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Samir rafla questions and answers asked in the exam of the medical rounds


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Samir rafla questions and answers asked in the exam of the medical rounds

  1. 1. Answer of questions, General notes on clinical cardiology 1- Hypertension causing end organ affection except liver 2- Marfan syndrome criteria: most common AR, aortic aneurysm, never stenotic lesion. 3- VSD, ASD, PDA cause Eisenmenger syndrome BUT Fallot never 4- Acute infective endocarditis does not cause clubbing while (sub acute, chronic) will cause clubbing 5- AF due to MS, thyrotoxicosis, rheumatic, coronary artery disease except corpulmonale 6- P-R interval is prolonged in bradycardia & shortened in tachycardia. 7- ASD has wide fixed splitted S2 8- Aortic stenosis: plateau pulse 9- Sure signs of heart failure: - gallop S3 sure S4 (impending HF) 10- Unequal pulse: aortic dissection 11- Chyne stock respiration due to CNS causes, heart failure 13- Congested painful liver: heart failure 14- Angina any type of pain except Stapping (dissecting aortic aneurysm) 15- Delayed femoral pulse (coarctation of aorta) 16- Hypertrophic obstructive cardiomyopathy: LT ventricular outflow obstruction 18- Sub-valvular, supravalvular aortic stenosis: normal A2 + ejection systolic murmur 19- Mechanism of Graham steel murmur (pulmonary incompetence due to dilated pulmonary artery from pulmonary hypertension), and Austin flint murmur (mitral diastolic murmur in presence of aortic incompetence due to fluttering of anterior cusp). 20- peripheral signs of aortic regurgitation : 21- pink frothy hemoptysis seen in pulmonary edema 22- timing of opening snap earlier than S3 23- Steep Y descent in neck veins present in restrictive cardiomyopathy 24- If you cannot count > 3 regular pulses so it is irregular irregularity (Atrial Fibrillation) , do not mix with premature beat 25- Causes of irregular pulse: *sinus arrhythmia *AF * Atrial extrasystole * atrial flutter with variable response * Ventricular extrasystole *2nd degree HB with variable response 26- Pulsus deficit: is the resultant difference between the actual heart rate and the rate counted at the radial art. (As many ectopic beats are too weak & not palpated at the radial artery) 27- Pulsus bigemini: in which ectopic beats occur regularly (i.e. every normal beat) 28- Renal disease is the commonest 2ry cause of HTN 29- Normally the jugular venous pulse falls on inspiration because the fall in the intra thoracic pressure is transmitted to Rt. Atrium. 174
  2. 2. If increases in inspiration = Kussmaul’s sign (in Pericardial effusion with tamponade or constrictive. pericarditis)  Vertical height in congestion is measured between the top of the venous pulsations and sternal angle. 30- HF is the commonest cause of increase jugular venous pulse, others include pericardial effusion (tamponade) 31- in AF : absent a wave; TR : giant v wave (systolic pulsation) TS giant a wave ; complete heart block cannon a wave (atrium contract against closed tricuspid valve) 33Carotid pulsation Rapid outward movement One peak per heart beat Palpable Pulsations un affected by pressure at the root of the neck. pressure Independent of posture & respiration Jugular pulsation Rapid inward movements 2 peaks per heart beat Not palpable Pulsations decreased by pressure at the root of the neck and increased by pressure at the abdomen Varies with posture & respiration 34- Apex is impalpable in overweight, muscular, asthma, emphysema……. 35- A midline sternotomy scar usually indicates pervious coronary bypass surgery or valve replacement, while a Lt. Sub-mammary scar usually indicates mitral valvotomy 36- The so called (tapping apex) which is found in MS is actually a palpable 1st HS. 37- Pulsations over Rt. Parasternal area (Rt. Ventricular heave) is usually abnormal in adult and indicative of Rt. Ventricular hypertrophy, e.g. pulmonary HT 38- The most commonly detected systolic thrill is that of aortic stenosis which is palpable at suprasternal area and carotids. 39- Renal, skeletal, coronaries take the main portion of cardiac output. 40- In mitral stenosis the longer the murmur the more is the stenosis. 41- AF needs anticoagulant therapy for life if risk score is 2 or more. 42- Infective endocarditis may cause serious thromboembolic manifestations; if in the middle cerebral artery hemiplagia 43- palpitation is the main complaint in AR (due to strong contraction) 44- dull sternum occurs in: * cardiomegaly * pleural effusion * Rt. Ventricular hypertrophy * infective endocarditis 45- the physiological splitting of the 2nd heart sound occurs because of the Lt. Ventricular contraction slightly precedes the Rt. Ventricular contraction so the pulmonary valve shuts after aortic valve. Splitting is increased during inspiration due to increased venous filling of the Rt. ventricle which delays pulmonary valve closure and conversely this separation disappears on expiration. 175
