PEP Fall 2025 Final

Anatomy of the heart

• Behind the sternum from the 3rd to the 6th costal cartilage

• Chest over the heart= precordium

• Adult heart- 12 cm long, 8 cm wide at widest point

Situs inversus

Heart and stomach are placed to the right and the liver to the left

Valves in diastole

• Mitral and Tricuspid are open

• Aortic and pulmonic closed

Valves in systole

• Mitral and tricuspid are closed

• Aortic and pulmonic are open

Arterial system is at

A higher pressure, venous return occurs at lower pressure

Deep veins in the leg

Carry 90% of the venous return from the legs

Cardiac output

Volume of blood ejected from each ventricle in 1 minute

• product of heart rate x stroke volume

Stroke volume

Volume of blood ejected with each heart beat

• Dependent on preload, myocardial contractility, and afterload

• EDV-ESV, normal is about 70 ml

Ejection fraction

Percentage of ventricular volume ejected during each heartbeat- normally 60%

Pulse pressure

Difference between systolic and diastolic pressure

• Pulse pressure greater than 40 mmHg is abnormal

• Narrow pulse pressure <25 can result from a decreased stroke volume

Women are more likely to report

Atypical symptoms when it comes to heart disease

• Ex. Fatigue, upper back/neck/jaw pain, N/V, SOB, PND

Tangential lighting shows underlying

Flicker of any cardiac movement

Lifts and heaves results from

Hypertrophy or fluid overload

• Severe aortic stenosis- apical lifts and heaves

• RVH- left sternal border heave

PMI

Point of maximal impulse- results from left ventricular contraction during systole

• Displaced- cardiomegaly, LVH

• Double impulse- seen in HOCM (hypertrophic cardiomyopathy and accompanying murmur)

Palpate for thrills

Ulnar surface of the hand

• Cardiac murmurs grade 4 or higher

• Vibrations of turbulent blood flow

Palpate heaves and lifts

Base of palm

• Heave is more forceful than lift

• Sustained or more forceful than expected

Lub S1

• First sound

• Louder and longer

• Start of ventricular systole

• Atrioventricular valves closing (mitral and tricuspid)

• Heard best over tricuspid and mitral- loudest at apex

Dub S2

• Second found

• softer and shorter

• Start of ventricular diastole

• Semilunar valves closing (aortic and pulmonic)

• Heard best over aortic and pulmonic (they are closing)- loudest at base

Splitting of S2

Occurs when mitral and tricuspid or pulmonic and aortic valves do not close simultaneously

• Heard in 2 phases A2, P2

S3

Ventricular gallop

• Follows S2

• Sound of blood hitting the residual blood left in the left ventricle at the beginning of diastole

S4

Atrial gallop

• Precedes S1

• Contraction of the atria pushing blood into a stiff/hypertrophic ventricle at the end of diastole

S3+S4

Summation gallop

The bell in cardiac auscultation

Used to hear low-pitched sounds

• best for mid-diastolic murmur of mitral stenosis, S3 and S4

The diaphragm in cardiac auscultation

Highlights high pitched sounds

• best for S1, S2, most murmurs and pericardial friction rub (remember diaphragm during Erb’s)

Intensity of a murmur

Rated on a scale from 1-6

1. Very faint, can only be heard with stethoscope under optimal conditions

2. Easily audible with stethoscope but quiet

3. Medium intensity, no thrill

4. Medium intensity, with thrill

5. Loudest murmur heard with stethoscope on chest and palpable thrill

6. Audible with stethoscope off chest and palpable thrill

Accentuating a right sided murmur

Deep inspiration increases venous return and right-sided filling

• tricuspid and pulmonic murmurs

Increasing left sided murmurs

Forced expiation with hold increases afterload

• mitral and aortic murmurs

Valsalva maneuver

Deep breath and bear down for 8-10 seconds against a closed glottis

• decreases most murmurs

• Will INCREASE HOCM and MVP

Squatting

Most murmurs will INCREASE with squatting, HOCM and MVP will NOT

Buerger test

Raise both legs until pallor develops

• Normal: mild to no pallor even at 90 degrees

• Arterial insufficiency- marked pallor or pallor at a low angle (20 degree)

Aortic stenosis

• 2 ICS RSB

• Midsystolic (ejection) murmur

• Crescendo-decrescendo, coarse

• Radiates to neck/carotid

Aortic regurgitation

• 3 ICS LSB

• Early diastolic

• Decrescendo, blowing

• May radiate along LSB

*Austin Flint Murmur: low pitched diastolic rumbling heard best at cardiac apex. Caused by AR jet abutting the LV endocardium

Cyanosis

Associated with congenital heart disease, severe heart failure

Diaphoresis

Associated with ACS (MI, unstable angina), cardiogenic shock, severe heart failure

Obvious JVD

R-sided heart failure, constrictive pericarditis, cardiac tamponade, Cor Pulmonale, tricuspid regurg or stenosis

Levine’s sign

Ischemic chest pain: ACS (STEMI/NSTEMI), stable or unstable angina

Lifts of heaves 

LVH (left parasternal heave), RVH (right parasternal lift)

