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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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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

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

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


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


Paradoxic split (delayed A2)



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)



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




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


Mid-diastolic apical murmur of inflammation of the mitral leaflets in the carditis of rheumatic fever