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The Cardiac Physical Exam

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The Cardiac Physical Exam These patients present with heart failure. The Cardiac Physical Exam Which endocrine disorder do they have? An assessment of the patient’s general appearance may provide important clues to an underlying cardiac diagnosis. 1. Hypothyroidism 2. Hyperthyroidism • Head and face 3. Cushing’s syndrome •Eyes 4. Addison’s disease 5. Acromegaly • Skin and Mucous membranes • Extremities This patient is likely to have which The Cardiac Physical Exam of the following problems? • Exophthalmos and stare occur in • 1. Muscular hyperthyroidism which can cause heart dystrophy failure in a patient with reduced cardiac • 2. Depression reserve. • 3. Hypothyroidism • 4. Lung cancer • Severe tricuspid regurgitation can cause • 5. Rheumatoid pulsatile exophthalmos (as well as arthritis pulsation of the earlobes). This mother and daughter have blue sclerae The Cardiac Physical Exam which can be seen in which of the following disorders? • Myxedema (hypothyroidism) is characterized by a dull, expressionless • 1. Marfan syndrome face, periorbital puffiness, loss of the • 2. Rheumatoid lateral eyebrows and dry, sparse hair. arthritis • The tongue is large. •3. Osteogenesis • The patients will complain of cold imperfecta intolerance, dry skin, hoarseness, • 4. Cystic Fibrosis constipation, and shortness of breath. • 5. Muscular dystrophy 1 This patient has reduced exercise tolerance. You The Cardiac Physical Exam suspect which of the following cardiac abnormalities? Osteogenesis Imperfecta • 1. left to right intracardiac shunt • A connective tissue disorder associated • 2. right to left with fragile bones (fractures with minimal intracardiac shunt trauma), blue sclerae, and aortic root • 3. rheumatic fever dilatation, aortic regurgitation, and mitral • 4. mitral valve prolapse valve prolapse. • 5. endocarditis This patient presents with shortness of breath and diabetes. What is the most likely The Cardiac Physical Exam diagnosis? • This patient has central cyanosis which is due to intracardiac or intrapulmonary right-to-left shunting and 1. Too much time in which involves the entire body including warm, well- Florida perfused areas such as the conjuctivae and the mucous membranes of the oral cavity. 2. Acromegaly 3. Amyloidosis • Peripheral cyanosis due to reduction of peripheral blood flow such as occurs in heart failure and peripheral 4. Hemochromatosis vascular disease is characteristically more prominent in 5. Cirrhosis cool, exposed areas that may not be well perfused such as the extremities, particularly the nailbeds. The Cardiac Physical Exam Hemochromatosis is a hereditary disorder in which the small intestine absorbs excessive iron. The excess is stored in glands and muscle such as the liver, pancreas and the heart. Iron deposition in the heart causes a restrictive cardiomyopathy, leading to congestive heart failure. It is seen much more commonly in men then in women (8:1 ratio). Girish, M.P. et al. N Engl J Med 2005;352:2424 2 This patient is a 40 year old woman. What is the most likely diagnosis? The Cardiac Physical Exam Hereditary hemorrhagic telangiectasia (Osler- • 1. Gout Weber-Rendu syndrome) is a disorder of the vascular structures involving the nose, skin, • 2. Rheumatoid arthritis brain, gastrointestinal tract and lung. • 3. Lupus Telangiectasias are focal dilatations of the postcapillary venules. Arteriovenous •4. Coronary artery disease malformations affect the brain (subarachnoid • 5. Leprosy hemorrhage), GI tract (GI bleeding) and lung (causing right to left shunts and central cyanosis). A patient with these skin lesions is likely to The Cardiac Physical Exam have which of the following conditions? This patient has familial hypercholesterolemia and has severe coronary artery disease. • 1. Lupus Physical exam is notable for marked • 2. Rheumatoid xanthomas. Xanthomas are an important arthritis manifestation of altered lipid metabolism. They are small, firm, painless nodules of a reddish • 3. Leprosy yellow color that can coalesce to form •4. Endocarditis multilobulated tumors. They usually develop in • 5. Melanoma pressure areas and are associated with increased levels of LDL cholesterol. This patient presents with gastrointestinal bleeding. The patient appears to have central cyanosis. This is The Cardiac Physical Exam most likely caused by? Panel A shows splinter • 1. Congestive heart hemorrhages which failure are normally seen • 2. COPD under the fingernails or toenails. They are •3. Pulmonary usually linear and red arteriovenous for the first two to fistulas three days and • 4. Cystic fibrosis brownish thereafter. • 5. Pulmonary emboli 3 This patient has cyanosis and CLUBBING. She The Cardiac Physical Exam most likely has which of the following? 