cardiomyopathy, hyperkinetic circulation, normal variant |
| Dicrotic pulse (first peak in systole, second peak in diastole—based on the relation to S2) | Hypotension, fever with decreased SVR, tamponade, severe heart failure, hypovolemic shock |
| Pulsus alternans | Severe LV dysfunction and a regular rhythm |
| What is the pulse pressure? | The systolic BP minus the diastolic BP; index = (systolic BP – diastolic BP)/(systolic BP) |
| What are causes of a wide pulse pressure? | Aortic regurgitation, PDA, truncus arteriosus, CHB, sinus bradycardia, fever, anemia, strenuous exercise, thyrotoxicosis, AV fistulas, and hot weather |
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