How To Tell Jugular From Carotid Pulsations

How can you tell a jugular from a carotid pulsation by palpation ANS Normal jugulars are not palpable. If the venous pressure is very high, you will occasionally feel an easily compressible, gentle undulation. The carotids produce a strong, almost incompressible impulse. Carotids are palpable as either a sharp tap if normal, or a push or nudge if there is aortic stenosis. 2. How can supraclavicular pressure help to separate jugular from carotid pulsations ANS Since jugular pulsations arise from...

The A Wave or Palpable Atrial Hump

How does a cineangiogram show the effect of a contracting atrium on the ventricle ANS With contrast material in the LV, a cineangiogram can show that the LV suddenly expands at the end of diastole in response to atrial contraction. 2. When is this end-diastolic or presystolic expansion of the LV palpable ANS The normal A wave is not palpable. Only a very strong left atrial contraction can expand the LV with enough force to cause a palpable presystolic hump on the LV impulse. Note If the atrial...

Other Auscultatory Signs of PDA

What auscultatory signs of the increased flow through the mitral valve and large volume load on the LV may be heard in patients with a PDA ANS There may be an S3 and or a mitral diastolic flow murmur and the S2 split may be paradoxical. 2. What are the multiple clicks or crackles heard at the end of systole and the beginning of diastole called Their significance ANS Eddy sounds. They signify a large flow ductus 11 . PDA with High Pulmonary Artery Pressure 1. What causes differential cyanosis...

Differential Diagnosis Of The Fixed Split

What may mimic a wide fixed split of the S2 ANS a. The A2 followed by an opening snap. b. A very wide split in which normal movements of the A2-P2 are difficult to perceive by auscultation. 2. Why does the split S2 in the normal subject tend to narrow on sitting or standing ANS This happens because when both ventricles receive less blood (due to pooling in the abdomen and the legs), the RV responds by ejecting its blood relatively faster than does the LV 5 . The RV responds more to changes in...

The S2 Split In Pulmonary Hypertension

What are the three general types of pulmonary hypertension ANS a. Hyperkinetic pulmonary hypertension, i.e., that due to excess volume flow, as in large left-to-right shunts. The pulmonary arterioles can dilate to accommodate up to three times the normal cardiac output before the pulmonary artery pressure must rise. b. Vasoactive pulmonary hypertension, i.e., that due primarily to pulmonary arteriolar constriction, as in response to either hypoxia or to a high left atrial pressure, as in...

Glossary

Aneurysm Localized dilatation of either a blood vessel or a heart chamber. The most common cause of an arterial aneurysm is atherosclerosis. Anywhere in the aorta atrophy of the media (muscular layer) deep to an atherosclerotic plaque results in either a saccular or a fusiform (spindle-shaped) dilatation. The most common site is the abdomen distal to the renal arteries. Syphilis (lues) used to be the most common cause of thoracic aortic aneurysm, usually in the ascending aorta. When infection...

Relative Loudness Pitch and Duration of the S1 and S2

When is it difficult to distinguish an S1 from S2 by stethoscope alone ANS When systole almost equals diastole in duration. This is called a ticktack rhythm (like the ticking of a clock) or embryocardia (like the fetal heart sounds). 2. What causes ticktack rhythm ANS Anything that shortens diastole more than it does systole, as in tachycardia. As the heart rate increases, both systole and diastole are shortened, but diastole is shortened relatively more than systole. Note a. The heart rate in...

Right Ventricular Enlargement

How can you best palpate for movement caused by a large RV ANS a. Since the RV is an anterior structure, its enlargement may produce an increased left parasternal movement. Diffuse left parasternal movements are often best palpated with the proximal part of the palm (thenar and hypothenar areas). The movement is then transmitted to the entire arm. The shoulder becomes the fulcrum and this amplifies the hand movements that are at the end of the arm lever. b. Look for systolic downward movement...