  3. 3. 46- murmurs of MS are best heard with by the bell while that of AR is best heard by the diaphragm, in the 2nd aortic area, patient leaning forward. Grade 3 murmur easily heard with no thrill while grade 4 murmur is a loud murmur with thrill 47- murmurs radiates in the directions of blood flow. 48- the most common cause of palpitation is anxiety 49- in water hammer pulse the diastolic blood pressure is very low < 50 mmHg 50- in cardiac examination: thyroid must be examined 51- AR due to rheumatic problem is best heard over the 2nd aortic while due to aneurysm & dissecting aneurysm best heard over the 1st aortic area (this is nonsense) 52-all organs are affected by HTN except the liver 53- hepato-jugular reflux is positive in congestive heart failure .1 54- Causes of v wave in neck vein pulsation is over filling of atrium 55- Causes of wide fixed splitting of s2 is … ASD 56- Definition of intermittent claudication … pain during walking relived by rest 57- Causes of unequal pulse … aortic aneurysm, dissecting aortic aneurysm 58- Causes of mid-diastolic murmur … MS, left atrial myxoma, Carey Combs murmur, Austin Flint murmur - Causes of murmur are all except … laminar flow - all of the following cause pulses alterans except … hyperkinetic circulation - cardiomyopathy cause all except… s3 - all causes hyperkinetic pulse except MS - all organs can be affected by hypertension except … livre - all cause eisenmenger syndrome except … fallots tetralogy - causes of weak femoral pulse … aortic coarctation - causes of low fixed cardiac output are all except … exertional cyanosis - pulmonary hypertension cause all except … systolic thrill - all causes AF except … corpulmonale - causes of paroxysmal nocturnal dysnea … MS - s4 is present in all of the following except … young adult murmer - decrease fixed cardiac output in sever MR -In Severe AS all the following are present except loud s2 ,pulsus bisferens - Causes of pulmonary hypertension : 1- increased flow from left to right Shunt 2- increase resistance caused by mitral stenosis or left ventricular failure leading to pulmonary congestion 3- lung disease (corpulmonale): asshistosomal corpulmonale ,COPD, interstitial lung disease, recurrent pulmonary embolism -176
  4. 4. -In MS Opening snap occurs earlier than s3 - Left. to right Shunt: 1- VSD 2- PDA 3- ASD MCQs - all of the following are present in MS except: - LT ventricular apex - mid diastolic murmer - accentuated S1 - diastolic thrill -S4 can be heared in all of the following except: - normal young adult - aortic stenosis - aortic regurge - heart failure -epigastric pulsation occurs in all except: 1- right ventricular enlargement 2- congestive heart failure 3-aortic aneurysm 4-portal HTN - accentuated first heart sound in all except 1- short P-R interval 2- increase cardiac output 3- MS 4- myocarditis S3 gallop on apex is due to: 1- decompensated heart failure 2- severe pulmonary hypertension (will cause S3 on right ventricle) 3- mitral regurge - unequal radial pulse: 1- sever MR 2- sever systemic hypertension 3- dissecting aortic aneurysm 4- none 177
  5. 5. - syncope on effort occur in all excepts: 1- HOCM 2- aortic stenosis 3- sever MR 4- none - Graham steel murmer 1- sever pulmonary stenosis 2- sever mitral stenosis 3- bilharzial corpulmonale 4- aortic regurge - causes of clubbing in cardiac patient: 1- rheumatic activity 2- pulmonary embolism 3- none -AF caused by except 1-IHD 2- thyrotoxicosis 3- corpulmonale - all of the following present with myocarditis except 1-soft s1 2- pulsus bisferience, 3- sinus tachycardia - s1 soft in 1-MS 2-myocarditis - edema of HF affect all except 1-L.L 2- addomen 3- eyelid -Tender calf muscle in all except: 1- DVT 2- myositis 3- neuritis 4- ischemia(acute arterial thrombosis) 178