Thrills

palpable murmurs→ significant structural disease

Holosystolic murmurs 

• Mitral regurg

• Tricuspid regurg

• Ventricular septal defect 

Displaced PMI/Sustained PMI

Left ventricular dilation/enlargement, LVH 

Auscultation in the left lateral recumbent position

Left-sided cardiac structures are closer to the chest wall, making murmurs and extra heart sounds much easier to hear

• Best heard: S3 and S4, mitral stenosis, and apical murmurs of mitral regurg

Mitral regurg

Holosystolic blowing murmur located at the 5th ICS MCL

• Radiates- axila

• Increases with handgrip and squatting

Tricuspid regurg

Holosystolic, blowing murmur at the 4th ICS LSB

• radiate: right sternal border

Characteristics of JVP 

Shows right atrial and right ventricular pressure changes

• not palpable, visual waveform (double bounce)

Why JVP on right side

Direct anatomical connection to the right atrium, better estimate of true pressure

Why do you incline the pt when you perform JVP

Visibility of the venous column is better

• 30-45 degrees

• Too flat- veins are engorged

• Too upright- column is collapsed and invisible

Normal JVP measurement 

<3-4 cm at sternal angle

Increased JVP

R sided heart failure, volume overload , pulm HTN, constrictive pericarditis, cardiac tamponade (increased RA pressure)

Decreased JVP

Hypovolemia, dehydration, hemorrhage, severe vasodilation (low RA pressure)

Venous hum description

• Continuous

• Louder in diastole

• absent if JVP is occluded

Order of eval of the carotids 

• Inspection

• Auscultation- bell 

• Palpation 

What are you looking for when auscultating the carotids

Carotid bruit→ harsh, whooshing systolic sound 

S/S that are suggestive of PAD

Intermittent claudication, rest pain (advanced), coolness in extremities, erectile dysfunction, hair loss, taut skin, ulcers in distal toes, muscle atrophy

S/S that are suggestive of chronic venous insufficiency

Warm leg with normal pulses, pitting edema, varicose veins, brown skin, venous ulcers (medial malleolus)

Pinguecula

Yellowish, raised, benign nodule on the bulbar conjunctiva

• usually on nasal side

• does not cross the cornea

• Caused by sun, wind, dust exposure

Pterygium

Fleshy, triangular fibrovascular overgrowth of conjunctiva

• starts nasally grow onto the cornea to the pupil

• can obscure vision if it reaches the visual axis

Xanthelasma 

Soft, yellow, cholesterol-rich plaques on the medial upper and lower eyelids 

• often bilateral

• associated with older age may indicate hyperlipidemia

Red reflex

Red/orange from the patient’s retina when light from the ophthalmoscope reflects bacl through the pupil

• Absence: cataract, retinoblastoma, vitreous hemorrhage, corneal opacity

Rosenbaum visual acuity

Near-vision equivalents of the Snellen chart

• first number: testing distance

• second number: distance which at a person with normal vision can read the line on the Snellen chart

Pupil size during examination

• Normal: Isocoric

• Small pupils: Miosis (constricted)

• Large pupils: Mydriasis (dilated)

• Unequal pupils: Anisocoria (unequal)

Accommodation test

Eye’s ability to change focus from far→ near

• Ask pt to look at distant object 

• The have them shift their focus to a near target held close to their nose

Convergence test

Test eyes ability to move medially 

• eyes should maintain fixation- no double vision

CN test during eye movements

LR6, SO4, all the rest 3

CN III- Oculomotor

• Superior rectus- up

• Inferior rectus- down

• Medial rectus- in

• Inferior oblique- up and out

CN IV- Trochlear

Superior oblique- down and in

CN VI- Abducens

Lateral rectus- out

Shadow over the nasal side of the iris

Narrow/closed-angle glaucoma risk

• Positive shadow test= narrow angle

Entropion

Inward turning of eyelid margin (usually lower lid)

• Hx: eye irritation, tearing, foreign body sensation

• PE: eyelashes rubbing cornea, redness/tearing, possible corneal abrasions/ulcers

Ectropion

Outwards turning of eyelid margin

• Hx: chronic tearing, dryness, irritation, exposure symptoms

• PE: lid eversion with possible conjunctiva, poor tear drainag

Blepharitis

irritated, swollen eyelids, is a common eye condition

• Hx: burning, itching, gritty/sandy sensation, crusting upon awakening

• PE: Inflamed eyelid margins, crusting/flaking at lash base, meibomian gland plugging

Hordeolum (stye)

Acute infection of glands of the eyelid (usually staph aureus)

• Hx: painful, tender nodule eyelid, rapid onset

• PE: erythematous painful bump, local swelling

Chalazion

Chronic granulomatous blockage of meibomian gland

• Hx: painless bump on eyelid, more chronic

• PE: firm, nontender nodule, no erythema, tends to be on upper lid

Allergic conjunctivitis

Allergens cause inflammation in the tissue that lines your eyelids and the whites of your eyes

• Hx: Intense itching, watery or stringy discharge, seasonal or allergen exposure 

