CLINICAL MEDICINE

CARDIO VASCULAR SYSTEM

2019

ECCENTRIC
CONCENTRIC ECCENTRIC LVH DILATATION RVH
WITH LIFT
§ Strong forceful § Displaced apical beat § Very strong pulsation § Not palpable § Apical Beat that
pulsation/impulse horizontally § *turn pt. on lateral retracts during systole
§ Pushes the decubitus-bring nearer
§ 5th ICS MCL/10cm § 5th ICS LAAL/12cm steth/Hands up to the chest wall*
§ 5th/6th ICS
§ Thick wall § Thick wall § Displaced § Very faintly palpable
Horizontally/Vertically beat on the middle of
§ Small cavity § Thick septum axilla

§ *Global hypokinesia
moving in 2D echo

Seen in Patient with : Seen in Patient with :
ü Chronic HPN
Seen in Patient with : Seen in patient with : Symptomatic patients:
ü Chronic HPN ü Volume overload ü Cardiomyopathy § Mitral stenosis
due to vulvular ü CAD § Congested heart
disease ü Chronic Ischemia disease
ü Mitral regurgitation Heart Disease § Cor pulmonale
ü Aortic regurgitation ü Coronary Bypass § Pulmonary
ü Congenital Heart ü Cox Virus embolism
Disease ü Echo virus-viral § Rheumatic heart
ü Eg. Patent Ductus cardiomyopathy disease o Left atrial
Arteriosus (PDA) enlargement o Right
ü Use of alcohol
ventricular
ü Taking illicit drugs
Symptomatic patients: § hypertrophy
§ DOB
§ Orthopnea
§ Peripheral edema w/
jugular vein
distention
§ On ECG
o Small QRS-
Hypokinetic
§ On X-ray
o Markedly
enlarged heart

PULSUS PARVUS ET PULSUS BIGEMINUS / PULSUS

PULSUS ALTERRANS CORRIGAN’S PULSE
TARDUS BISFERIENS PARADOXICUS

§ Alternating strong § Small and late pulse § Premature ventricular § Very Strong pulse § Not a pulse
weak pulse contraction § Collapsing pulse § Take patient BP and
Deep breath
ü CHF ü Aortic stenosis ü Aortic stenosis + o More than 10mm
Regurgitation ü Chronic Aortic lowering in
Regurgitation systolic BP

ü Chronic Constrictive
Pericarditis

§ CARVALLOS’S SIGN – § INTERMITTENT § ASD – Fixed Splitting of S2

Tricuspid regurgitation CLAUDICATION – pain in the
right calf upon walking can be § VSD – Holosystolic murmur at the
§ KUSSMAULS SIGN – relieve by rest Left parasternal area to right
constrictive pericarditis and sternal border
pericardial effusion § EBSTEIN ANOMALY – Sail
Sound Additional: RAA tables
§ HEPATOJUGULAR – CHF
§ GRAHAM STEELE – Pulmonary § DYNAMIC HEART – LVH
§ AUSTIN FLINT – Chronic Aortic regurgitation
regurgitation § BIGEMINY - continuous
§ CAREY COOMBS – Rheumatic alternation of long and short
§ GALLAVARDIN’S SIGN – Aortic heart Disease heart beats, premature
Stenosis ventricular contraction (PVC),
§ COARTATION OF AORTA – BP aortic stenosis
§ MACHINARY LIKE – PDA elevated in UE and low in LE

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BEST HEARD

AORTIC PULMONIC ERB’S POINT TRICUSPID MITRAL

RIGHT ICS PSL LEFT ICS PSL LEFT ICS LEFT ICS PSB LEFT ICS MAL
2ND
2nd 3rd 4th 5th
§ Paradoxical § Physiologic Splitting of § Mitral Valve Prolapse § Tricuspid § Mitral
Splitting of S2 S2 (MVP) Regurgitation Regurgitation

§ Aortic Stenosis § Persistent Splitting of S2 § Vetricular Septal § ASD § Mitral Stenosis

Defect (VSD)
§ Aortic Aneurysm § Pulmonic Aneurysm § Physiologic Splitting of § S3
§ Aortic Regurgitation S1
§ Pulmonary Stenosis § S4
§ Quadruple Rhythm § Ebstein Anomaly
§ Dilated
§ PDA – Patent Ductus
§ Hypertrophic Cardiomyopathy
Arteriosus
Cardiomayopathy
§ ASD – Atrial Septal
Defect

HEART SOUNDS

S1 S2
LOUD S1 (TIM)
§ Tachycardia LOUD A2 (LA-SA) LOUD P2 (LP-PA)
§ Increased Temperature
§ Mitral Stenosis § Systemic HPN § Pulmonary HPN
§ Aortic Dilatation § ASD – Arial Septal Defect
SOFT S1 (VAMCC)
§ Volume Overload SOFT A2 SOFT P2
§ Atrial Fibrillation
§ Mitral Regurgitation § Aortic Stenosis § Pulmonary Stenosis
§ CHF - Chronic Heart Failure
§ CAD - Coronary Artery Disease

