CARDIOVASCULAR SYSTEM




PHYSICAL
EXAMINATION
 III. DIAGNOSIS
of
CARDIAC
DISEASES


 a. Underlying
etiology

I. SYMPTOMS
 ‐ Is
 the
 disease
 congenital,
 infectious,
 hypertensive
 or

A. CHEST
PAIN
 ischemic
in
origin?

‐ Most
common
symptom
of
heart
disease
 b. Anatomic
abnormalities

‐ Also
present
in
pulmonary
diseases
 ‐ Which
chambers
are
involved?

‐ Levine
 sign:
 patient
 seen
 clenching
 his
 fist
 over
 the
 ‐ Are
they
hypertrophied,
dilated
or
both?

anterior
chest
 ‐ Which
valves
are
affected?


 ‐ Are
they
regurgitant
and/or
stenotic?

B. DYSPNEA
 ‐ Is
there
pericardial
involvement?

‐ Difficulty
of
breathing
 ‐ Has
there
been
a
myocardial
infarction?

‐ May
relieve
by
shifting
in
upright
position
 c. Physiologic
disturbances

‐ Types:
 ‐ Is
an
arrhythmia
present?

 Orthopnea
 ‐ Is
 there
 evidence
 of
 congestive
 heart
 failure
 or

 Paroxysmal
Nocturnal
Dyspnea
 myocardial
ischemia?


 d. Functional
ability

C. FATIGUE
 ‐ How
 strenuous
 is
 the
 physical
 activity
 required
 to
 elicit

‐ Decreases
 cardiac
 output
 and
 peripheral
 vascular
 symptoms?

resistance
 


 

D. EDEMA
 IV. THE
GENERAL
EXAM

‐ Considered
 as
 part
 of
 physical
 examination
 NOT
 a
 a. Appearance
should
be
evaluated

symptom
 ‐ Tiredness:
maybe
because
of
chronic
low
cardiac
output

‐ Activates
the
RAAS
because
of
decrease
renal
perfusion
 ‐ Increased
respiratory
rate:
pulmonary
venous
congestion

‐ Diseases:
 ‐ Central
cyanosis

 Heart
failure
edema
  Associated
with
clubbing
of
fingers
and
toes

 Jugular
venous
distention
  Indicates
 right‐to‐left
 cardiac
 or
 extracardiac

 Crackles
 shunting
or
inadequate
oxygenation
of
blood
by
the

 Dyspnea
 lungs

‐ May
also
be
seen
in
the
lower
extremities
 ‐ Cyanosis
in
the
distal
extremities,
cool
skin
and
increased


 sweating
 result
 from
 vasoconstriction
 in
 patients
 with

E. PALPITATION
 severe
heart
failure

‐ Awareness
of
one’s
heart
beating
 


 b. Blood
pressure

F. OTHERS
 ‐ Should
be
taken
in
both
arms
and
with
the
patient
supine

‐ Crackles:
maybe
a
diagnosis
for
heart
failure
 and
upright

‐ Neck
distention:
increase
in
jugular
venous
pressure
 ‐ Orthostatic
 hypotension
 and
 tachycardia
 may
 indicate
 a

‐ Hepatojugular
 reflux:
 support
 the
 diagnosis
 of
 heart
 reduced
blood
volume

failure
 ‐ Resting
tachycardia
may
be
due
to
heart
failure


 


 c. Examination
of
the
Retina

II. RISK
FACTORS
 ‐ Severe
hypertension

a. Age
  Scattered
flame‐shaped
hemorrhages

‐ Male:
40
years
old
and
above
  Very
constricted
arterioles

‐ Female:
50
years
old
and
above
  Cotton‐wool
spots

b. Sex
 ‐ Optic
disc

c. Family
history
  Evidence
of
edema
and
blurred
margins

d. Obesity
  Neovascularization
 or
 the
 pallor
 of
 optic
 atrophy

e. Increase
in
blood
pressure
 should
be
ruled
out

f. Lifestyle
 

g. Diabetes
mellitus
 d. Examination
of
the
Abdomen


 ‐ Heart
failure


  Large,

tender
liver


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 CARDIOVASCULAR SYSTEM



 Palpable
spleen
 Pulsus
alterans

 Ascites
 ‐ Regular
 alterations
 of
 the
 pressure
 pulse
 amplitude

‐ Constrictive
pericarditis
 despite
a
regular
rhythm

 Large,
tender
liver
 ‐ Conditions:

