Name the disease in which grotesque facial features are seen? Enumerate the cardiac conditions associtaed

• HURLER'S SYNDROME
• Grotesque facial features - prominent supraorbital ridge, depressed nasal bridge, thick lips, corneal clouding, peg shaped teeth
• CARDIAC CONDITIONS ASSOCIATED ARE

• CAD
• AR
• HOCM
• Mitral annulus calcification (MR)

What are Brushfield's spots?

• Grayish white spots at the periphery of the iris
• It is more clearly seen in dark pigmented iris
• Seen in DOWN'S SYNDROME

 

What are the causes of Precordial tenderness?

• Tietze syndrome
• Acute pericarditis
• Acute myocarditis

Why is Internal Jugular Vein (IJV) preferred over External Jugular Vein (EJV)?

• IJV is in direct continuation of right atrium
• Right atrial pulsation is not transmitted well as there are prominent valves at the proximal EJV
• Adjoining structures of neck and upper thorax can cause extrinsic compression of EJV
• Increased sympathetic activity can cause vasoconstriction of EJV thus making its pulsation invisible

Why Right internal jugular vein is preferred to left internal jugular vein?

• Right jugular vein and innominate vein extends in a straight line from superior vena cava and right atrium
• Left innominate vein into which left internal jugular vein drains does not extend in a straight line from superior vena cava and right atrium
• Left innominate vein may be kinked or compressed by dilated aorta or aneurysm or other surrounding structures

When does bruit suggest?

• Bruit suggests partial obstruction of an artery or transmission of a cardiac murmur
• Bruit is heard if the obstruction in an artery is equal to or more than 50%
• If the obstruction is equal to 80%, a continuous bruit is heard
• If obstruction is more than 80%, no bruit heard

How should we record the Blood pressure if the patient has Atrial Fibrillation?

• 3-5 recordings are done. It is the mean of 3-5 recordings.
• Systolic BP is recorded as the maximum audible sound at a particular level.If the difference between the two recording is less than or equal to 5mm, average of the two recordings are taken. 
• Beat to beat variation can lead to underestimation of the blood pressure.
• Blood pressure recorded after a long cycle can be falsely high.

What is Clindactyly?

• Clindactyly means incurved fingers 
• Claw like appearance of the hand
• Seen in Down's syndrome
• Ellis van Creveld syndrome
• Hurler's syndrome

What are the techniques to record Blood pressure?

• Palpatory method
• Auscultatory method
• Flush method
• Ultrasound Doppler method
• Arterial tonometry/ Oscillometric method
• Ambulatory BP monitor(ABPM)

Differential Diagnosis - Upper limb and Lower limb Blood pressure difference

• Coarctation of aorta
• Aortic dissection
• Aortic arch syndrome
• Subclavian steal syndrome
• Severe chronic aortic regurgitation
• Inaapropriate cuff size for thigh

Difference of more than 20 mmHg Blood pressure is considered significant.

 

Differential Diagnosis - Upper limb Blood pressure difference

• Aortic Arch Syndrome/ Coarctation of Aorta
• Supravalvular aortic stenosis
• Subclavian steal syndrome
• Scalenus anticus syndrome/ Cervical rib syndrome
• Aneurysm of subclavian or innominate artery
• Thrombosis of innominate or subclavian artery

A Blood Pressure difference of more than 10 mmHg between the two arms is considered significant. 

What is Mean Blood Pressure?

• It is the average blood pressure during a single cardiac cycle.
• It can be determined from the formula MAP = (CO X SVR) + CVP where CO is cardiac output, SVR is systemic vascular resistance and CVP is central venous pressure.
• At nomal heart rate, it can be estimated as MBP = DBP+ 1/3 PP

(Mean blood pressure = Diastolic blood pressure + 1/3 Pulse pressure,
PP = SBP- DBP)

• At higher heart rate, MAP is the arithmetic mean of systolic and diastolic blood pressure
• The regional blood flow or the organ perfusion depends on MBP
• Normal ranges between 95-100 mmHg.
• MAP greater than 60 mmHg is enough to sustain the perfusion of organs

What are Korotkoff sounds? What are its five phases?

• Korotkoff sound represents arterial oscillation resulting from distension of the arterial wall with each cardiac impulse due to partial occlusion of artery by the cuff. 
•  Low pitch sound
• Five phases are
• PHASE 1 - CLEAR TAPPING SOUND   (SBP)
• PHASE II - ONSET OF SWISHING SOUND OR SOFT MURMUR
• PHASE III- LOUD SLAPPING SOUND
• PHASE IV - SUDDEN MUFFLING OF SOUND
• PHASE V - DISAPPEARANCE OF SOUND / PHASE OF SILENCE (DBP)
• "Tap - Murmur - Slap - Muffle - Silence"
• It was described by Nikolai Korotkoff, a Russian surgeon in 1905

 

What is the average Blood Pressure in children?

• At 1 yr of age , average Systolic Blood Pressure(SBP) is 90mmHg
• Every 3 yr , increases by 5 mmHg
• At 12 yrs , reaches adult level
• Diastolic Blood pressure remains average 60mmHg
• Formula to calculate SBP in children 

SBP = 90+(AGE X 5)/3

What is Murmur? How does it differ from Heart Sounds?

• Murmur is a latin word
• It is defined as a prolonged series of audible signals/ vibrations of varying intensity, frequency, configuration and duration.
• Heart sounds results from sudden deceleration of blood.
• Murmurs are produced by turbulent blood flow.

What is the meaning of the word " STETHOSCOPE"?

• Stethoscope is derived from greek word stethos meaning " chest" and scope meaning " to view"
• It was invented by a French physician Rene' The'ophile Hyacinthe Laennec  in 1816

What is Pulse pressure(PP)? What is Proportional pulse pressure(PPP)?

• Pulse pressure = Systolic blood pressure -  Diastolic blood pressure( PP= SBP-DBP)
• It indicates pulse volume 
• Average PP is 30- 40 mmhg
• Proportional Pulse Pressure = Pulse pressure / Systolic blood pressure(PPP= PP/SBP)
• It is an indicator of LV function
• If PPP < = 25% , indicates LVF and Cardiac index <= 2.2 l/min/m2

What are Pacemaker sounds?

• High frequency, clicking, pre-systolic sound
• Produced by transvenous pacemakers
• Due to stimulation of intercostal muscles by the endocardial leads
• Timing correlates with pacemaker spike in ECG
• Associated with twitching of chest wall muscle - contraction of chest wall muscle following spread of electrical impulse from pacemaker
• Diaphragmatic stimulation can also occur
• Very loud sound may suggest myocardial perforation

Perception of pulse is by which receptors?

Tactile receptors - Meissener's corpuscles, Pacinian corpuscles and Merkel's discs 
mediate tactile sensation on the finger tips. 

Character of pulse depends on what factors?

• Stroke volume
• Ejection velocity
• Vascular compliance
• Systemic vascular resistance