Review of Critical Care Medicine

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Posted by Dr KAMAL DEEP on March 25, 2011

1. How strenuous is the physical activity required
to elicit symptoms? The classification provided by the New
York Heart Association has been found to be useful in describing
functional disability

New York Heart Association Functional Classification

Class I

  No limitation of physical activity

  No symptoms with ordinary exertion

Class II

  Slight limitation of physical activity

  Ordinary activity causes symptoms

Class III

  Marked limitation of physical activity

  Less than ordinary activity causes symptoms

  Asymptomatic at rest

Class IV

  Inability to carry out any physical activity without discomfort

  Symptoms at rest

Modified from The Criteria Committee of the New York Heart Association

Limitation of physical activity & symptom association alongwith is basis of NYHA classification.

Important point for MCQ:- if symptoms occurs on More than ordinary activity or on heavy exertion ,they are not part of NYHA.

2. Loud first heart sound is heard in – a)Mitral stenosis b)M.R.
d)Calcified mitral leaflet

ANS IS A i.e mitral stenosis

The intensity of the first heart sound (S1) is influenced by (1) the position of the mitral leaflets at the onset of ventricular systole:- [The loud S1 in mitral stenosis usually signifies that the valve is pliable and that it remains open at the onset of isovolumetric contraction because of the elevated left atrial pressure.]; if AV flow is increased because of high cardiac output or prolonged because of mitral stenosis.;S1 is louder if diastole is shortened because of tachycardia ,or if atrial contraction precedes ventricular contraction by an unusually short interval, reflected in a short PR interval

(2) the rate of rise of the left ventricular pressure pulse;A soft S1may be due to slow rise of the left ventricular pressure pulse AND a long PR interval,

In short PR interval and Tachycardia both position and rate of rise of left ventricular pressure pulse increases the First heard sound loudness

(3) the presence or absence of structural disease of the mitral valve; a Soft S1 may be due to imperfect closure due to reduced valve substance, as in mitral regurgitation.S1 is also soft when the anterior mitral leaflet is immobile because of rigidity and calcification, even in the presence of predominant mitral stenosis.

(4) the amount of tissue, air, or fluid between the heart and the stethoscope.:-A soft S1may be due to poor conduction of sound through the chest wall.


Schematic diagrams of the configurational changes in carotid pulse and their differential diagnoses. Heart sounds are also illustrated. . S4, fourth heart sound; S1, first heart sound; A2 aortic component of second heart sound; P2 pulmonic component of second heart sound.


A. Normal


B. Aortic stenosis. Anacrotic pulse with slow upstroke to a reduced peak.


C. Bisferiens pulse with two peaks in systole. This pulse is rarely appreciated in patients with severe aortic regurgitation



D. Bisferiens pulse in hypertrophic obstructive cardiomyopathy. There is a rapid upstroke to the first peak (percussion wave) and a slower rise to the second peak (tidal wave).



E. Dicrotic pulse with peaks in systole and diastole. This waveform may be seen in patients with sepsis or during intra-aortic balloon counterpulsation with inflation just after the dicrotic notch


Commonest cause of pulsus paradoxus is – (A192)
a) Pericardial effusion
b) Adhesive pericarditis
c) Constrictive peircarditis
d) Chylopericardium

Pulsus paradoxus refers to a fall in systolic pressure >10 mmHg with inspiration that is seen in patients with pericardial tamponade but also is described in those with massive pulmonary embolism, hemorrhagic shock, severe obstructive lung disease, and tension pneumothorax. Pulsus paradoxus is measured by noting the difference between the systolic pressure at which the Korotkoff sounds are first heard (during expiration) and the systolic pressure at which the Korotkoff sounds are heard with each heartbeat, independent of the respiratory phase. Between these two pressures, the Korotkoff sounds are heard only intermittently and during expiration. The cuff pressure must be decreased slowly to appreciate the finding. It can be difficult to measure pulsus paradoxus in patients with tachycardia, atrial fibrillation, or tachypnea. A pulsus paradoxus may be palpable at the brachial artery or femoral artery level when the pressure difference exceeds 15 mmHg. This inspiratory fall in systolic pressure is an exaggerated consequence of interventricular dependence.

Pulsus bisferiens may be seen in all except

a)Combined AS+AR (PGI 80, UPSC 83)
b) Hypertrophic subaortic stenosis
c) Normal individuals
d) None of the above

Pulsus paradoxius is associated witha)
Cardiac tamponade (JIPMER 81, AMU 89)
b) Patent ductus arteriosus
c) Hypertension
d) ASD
e) VSD

Opening snap in mitral area corresponds toa)
‘X’ descent in JVP (JIPMER 93)
b) ‘A’ wave in JVP
c) Dicrotic notch of carotid pulse
d) ‘C’ point of apex cardiogram

Pulses bisferiens is seen in – (PGI 89)
a) AS b) MR
c) AR d) Hypertrophic cardiomyopathy

A palpable double systolic arterial pulse, the so-called bisferiens pulse, excludes pure or predominant AS and signifies dominantAR.

