Different Blood Pressures

in Right & Left Arms 

(Difference > 10 mmHg)

Ddx:

1) Vascular abnormality - usually not a problem

2) Aortic dissection

Phys:

Aortic dissection - if the tear begins between the brachiocephalic trunk & the left subclavian artery or if a subclavian artery is occluded

Different Blood Pressures

in the Arms vs. the Legs

(Difference > 10 mmHg)

Ddx:

1) Coarctation of the aorta - A discrete congenital narrowing of the aorta

Phys:

To be cont.

Widened Pulse Pressure

(Difference btwn Systolic & Diastolic

>55-60 mmHg)

Ddx:

1) Aortic regurgitation

2) Other high CO states

3) Decreased LV compliance

4) Decreased afterload --> decreased diastolic BP

Phys:

To be cont.

Narrow Pulse Pressure

(Difference btwn Systolic & Diastolic

< 20-25 mmHg)

Ddx:

Decreased CO, which can be caused by:

1) Aortic Stenosis

2) HOCM?

3) Mitral stenosis

4) Congestive Heart Failure

5) States of increased systemic resistance

Phys:

Narrow pulse pressure is caused by low CO, which can be due to:

- LV outflow obstruction (e.g. aortic stenosis, HOCM)

- Low LV volume (e.g. mitral stenosis)

- Low stroke volume (congestive heart failure)

- Increased systemic resistance (e.g. increased catchols, heart failure)

Orthostatic Changes in Blood Pressure 

(Pressure >20 mmHg lower when standing)

Bisferiens (Bifid) Pulse

A pulse with two positive waves during systole

    - The first wave rises rapidly & forcefully

    - The second wave is smaller & slower rising

Ddx:

1) Obstructive hypertrophic cardiomyopathy (HOCM)

2) Aortic regurgitation

3) States involving rapid ejection of increased SV out of the LV (fever, exercise, patent ductus arteriosus)

Phys:

Indicates LV ejection abnormalities... (to be cont.)

Dicrotic Pulse

A pulse with two peaks, one in systole and one in diastole

Ddx:

1) Impaired LV function - low CO, low SV, high LV end-diastolic pressure, high systemic arterial resistance

Phys:

To be cont.

Pulsus Alternans

A pulse that is alternately strong & weak in an every-other pattern

Ddx:

1) Severe impairment of LV function (an early sign of cardiac decompensation)

Phsy:

Impairment of electromechanical coupling in some cels during the weaker contraction... (to be cont.)

 Pulsus Paradoxus

(Paradoxical pulse)

A marked decreased in pulse amplitude (or systolic BP) during inspiration

Ddx:

1) Cardiac tamponade

2) Constrictive pericarditis (pulsus paradoxus infreq. seen)

3) Superior vena cava obstruction

4) Asthma, obstructive airway disease

5) Pulmonary embolism

Phys:

To be cont.

Radial-Femoral Lag

A delayed & weakened femoral pulse when compared with the radial pulse

Ddx:

1) Coarctation of the aorta

Phys:

To be cont.

Not all apical beats are felt at the radial pulse

Ddx:

1) Atrial fibrillation

2) Other causes of low CO

Phys:

To be cont.

Decreased Ankle-Brachial Index

(<0.95)

ABI = systolic BP at ankle / systolic BP at arm

<0.95 = vascular disease, <0.6 = intermittent claudication

Ddx:

1) Atheroscerotic peripheral artery disease

2) Giant cell arteritis

3) Aortic dissection

4) Arterial emboli

Phys:

to be cont.

Absent Posterior Tibial Pulse

Ddx:

1) Peripheral vascular disease

Absent Dorsalis Pedis Pulse

Ddx:

1) Peripheral vascular disease

2) Normal individual (congenitally absent in 10-12% of people)

Phys:

to be cont.

Enlarged Aorta

( > 4cm)

Ddx:

1) Aortic aneurysm

Phys:

to be cont.

Carotid Bruits

Low-pitched murmur over the carotid arteries

Ddx:

1) Atherosclerotic plaque

Phys:

Sound caused by turbulent flow, due to an obstruction

Aortic Bruits

Low- pitched murmur over the aorta

Ddx:

1) Atherosclerotic plaque

2) Aortic aneurysm

Phys:

Sound caused by turbulent flow in the aorta

Elevated Jugular Venous Pulse

Estimates CVP.

Normal CVP = 7 cm H2O

Normal JVP = 2 cm above sternal angle (angle of Louis)

Abdomino-jugular (Hepato-jugular) Reflux

"cv" Wave

on the JV Waveform

Ddx:

1) Tricuspid regurgitation

Phys:

To be cont.

Venous Hums

over the Jugular Veins

Ddx:

1) Usually benign (esp. common in children)

2) Hyperdynamic state (e.g. anemia or thyrotoxicosis)

Phys:

Caused by blood flow through the internal jugular. Can be distinguished from other murmurs by the fact that it disappears when pressure is placed over the jugular.

Right Ventricular Heave

(Parasternal Lift / Impulse)

Ddx: 

1)

2) Some motion is normal in children < 12

Phys:  

Caused by a dilated or hypertrophied right ventricle

Enlarged Apical Impulse

Normally the size of a dime

Ddx:

1) Arterial hypertension

2) Aortic stenosis

3) Coarctation of the aorta

4) Hypertrophic cardiomyopathy (HCM or HOCM) 

Phys:

An enlarged apical impulse (like a sustained impulse)

indicates LV hypertrophy. Often this is a response to LV pressure overload.

1) Arterial HTN - Increased afterload causes pressure overload of LV

2) Aortic stenosis - Narrowed LV outflow tract (increased afterload) causes pressure overload of LV

3)  Aortic stenosis - Narrowed aorta causes increased afterload which causes pressure overload of LV

4) HCM - Genetically inherited condition of hypertrophy

Sustained Apical Impulse

Presystolic Apical Impulse

A small impulse felt shortly before the normal systolic apical impulse. (Usually accompanied by a sustained apical impulse)

Ddx:

Phys:

The presystolic impulse is a palpable S4. It occurs when the atria contract into a stiffened LV.

Laterally Displaced

Apical Impulse

Normally located in the mid-clavicular line at the 5th intercostal space

Ddx:

1) Mitral regurgitation

2) Aortic regurgitation

3) Patent ductus arteriosus (PDA)

4) Ventricular septal defect (VSD)??

5) Other high-volume states (e.g. thyrotoxicosis, anemia)

Phys:

A laterally displaced apical impulse indicates a dilated left ventricle. Dilation is due to LV volume-overload.

Cardiac Thrill

A murmur that can be palpated.