 Peripheral
edema
  Alternating
left
ventricular
contractile
force

‐ Tricuspid
regurgitation
  Severe
impairment
of
left
ventricular
function

 Systolic
hepatic
pulsations
  Congestive
heart
failure

 Enlarged
pulsating
liver
  Loud
third
heart
sound

 Ascites
  Paroxysmal
tachycardia


  Premature
beat
in
patients
without
heart
disease


 

ARTERIAL
PRESSURE
PULSE
 Pulsus
bigeminus

‐ Normal
 central
 aortic
 pulse
 wave
 is
 characterized
 by
 a
 ‐ Regular
 alterations
 in
 pressure
 pulse
 amplitude
 caused

fairly
rapid
rise
to
a
somewhat
rounded
peak
 by
a
premature
ventricular
contraction

‐ Incisura:
 sharp,
 downward
 deflection,
 coinciding
 with
 

aortic
valve
closure
 Pulsus
paradoxus

‐ Carotid
pulse
 ‐ Decrease
in
systolic
arterial
pressure

 SCM
should
be
relaxed
 ‐ Accompanies
 the
 reduction
 of
 arterial
 pulse
 amplitude

 Patient’s
head
slightly
rotated
toward
the
examiner
 during
inspiration

‐ Brachial
arterial
pulse
 

 Support
the
patient’s
elbow
with
the
right
arm
while
 Dicrotic
pulse
 
 
 Typhoid
fever

compressing
the
brachial
pulse
with
the
thumb
 Pulsus
tardus
 
 
 Aortic
stenosis

 Compress
 the
 artery
 with
 the
 thumb
 or
 forefinger
 Pulsus
alterans
 
 
 Congestive
heart
failure

until
the
maximum
pulse
is
sensed
 Pulsus
parvus
et
tardus
 
 Stenosis
&
Regurgitation


 Pulsus
bigeminus

 
 Bigeminy

Pulsus
parvus
 

‐ Small,
weak
pulse
 

‐ Conditions:
 JUGULAR
VENOUS
PRESSURE

 Diminished
left
ventricular
stroke
volume
 ‐ Objectives:

 Narrow
pulse
pressure
  Examination
of
the
waveforms
of
the
neck
veins

 Increased
in
peripheral
resistance
  Estimation
of
the
central
venous
pressure


 ‐ Right
jugular
vein
is
usually
palpated

0
Pulsus
tardus
 ‐ Patient
should
be
inclined
by
less
than
30 

‐ Delayed
systolic
peak
 ‐ Shining
 of
 beam
 light
 tangentially
 may
 expose
 the

‐ Conditions:
 pulsation
of
the
internal
jugular
vein

 Aortic
stenosis
 ‐ Reflects
phasic
pressure
changes
in
the
right
atrium

 Obstruction
of
left
ventricular
ejection
 ‐ Consists
of
two
or
three
positive
waves
and
two
negative


 troughs

Bisferiens
pulse
  A
wave:
atrial
contraction

‐ Has
two
systolic
peaks
  C
wave:
bulging
of
the
tricuspid
valve

‐ Conditions:
  V
wave:
atrial
filling

 Aortic
regurgitation
  X
descent:
atrial
relaxation

 Hypertrophic
cardiomyopathy
  Y
descent:
opening
of
the
tricuspid
valve


 ‐ Sternal
angle
is
used
as
the
reference
point

Dicrotic
pulse
  Center
 of
 the
 right
 atrium
 lies
 approximately
 5
 cm

‐ Has
two
palpable
waves,
one
is
systole
and
the
other
in
 below
the
sternal
angle

diastole
 ‐ Maximum
pulsation
is
seen
above
the
clavicle

‐ Conditions:
 

