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Cardiac Physical exam
Imagine there’s no Echo
It’s easy if you try…
Arterial Pulses
• Paradoxus - tamponade, asthma
• Parvus et Tardus - aortic stenosis
• Asymmetric - aortic dissection
• Diminished or absent - PAD, coarctation
• Bisferiens - aortic insufficiency, HCM• Alternans - severe LV dysfxn, bigemminy
The Neck Veins
http://www.youtube.com/watch?v=tJzBKdKg2k0
Abdominal Jugular Test
• Press firmly for 10 seconds
• If CVP > 4 cm for 10 seconds (or falls > 4 cm with release of pressure) POSITIVE
• Pos AJR is an accurate sign of elevated LEFT ATRIAL PRESSURE (LR = 8.0)
Sustained Left lower parasternal movements (i.e. Heave)
• Can be caused by RV volume overload, MR
• If they are excluded, can be associated with degree of pulmonary HTN– RV pressure > 50 (+LR 3.6)
Heart Sounds
• S1 - closing of mitral and tricuspid valves– Incr with short PR, MS, hyperdynamic LV
• S2 - closing of aortic and pulmonic valves– splitting
• S3 - increased early diastolic filling pressure– Can be normal in kids and athletes– Depressed EF (LR – 3.8; not very sensitive, very
specific)
• S4 - decrease ventricular compliance– Never normal, ie LVH, ischemia, AS
How to Describe a Murmur
• Intensity
• Pitch
• Quality
• Configuration
• Location
• Timing
Intensity
• I/VI : Faint, only heard with special effort• II/VI : Immediately identified• III/VI : Moderately loud• IV/VI : Loud with a palpable thrill• V/VI : One edge of stethoscope on chest• VI/VI : No stethoscope required
Pitch
• High– MR, AI
• Low– MS, Gallops
Quality
• Harsh
• Rumbling
• Scratchy
• Blowing
• Musical
• Squeaky
Configuration
• Crescendo– Severe AS, MVP
• Decrescendo– AI
• Crescendo-decrescendo (diamond shaped)– Innocent murmur
• Plateau– MR
Location
• Apex
• Bases
• Parasternal– Right or left– Which ICS
• Does it radiate?
Timing
• Systolic/Diastolic– Early– Mid– Late– Holo
• Continuous
Murmurs
• Systolic– Flow murmurs, AS, PS, MR, TR, VSD
• Diastolic– AI, PI, MS, TS
• Continuous– Patent ductus arteriosus
Aortic Stenosis
Mitral Regurgitation
Aortic Regurgitation
Exam Maneuvers
• Respiration
• Standing
• Squatting
• Valsalva
• Hand Grip
• Post Ectopic Beats
• Amyl Nitrate
Murmurs
• All murmurs: – louder with increased flow (ie recumbency, squatting) – and softer with decreased flow (ie valsalva, standing) – except MVP and HCM
• MVP vs HCM – sustained handgrip: MVP louder HCM softer
• Right sided murmurs increase with inspiration • Left sided murmurs louder during expiration• All diastolic murmurs are abnormal (echo)
Respiration
• Inspiration increases venous return to the right heart, and decreases return to the left heart
• Inspiration increases the split of S2– P2 moves farther away from A2
• Inspiration increases the intensity of right sided Murmurs and Gallops– TR Carvallo’s sign
Standing
• Decreases venous return, stroke volume, arterial blood pressure– AS decreased– MR/TR decreased– VSD decreased– MVP earlier click, longer murmur– HCM INCREASED
Squatting
• Increases preload, afterload, and arterial pressure– MR/TR increased– VSD increased– AI increased– AS variable– MVP delayed click, shorter increased murmur– HCM DECREASED
Valsalva
• Decreased venous return, ventricular volumes, stroke volumes, arterial pressure– AS/PS decreased– AI/PI decreased– MR/TR decreased– MS/TS decreased– MVP earlier click, longer murmur– HCM INCREASED
20-30 Sec Handgrip
• Increased SVR, arterial pressure, cardiac output, LV volume– AS DECREASED– MR/MS increased– AI increased– VSD increased– MVP later click, shorter murmur– HCM decreased
Post ectopic beat
• Increased ventricular volume and contractility (effect of increased contractility > increased volume)– MR NO CHANGE– AS/AI increased– HCM increased– TR increased– MVP earlier click, longer murmur
• Effect of contractility > volume
Murmurs with names
• Austin Flint– Late diastolic murmur in aortic insufficiency of jet
causing vibration of anterior mitral valve leaflet or antero-apical wall
• Graham Steell– Early diastolic murmur of pulmonic insufficiency in the
setting of pulmonary HTN
• Carey-Coombs– Mid-diastolic apical murmur of inflammation of the
mitral leaflets in the carditis of rheumatic fever
Extra Heart Sounds
Splitting of S2
• Physiologic split– Splits during inspiration
• Widened split– RBBB (Late P2), MR (early A2)
• Fixed split– ASD
• Paradoxic split (delayed A2)– LBBB, AS, HCM