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CARDIOVASCULAR SYSTEM

Mitral stenosis

1) Grading of severity of mitral stenosis by echo and symptoms.


A) Echo: minimal (valve orifice 2.5 – 4 cms)
Mild (2.5-1.5 cms)
Moderate(1.5-1 cms)
Severe ( <1 cms)

2) Complications of MS
A) Acute left atrial failure, acute pulmonary edema, pulmonary
hypertention, CCF, atrial fibrillation, atrial flutter,
ventricular or atrial premature beats, embolic manifestation,
infective endocarditis, haemoptysis, ortner’s syndrome.

3) Mechanism of haemoptysis in MS.


A) Pulmonary apoplexy due to rupture of thin walled bronchial
veins or pulmonary veins resulting from sudden rise in left
atrial pressure,
Winter bronchitis
Acute pulmonary edema producing pink frothy sputum due to
rupture of capillaries into alveoli.
Pulmonary infarction causing frank haemoptysis.
Anticoagulant therapy for AF
Pulmonary haemosiderosis.

4) Causes of MDM at apex.


A) Carey coomb’s murmur
Austin flint murmur
MS and conducted murmur of TS
Left atrial myxoma and balve valve thrombus.
Funtional MDM in VSD and PDA.

5) Causes of MS
A) Congenital: parachute mitral valve.
Acquired: Rheumatic MS, Carcinoid syndrome, collagen
vascular disorder, endomyocardial fibrosis,
mucopolysaccharidosis.

6) What is lutembacher’s syndrome?


A) ASD with MS of rheumatic origin.

7)Ortner’s syndrome.

A) hoarseness of voice due to compression of left recurrent


laryngeal nerve by enlarged left atrium in MS.

8)Difference between Rheumatic MS, Austin flint and carey comb


murmur.

Features MS Austin flint Carey


coomb’s
Opening snap present Absent Absent
Loud S1 present Absent Absent
S3 Absent Present absent
Lt ventricular Absent present Absent
hypertrophy
Rt ventricular Present Absent Usually
hypertrophy absent
Change in Intensity does Intensity No change
murmur with not decrease decreases
amyl nitrate
Atrial May be Usually Usually
fibrillation present absent absent
Diastolic thrill May be May be Absent
present present

9) Clinical grading of MS.

A) The severity of mitral stenosis is clinically judged by the


distance between the opening snap and the aortic component of
the second sound.

The closer the opening snap to the second sound, the more
severe is the obstruction.

And also severe pulmonary HTN occurs only with severe MS

Mitral regurgitation

1) Cause for mitral regurgitation.

A) Causes for acute MR – trauma, Infective endocarditis, MI,


Acute rheumatic fever, cardiac surgery
Causes for chronic MR- RHD, collagen vascular disorders,
dilated cardiomyopathy, congenital

2) Difference between acute and chronic MR

A)
features Acute MR Chronic MR
Symptoms Sudden onset Gradual onset of
dyspnoea , PND, symptoms
orthopnoea
Apex beat unremarkable Displaced and
dynamic
First heart sound soft Normal / soft
murmur Early/holosystolic holosystolic
Fourth heart heard Not heard
sound
ECG Normal except in LA enlargement,
acute MI AF, LVH
Radiology Heart size normal cardiomegaly

3) Causes for pansystolic murmur

A) MR, VSD, TR

4) Difference between MR,TR and VSD

Features MR TR VSD
Site Apex Left parasternal Left parasternal
5th or 6th 3rd or 4th
intercostal space intercoastal
space
Conduction To axilla Localised Localised
Accentuation In expiration In inspiration In inspiration
with respiration

5) Complications of MR

A) a. Acute LVF

b. Infective endocarditis

c. CCF

d. Arrythmias – ventricular ectopics, atrial fibrillation

e. Giant left atrium producing pressure symptoms like dysphagia,

hoarseness of voice

f. Recurrent respiratory tract infections.