• PE: bilateral, cobble stoning of tarsal conjunctiva, clear/watery discharge

Viral Conjunctivitis

Usually caused by adenovirus

• Hx: recent URI, burning/gritty sensation, watery discharge, starts unilateral and becomes bilateral

• PE: preauricular lymphadenopathy, watery discharge, diffuse conjunctival injection

Bacterial Conjunctivitis

Hx: purulent thick discharge, eyelids may be “stuck shut” in the morning, less itching

PE: mucopurulent yellow-green discharge, unilateral or bilateral

Acute angle-closure glaucoma

a medical emergency that happens when fluid can’t drain from your eye and causes high pressure

• Hx: sudden and severe, blurred vision or halos around eyes, headache, N/V

• PE: Red, fixed mid-dilated pupil, cloudy cornea, very firm globe

Papilledema

swelling of both optic discs in your eyes due to increased intracranial pressure (intracranial hypertension)

• Hx: HA, N/V

• PE: swollen, edematous disc, blurred disc margins, flame retinal hemorrhages, veins dilated and pushed forward

Cataracts

cloudy areas in the lens of your eye that affect your vision

• Hx: old age, steroid use, DM, smoking, cloudy/blurry vision, faded colors, halo around lights

• PE: cloudiness of lens that is visible without special equipment

Non-Proliferative diabetic retinopathy

Hx: DM

PE: micro aneurysms, blot-dot hemorrhages, cotton wool spots, hard exudates, NO VISION LOSS

Proliferative Diabetic Retinopathy

Abnormal blood vessel growth (new), maculopathy (edema, exudates), VISION LOSS

Hypertensive retinopathy

Flame shaped hemorrhages, AV NICKING, cotton wool spots, hard exudates

Retinal artery occlusion

Hx: Amaurosis fugax

PE: sudden painless monocular vision loss, pale with the sparing of the macula (CHERRY RED SPOT)

Macular degeneration dry atrophic 

Hx: age >50, women, Caucasian, smoking

PE: presence of Drusen bodies, gradual breakdown of macula cells

Macular degeneration wet-neovascular type

HX: age>50, female, smoking, Caucasian

PE: new abnormal retinal growth under central retina, sub retina neovascular membrane, HEMMORHAGE AND SCAR FORMATION

Manipulating the ear canal

Adult- up, back, and out

Children- down and back

TM findings

• Pearly, grey translucent

• Not bulged or retracted

• See umbo, manubrium and short process of the malleus 

• Should move with pneumatic insufflation

Weber 

Lateralization of sound 

• Conductive: sound is better in damaged ear

• Sensorineural: sound is better in non damaged ear

Rinne

Compares air conduction to bone conduction

• Conductive loss: negative rinne

• Sensorineural loss: postitive rinne test

Otitis media

Hx: ear pain, fever, hearing loss or fullness, recent URI

PE: bulging TM, red opaque RM, decreased/absent mobility of insufflation, loss of landmarks

Serous otitis media (otitis media with effusion)

Hx: ear fullness or pressure, popping/crackling, mild hearing loss, often follows AOM or URI, usually not painful

PE: amber/yellow fluid level behind TM, air-fluid levels or bubbles, mobility decreased, cone of light distorted

Cholesteatoma

Abnormal keratinizing epithelial growth in middle ear; destructive

• HX: chronic, foul-smelling otorrhea, conductive hearing loss, recurrent or non-resolved ear infections

• PE: white pearly mass behind RM, granulation tissue

Mastoiditis- serious complication of AOM

Hx: persistent AOM symptoms, fever, severe ear pain, postauricular pain

PE: mastoid tenderness, erythema and swelling behind the ear, protruding/pushed forward pinna

Otitis Externa (Swimmer’s Ear)

Hx: ear pain worse with tugging/pulling on pinna, itching, discharge, water exposure or trauma

PE: tender tragus, pain with auricle manipulation, purulent debris in canal, TM usually normal

Perforated TM

Hx: sudden ear pain→ relief, hearing loss, tinnitus

PE: visible TM tear, missing cone of light

Lymph node exam

Pads of fingers, use gentle circular motion and compare both sides simultaneously

Anterior nosebleeds

Kiesselbach’s plexus 

Nasal polyps are associated with

chronic rhinosinusitis

asthma

allergic rhinitis

cystic fibrosis

AERD/Samter’s triad (asthma, nasal polyps, aspirin)

Allergic rhinitis

Hx: itching, clear/watery rhinorrhea, seasonal triggers

PE: PALE BOGGY EDEMATOUS TURBINATES, clear discharge, allergic salute

Viral rhinitis (common cold)

Hx: nasal congestion, sore throat, mild fever, malaise, clear micro purulent discharge

PE: erythematous swollen nasal mucosa, clear to yellow discharge, pharyngeal erythema 

Bacterial rhinosinusitis

S pneumoniae, H. infliuenzae, M. catarrhalis

• Hx: s/s >10 days, worsens after initial illness, facial pain or pressure, purulent nasal discharge, congestion

• PE: purulent drainage, tenderness, erythematous/swollen turbinate