In The Left Lateral Decubitus Position

With the patient in the left lateral decubitus position, how can you tell that you are feeling a left or right ventricular apical impulse ANS There are two methods. Palpate the apical impulse to see if there is a sensation of a localized thrust. In the left lateral decubitus position an LV impulse feels as if a Ping-Pong ball were protruding between the ribs in systole. An RV impulse is usually more diffuse. Look for medial or lateral retraction. An LV impulse will manifest medial retraction...

Summary of How to Tell an S3 from an Opening Snap

The OS is not usually more than 100 ms (a rapid pa-pa) from the S2. The S3 is rarely less than 120 ms (0.12 s) from the A2, i.e., a relaxed two-three interval. 2. The OS is usually a short, sharp click, best heard with the diaphragm near the left sternal border. The S3 is a thud or boom, best heard by applying light or moderate pressure with the bell near the apex. 3. The OS is associated with a sharp, loud Sj. The S3 may or may not have a loud Sj. 4. An OS will separate further from the A2...

Jules Constant md facc

Clinical Associate Professor of Medicine State University of New York at Buffalo School of Medicine Humana Press Totowa, New Jersey 2003 Humana Press Inc. 999 Riverview Drive, Suite 208 Totowa, New Jersey 07512 www.humanapress.com All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the Publisher. The...

Loudness Of The S3

Which chest piece and degree of stethoscope pressure best brings out the S3 ANS The bell, applied with light to moderate pressure so that the low frequencies will not be damped out. 2. What increases the loudness of the S3, inspiration or expiration ANS Either. Expiration can make the S3 louder by squeezing blood out of the lungs into the left atrium and ventricle, and by bringing the stethoscope closer to the heart. Inspiration can make it louder by increasing sympathetic tone to the heart and...

Ejection Sound in Pulmonary Stenosis PS

What proof can be offered that the ejection sound heard in valvular PS it an opening sound of the pulmonary valve ANS a. It is not present in pure infundibular stenosis. b. It occurs at the peak of opening of the pulmonary valve on echocardiography. 2. Why does the pulmonary ejection sound tend to disappear with inspiration in valvular PS ANS The sudden upward movement of a dome-shaped pulmonary valve produces the sound. If the valve is already in the domed or near-domed position when the RV...

The S4 in Myocardial Infarction

What proportion of patients with acute myocardial infarction have an S4 ANS Almost all will have a phonocardiography S4 unless they have MS or atrial infarction. It is heard by auscultation in about half of the patients during the first few days following infarction 2 . Note An infarcted area, whether dyskinetic (bulges out like an aneurysm in systole) or akinetic (no movement during systole), causes loss of compliance of the LV. Presence of excess catecholamines, which is usual in the first...

And Presence Of An S4

What does the presence of an S4 indicate about the gradient in (a) aortic stenosis (AS) and (b) pulmonary stenosis (PS) ANS a. In valvular AS it suggests a severe gradient of at least 70 mmHg across the aortic valve 5 . This is not valid either in subjects with angina, in whom ischemic heart disease may be an additional cause of an S4, or in subjects with hypertrophic obstructive cardiomyopathy (HOCM), who may have an S4 with any gradient. b. In PS it also suggests a gradient across the...

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...

The Widely Split S2

What is meant by a wide split of the S2 ANS A persistent split that widens on inspiration to at least 60 ms (0.06 s). (Say pa-da as quickly as possible for 60 ms.) Note The concept of wide and narrow splitting is best understood if you practice the vocal imitation of splitting widths as follows A normal narrow split on inspiration is 30-40 ms (0.03-0.04 s). Imitate this by rolling the tongue, as in the Spanish dr or tr. For a slightly wider split of 50-60 ms (0.05-0.06 s) say pa-da quickly....

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...

The Physiological Versus The Pathological S3

What is the difference in timing and quality between the physiological and the pathological S3 ANS None, except that the S3 found in constrictive pericarditis may occur earlier than usual. 2. How can you usually tell a physiological from a pathological S3 ANS Only by knowing the circumstances under which it occurs, i.e., by finding the reason for the pathological S3, such as symptoms and signs of heart failure or myocardial abnormalities. Note Some patients with a pathological S3 secondary to a...

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 Aortic Sclerosis Murmur

What percentage of patients over age 50 have an easily audible aortic ejection murmur without valvular stenosis ANS About 50 . Echoardioqrams have shown that many elderly patients have a septum that bends into the outflow tract, the so-called sigmoid septum sigma Greek S . This could create enough turbulence to mimic the murmur of aortic valve sclerosis sclerosis Greek hard . Therefore a more nonspecific terminology should be used. Since about 50 of patients over age 50 have the murmur...

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...

The LV Impulse in Left Ventricular Hypertrophy LVH

How can you establish by palpation that an LV apex beat is normal, i.e., that there is no hypertrophy, dilatation, or loss of compliance ANS In the supine and left lateral decubitus positions the normal apex beat rises in systole and falls away rapidly to reach the S2 at the bottom of the fall or even before the last one-third of systole. This is not a visual phenomenon, so only compare what you hear with what you feel. This depicts a normal apex impulse apex cardiogram, or ACG recorded over...

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...

The Cannon Wave

ANS It is the high A wave caused by atrial contraction against a closed tri-cuspid valve. 2. When will the atrium contract against a closed tricuspid valve ANS When there is atrioventricular dissociation or when a very early P wave occurs on a T wave, as with a premature atrial contraction or a junctional pacemaker. Note that in this patient with complete atrioventricular block, every other P wave happens to fall on a T wave, i.e., it occurs during ventricular systole when the tricuspid valve...

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...

Leg Blood Pressure in Aortic Regurgitation

How does AR affect the blood pressure in the legs in comparison with that in the arms What is this sign of AR called ANS AR exaggerates the tendency for the leg systolic pressure to be higher than that in the arms. If the difference is greater than normal, i.e., more than 20 mmHg, it is known as a positive Hill's sign 7 . Note It is easy to remember because blood pressure increases, i.e., goes uphill in AR as the examiner goes down the body. 2. Why is the cuff systolic pressure in AR higher...

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...

Physiology Of The Normally Moving Split

Does the normal split of the S2 widen on inspiration or expiration ANS It widens on inspiration, so that the A2P2 becomes an A2-P2. 2. Does the split movement of the S2 occur because of the movement of the A2 or the movement of the P2 ANS Both. The P2 moves out, away from the A2, and the A2 moves inward, away from the P2. 3. Which component moves more, the A2 or the P2 The P2 outward movement contributes more to the inspiratory widening of the S2 than does the inward movement of the A2. 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...