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Cardiac Physical exam

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

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Cardiac Physical exam

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  1. Cardiac Physical exam

  2. Imagine there’s no Echo It’s easy if you try…

  3. 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

  4. The Neck Veins http://www.youtube.com/watch?v=tJzBKdKg2k0

  5. 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)

  6. 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)

  7. 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

  8. How to Describe a Murmur • Intensity • Pitch • Quality • Configuration • Location • Timing

  9. 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

  10. Pitch • High • MR, AI • Low • MS, Gallops

  11. Quality • Harsh • Rumbling • Scratchy • Blowing • Musical • Squeaky

  12. Configuration • Crescendo • Severe AS, MVP • Decrescendo • AI • Crescendo-decrescendo (diamond shaped) • Innocent murmur • Plateau • MR

  13. Location • Apex • Bases • Parasternal • Right or left • Which ICS • Does it radiate?

  14. Timing • Systolic/Diastolic • Early • Mid • Late • Holo • Continuous

  15. Murmurs • Systolic • Flow murmurs, AS, PS, MR, TR, VSD • Diastolic • AI, PI, MS, TS • Continuous • Patent ductus arteriosus

  16. Aortic Stenosis

  17. Mitral Regurgitation

  18. Aortic Regurgitation

  19. Exam Maneuvers • Respiration • Standing • Squatting • Valsalva • Hand Grip • Post Ectopic Beats • Amyl Nitrate

  20. 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)

  21. 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

  22. Standing • Decreases venous return, stroke volume, arterial blood pressure • AS decreased • MR/TR decreased • VSD decreased • MVP earlier click, longer murmur • HCM  INCREASED

  23. Squatting • Increases preload, afterload, and arterial pressure • MR/TR increased • VSD increased • AI increased • AS variable • MVP delayed click, shorter increased murmur • HCM  DECREASED

  24. 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

  25. 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

  26. 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

  27. 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

  28. Extra Heart Sounds

  29. 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

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