Capillary Pulsation

How do you elicit capillary pulsation (Quincke's sign) ANS Compress the skin of the face or hands with a glass slide, or exert slight pressure on the nail beds and watch for intermittent flushing. You can also transilluminate the nail bed with a flashlight against the pad of the patient's finger while shading the finger with the other hand. 2. What is the mechanism of capillary pulsations and what noncardiac conditions can cause it ANS The mechanism is the transmission of the arterial pulse...

The S3 Versus The Opening Snap

What is the difference between the A2-OS interval and the S2-S3 interval ANS The A2-OS interval is rarely more than 100 ms (0.10 s), whereas the shortest A2-S3 interval is usually 120 ms (0.12 s). The difference between 100 and 120 ms is merely the difference between saying pa-pa as quickly as possible and saying it at a normal speaking rate. 2. How does the S3 of a tumor plop differ from the usual S3 ANS A tumor plop is the early diastolic sound produced when a left (or right) atrial myxoma...

The V Wave and Y Descent

Pressure Tracing

When does RV contraction become too weak to continue pulling down the base How does this affect right atrial pressure ANS The phase of reduced ejection occurs in mid-systole. This attenuates the descent of the base and allows the filling of the right atrium from the venae cavae to raise right atrial pressure. This rise in pressure during systole is not named. The C wave and X' descent. Most authors use the letter X to name both atrial relaxation and the fall in pressure due to the descent of...

Physiology and Etiologies

Qrs Arterial Pressure

What is meant by a reversed or paradoxical split of the S2 ANS This is a split in which the order of components is P2A2 instead of the normal A2P2. 2. Can too early a P2 cause a reversed split ANS A reversed split is nearly always caused by a delayed A2. 3. What can delay the A2 enough to cause a paradoxical splitting ANS a. Conduction defects that delay depolarization of the LV, such as complete LBBB and some types of Wolff-Parkinson-White W-P-W preexcitation that imitate LBBB. Note The...

The Humming Systolic Ejection Murmur

What adjectives have been used to describe the quality, or timber, of the humming innocent ejection murmur that is found in children What eponym has been used for it ANS It has been described as a buzzing, vibratory, twanging, moaning, or groaning murmur. It has also been called Still's murmur, after the British author of a pediatric textbook published in 1918, who described it as a twanging string murmur. 2. Why was it thought by some to be an aortic murmur ANS A fine vibration can...

Ejection Sound in Pulmonary Hypertension

Why is an ejection sound heard in pulmonary hypertension ANS The high pressure in the pulmonary artery may dilate the pulmonary artery root, and the valve ring will be stretched. The tautened cusps, opening at a very rapid rate, probably produce the sound or click. This high-frequency phonocardiogram and simultaneous carotid tracing is from a patient with severe pulmonary hypertension secondary to a VSD Eisenmenger syndrome . Note that the pulmonary ejection E J sound does not diminish with...

Sites of A2 and P2 Loudness

What is wrong with using the expression A2 is louder than P2, or vice versa ANS If by A2 is meant the entire second sound in the second right interspace and by P2 is meant the entire second sound in the second left interspace as was true before 1960 , then it has no meaning. If it refers to individual components of a split second sound, then A2 is louder than P2, or vice versa may have meaning. 2. Which component of the S2 is best heard in normal subjects at the second left interspace...

Other Causes of Continuous Murmurs

What is meant by a pulmonary arteriovenous fistula ANS This is a right-to-left shunt from pulmonary artery to pulmonary vein. It is usually congenital. 2. By inspection alone, what clues indicate that the continuous murmur is due to a pulmonary arteriovenous fistula. ANS Cyanosis, clubbing, and telangiectasia on the skin or mucous membranes. 3. What should you suspect as a cause of a continuous murmur that is heard bilaterally in a patient with cyanosis and a roentgenogram that suggests no...