 Dilated
cardiomyopathy
 KUSSMAUL’S
SIGN

 Typhoid
fever
 ‐ Increase
 rather
 than
 normal
 decrease
 in
 the
 CVP
 during


 inspiration


 ‐ Caused
 by
 right‐sided
 heart
 failure,
 constrictive


 pericarditis
or
right
ventricular
infarction


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 CARDIOVASCULAR SYSTEM



PRECORDIAL
PALPATION
 Concentric
Left
Ventricular
Hypertrophy

‐ Location,
amplitude,
duration
and
direction
 ‐ thickened
wall


 ‐ narrow
cavity

Apex
Beat
 ‐ apical
beat
not
displaced

 Left
midclavicular
line
 

th th
 4 
or
5 
intercostal
space
 Eccentric
Left
Ventricular
Hypertrophy

 Tapping,
early
systolic
outward
thrust
 ‐ bigger
cavity

 Due
primarily
to
recoil
of
the
heart
as
blood
is
ejected
 ‐ thick
wall

 Evaluated
 with
 the
 patient
 supine
 and
 in
 the
 left
 lateral
 ‐ (+)
lift

decubitus
position
 ‐ Displacement
of
apical
beat
at
left
anterior
axillary
line

 Conditions:
 

• Left
ventricular
hypertrophy
 Left
Ventricular
Dilatation

• Exaggeration
in
the
duration
and
amplitude
 ‐ Displacement
of
the
apical
beat

• Dilated
cardiomyopathy
 ‐ Big
cavity

• Displacement
 of
 the
 beat
 laterally
 and
 ‐ Thin
walls

th th
downward
into
the
6 
or
even
7 
ICS
 ‐ Heart
does
not
properly
move

• Myocardial
ischemia/failure
 

• Left
ventricular
failure
 

• Mitral
regurgitation
 

• Hypertrophic
cardiomyopathy
 


 

Right
Ventricular
Hypertrophy
 

‐ Sustained
systolic
lift
at
left
parasternal
area
 

‐ Starts
in
early
systole
 

‐ Synchronous
with
the
left
ventricular
apical
impulse
 


 

Left
parasternal
lift
 

‐ Severe
mitral
regurgitation
 

‐ Occurs
later
than
the
left
ventricular
apical
impulse
 

‐ Synchronous
with
the
v
wave
in
the
left
atrial
pressure
 

‐ Due
to
displacement
of
the
right
ventricle
by
an
enlarged
 

left
atrium
 


 

Pulmonary
artery
pulsation
 

nd
‐ is
often
visible
and
palpable
in
the
2 
left
ICS
 

‐ normal
in
children
and
thin
young
adults
 

‐ may
 denote
 pulmonary
 hypertension,
 increased
 

pulmonary
 blood
 flow,
 post‐stenotic
 pulmonary
 artery
 

dilation
 


 

THRILLS
 

‐ palpable,
low‐frequency
vibrations
 

‐ often
associated
with
murmurs
 

‐ conditions:
 

 mitral
regurgitation:
apex
 

 aortic
stenosis:
radiates
to
the
carotid
artery
 

 pulmonic
 stenosis:
 radiates
 to
 the
 left
 side
 of
 the
 

neck
 

rd th
 ventricular
 septal
 defect:
 3 
 or
 4 
 
 ICS,
 left
 sternal
 

border
 


 


 


 


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 CARDIOVASCULAR SYSTEM



HEART
SOUNDS
  Loud
A2


 • Systemic
hypertension

TIPS:
 • Aortic
dilatation

‐ Should
be
performed
in
a
quiet
room
  Soft
A2

‐ Focus
on
the
phases
of
cardiac
cycle
 • Aortic
stenosis

‐ Timing
of
the
heart
sound
or
murmur
  Loud
P2

‐ Define
 the
 timing
 and
 intensity
 of
 the
 cardiac
 sound
 or
 • Pulmonary
hypertension

murmur
 • Atrial
septal
defect


  Soft
P2


 • Pulmonic
stenosis

HEART
SOUNDS
 

‐ Vibrations
 associated
 with
 the
 abrupt
 acceleration
 and
 SPLITTING
of
the
SECOND
HEART
SOUND
(S2)

deceleration
of
blood
 ‐ Splits
 into
 aortic
 and
 pulmonic
 components
 during

‐ First
and
second
heart
sounds
are
produced
primarily
by
 inspiration

the
closure
of
the
atrioventricular
and
semilunar
valves
 ‐ Aortic
is
heard
first
before
pulmonic

‐ Normally,
S1
is
louder
than
S2
  Pressure
on
the
left
side
of
the
heart
is
greater
than


 the
right
side

S1
 ‐ Augmented
 inflow
 into
 the
 right
 ventricle
 →
 ↑
 stroke

‐ First
heart
sound
 volume
 &
 ejection
 period
 →
 delay
 closure
 of
 the

‐ Attributed
 to
 the
 time
 of
 closure
 of
 the
 mitral
 and
 pulmonic
valve

tricuspid

valves
 ‐ Conditions:

