CONCENTRIC ECCENTRIC ECCENTRIC WITH LIFT LVH DILATATION RVH

 Strong forceful  Displaced  Very strong pulsation  Not palpable *turn pt.  Apical Beat that
 pulsation/impulse apical  Pushes the steth/Hands up on lateral decubitus-bring retracts during systole
 5th ICS  beat  Displaced nearer to the chest wall*
MCL/10cm horizontally  Horizontally/Vertically  5th/6th ICS Symptomatic patients:
 Thick wall  5th ICS  Very faintly palpable  Mitral stenosis
 Small cavity LAAL/12cm Seen in Patient with: beat on the middle of  Congested heart disease
 Thick wall  Volume overload axilla  Cor pulmonale
Seen in Patient with:  Thick septum due to valvular disease  *Global hypokinesia  Pulmonary embolism
 Chronic HPN  Mitral regurgitation moving in 2D echo  Rheumatic heart disease
Seen in Patient with:  Aortic regurgitation o Left atrial enlargement
 Chronic HPN  Congenital Heart Seen in patient with: o Right ventricular
 Disease  Cardiomyopathy hypertrophy
 Eg. Patent Ductus  CAD
 Arteriosus (PDA)  Chronic Ischemia
Symptomatic patients:  Heart Disease
 DOB  Coronary Bypass
 Orthopnea  Cox Virus
 Peripheral edema  Echo virus-viral
w/ jugular vein distention cardiomyopathy
 On ECG  Use of alcohol
o Small QRS- Hypokinetic  Taking illicit drugs
 On Xray
o Markedly enlarged heart

PULSUS ALTERRANS PULSUS PARVUS ET PULSUS BIGEMINUS/BISFRIENS CORRIGAN’S PULSUS PARADOXICUS

TARDUS PULSE
 Alternating strong  Small and late pulse  Premature ventricular  Very Strong pulse  Not a pulse
weak pulse contraction]  Collapsing pulse  Take pt BP and Deep
breath
*CHF *Aortic stenosis *Aortic stenosis +Regurgitation *Chronic Aortic More than 10mm lowering
Regurgitation in systolic BP

*Chronic Constrictive
 Pericarditis
Carvallos’s sign – Tricuspid regurgitation Ebstein Anomaly – Sail Sound
Kussmauls sign – Constrictive pericarditis and Pericardial effusion Graham Steele – Pulmonary regurgitation
Hepatojugular – CHF Carey Coombs – Rheumatic heart Disease
Austin Flint – Chronic Aortic regurgitation Coartation of Aorta – BP elevated in UE and low in LE
Gallavardin’s sign – Aortic Stenosis ASD – Fixed Splitting of S2
Machinery like – PDA VSD – Holosystolic murmur at the Left parasternal area to right sternal
Intermittent Claudication – pain in the right calf upon walking can be border
relieve by rest

Addition: RAA tables

Dynamic heart – LVH
Bigeminy - continuous alternation of long and short heart beats, premature ventricular contraction (PVC), aortic stenosis
BEST HEARD:

2nd RIGHT ICS PSL 2nd LEFT ICS PSL 3rd LEFT ICS 4th LEFT ICS PSB 5th LEFT ICS MAL
(AORTIC) (PULMONIC) (ERB’S POINT) (TRICUSPID) (MITRAL)

1. Paradoxical Splitting 1. Physiologic Splitting of S2 1. Mitral Valve Prolapse 1. Tricuspid Regurgitation 1. Mitral Regurgitation
of S2 2. Persistent Splitting of S2 - (MVP) 2. ASD 2. Mitral Stenosis
2. Aortic Stenosis 3. Pulmonic Aneurysm 2. Ventricular Septal 3. Physiologic Splitting of S1 3. S3
3. Aortic Aneurysm 4. Pulmonary Stenosis Defect (VSD) 4. Ebstein Anomaly 4. S4
5. PDA 3. Aortic Regurgitation 5. Hypertrophic 5. Dilated Cardiomyopathy
6. ASD 4. Quadruple Rhythm Cardiomyopathy
A. HEART SOUNDS:

S1 S2
LOUD A2 (LA-SA) LOUD P2 (LP-PA)

SOFT S1 (VAMCC) Systemic HPN Pulmonary HPN

LOUD S1 (TIM) Vol. Overload Aortic Dilatation ASD
Tachycardia A-FIB SOFT A2 SOFT P2
Increased Temp Mitral Regurgitation
Mitral Stenosis CHF Aortic Stenosis Pulmonary Stenosis
CAD
B. HEART SOUND