Anacrotic pulse in felt in- (NIMHANS 88)
a) AR b) MR
c) MS d) AS

This wave form is characterised by a slow upstroke. It is particularly prominent in the brachial and carotid pulses. The time taken to reach the peak is prolonged and the entire wave is flattened and of small amplitude. Slow rising pulses are less obvious in the peripheral pulses.

Possible causes include :-

  • Aortic valve stenosis – in this condition the rate of ejection of blood into the aorta is decreased so that the duration of the ejection is prolonged. The amplitude of the pulse is diminished as a consequence
  • poorly functioning left ventricle may give rise to a slow rising wave form due to slow ejection from the poorly functioning ventricle

Pulses alternans is seen in – (NIMHANS 88)
a) Left ventricular failure b) Digitalis poisoning
c) AS with AR d) MS with MR

Pulses paradoxus is seen in – (NIMHANS 88)
a) Mitral stenosis b) Artrial fibrillation
c) Aortic stenosis d) Asthma

Varying pulse pressure with normal rhythum is
seen in – (JIPMER 78, PGI 87, 93)
a) Left ventricular failure b) Asthma
c) Respiratory failure d) Cardiac tamponade

Water hammer pulse is seen in all except –
a) AR b) Anaemia (CMC 98)
c) Pregnancy d) MR
e) MS

Pulsus bisiferians is best felt at – (AIIMS 98)
a) Carotids b) Radial
c) Brochial d) Femoral

Dicrotic pulse is seen in – (Jipmer 2K)
a) Cardiac tamponade
b) Aortic regurgitation
c) Dilated cardiomyopathy
d) Retrictive cardiomyopathy

A bifid pulse is easily appreciated in patients on intra-aortic balloon counterpulsation (IABP), in whom the second pulse is diastolic in timing.

The dicrotic pulse has two palpable waves, one in systole and one in diastole. It usually denotes a very low stroke volume, particularly in patients with dilated cardiomyopathy.

True about pulsus paradoxus is – (PGI 98)
a) Arm-tongue circulation time is increased
b)inc. Stroke volume
c) Seen in constrictive pericarditis
d)inc. HR

Pulsus alternans occurs in – (PGI 98)
a) Constrictive pericarditis b) Viral myocarditis
c) Hypokalemia d) MI

Water hammer pulse seen in – (Aiims May 07)
a) Aortic stenosis
b) Aortic regurgitation
c) Aortic stenosis and Aortic regurgitation
d) Mitral regurgitation

Which one of the following does not cause pulsus
paradoxus ? (UPSC 07)
a) Severe aortic regurgitation
b) Cardiac tamponade
c) Constrictive pericardities
d) Acute severe bronchial asthma

Pulsus paradoxus seen in – • (PGI June 06)
a) Cardiac tamponade
b) Constrictive pericarditis
d) AR
e) Severe asthma

One of the following is not an indicator of the severity
of asthma – (AIIMS 78, PGI 81)
a) Use of accessory muscles
b) Pulsus paradoxus
c) Cyanosis
d) Systolic hypertension

A post-operative cardiac surgical patient developed
sudden hypotension, raised central venous pressure,
pulsus paradoxus at the 4 post operative hour. The
most probable diagnosis is:
A. Excessive mediastinal bleeding
B. Ventricular dysfunction
C. Congestive cardiac failure
D. Cardiac tamponade

Pulse pressure in a particular vessel is determined
chiefly by – (Bihar 91)
a) Distance from heart
b) Frictional characteristics lumen
c) Distensibility
d) Cross sectional area

The arterial pulse pressure in the femoral artery
is normally – (PGI 91)
a) Less than the pulse pressure in the upper aorta
b) Less than 20 mm Hg
c) Greater than the pulse pressure in the upper aorta
d) Equal to the pressure in the upper aorta
e) None of the above

Blood pressure is defined as the product of –
a) Systolic pressure x pulse (PGI 98)
b) Diastolic pressure x pulse rate
c) Pulse pressure x pulse rate
d) Cardiac output x peripheral resistance

Best artery to palpate for pulse in infants is –
a) Femoral a b) Radial a (PGI 2000)
c) Carotid a d) Brachial a

All of following tend to increase in old age
except – (Delhi 96)
a) Residual volume b) Systolic BP
c) Pulse pressure d) Vital capacity

Which tends to decrease with increasing
age – (AIIMS 85)
a) Vital capacity b) Systolic B.P.
c) Pulse pressure d) Residiial volume



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