‐ Heard
as
LUB
  Physiologic
splitting
of
S2

th th nd rd
‐ Maybe
heard
at
4 
or
5 
ICS
 • Heard
in
the
2 
or
3 
left
ICS

‐ Conditions:
 • Delay
in
closure
of
the
pulmonic
valve

 Loud
S1
 • Atrial
septic
defect

• Tachycardia
 • Right
bundle
branch
block

• Mitral
stenosis
  Wide
splitting
of
S2

 Soft
S1
 • Delay
in
the
closure
of
the
pulmonic
valve

• Mitral
regurgitation
 • Pulmonic
stenosis

• Congestive
heart
failure
 • Right
bundle
branch
block

• Coronary
artery
disease
 • Mitral
regurgitation

‐ Splitting
of
S1
  Fixed
splitting
of
S2

 First
component
is
attributed
to
closure
of
the
mitral
 • Wide
 splitting
 that
 does
 not
 vary
 with

valve
 respiration

 Second
 component
 is
 attributed
 to
 closure
 of
 the
 • Atrial
septic
defect

tricuspid
valve
 • Right
ventricular
failure

 Widening
of
the
S1
  Paradoxical
splitting
of
S2

• Complete
RBBB
 • Appears
 on
 expiration
 and
 disappears
 on

• Delay
 in
 onset
 of
 the
 right
 ventricular
 pressure
 inspiration

pulse
 • Delay
in
closure
of
the
aortic
valve

 Reversed
splitting
of
S1
 • Aortic
stenosis

• Severe
Mitral
Stenosis
 • Left
RBBB

• Left
atrial
myxoma
 • Hypertrophic
cardiomyopathy

• LBBB
 


 

S2
 SYSTOLIC
SOUNDS

‐ Second
heart
sound
 1. EJECTION
SOUND

‐ Attributed
 to
 the
 time
 of
 closure
 of
 the
 aortic
 and
 ‐ Sharp,
high‐pitched
sound
in
early
systole

pulmonic
valves
 ‐ Follows
the
first
heart
sound

‐ Heard
as
DUB
 ‐ Aortic
 ejection:
 best
 heard
 at
 the
 Left
 ventricular
 apex

nd nd nd
‐ Maybe
heard
at
the
Right
2 
ICS
(Aortic)
and
Left
2 
ICS
 and
2 
ICS

(Pulmonic)
 ‐ Pulmonary
ejection:
best
heard
at
the
upper
left
sternal

‐ Conditions:
 border
and
during
expiration


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 CARDIOVASCULAR SYSTEM



‐ Conditions:
 ‐ Accentuated
 by
 mild
 isotonic
 or
 isometric
 exercise
 in

 Dilation
of
the
aorta
or
pulmonary
artery
 supine
position

 Aortic
stenosis
 ‐ Causes:

 Pulmonic
stenosis
  Absent
in
patients
with
atrial
fibrillation


  Systemic
hypertension

2. NONEJECTION
SOUND
/
MIDSYSTOLIC
CLICKS
  Aortic
stenosis

‐ Occurring
with
or
without
a
late
systolic
murmur
  Hypertrophic
cardiomyopathy

‐ Denote
prolapsed
of
mitral
valve
  Ischemic
heart
disease

‐ Maybe
caused
by
tricuspid
valve
prolapsed
  Mitral
regurgitation

‐ Best
heard
on
the
apex
or
lower
left
sternal
border
 

‐ Conditions:
 

 Mitral
valve
prolapsed
(heard
on
Erb’s
point)
 HEART
MURMURS

 Barlow’s
syndrome
 


 ‐ Result
from
vibrations
set
up
in
the
bloodstream
and
the


 surrounding
heart
and
great
vessels

DIASTOLIC
SOUNDS
 ‐ Result
 of
 turbulent
 blood
 flow,
 formation
 of
 eddies
 and

1. OPENING
SNAP
 cavitation

‐ Brief,
high‐pitched
early
diastolic
sound
 ‐ Evaluation
depends
on
the
intensity,
timing,
location
and

‐ Heard
best
at
the
lower
left
sternal
border
 radiation
and
response
to
physical
maneuvers

