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Heart and Neck Vessels By InnaKorda. Surface Anatomy.

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1 Heart and Neck Vessels By InnaKorda

2 Surface Anatomy

3 Cardiac Anatomy

4 Direction of Blood Flow

5 Cardiac Cycle Diastole Diastole Ventricles are relaxed, AV valves are open Ventricles are relaxed, AV valves are open Pressure in atria are higher than in ventricles  causing blood to pour into the ventricles Pressure in atria are higher than in ventricles  causing blood to pour into the ventricles Atria contract casing more blood to enter the ventricles “atrial kick” Atria contract casing more blood to enter the ventricles “atrial kick” Systole Systole Pressure in ventricles is higher than in atria  causing AV valves (mitral and tricuspid) valves to close. First heart sound. Pressure in ventricles is higher than in atria  causing AV valves (mitral and tricuspid) valves to close. First heart sound. Pressure of ventricle begins to become greater than pressure of aorta and pulmonary artery  blood is ejected from the ventricles Pressure of ventricle begins to become greater than pressure of aorta and pulmonary artery  blood is ejected from the ventricles When the ventricles’ pressure falls below the pressure of the aorta (or pulmonary artery), some blood flows backwards toward the ventricles, causing the semilunar (aortic, pulmonic) valves to close. Second heart sound. When the ventricles’ pressure falls below the pressure of the aorta (or pulmonary artery), some blood flows backwards toward the ventricles, causing the semilunar (aortic, pulmonic) valves to close. Second heart sound.

6 Neck Vessels

7 Neck Muscles

8 Developmental Considerations

9 Ageing Adult Hemodynamic changes Hemodynamic changes Systolic pressure tends to increase 20 mm Hg due to arteriosclerosis Systolic pressure tends to increase 20 mm Hg due to arteriosclerosis Decreased cardiac output with exercise Decreased cardiac output with exercise Blacks, Mexicans, and Native Americans have higher incidence of hypertension Blacks, Mexicans, and Native Americans have higher incidence of hypertension Arrhythmias Arrhythmias Increase with age Increase with age ECG changes ECG changes Prolonged P-R interval and prolonged Q-T interval Prolonged P-R interval and prolonged Q-T interval

10 Health History Chest pain Chest pain Onset – When did it start? How long have you had it? Have you ever had this pain before? Onset – When did it start? How long have you had it? Have you ever had this pain before? Location – Where did it start? Where does it radiate? Location – Where did it start? Where does it radiate? Character Character Associative and alleviating factors – What brought on the pain? What relieves it? (nitroglycerin Associative and alleviating factors – What brought on the pain? What relieves it? (nitroglycerin Associative symptoms – sweating, pale skin, SOB, N&V, tachycardia? Associative symptoms – sweating, pale skin, SOB, N&V, tachycardia? Dyspnea (shortness of breath) Dyspnea (shortness of breath) What type of activity brought it on? What type of activity brought it on? DOE – Dyspnea on exertion. Ex: walking DOE – Dyspnea on exertion. Ex: walking Onset Onset Duration Duration Positional Positional Nocturnal dyspnea occurs with heart failure. Nocturnal dyspnea occurs with heart failure. Does it awaken you at night? Does it awaken you at night?

11 Question 1 A client with no history of cardiovascular disease presents to the ambulatory clinic with flulike symptoms. The client suddenly complains of chest pain. Which of the following questions would best help a nurse to discriminate pain caused by a noncardiac problem? 1. “ Have you ever had this pain before?” 2. “ Can you describe the pain to me?” 3. “ Does the pain get worse when you breathe in?” 4. “ Can you rate the pain on a scale of 1 to 10, with 10 being the worst?”

12 Health History Orthopnea Orthopnea Do you need to assume an upright position when sleeping? How many pillows are used? Do you need to assume an upright position when sleeping? How many pillows are used? Cough Cough Duration Duration Frequency Frequency Type – dry, hacking, congested? Type – dry, hacking, congested? Mucus? Color, odor, blood? Mucus? Color, odor, blood? Associative and alleviative factors Associative and alleviative factors Fatigue Fatigue Do you tire easily? Do you tire easily? Fatigue due to decreased cardiac output (CO) is worse in evening Fatigue due to decreased cardiac output (CO) is worse in evening Onset – When did fatigue start? Was it sudden or gradual? Onset – When did fatigue start? Was it sudden or gradual? Cyanosis or pallor Cyanosis or pallor Occurs with myocardial infarction (MI) or low CO  decreased tissue perfusion Occurs with myocardial infarction (MI) or low CO  decreased tissue perfusion

