Physical Examination of the Heart Flashcards
Pulsus tardus
Delayed upstroke (aortic stenosis)
Bounding (hyperkinetic) pulse
Hyperkinetic circulation, aortic regurgita-
tion, patent ductus arteriosus, marked vasodilatation
Pulsus bisferiens
Double systolic pulsation (aortic regurgitation, hypertrophic cardiomyopathy)
Pulsus alternans
Regular alteration in pulse pressure amplitude (severe LV dysfunction)
Pulsus paradoxus
Exaggerated inspiratory fall (>10 mmHg) in systolic bp (pericardial tamponade, severe obstructive lung disease)
Jugular venous distention develops in…
right-sided heart failure, constrictive pericarditis, pericardial tamponade, obstruction of superior vena cava.
JVP normally falls with inspiration but may rise (Kussmaul sign) in…
constrictive pericarditis.
Pulsus parvus
Weak upstroke due to decreased stroke volume (hypovolemia, LV failure, aortic or mitral stenosis)
Large “a” wave
Tricuspid stenosis (TS), pulmonic stenosis, AV dissociation (right atrium contracts against closed tricuspid valve)
Large “v” wave
Tricuspid regurgitation, atrial septal defect
Steep “y” descent
Constrictive pericarditis
Slow “y” descent
Tricuspid stenosis
Cardiac apical impulse is normally localized at the…
fifth intercostal space, midclavicular line.
Forceful apical thrust
Left ventricular hypertrophy
Lateral and downward displacement of apex impulse
Left ventricular dilatation
Prominent presystolic impulse
Hypertension, aortic stenosis, hypertrophic cardiomyopathy
Double systolic apical impulse
Hypertrophic cardiomyopathy
Sustained “lift” at lower left sternal border
Right ventricular hypertrophy
Dyskinetic (outward bulge) impulse
Ventricular aneurysm, large dyskinetic area post MI, cardiomyopathy
Loud S1
Mitral stenosis, short PR interval, hyperkinetic heart, thin chest wall
Soft S1
Long PR interval, heart failure, mitral regurgitation, thick chest wall, pulmonary emphysema
Describe S2.
Normally A2 precedes P2 and splitting increases with inspiration.
Widened splitting of S2
Right bundle branch block, pulmonic stenosis, mitral regurgitation
Fixed splitting of S2 (no respiratory change in splitting)
Atrial septal defect
Narrow splitting of S2
Pulmonary hypertension
Paradoxical splitting of S2 (splitting narrows with inspiration)
Aortic stenosis, left bundle branch block, heart failure
Loud A2
Systemic hypertension
Soft A2
Aortic stenosis (AS)
Loud P2
Pulmonary arterial hypertension
Soft P2
Pulmonic stenosis (PS)
Describe S3.
Low-pitched, heard best with bell of stethoscope at apex, following S2; normal in children; after age 30–35, indicates LV failure or volume overload.
Describe S4.
Low-pitched, heard best with bell at apex, preceding S1; reflects atrial contraction into a noncompliant ventricle; found in AS, hypertension, hypertrophic cardiomyopathy, and coronary artery disease (CAD).
Describe an opening snap (OS).
High-pitched; follows S2 (by 0.06–0.12 s), heard at lower left sternal border and apex in mitral stenosis (MS); the more severe the MS, the shorter the S2–OS interval.
What is an ejection click?
High-pitched sounds following S1; observed in dilatation of aortic root or pulmonary artery, congenital AS (loudest at apex) or PS (upper left sternal border); the latter decreases with inspiration.
Ejection-type (systolic) murmurs
Aortic outflow tract
1) Aortic valve stenosis
2) Hypertrophic obstructive cardiomyopathy
3) Aortic flow murmur
Pulmonary outflow tract
1) Pulmonic valve stenosis
2) Pulmonic flow murmur
Holosystolic murmurs
Mitral regurgitation
Tricuspid regurgitation
Ventricular septal defect
Late-systolic murmurs
Mitral or tricuspid valve prolapse
Early diastolic murmurs
Aortic valve regurgitation
Pulmonic valve regurgitation
Mid-to-late diastolic murmurs
Mitral or tricuspid stenosis
Flow murmur across mitral or tricuspid valves
Continuous diastolic murmurs
Patent ductus arteriosus
Coronary AV fistula
Ruptured sinus of Valsalva aneurysm