1. A very active social life Panel B shows 2. Cyanotic conjunctival congenital heart petechiae disease 3. Cystic fibrosis 4. Lupus 5. Rheumatic fever The Cardiac Physical Exam Panel C shows • Clubbing of the digits is characteristic of Osler’s nodes which cyanotic congenital heart disease or are tender, pulmonary disease with hypoxia. It may subcutaneous also occur within a couple of weeks of the nodules, often in the development of endocarditis. Clubbing is pulp of the digits or characterized by the loss of the normal the thenar eminence. angle between the base of the nail and the skin. The patient who can do the following maneuver is The Cardiac Physical Exam likely to have which of the following conditions? Panel D shows • 1 Hyperthyroidism Janeway’s lesions •2 Marfan syndrome which are nontender • 3 Rheumatic Heart erythematous, hemorrhagic or disease pustular lesions, often • 4. Rheumatoid on the palms or soles. Arthritis • 5. Lupus 4 The Cardiac Physical Exam Marfan syndrome – a connective tissue disorder • CD Rom characterized by: Skeleton: joint hypermobility, tall stature, arachnodactyly, chest deformities Eye:retinal detachment Cardiovascular: mitral valve prolapse, dilatation of the aortic root, aortic dissection Pulmonary: spontaneous pneumothorax Skin: inguinal hernias A “standard” blood pressure cuff The Cardiac Physical Exam can be used on all patients? Pectus excavatum (funnel chest), a condition in which the sternum is displaced posteriorly, is commonly observed in Marfan syndrome, • 1. True homocystinuria, Ehler- Danlos syndrome, and a • 2. False small percentage of patients with mitral valve prolapse. Rarely there can be significant compression of the heart and elevation of intracardiac pressures. The Cardiac Physical Exam The Cardiac Physical Exam Pectus carinatum When a standard size cuff is applied to a (pigeon breast) is often larger upper arm, arterial pressure is found in patients with overestimated and when applied to a Marfan syndrome. It small arm, the pressure is does not directly affect cardiovascular underestimated. function. 5 An exaggerated fall in arterial blood The first heart sound S1 is typically made pressure with inspiration is called? up of two audible components. • 1. Pulsus alternans •1. True • 2. Pulsus bigeminus • 2. False • 3. Pulsus paradoxus • 4. Bisferiens pulse The second heart sound S2 is typically The Cardiac Physical Exam made up of two audible components Pulsus Paradoxus is an exaggerated reduction (more than 10 mmHg during quite breathing) in the strength of the arterial pulse during normal inspiration due to an exaggerated inspiratory fall in blood pressure. It is a frequent, often “characteristic” finding in patients with cardiac • 1. True tamponade but can be seen in patients with • 2. False constrictive pericarditis, pulmonary disease (emphysema and bronchial asthma), hypovolemic shock, pulmonary embolism, and extreme obesity. If tachycardia makes the identification of S1 difficult, The second heart sound S2 normally splits on the palpation of which pulse should be used for timing? inspiration and is single on expiration • 1. brachial • 2. radial • 1. True • 3. femoral • 2. False •4. carotid • 5. dorsalis pedis 6 “Fixed” splitting of S2 classically occurs in which of the following conditions? The Cardiac Physical Exam • CD-ROM • 1. Pulmonary hypertension • 2. Atrial septal defect • 3. Ventricular septal defect • 4. Mitral regurgitation • 5. Aortic stenosis The pulmonic (P) component of S2 is usually softer than the aortic (A) component and is heard only in the pulmonic area except in An S4 gallop would be heard before or the following condition where P2 is loud and heard more diffusely? after the carotid upstroke? • 1. Pulmonic stenosis • 2. Pulmonary hypertension • 1. Before • 3. Aortic stenosis • 2. After • 4. Systemic Hypertension • 5. Atrial septal defect “Paradoxical” splitting of S2 (on expiration) occurs when A2 is delayed because of late left ventricular activation. All of the The Cardiac Physical Exam following can delay LV activation except: • 1. Left-sided congestive heart failure An S4 gallop (an atrial filling sound) is • 2. Left bundle branch block always abnormal in a 20 year old. • 3. Severe aortic stenosis • 4. Atrial septal defect • 1. True • 5. Pacing (always from RV apex) • 2. False 7 Sounds heard in systole include The Cardiac Physical Exam all of the following except? An S4 gallop (atrial filling sound) may be • 1. Opening snap normal in individuals over the age of 50. • 2. Aortic ejection click • 3. Pulmonic ejection click • 1. True • 4. Mitral click •2. False • 5. Tricuspid click An S3 gallop (ventricular filling sound) can be Mitral stenosis is most commonly caused by rheumatic a normal finding in individuals under the age of fever. Which sound would you most likely hear in a 30. patient with this
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