Cardiac exam
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Cardiac Exam. Arterial Pulses. Paradoxus - tamponade , asthma Bisferiens - aortic insufficiency , HCM Alternans - severe LV dysfxn , bigemminy Parvus et Tardus - aortic stenosis Asymmetric - aortic dissection Diminished or absent - PAD , coarctation.

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Cardiac Exam

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Cardiac exam

Cardiac Exam


Arterial pulses

Arterial Pulses

Paradoxus - tamponade, asthma

Bisferiens - aortic insufficiency, HCM

Alternans - severe LV dysfxn, bigemminy

Parvus et Tardus - aortic stenosis

Asymmetric - aortic dissection

Diminished or absent - PAD, coarctation


Normal carotid upstroke

Normal carotid upstroke


Pulsus parvus et tardus

Pulsus parvus et tardus


Bisferiens pulse

Bisferiens Pulse


Venous waveforms

Venous Waveforms

Giant A waves - RVH/PHTN, TS, PS

Cannon A waves - AV dissociation, pacing

Rapid X decent - tamponade

Large V wave - severe TR, septal rupture

Rapid X & Y - constrictive pericarditis

and restrictive cardiomyopathy

Slow Y decent – Tricuspid stenosis


Large v waves severe tr

Large V waves (Severe TR)


Giant a waves

Giant A waves


Constrictive pericarditis

Constrictive pericarditis


Exam maneuvers

Exam maneuvers

Recumbency - increases venous return

Squatting - increases venous return

Inspiration - increases venous return

Standing - decreases venous return

Valsalva - decreases venous return

Hand Grip - increases afterload (BP)

Amyl Nitrate - vasodilator, decreases BP

increases cardiac output


Heart sounds

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

S4 - decrease ventricular compliance

Never normal, ie LVH, ischemia, AS


Splitting of s2

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


Murmurs

Murmurs

All murmurs get louder with increased flow (ie recumbency, squatting) and softer with decreased flow (ie valsalva, standing) except MVP and HCM

Distinguish between MVP (louder) and HCM (softer) with sustained handgrip

Right sided murmurs are louder during inspiration, left sided louder during expiration

All diastolic murmurs are abnormal (echo)


Murmurs1

Murmurs

Systolic

Flow murmurs, AS, PS, MR, TR, VSD

Diastolic

AI, PI, MS, TS

Continuous

Patent ductus arteriosus


Murmurs with names

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


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