What are the primary causes of S2...

1. Physiological split
2. Paradoxical split
3. Wide split
4. Fixed split

1. Inhalation causes delay in pulmonary valve closure
2. Delay of aortic valve closure ameliorated by breathing in; seen in left bundle branch block and aortic stenosis
3. Delayed closure of pulmonic valve; seen in pulmonic stenosis and right bundle branch block
4. Split that does not vary with inspiration; atrial septal defect and right ventricular failure

What are common causes for...

1. S3
2. S4
3. Opening snap
4. Early systolic (ejection) click
5. Mid-late systolic click
6. Rub

1. Mitral and tricuspid regurgitation; decreased myocardial contractility; CHF
2. 
   
   • Right side = pulmonic stenosis, pulmonary hypertension
   • Left-sided = hypertensive heart disease, CAD, aortic stenosis, cardiomyopathy
3. Mitral stenosis
4. Pulmonary stenosis, atrial septal dysfunction
5. Mitral valve prolapse
6. Pericarditis

AI is best heard sitting at 2nd right ICSP, MS is best heard at apex, in left lateral decubitus, with bell

AI murmur begins immediately upon S2, MS murmur occurs after S2

• Increased right-sided heart pressures (e.g. CHF)
• Increased resistance to right atrial contraction (e.g. tricuspid stenosis, AV dissociation hypertrophied right ventricle)
• Tricuspid reguritation (increased right atrial diastolic pressure)

Drop in systolic BP >10 mm with inspiration

• Cardiac tamponade (look for trauma, uremia, TB, CA)
• Pericardial effusion
• Asthma (moderate to severe)
• COPD

What are the causes of assymetric blood pressure...

• Between left and right arm?
• Between arm and leg?

• Arm vs. arm
  • Aortic dissection (CAD, Marfan's)
  • Takayasu's arteritis (young woman)
  • Thoracic outlet obstruction (cancer)
• Arm vs. leg = coarctation of the aorta

What are the possible causes for the following respiratory symptoms:

1. Dullness to percussion
2. Hyperresonance to percussion
3. Change in fremitus
4. Bronchial breath sound
5. Decreased breath sounds

1. Dullness to percussion = pleural effusion, consolidation (pneumonia), atelectasis
2. Hyperresonance on percussion = pneumothorax, emphysema
3. Change in fremitus
   • Decrease = pleual effusion, pneumothorax, atelectasis, emphysema
   • Increase = consolidation
4. Pneumonia (consolidation)
5. Pleural effusion, pneumothorax, atelectasis, emphysema

Which diseases that induce chest pain are symptomatically relieved by...

• Rest
• Nitroglycerin
• Lying on involved side
• Sitting forward

• Angina pectoris
• Angina pectoris, diffuse esophageal spasm
• Tracheobronchitis
• Pericarditis

Match the quality of the chest pain to the disease most likely to cause it

• Pressing, squeezing, tight, heavy, occasionally burning
• Sharp-knifelike
• Crushing
• Ripping, tearing
• Burning
• Stabbing, sticking or dull, aching

• Angina pectoris, MI
• Pericarditis, pleural pain
• Pericarditis
• Dissecting aortic aneurysm
• Tracheobronchitis, reflex esophagitis
• Chest wall pain, anxiety

Match the aggravating factors with diseases that cause chest pain

• Exertion, emotional stress, occasionally at rest, emotional stress
• Changing position, breathing, lying down
• Hypertension
• Coughing

• Angina pectoris
• Pericarditis
• Dissecting aortic aneurysm 
• Pericarditis, pleual pain, tracheobronchitis

CRoWS

Cocaine abuse, relapsing polychondritis, Wegener's granulomatosis, syphilis

ESCAPE A

Eosinophilia, skin reactive to Aspergillus antigen, central bronchiectasis, asthma, pulmonary infiltrates, eleveated serum IgE levels, antibodies to Aspergillus

Some random "high-yield" respiratory facts:

1. Most sensitive physical sign of pulmonary embolism?
2. Livedo reticularis + shortness of breath following fracture of femur...?
3. Blue bloater, pink puffer

1. Sinus tachycardia
2. Fat emboli
3. Chronic bronchitis, emphysema

You are palpating a patient's abdomen. When you withdraw your hand, they yelp in pain. What are the most likely causes?

Suppose they had tenderness in their RUQ, causing them to spontaneously to arrest inspiration. What would the diagnosis be in that case?

• Rebound tenderness = peritoneal irritation (peritonitis, appendicitis)
• Positive Murphy's sing = cholecystitis

Signs of appendicitis

• Obturator = flex thigh at hip, with knee bent, and rotate leg internally. Look for tenderness in right hypogastric region
• Psoas = With hand on patient's right kniee, ask patient to raise thigh or turn onto left side. Positive sign = increased abdominal pain

• Painless = vascular accident (stroke, retinal artery occlusion), retinal detachment
• Painful = narrow angle glaucoma, ischemic optic neuritis (associated with headache)

• Fibroadenoma - in young women (15-25), large, very mobile, well delineated, non-tender, no retraction signs
• Cysts - older population (30-50), regresses after menopause, often tender, otherwise similar to fibroadenoma
• Cancer - Seen in ages 30-90, common over 50, irregular shape or stellate, hard consistence, often fixed and nontender with retraction signs

Biliary pain, jaundice, fever (with chills and rigor)

In 10%, also see mental confusion and refractory sepsis (hypotension)

High stroke volume- AI, PDA, fever, pregnancy, hyperthyroidism, beriberi, anemia, and Paget's disease

Low stoke volume- pericardial tamponade, constrictive pericarditis, AS, tachycardia

Mitral regurgitation (non-murmur = 1st degree heart block)

Aortic stenosis