‐ Radiates
to
the
base
of
the
heart
 

‐ Conditions:
 GRADATIONS
of
MURMURS

 AV
valve
stenosis
 Very
faint,
heard
only
after
listener
has
tuned

Grade
I


 in;
may
not
be
heard
in
all
positions

2. S3
 Quiet,
heard
immediately
after
placing
the

‐ Low‐pitched
sound
 Grade
II

stethoscope
on
the
chest

‐ Normally
heard
in
children
 Grade
III
 Moderately
loud

‐ Resistance
in
early
diastole
 Grade
IV
 Loud
with
palpable
thrill

‐ Ventricular
gallop
 Very
loud
with
thrill;
may
be
heard
when
the

‐ Persistent
increase
in
volume
→
volume
overloading
 Grade
V

stethoscope
is
partly
off
the
chest

‐ Left‐sided
 S3:
 heard
 best
 at
 the
 apex
 during
 expiration
 Very
loud
with
thrill;
may
be
heard
with

and
patient
in
left
lateral
position
 Grade
VI

stethoscope
entirely
off
the
chest

‐ Right‐sided
 S3:
 heard
 best
 at
 the
 left
 sternal
 border
 or
 

beneath
the
xiphoid
and
is
louder
during
inspiration
 

‐ Causes:
 TRANSMISSION
of
SOUNDS:

 Cardiac
tamponade
 ‐ Aortic
stenosis:
carotid
arteries

 Tricuspid
regurgitation
 ‐ Mitral
regurgitation:
axilla
or
scapula

 Mitral
regurgitation
 

 Constrictive
pericarditis



TURBULENCE

3. S4

‐ Late
period
of
diastole

‐ Slow
filling
rate

‐ Atrial
gallop
 VALVE
 MURMUR/BRUIT

‐ Ventricles
are
about
to
be
filled
but
there
is
presence
of

resistance
due
to
early
filling

‐ Low‐pitched,
presystolic
sound

‐ Diminished
 ventricular
 compliance
 →
 resistance
 to
 STENOSIS
 REGURGITATION
 SHUNT


ventricular
filling
 



‐ Usually
 accompanied
 by
 visible
 and
 palpable
 left



ventricular
distention



‐ Loudest
 at
 the
 apex
 when
 patient
 is
 in
 the
 left
 lateral



position




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 CARDIOVASCULAR SYSTEM



GENERALIZATIONS:
 ‐ Also
called
Systolic
Ejection
Murmurs

‐ Not
all
murmurs
are
abnormal
 ‐ Often
crescendo‐decresendo
in
shape

‐ Stenosis:
valves
cannot
open
completely
 ‐ Occur
when
blood
ejected
across
the
aortic
or
pulmonic

‐ Regurgitation:
valves
cannot
close
completely
 outflow
tracts

‐ All
 murmurs
 originating
 from
 the
 right
 side
 of
 the
 heart
 ‐ Intensified
 after
 amyl
 nitrite
 inhalation
 and
 during

are
 louder
 in
 inspiratory
 phase
 except:
 PULMONIC
 cardiac
cycle
following
a
premature
ventricular
beat

STENOSIS
 

‐ Diastolic
murmurs
are
always
pathologic
 CONDITIONS
that
accompany
MIDSYSTOLIC
MURMURS

‐ To
 differentiate
 aortic
 and
 pulmonic
 murmurs,
 ask
 the
 1. AORTIC
STENOSIS

patient
to
inhale
 ‐ Prototype
of
left‐sided
midsystolic
murmur

nd

 ‐ Can
be
heard
at
the
right
2 
interspace


 SYSTOLE
 DIASTOLE
 ‐ Valvular
Aortic
Stenosis

nd
Mitral
  Maximal
in
the
2 
right
intercostals
space

REGURGITATION
 STENOSIS

Tricuspid
 ‐ Supravalvular
Aortic
Stenosis

Aortic
  Loudest
and
highest
into
the
right
carotid
artery

STENOSIS
 REGURGITATION
 

Pulmonic


 2. HYPERTROPHIC
CARDIOMYOPATHY


 ‐ Originates
in
the
left
ventricular
cavity


 ‐ Maximal
at
the
lower
left
sternal
edge
and
apex

rd th
SYSTOLIC
MURMURS
 ‐ Can
be
heard
at
the
3 
or
4 
left
interspaces


 