13 Health History Edema (swelling) Edema (swelling) Onset Onset Frequency Frequency Cardiac edema is worse at evening and better in morning Cardiac edema is worse at evening and better in morning Amount - How much swelling occurs normally? Equal on both sides? Amount - How much swelling occurs normally? Equal on both sides? Associative and alleviative factors – SOB? Before or after leg swelling Associative and alleviative factors – SOB? Before or after leg swelling Nocturia Nocturia Do you awaken at night with an urgent need to urinate? Do you awaken at night with an urgent need to urinate? More fluid reabsorption and excretion in pt with heart failure More fluid reabsorption and excretion in pt with heart failure Past cardiac history Past cardiac history HTN, cholesterol, murmur, congenital heart disease, rheumatic fever HTN, cholesterol, murmur, congenital heart disease, rheumatic fever How was it treated? How was it treated? Family history Family history

14 Health History Personal habits Personal habits Nutrition – Usual diet? Usual weight? Changes in weight? Nutrition – Usual diet? Usual weight? Changes in weight? Smoking – Cigarettes or tobacco? Onset? Packs per day? Smoking – Cigarettes or tobacco? Onset? Packs per day? Alcohol – Drinks per week/day? Alcohol – Drinks per week/day? Exercise – Type, duration Exercise – Type, duration Drugs – Medication, street drugs Drugs – Medication, street drugs Coronary Heart Disease Risk Factors 4 cig per day = 2x risk for cardio disease 20 cig per day = 4x risk for cardio disease Pack Years = Packs per day X Years smoked

15 Preparation for Physical Examination Environment Environment Should be warm. Shivering might interfere with heart sounds Should be warm. Shivering might interfere with heart sounds Privacy Privacy Make sure the female’s breasts remain draped. When auscultating the heart, gently displace the breast or ask the woman to hold it out of the way Make sure the female’s breasts remain draped. When auscultating the heart, gently displace the breast or ask the woman to hold it out of the way Order of exam Order of exam Begin with observations peripherally and move toward the heart. Begin with observations peripherally and move toward the heart. 1. Pulse and blood pressure 2. Extremities – peripheral vascular assessment 3. Neck vessels 4. Precordium – (portion of body over heart and thorax)

16 General Appearance General build General build Chronic HF may appear malnourished, thin, cachectic Chronic HF may appear malnourished, thin, cachectic Skin Skin Jaundice and generalized edema in late HF Jaundice and generalized edema in late HF LOC LOC Poor cardiac output and decreased cerebral perfusion may cause mental confusion, memory loss, slowed verbal responses Poor cardiac output and decreased cerebral perfusion may cause mental confusion, memory loss, slowed verbal responses

17 Blood Pressure Normal for adults Normal for adults 90 to 140 mm Hg systolic 90 to 140 mm Hg systolic 60 to 90 mm Hg diastolic 60 to 90 mm Hg diastolic Pressure greater than 140/90 is considered hypertension Pressure greater than 140/90 is considered hypertension Pressure less than 90/60 is considered hypotension and may be inadequate to provide oxygenation to cells Pressure less than 90/60 is considered hypotension and may be inadequate to provide oxygenation to cells Postural blood pressure (orthostatic) Postural blood pressure (orthostatic) Moving from lying to sitting or standing position Moving from lying to sitting or standing position ↑ in mm Hg by 10 and/or ↑ in pulse by 10 after a minute ↑ in mm Hg by 10 and/or ↑ in pulse by 10 after a minute May be caused by cardiac drugs or loss of autonomic NS compensatory ability, generally in older adults May be caused by cardiac drugs or loss of autonomic NS compensatory ability, generally in older adults Paradoxical blood pressure Paradoxical blood pressure Decrease in systolic BP more than 10 mm Hg during inspiration Decrease in systolic BP more than 10 mm Hg during inspiration

18 Question 2 A client is admitted to an emergency room with chest pain and is being ruled out for myocardial infarction (MI). Vital signs are as follows: at 11:00 a.m., pulse (P) 92, respiratory rate (RR) 24, blood pressure (BP) 140/88 mm Hg; 11:15 a.m., P 96, RR 26, BP 128/82 mm Hg; 11:30 a.m., P 104, RR 28, BP 104/68 mm Hg; 11:45 a.m., P 118, RR 32, BP 88/58 mm Hg. A nurse alerts the physician because these changes are most consistent with: 1. C ardiogenic shock 2. C ardiac tamponade 3. P ulmonary embolism 4. D issecting thoracic aortic aneurysm

19 Question 3 A nurse is assessing the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following? 1. S eating the client with arm bared, supported, and at heart level 2. M easuring the blood pressure after the client has been seated quietly for 5 minutes 3. U sing a cuff with a rubber bladder that encircles at elast 80% of the limb 4. T aking the blood pressure within 30 minutes after nicotine or caffeine ingestion

20 Assessing Neck Vessels Carotid Artery Carotid Artery Palpate the carotid artery Palpate the carotid artery Avoid excessive pressure. Excessive vagal stimulation could slow down heart rate. Avoid excessive pressure. Excessive vagal stimulation could slow down heart rate. Carotid arteries should be same bilaterally Carotid arteries should be same bilaterally Auscultation Auscultation Listen for bruits – blowing, swishing sounds indicating blood flow turbulence. Caused by atherosclerotic narrowing (one half or two thirds of artery). Listen for bruits – blowing, swishing sounds indicating blood flow turbulence. Caused by atherosclerotic narrowing (one half or two thirds of artery).