S1 S2
SPLITTING  1st-Closure of mitral valve  1st – Aortic
 2nd – Pulmonic
WIDENING  Complete RBBB  RBBB
 Delayed onset of RV pressure pulse  Delayed closure of PV
 Mitral regurgitation
REVERSED  Severe mitral stenosis
 LBBB
 Left atrial myxoma
PHYSIOLOGIC  Delayed closure does not vary with pulmonic
valve
 ASD
 RBBB
FIXED  Does not vary with respiration
 ASD
 RVF
PARADOXICAL  Does not vary on expiration and disappears
on inspiration
 Delayed closure at AV
 Aortic stenosis
 LBBB
 Hypertrophic Cardiomyopathy

C. SYSTOLIC SOUND

EJECTION SOUNDS NON-EJECTION SOUND/ MIDSYSTOLIC CLICK

-HIGH PITCH SOUND (DAPE) MVP
Dilatation of Aorta Barlow’s Syndrome
Aortic Stenosis
Pulmonic Stenosis
Early Systole
D. Diastolic Sound

OPENING SNAP S3 S4
- Brief high pitch - Low pitched - Low pitched
- LLSB - Normal in children - Pre-systolic sound
- Radiates to the base of heart

AV Stenosis Early Diastole Absent in AF

Cardiac tamponade Systemic HPN
Tricuspid regurgitation Aortic Stenosis
Constrictive pericarditis *vol. overload Hypertrophic Cardiomyopathy
Ventricular Gallop After S2 Ischemic Heart Disease
Heart Failure Mitral Regurgitation
Aortic Regurgitation
Weak Contractility

REVIEW:

Normal
Apex: Loud S1 Soft S2
Based: Loud S2 Soft S1

The intensity of first heart sound is being affected by heart rate. In patient with very fast heart (FEVER, PREGNANCY, and HYPERTHYROIDISM –
S1 becomes loud all over

Physiologic Splitting of S2 in Normal Breathing

Persistent Splitting of S2 in Pulmonic Stenosism Atrial Septal Defect
Paradoxical Splitting: P2 Louder than A2 (in comparison to physiologic and persistent splitting which has louder A2 than P2)

S3
-Mitral Regurgitation
-Hypertropic Cardiomyopathy
-Restrictive in early diastole (ventricular filling)

HEART MURMUR
Systolic Diastolic
 MITRAL VALCE
TRICUSPID VALVE REGURGITATTION STENOSIS
(Holosystolic) (MID SYSTOLIC MURMUR)

AORTIC VALVE STENOSIS REGURGITATION

PULMONIC VALVE (Midsystolic/Systolic Ejection Murmur) (EARLY DIASTOLIC MURMUR)

SYSTOLIC DIASTOLIC
MIDSYSTOLIC (APAH) EARLY DIASTOLIC (APA)
- Aortic Stenosis - AORTIC REGURGITATION
- Pulmonic stenosis - PULMONIC REGURGITATION
- ASD - AUSTIN FLINT
- HOCM – Hypertrophic Cardiomyopathy
HOLOSYSTOLIC (MTV) MID-LATE DIASTOLIC (MT)
- Miral Valve Regurgitation - Mitral Stenosis
- Tricuspid Regurgitation - Tricuspid Stenosis
- VSD
LATE SYSTOLIC
- MVP

CONTINOUS MURMUR VENOUS HUM – Loudest in Diastole: PERICARDIAL FRICTION RUB –

PDA- MACHINERY LIKE MURMUR Humming or Rearing Sound Scratchy, scraping sound at Erb’s
point

Austin Flint – Soft rumbling murmur. Late systolic

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 Mild aortic
regurgitation
HEART
Aortic Stenosis  Ejection systolic murmur transmitted into carotids
 Crescendo-decrescendo murmur
 Ejection clicks or sound
 Paradoxical splitting of S2
Aortic regurgitation  Diastolic blowing murmur
 Wide systolic pressure
Hypertrophic
Cardiomyopathy
Atrial Septal Defect  Fixed/persistent splitting of S2
Ventricular Septal Defect  Holosystolic murmur → Heard at Erb’s, transmitted to the right sternal border
Tricuspid regurgitation  4th ICS parasternal line
Pulmonic stenosis  RBBB
 Mid-diastolic murmur → radiates to left shoulder
 Crescendo-decrescendo
 Persistent splitting of S2
Pulmonic regurgitation
Mitral stenosis  Opening snap
 Diastolic murmur
 Loud S1
Mitral regurgitation  Holosystolic murmur displaced to the left axilla/intrascapular
 Diminished S1
 Rumbling murmur
Mitral valve prolapses  Mid-systolic click
 Late systolic murmur
 Non-ejection sound
Coarctation of aorta  Greater BP in the UE compared to LE