HOLOSYSTOLIC
MURMURS
 3. PULMONIC
STENOSIS

rd
‐ Are
pathologic
 ‐ Can
be
heard
at
3nd
or
3 
left
interspaces

‐ Arising
 from
 the
 blood
 flow
 from
 a
 chamber
 with
 high
 ‐ Impairs
flow
across
the
valve
increasing
right
ventricular

pressure
 to
 one
 of
 lower
 pressure
 or
 a
 valve
 or
 other
 afterload

structure
that
should
be
closed
 ‐ S2
is
widely
split,
P2
is
diminished
or
inaudible

‐ Pressure
 gradient
 occurs
 early
 in
 contraction
 and
 lasts
 

until
relaxation
 

‐ Begins
before
aortic
ejection
 EARLY
SYSTOLIC
MURMURS

‐ Begins
with
S1
and
end
after
S2
 ‐ Begins
with
the
first
heart
sound
and
end
in
midsystole


 ‐ Causes:


  Large
 ventricular
 septal
 defect
 with
 pulmonary

CONDITIONS
that
accompany
HOLOSYSTOLIC
MURMURS
 hypertension

1. MITRAL
REGURGITATION
  Tricuspid
 regurgitation
 occurring
 in
 the
 absence
 of

‐ Can
be
heard
at
the
apex
 pulmonary
hypertension

‐ Soft
to
loud
with
an
apical
thrill
  Common
 in
 narcotic
 abusers
 with
 infective

‐ Usually
continues
throughout
systole
 endocarditis

‐ Augmented
by
transient
exercise
  Acute
mitral
regurgitation


 

2. TRICUSPID
REGURGITATION
 

‐ Associated
with
pulmonary
hypertension
 LATE
SYSTOLIC
MURMURS

‐ Increases
during
inspiration
 ‐ Faint
or
moderately
loud

‐ Can
be
heard
at
the
left
lower
sternal
border
 ‐ High‐pitched
apical
murmurs

‐ Caravallo’s
sign
 ‐ Starts
after
ejection
and
do
not
mask
either
heart
sound


 ‐ Causes:

3. VENTRICULAR
SEPTAL
DEFECT
  Myocardial
infarction
or
ischemia

‐
th th
Can
be
heard
at
Erb’s
point,
4 
or
5 
interspaces
  Left
ventricular
dilation

‐ Often
very
loud
with
a
thrill
  Angina

‐
th
More
distinct
at
4 
interspace,
sternal
area
  Maybe
heard
in
Mitral
Regurgitation

MIDSYSTOLIC
MURMURS
 DIASTOLIC
MURMURS

‐ Most
common
kind
of
murmurs
 

‐ Peak
near
midsystole
 EARLY
DIASTOLIC
MURMUR

‐ Stops
before
S2
 ‐ Begin
with
or
shortly
after
S2


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 CARDIOVASCULAR SYSTEM



‐ Decrescendo
type
 

‐ Signifies
 regurgitant
 flow
 
 through
 an
 incompetent
 4. AUSTIN‐FLINT
MURMUR

semilunar
valve
 ‐ Occurs
in
severe,
chronic
aortic
regurgitation

‐ More
common
in
the
aortic
 ‐ May
present
as
mid‐diastolic
or
presystolic
murmur


 ‐ Originates
at
the
anterior
mitral
valve
leaflet
when
bllod

CONDITIONS
that
accompany
EARLY
DIASTOLIC
MURMUR
 enters
 the
 left
 ventricle
 simultaneously
 from
 both
 the

1. AORTIC
REGURGITATION
 aortic
root
and
the
left
atrium

nd th
‐ Can
be
heard
at
2 
or
4 
left
interspace
 

‐ Generally
decrescendo
 

‐ There
is
progressive
decline
in
the
volume
or
rate
of
the
 CONTINUOUS
MURMURS

regurgitant
flow
 

‐ Enhanced
by
an
acute
elevation
of
the
arterial
pressure
 ‐ Begins
 in
 systole,
 peak
 near
 S2
 and
 continue
 into
 all
 or