AORTIC STENOSIS

1) Severity of grading of AS

A) 1. By ECHO – Mild – size of aperture >0.75


Moderate – size of aperture 0.5-0.75
Severe – size of aperture < 0.5
2. By the pressure gradient between LV and aorta
0 – mild
0-30mmHg – moderate
30 – 50mmHg – severe
>50mmHg - very severe

2) Causes of AS

A) Congenital , Rheumatic , Degenerative ( calcific AS) ,

Atherosclerotic AS.

3) Cardinal signs of AS

A) - slow rising, small volume pulse


- Heaving apex beat
- S4 may be heard
- Ejection click
- Carotid thrill is felt
- Rough ejection systolic murmur in the aortic area radiating
towards the carotids and apex
- AS murmur – low pitched, rough , rasping in character.

4) What is Gallaverdins phenomenon ?

A) In aortic stenosis, the high frequency component of the ejection


systolic murmur may radiate to the apex. This therefore falsely
suggests MR.

AORTIC REGURGITATION

1) Causes for AR

A) – Rheumatic
- Traumatic
- Infective endocarditis
- Bicuspid aortic valve
- Atherosclerotic
- Dissection of aorta
- Syphlitic
- Marfans syndrome
- Ankylosing spondylosis
- Rheumatic arthritis.

2) Difference between acute and chronic AR

A)
FEATURES ACUTE AR CHRONIC AR
Onset Early, sudden Late, insedious
Pulse pressure Near normal wide
Systolic pressure Normal / decreased Increased
Diastolic pressure Normal / decreased Markedly decreased
LV impulse Normal/ Hyperdynamic
hyperdynamic
Auscultation Soft/absent S1, Normal S1 & P2. S3
increased P2 , S3 not heard, AR
heard. AR murmur murmur is long &
short & medium high pitched
pitched
Peripheral arterial absent present
signs
ECG Normal LV Enlarged LV
Chest Xray Normal Enlarged LV with
prominent aortic
root.
3) Differences between Rheumatic and Syphylitic AR.

A)
FEATURES RHEUMATIC AR SYPHILITIC AR
History Rheumatic fever syphilis
Angina Less common common
A2 Normal/ soft Loud tambour like
Diastolic murmur Third space to left of Second space to
site sternum right of sternum
Peripheral signs of Not well marked Very well marked
AR
Other valvular common Never present
lesions
VDRL Negative Positive
X ray Negative Positive calcification
calcification of confined to
aortic valve may be ascending aorta.
seen when Irregularity of aortic
associated with AS shadow seen.

4) Peripheral signs of Aortic Regurgitation

A) LIGHT HOUSE SIGN – Alternate flushing and blanching of


forehead
B) LANDOLFI’S SIGN – Change in papillary size in accordance
with cardiac cycle & not related to light.
C) BECKER’S SIGN – Retinal artery pulsations.
D) DE MUSSET’S SIGN – Head bobbing with each heart beat
E) MULLER’S SIGN – Systolic pulsations of uvula
F) QUINCKES’S SIGN – Capillary pulsations detected by
pressing glass slide on patient’s lips.
G) CORRIGAN’S SIGN – Dancing carotids
H) Locomotor Brachii
I) Collapsing or water hammer pulse
J) Bisferiens pulse
K) TRAUBE’S SIGN – Pistol shot femorals
L) DUROZIEZ’S SIGN – Systolic murmur heard over femoral
artery when it is compressed proximally and diastolic murmur
when it is compressed distally using bell of stethoscope.

M) HILL’S SIGN – Popliteal cuff pressure exceeds brachial cuff


pressure by >20mmHg.

N) ROSENBACH’S SIGN- pulsations of liver

O) GERHARDT’S SIGN – pulsations over enlarged spleen.

5) What is Carvallo’s sign

A) All right sided murmurs are best heard during inspiration


except pulmonary ejection click which is better heard during
expiration.