S1 S2

§ 1st – Aortic
§ 1 - Closure of mitral valve
st
SPLITTING
§ 2nd – Pulmonic

§ RBBB - Right bundle branch block

§ Complete RBBB
WIDENING § Delayed closure of PV
§ Delayed onset of RV pressure pulse
§ Mitral regurgitation
§ Severe mitral stenosis
REVERSED § LBBB – Left bundle brunch block
§ Left atrial myxoma
§ Delayed closure not vary with pulmonic valve
PHYSIOLOGIC § ASD – Atrial Septal Defect
§ RBBB – Right bundle branch block
§ Does not vary with respiration
FIXED § ASD – Atrial Septal Defect
§ RVF – Right Ventricular Failure

§ Does not vary on expiration and disappears on

inspiration
§ Delayed closure at AV
PARADOXICAL
§ Aortic stenosis
§ LBBB - Left bundle brunch block
§ Hypertropic Cardiomyopathy

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 SYSTOLIC SOUND DIASTOLIC
NON-EJECTION/
EJECTION OPENING SNAP S3 S4
MIDSYSTOLIC CLICK
HIGH PITCH SOUND § Brief high pitch § Low pitched § Low pitched
§ LLSB § normal in children § Pre-systolic sound
(DAPE)
§ Radiates to the
base of heart AV
ü Dilatation of Aorta ü MVP
ü Aortic Stenosis ü Barlow’s ü Stenosis ü Early Diastole ü Absent in AF
ü Pulmonic Stenosis Syndrome ü Cardiac tamponade ü Systemic HPN
ü Early Systole ü Tricuspid ü Aortic Stenosis
regurgitation
ü Constrictive ü Hypertropic
Cardiomyopathy
pericarditis
* volume overload ü Ischemic Heart Disease
ü Ventricular Gallop
After S2 ü Mitral Regurgitation
ü Heart Failure
ü Aortic Regurgitation
ü Weak Contractility

REVIEW:
§ Physiologic Splitting of S2 in Normal Breathing
§ Normal § Persistent Splitting of S2 in Pulmonic Stenosis Atrial Septal
a. Apex: Loud S1 Soft S2 Defect
b. Base: Loud S2 Soft S1 § Paradoxical Splitting: P2 Louder than A2 (in comparison to
physiologic and persistent splitting which has louder A2 than
§ The intensity of first heart sound is being affected by P2)
heart rate.
§ In patient with very fast heart: -- S1 becomes loud all over § S3
a. Fever a. Mitral Regurgitation
b. Pregnancy b. Hypertropic Cardiomyopathy
c. Hyperthyroidism c. Restrictive in early diastole (ventricular filling)

HEART MURMUR
SYSTOLIC DIASTOLIC

MITRALVALVE REGURGITATION STENOSIS

TRICUSPID VALVE (Holosystolic) (Mid-systolic murmur)

AORTIC VALVE STENOSIS REGURGITATION

PULMONIC VALVE (Mid-systolic. (Early Diastolic Murmur)
Systolic Ejection Murmur)

SYSTOLIC DIASTOLIC
MID SYSTOLIC EARLY DIASTOLIC
(APAH) (APA)
§ Aortic Stenosis § Aortic Regurgitation
§ Pulmonic Stenosis § Pulmonic Regurgitation
§ ASD - Atrial Septal Defect § Austin Flint
§ HOCM – Hypertropic Cardiomyopathy

HOLOSYSTOLIC MID-LATE DIASTOLIC

(MTV) (MT)
§ Miral Valve Regurgitation § Mitral Stenosis
§ Tricuspid Regurgitation § Tricuspid Stenosis
§ VSD – Ventricular Septal Defect
LATE SYSTOLIC
(MTV)
§ Miral Valve Regurgitation
§ Tricuspid Regurgitation
§ VSD – Ventricular Septal Defect

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Continuous Murmur Venous Hum Pericardial Friction Rub Austin Flint
PDA-Machinery Like § Loudest in § Scratcy, scraping § Soft rumbling
Murmur DIASTOLE: sound at Erb’s murmur
§ Humming or point § Late systolic
Rearing Sound

POSITIONING

Valsalva Increase hypertrophic cardiomyopathy murmur

Deep breathing Right sided murmur

Hand grip Left sided murmur

Standing from squatting MVP

Squatting from standing Decrease hypertrophic cardiomyopathy murmur

Squatting and leg raising Increase venous return to the heart

AUSCULTATION

Sitting and Leaning Mid-aortic regurgitation

HEART
Aortic Stenosis
Aortic regurgitation
Hypertrophic Cardiomyopathy
Atrial septal defect
Ventricular septal defect
Tricuspid regurgitation
§ Ejection systolic murmur transmitted into carotids
§ Crescendo-decrescendo murmur
§ Ejection click or sound
§ Paradoxical splitting of S2
§ Diastolic blowing murmur
§ Wide systolic pressure
§ Fixed/persistent splitting of S2
§ Holosystolic murmur - Heard at Erb’s, transmitted to the
right sternal border
§ 4th ICS parasternal line

§ RBBB
§ Mid-diastolic murmur - radiates to left shoulder
Pulmonic stenosis
§ Crescendo-decrescendo
§ Persistent splitting of S2
Pulmonic regurgitation
§ Opening snap
Mitral stenosis § Diastolic murmur
§ Loud S1
§ Holosystolic murmur displaced to the left
axilla/infrascapular
Mitral regurgitation
§ Diminished S1
§ Rumbling murmur
§ Mid-systolic click
Mitral valve prolapse § Late systolic murmur
§ Non-ejection sound
Coarctation of aorta § Greater BP in the UE compared to LE

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