‐ Diminishes
 with
 a
 decrease
 in
 arterial
 pressure
 as
 with
 part
of
diastole

amyl
nitrite
inhalation
 ‐ Result
 from
 continuous
 flow
 due
 to
 a
 communication


 between
 high
 and
 low
 pressure
 areas
 that
 persists

2. PULMONIC
REGURGITATION
 through
the
end
of
systole
and
the
beginning
of
diastole

‐ Low
to
medium
pitched
 

‐ Onset
is
delayed
 CONDITIONS
that
accompany
CONTINUOUS
MURMURS

‐ Regurgitant
 flow
 is
 minimal
 at
 the
 onset
 of
 pulmonic
 1. PATENT
DUCTUS
ARTERIOSUS

valve
closure
 ‐ Intensified
by
elevation
of
the
systemic
arterial
pressure


 ‐ Causes
continuous
murmur
as
long
as
the
pressure
in
the


 pulmonary
artery
is
much
below
that
in
the
aorta

nd
MID‐DIASTOLIC
MURMUR
 ‐ Can
be
heard
at
the
2 
left
interspace

‐ Occurs
during
early
ventricular
filling
 ‐ Machinery‐like
murmur

‐ Due
to
disproportion
between
valve
orifice
size
and
flow
 

rate
 2. VENOUS
HUM

‐ Maybe
quite
loud
 ‐ Continuous
without
a
silent
interval

‐ Maybe
 soft
 when
 there
 is
 marked
 reduction
 in
 the
 ‐ May
be
heard
above
the
clavicles

cardiac
output
 ‐ Loudest
in
diastole

‐ Low‐pitched
 sound
 so
 the
 examiner
 should
 use
 the
 bell
 ‐ Humming
or
roaring
murmur

of
the
stethoscope
 

‐ Rumbling
murmurs
 3. PERICARDIAL
FRICTION
RUB

rd

 ‐ Best
heard
in
the
3 
interspace
left
sternal
border

CONDITIONS
that
accompany
MID‐DIASTOLIC
MURMUR
 ‐ Scratchy,
scraping
sound

1. MITRAL
STENOSIS
with
MITRAL
VALVE
PROLAPSE
 ‐ High‐pitched
sound

‐ Low‐pitched
sound
following
opening
snap
 

‐ Bell
at
the
sight
of
left
ventricular
impulse
 

‐ Place
 the
 patient
 at
 left
 lateral
 decubitus
 to
 emphasize
 EARLY
SYSTOLIC
MURMUR

the
murmur
 ‐ Acute
Severe
Mitral
Regurgitation

‐ Frequently
present
only
at
the
left
ventricular
apex
 ‐ Mitral
Valve
Prolapse

‐ May
 increase
 in
 intensity
 by
 mild
 supine
 exercise
 or
 by
 

inhalation
of
amyl
nitrite
 HOLOSYSTOLIC
MURMUR


 ‐ Mitral
Regurgitation
from
Ruptured
Chordae
Tendinae

2. TRICUSPID
STENOSIS
 ‐ Severe
Rheumatic
Mitral
Regurgitation

‐ Localized
at
the
left
sternal
edge
 ‐ Tricuspid
Regurgitation

‐ Louder
during
inspiration
 ‐ Small
Muscular
Ventricular
Septal
Defect


 ‐ Severe
Pulmonic
Stenosis

3. ACUTE
RHEUMATIC
FEVER
 

‐ Soft
murmur
 

‐ Carey‐Coombs
murmur
 MIDSYSTOLIC
MURMUR

‐ Attributed
 to
 inflammation
 of
 the
 mitral
 valve
 cusps
 or
 ‐ Congenital
Aortic
Bicuspid
Aortic
Regurgitation

excessive
left
atrial
blood
flow
as
a
consequence
of
mitral
 ‐ Aortic
Stenosis

regurgitation
 ‐ Moderate
Pulmonary
Stenosis


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 CARDIOVASCULAR SYSTEM



‐ Mild
Pulmonary
Stenosis



LATE
SYSTOLIC
MURMUR

‐ Mitral
Valve
Prolapse





EARLY
DIASTOLIC
MURMUR

‐ Acute
Severe
Aortic
Regurgitation

‐ Chronic
Severe
Aortic
Regurgitation

‐ Mild
Aortic
Regurgitation

‐ Moderate
Pulmonic
Regurgitation

 Eisenmenger
Ventricular
Septal
Defect



MID‐DIASTOLIC
MURMUR

‐ Moderate
Mitral
Stenosis

‐ Tricuspid
Stenosis

‐ Aortic
Stenosis

‐ Austin‐Flint
Murmur

 Chronic
Aortic
Regurgitation

 Acute
Severe
Aortic
Regurgitation


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