Contents

Preface

A Complete Course in Heart Sounds and Murmurs on CD

Inside Back Cover vu

1 The Checklist in History Taking

Advantages of a Checklist 1 Reminder List History 2 Etiologies 3 Follow-Up Questions 7

New York Heart Association Functional and Therapeutic Classification 14

Skin 17

Congenital and Acquired Facies 20

Eyes 22

Edema 25

Extremities 26

Chest and Respiration 27

3 Arterial Pulses and Pressures 29

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

Korotkoff Sounds 41

Chest Piece Placement and Choice 42

Equipment Sources of Error 43

Systolic Pressure Measurement 44

Diastolic Blood Pressure Recording 45

Accuracy of Blood Pressure Recording 46

2 Cardiac Clues from Physical Appearance

Summary of How to Take Arm Blood Pressures by Listening for Korotkoff Sounds 48 Pseudohypertension 49 Pulsus Alternans 49

Blood Pressure and Pulses in the Legs 51 Pulsus Paradoxus 55 Capillary Pulsation 58 Abdominal Aortic Aneurysm (AAA) 58

How to Tell Cardiac Function by Blood Pressure Response to a Valsalva Maneuver 58

4 Jugular Pressure and Pulsations 63

Venous Pressure by Jugular Inspection 63

How to Use the Internal Jugulars as a Manometer 65

Method of Obtaining an Accurate Measurement of Venous Pressure 66

How to Tell Jugular from Carotid Pulsations 68

The Abdominal Compression Test (Hepatojugular Reflux) 70

Jugular Pulse Contours 73

5 Inspection and Palpation of the Chest 89

Ventricular Enlargement from Examination of the Chest 89 Cardiac Dilatation Signs in the Left Lateral Decubitis Position 94 Right Ventricular Enlargement 96 Left-Sided Causes of Left Parasternal Movement 99 X-ray Evaluation of Cardiac Size 101

Diagnosis of Ventricular Hypertrophy by Physical Examination of the Precordium 103

6 The Stethoscope 111

The Bell Chest Piece 111

The Smooth Diaphragm 113

The Tubing 114

Air Leaks and Ear Tips 115

Summary of Good Stethoscope Characteristics 116

7 Diagramming and Grading Heart Sounds and Murmurs 117

The Auscultogram 117

Grading of Heart Sounds and Murmurs 119

8 The First Heart Sound (S1) 121

Physiology of the First Sound Components 121

The Mj Plus Aortic Ejection Sound as the Cause of a Split Sj 123

The Pulmonary Ejection Sound 125

Loudness of the Mj 129

Contents xi

The Second Heart Sound (S2) 133

Physiology and Nomenclature for the S2133

Explanation of Normal Splitting Sequence of S2134

Physiology of the Normally Moving Split 136

Loudness of the Components of S2137

The Widely Split S2143

The A2-P2 in Pulmonary Stenosis 144

ASDs with Narrow Splits 146

Differential Diagnosis of the Fixed Split 147

The Narrowly Split S2148

The S2 Split in Pulmonary Hypertension 149

The Reversed or Paradoxically Split S2150

10 The Opening Snap 155

Mechanism and Timing 155

Relation Between the 2-OS Interval and the Severity of Mitral Stenosis 156 The Loudness of the Opening Snap 159 How to Tell an A2-P2 from an A2-OS 160

11 The Third Heart Sound (S3) 163

Nomenclature 163 Timing 163

Mechanism of Production 165 The Physiological S3166 Loudness of the S3167 The Exaggerated Physiological S3169 The Pathological S3170

The Physiological Versus the Pathological S3170 The Right Versus the Left Ventricular S3171 The S3 Versus the Opening Snap 172

12 The Fourth Heart Sound (S4) 175

Nomenclature 175

Mode of Production 175

Recognizing the Rhythm of the S4 Gallop 177

The Physiological S4177

The Pathological S4 178

Loudness and Audibility of the S4180

Differentiation of the S4 from the S3181

Differentiation of an S4-Sj from a Split Sj (M-Aj or M-Tj) 182 Severity of Cardiac Dysfunction and Presence of an S4183 The S4-Sj Interval and Severity of Dysfunction 184 Summation and Augmented Gallops 184 The Pacemaker S4-Like Click 186

13 Ejection Murmurs

Physical Causes 187

Characteristics of the Ejection Murmur 188

Types of Ejection Murmurs 193

Systolic Flow Murmurs 193

Aortic Stenosis Ejection Murmurs 200

Pulmonary Stenosis Ejection Murmurs 206

The Effect of Respiration on PS Ejection Murmurs 208

Thoracic, Subclavian, Carotid, and Thyroid Artery Flow Murmurs 209

The Effect of a Sudden Long Diastole on Left-Sided Regurgitant Murmurs 214 Mitral Regurgitation Murmurs 215

Effect of Drugs and Maneuvers on Systolic Regurgitant Murmurs 223

The Prolapsed Mitral Valve Syndrome (Barlow's Syndrome) 225

Tricuspid Regurgitation (TR) Murmurs 229

The Cardiorespiratory Murmur 230

VSD Murmurs 231

Continuous Murmurs 234

Diastolic Atrioventricular Valve Murmurs 243 Tricuspid Diastolic Flow Murmurs 253 Tricuspid Stenosis (TS) Diastolic Murmurs 253 Diastolic Semilunar Valve Murmurs 254 Pulmonary Regurgitation Murmurs 258 Pericardial Friction Rubs 259

14 Systolic Regurgitant Murmurs

15 Diastolic Murmurs

16 Abdominal Murmurs

Normal Abdominal Murmurs 265 Abnormal Abdominal Murmurs 265

Glossary Index

267 287

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Blood Pressure Health

Blood Pressure Health

Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

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