Characteristics Of The Ejection Murmur

What valvular flow event is implied by the term ejection murmur ANS The term implies a murmur that is produced by blood flowing forward through a semilunar valve aortic or pulmonary valve during systole. 2. What is characteristic of ejection murmurs on a phonocardiogram ANS They start with the final component of the first heart sound S1 are diamond, rhomboid, or kite-shaped and finish before the second sound of the side of the heart from which the murmur originates. This means that a...

The Auscultogram

Cardiology Auscultation

A graphic method for illustrating auscultatory findings is offered here, not only as a means of keeping records as conveniently and efficiently as possible, but also as an aid in learning auscultation. One such auscultogram see figures can equal a 629-word description of the auscultatory findings. The graph can tell the story at a glance once the symbols are understood. Filling in such auscultograms serves a self-teaching function in training a person in auscultation, because one is forced to...

Causes of a Loud A2 or P2

What conditions tend to make the aortic component of the second sound louder than normal ANS a. Conditions that raise aortic systolic pressure, e.g., systemic hyper tension, which occasionally produces a drumlike sound or tambour S2. A tambour is a small drum that is covered only on one side. The tambour effect may persist even after the blood pressure has been lowered to normal by medication. b. Conditions that produce a hyperkinetic systemic circulation, e.g., youth, or thyrotoxicosis. The...

The Austin Flint Murmur Versus the Mitral Stenosis Murmur

Diastolic Rumble Apex

What is the Austin Flint murmur 4 ANS It is an apical diastolic rumble imitating the murmur of organic MS but is due to an aortic regurgitation AR stream that prevents the mitral valve from opening fully. 2. What is the most plausible theory explaining the mechanical cause of the Austin Flint murmur ANS The AR stream may impinge on the undersurface of the anterior leaflet of the mitral valve and push it up, creating a relative MS. Support for this theory is found in the following a. A yellow...

The Exaggerated Physiological S3

List the common shunts and the valvular lesion that may cause excessive flow through the mitral valve, therefore exaggerating or bringing back the physiological S3. ANS a. The two left-to-right shunts, ventricular septal defect VSD and persistent ductus arteriosus PDA . Atrial septal defects ASDs do not increase flow through the mitral valve. b. An incompetent mitral valve, i.e., mitral regurgitation MR . Low-frequency phonocardiogram from a 15-year-old girl with severe rheumatic MR. Besides...

What Does A Venous Hum Sound Like

Where is the venous hum best heard ANS Just above the clavicle, either medial to the sternocleidomastoid muscle or between its insertions. A venous hum is more likely to be heard on the right side because the right jugular is larger than the left, since it must carry about two-thirds of the intracranial venous drainage. 2. What does a venous hum sound like ANS Sometimes like a continuous roar at other times like the sound of the sea heard by putting a seashell to the ear and sometimes as a...

Leg Pulses and Blood Pressure in Coarctation of the Aorta

When should you suspect coarctation of the aorta ANS In any patient with hypertension. 2. What are the characteristics of the pulses proximal to and beyond an aortic coarctation ANS The proximal pulses, i.e., the carotid and brachial pulses, are large, bounding pulses. The parts of the body beyond the coarctation i.e., usually beyond the left subclavian artery receive blood through enlarged collaterals that do not transmit the percussion wave well. Therefore, not only do the lower extremity...

Contents

A Complete Course in Heart Sounds and Murmurs on CD Advantages of a Checklist 1 Reminder List History 2 Etiologies 3 Follow-Up Questions 7 New York Heart Association Functional and Therapeutic Classification 14 3 Arterial Pulses and Method of Arm Palpation 29 Rates of Rise and Pulse Volume 30 Pulsus Bisferiens 37 Palpation of the Leg Pulses 38 Estimating Systolic Blood Pressure by Palpation Alone 39 Accurate Blood Pressure Measurement 40 Diastolic Blood Pressure Recording 45 Accuracy of Blood...