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.
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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.
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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
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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
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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)
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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:
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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
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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
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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.)
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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)
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