6) Complications of AR

A) - Acute LVF
- Infective endocarditis
- CCF
- Arrhythmias
- Heart block

-
1) Difference between pericardial rub and murmur.
Pericardial rub Murmur
In cardiac cycle Does not coincide Coincides with systole or
diastole
character scratchy Blowing/rumbling/musical
conduction no May conduct
variability present Not present
audibility superficial deep
Variability of Not present present
heart sound
Pressure of Alters the Doesn’t alter the intensity.
stethoscope intensity

2) Influence of exercise on murmur

A) Stenotic murmurs like MS, AS, PS become louder with isotonic


and isometric exercise.
MR, AR & VSD increase with handgrip.
Murmur of HOCM decreases with handgrip.

3) Site and radiation of murmurs.

A)

Mitral stenosis Mid diastolic murmur heard at


apex. Well localised
Mitral regurgutation Pansystolic murmur heard at
apex. Radiates to axilla and left
infrascapular area.
Aortic stenosis Midsystolic murmur heard at
the aortic area. Radiates to the
carotids.
Aortic regurgitation Early diastolic murmur heard at
the Erb’s area. Radiates to left
strnal border.

4) Grading of murmurs. ( only systolic )

A) Grade I – very soft heard in a quiet room.


Grade II – soft
Grade III - moderate
Grade IV – loud with thrill
Grade V – very loud with thrill (heard with stethoscope)
Grade VI – very loud with thrill ( heard even with stethoscope
slightly away from the chest wall ).

5) Difference between arterial pulse and venous pulse.

A)
CAROTID ARTERY PULSE JUGULAR VENOUS PULSE
Seen internal to the Seen in triangle formed by two
sternomastoid heads of SCM & clavicle.
Better palpable Better visible
Predominant outward movement Predominant inward movement
One peak per heart beat Two peaks per heart beat
No variation with posture or Variation with posture,
respiration respiration, abdominal
compression.
Not obliterable Obliterable

6) Austin flint murmur

A) – heard at apex
- Mid diastolic murmur
- Low pitched, soft rumbling murmur
- Well localized to apex
- Best heard with bell of stethoscope
- Heard in sever AR with AS.

7) Carey Coomb’s murmur

A) - heard at apex
- Mid diastolic murmur
- Low pitched soft murmur
- Well localized to apex
- Best heard with bell of stethoscope
- Heard in Rheumatic carditis

8) Graham Steele murmur

A) – heard at the pulmonary area


- Early diastolic murmur
- High pitched, soft blowing in character
- Radiates to left sternal border
- Best heard with diaphragm of stethoscope with patient
sitting up and stooping forward.
- Heard in pulmonary regurgitation.

9) Gibson’s murmur

A) It is a continuous murmur. It begins in systole, peaks near 2nd


heart sound and continues into diastole. Heard in PDA.

10. Abdominal jugular reflex


A) Firm compression is given in the periumbilical area for 30
seconds. In normal individuals the JVP rises transiently by less than
3cm and falls down even when the pressure is continued, whereas in
patients with right or left heart failure the JVP remains elevated.
Positive abdominojugular reflex is seen in RHF/LHF , TR.

11. Peripheral signs of Infective endocarditis.

A) clubbing, splenomegaly, pallor, new changing murmurs,


petechiae, splinter subungual hemorrhages, Osler’s nodes, Janeway
lesions, Roth’s spots, arthritis/arthralgia.

12) Abnormal pulse

a) Anacrotic pulse : Low volume pulse with upstroke felt in the


ascending limb. Seen in severe AS

b) Dicrotic pulse : Low volume pulse with upstroke felt in the


descending limb of the pulse wave. Found in 2nd week of typhoid fever,
endotoxic shock, hypovolaemic shock, diffuse myocardial disease.

c) Pulsus bisferiens : Single pulse wave with 2 peaks in systole. Found


in combined AS & AR, isolated AR and HOCM.

d) Pulsus paradoxus : pulse volume decreases with inspiration and


increases with expiration. Found in acute severe asthma, cardiac
tamponade, chronic constrictive pericarditis, COPD.

e) Pulsus Alternans : When alternate pulse waves are weak, ie, of low
volume in a patient with acute LVF.
f) Pulsus Bigemini : Clinically, two beats and a pause thereafter recur
repeatedly in a regular fashion. Found in digitalis toxicity and 3:2 heart
block.

g) Water Hammer pulse : it is characterized by high volume pulse,


sharp rise ill sustained and sharp fall. Found in AI , VSD, PDA,
Anaemia, thyrotoxicosis, Complete heart bock.

h) Pulsus parvus : small weak pulse,ill-sustained ( small volume and


narrow pulse pressure ). Found in cardiac failure, shock, MS, AS.

i) Pulsus parvus et tardus :slow rising low volume pulse well


sustained. Found in severe AS.