  6. 6. - epigastric pulsation in all except: 1- congestive heart failure 2- portal hypertension,(pulmonary hypertension) 3- aortic aneurysm 4- rt. ventricular hypertrophy - edema in congestive heart failure in all except: 1- Periorpital 2- ankle 3- sacrum 4- ext. genitalia - unequal right,left blood pressure in all except: 1- subclavian steal obstruction 2- aortic coarctation 3- subclavian aortic stenosis 4- descending aortic aneurysm - all are signs of infective endocarditis except: 1- ostlers nodule 2- pale clubbing 3- splinter haemorrhage 4- sclerodactyly -chynestoke breathing present in all except: 1- epilepsy 2- cerebrovascular stroke 3- advanced lt. ventricular failure - pink frothy sputum in all except 1- pulmonary edema 2- pulmonary embolism 3- bronchial asthma 4- bronchogenic carcinoma - squatting after exercise present in: 1- Fallot’s tetralogy 2- PDA 3- ASD 4- VSD - water hammer pulse associated with all except: 179
  7. 7. 1- increased stroke volume 2- capillary pulsation 3- wide pulse pressure 4- increased peripheral vascular resistance - non pulsating congested neck veins in: 1- tricuspide stenosis 2- superior mediastinal syndrome (SVC obstruction) 3- COPD -Mitral Stenosis includes all except: a- long diastolic rumbling murmur b- Opening Snap c- S2 Closed split d- Diastolic shock e- Hyperkinetic ventricular apex -AF is caused by all except: f- Ischemic heart disease g- Thyrotoxicosis h- Mitral valve disease i- Core pulmonale -S4 is presented in: j- Volume overload on ventricle k- Pressure overload on ventricle l- Cardiomyopathy m- Myocardial infarction n- All of the above (√) - in pulmonary hypertension all is present except: o- systolic thrill on the pulmonary area (x) p- S2 closed split q- Diastolic shock r- Ejection systolic murmur - In AF all is present except s-absent a wave t- S4 u- S1 of visible intensity v- Systolic neck venous pulsation w- Irregular irregularity in the pulse - S3 gallop on the apex is due to: x- decompensated HF 180
  8. 8. y- severe pulmonary hypertension z- mitral stenosis - Angina pectoris is due to aa- myocardial ischemia bb- severe ventricular dilatation cc- stretch of pericardium dd- severe ventricular dilatation ee- increase myocardial contractility - In severe aortic regurge all is present except ff- Pistol shot gg- Hill’s sign hh- Capillary pulsations ii- Pulsus paradoxus - Epigastric pulsations in all except: jj- portal hypertension kk- aortic aneurysm ll- congestive heart failure mm- Rt ventricular enlargement - Giant a wave in all except: nn- tricuspid stenosis oo- pulmonary stenosis pp- pulmonary hypertension qq- Fallot`s tetralogy - Eisenmenger syndrome in all except: rr- Large VSD ss- Large ASD tt- PDA uu- Fallot`s tetralogy - Graham-steel murmur occur in : 1-cor pulmonale 2-AR 3-severe MS 4-severe PS -AF is caused by all following except: 1-Corpulmonale 2-IHD 181
  9. 9. 3-Thyrotoxicosis 4- Mitral valve prolapse -In myocarditis all of the following are present except: 1-LHF 2-Gallop 3- Arrhythmia 4- Cardiomyopathy In clinical: - pulse :either AF or water hammer pulse -congested neck veins: either 1- AF (absent a wave) Or 2- TR (systolic venous pulse{prominent v wave}) - mitral area (MR- MS – double) - Pulmonary area ( pulmonary hypertension) - Pale clubbing---(infective endocarditis) - AF Complication -thromboembolic -diminished cardiac perfusion Infective endocarditis: Cardiac: Increase in murmur , Deteriorates in HF, Acute AR, Acute MR Embolic eyes: -blindness, Retinal a. occlusion, -Roth spots. Fingers : Osler`s nodules, Splinter he. Renal : Hematuria, Immune GN, Renal Failure Fever, toxins Infective endocarditis: Duke major criteria: Positive Blood culture; Vegetations by echo Minor criteria: Enlarged tender spleen, tender sternum, prolonged fever, toxaemia - Aortic dissection: -severe lancinating pain in chest -unequal pulses (dissecting closing ostium of subclavicular a.) 182
  10. 10. - AS Harsh eject systolic Systolic thrill Absent A2 Sustained apex Plateau pulse - TR Pansystolic over TA, increases with inspiration Systolic V. pulsation in neck veins Systolic Pulsations in liver Myocardial Infarction : Chest pain, compressing, severe, more than 15 minutes, radiating to arms back, neck associated with vomiting, sweating syncope Heart : S4 (atrial gallop) 183