13) Eisenmenger’s syndrome

A) Pulmonary hypertension with reversal of shunt ( right to left ) from


an initial left to right shunt is called as Eisenmenger’s syndrome.
Causes are : VSD, PDA, ASD.

SIGNS : Central cyanosis, polycythemia, clubbing, prominent a-


wave in neck veins, features of RHF, loud palpable P2, Ejection click
and ejection systolic murmur due to pulmonary hypertension.

14) Eisenmenger’s complex

A) VSD with reversal of shunt .

15) Roger’s murmur

A) It is a loud pansystolic murmur heard at the left sternal border.


Heard in small VSDs.
16) Suzman’s sign

A) Arterial pulsations seen at the inferior angle of the scapula in co-


arctation of the aorta.

17) Mechanism of PND and orthopnoea

A) PND : At night when patient lies supine, there is movement of fluid


from extravascular (splanchnic circulation ) to intravascular
compartment therefore increasing the venous return. Due to increased
venous return the heart fails and patient feels breathless. When patient
walks to window fluid shifts back to extravascular compartment thus
reducing the venous return and patient feels comfortable.

ORTHOPNOEA : Dyspnoea in supine position. This occurs as in


supine position the action of gravity on the lower limbs is eliminated
thus increasing blood flow to the heart causing it to fail. Also, in supine
position, the diaphragm falls on the lung preventing it from expanding
thus causing dyspnoea.

18) Types of ASD

A) 1. Ostium secundum (90%)

2. Ostium primum (5%)

3. Sinus venosus (5%)

4. Coronary sinus type.


19) What are the indications for percussion in CVS?

A) a. pulmonary artery dilatation due to pulmonary hypertension.

b. pericardial effusion.

c. dextrocardia

d. Dilated cardiomyopathy.

20) Contraindications for percussion in CVS

A) infective endocarditis, left atrial thrombus

21) Conditions in which apex beat is not seen

A) 1. Apex lying behind a rib

2. obesity or thick chest wall

3. emphysema

4. left sided pleural effusion, pneumothorax

5. constrictive pericarditis

6. pericardial effusion.

22) Grading of parasternal heave.

A) Grade 1- seen but not felt.

Grade 2 – seen felt and can be obliterated


Grade 3 – seen , felt and cannot be obliterated.

23)JVP (a wave, v wave, y descent).

A) a wave is caused due to atrial contraction.

V wave is due to passive right atrial filling during ventricular systole

Both are positive waves.

Y descent is due to right ventricular filling with atrial emptying.

24)Causes for edema of feet.

A) unilateral: lymphatic obstruction, cellulitis.

Bilateral: Pitting: Liver failure, nephrotic syndrome,congestive cardiac


failure, hypoproteinemia.

Non pitting: myxoedema, filariasis.

25) Causes for acute heart failure.

A) Acute MI, Malignant hypertention, dissection of aorta, Massive


pulmonary thromboembolism, Arrythmias, Circulatory overload,
Myocarditis, Acute mitral and aortic regurgitation.

26) Causes for raised JVP.

A) Pulsatile: Cardiac failure, TS, TR, Constrictive pericarditis, cardiac


tamponade, Excess IV infusion.
Non pulsatile: SVC obstruction, innominate vein thrombosis.

27) Causes for malar flush.

A) High altitude, myxoedema, mitral stenosis, cushings syndrome,


thyrotoxicosis, chronic alcoholism, polycythemia, carcinoid syndrome,
pheochromocytoma.

28) causes of changing murmur.

A) Infective endocarditis, Atrial myxoma, Atrial thrombus.

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