21 Assessing Neck Vessels Jugular Veins Jugular Veins Can be used to assess central venous pressure (CVP) and cardiac efficiency Can be used to assess central venous pressure (CVP) and cardiac efficiency Distended external jugular veins signify increased CVP, as with heart failure Position the patient at degree angle, wherever pulsations can be seen best. Remove pillow to avoid flexion of head. Position the patient at degree angle, wherever pulsations can be seen best. Remove pillow to avoid flexion of head. The higher the CVP, the higher the position you will need The higher the CVP, the higher the position you will need Turn the pt’s head away from examiner’s side Turn the pt’s head away from examiner’s side Distinguish from carotid artery pulsations. Internal jugular pulse is lower, varies with respiration, not palpable, and disappears as person is sitting. Distinguish from carotid artery pulsations. Internal jugular pulse is lower, varies with respiration, not palpable, and disappears as person is sitting.

22 Assessing Neck Vessels Jugular Venous Pressure Estimate Jugular Venous Pressure Estimate Used to assess heart failure Used to assess heart failure Position the patient at degree angle. Place one ruler vertically at the manubriosternal angle. Place a second ruler perpendicular to the first and record the height of pulsation of the internal jugular vein. Position the patient at degree angle. Place one ruler vertically at the manubriosternal angle. Place a second ruler perpendicular to the first and record the height of pulsation of the internal jugular vein. Normal pulsation is 2 cm or less above sternal angle Normal pulsation is 2 cm or less above sternal angle Pulsations 3 or more cm above sternal angle while at 45 degrees occur with heart failure Pulsations 3 or more cm above sternal angle while at 45 degrees occur with heart failure Record height of pulsations and degrees of elevation Record height of pulsations and degrees of elevation

23 Question 4 The examiner has estimated the jugular venous pressure. Identify the finding that is abnormal. 1. P atient elevated to 30 degrees, internal jugular vein pulsation at 1 cm above sternal angle. 2. P atient elevated to 30 degrees, internal jugular vein pulsation at 2 cm above sternal angle 3. P atient elevated to 40 degrees, internal jugular vein pulsation at 1 cm above sternal angle 4. P atient elevated to 45 degrees, internal jugular vein pulsation at 4 cm above sternal angle

24 Assessing the Heart Apical Impulse Apical Impulse Apical impulse may or may not be seen against the chest wall. (Seen more in children) Apical impulse may or may not be seen against the chest wall. (Seen more in children) A heave or lift is a sustained forceful thrusting of ventricle during systole. Occurs with ventricular hypertrophy. Seen in 4 th or 5 th intercostal space, midclavicular line. A heave or lift is a sustained forceful thrusting of ventricle during systole. Occurs with ventricular hypertrophy. Seen in 4 th or 5 th intercostal space, midclavicular line. Palpate the apical impulse. May need to ask pt to exhale or to roll to the left. Palpate the apical impulse. May need to ask pt to exhale or to roll to the left. Location – should occupy only one interspace (4 th or 5 th ) and be at or medial to midclavicular line Location – should occupy only one interspace (4 th or 5 th ) and be at or medial to midclavicular line Size – normally 1cm x 2cm Size – normally 1cm x 2cm Amplitude – normally a short gentle tap Amplitude – normally a short gentle tap Duration – short, first half of systole Duration – short, first half of systole Abnormalities: Left ventricular dilatation (volume overload) displaces impulse down and left Left ventricular hypertrophy (pressure overload) increases force and duration but no change in location

25 Assessing the Heart Palpation Palpation Use the palms of your fingers to palpate across chest to search for any other pulsations Use the palms of your fingers to palpate across chest to search for any other pulsations A thrill is a palpable vibration. Signifies turbulent blood flow and accompanies loud murmurs A thrill is a palpable vibration. Signifies turbulent blood flow and accompanies loud murmurs Percussion Percussion Used to outline cardiac borders Used to outline cardiac borders Not as accurate as X-ray or echocardiogram Not as accurate as X-ray or echocardiogram Hypertrophy may be due to hypertension, CAD, heart failure, cardiomyopathy Hypertrophy may be due to hypertension, CAD, heart failure, cardiomyopathy

26 Auscultation 2 nd right interspace – Aortic valve area 2 nd left interspace – Pulmonic valve area Left lower sternal border – Tricuspid valve area 5 th interspace around midclavicular line- Mitral valve area Move stethoscope in a Z pattern, Aortic  Pulmonic  Right  Left Erb’s point

27 Auscultation Tune out any distractions Tune out any distractions Listen to one sound at a time Listen to one sound at a time 1. Note rate and rhythm 2. Identify S1 and S2 3. Assess S1 and S2 separately 4. Listen for extra heart sounds 5. Listen for murmurs

28 Rate and Rhythm Normal beats per minute for adults. Normal beats per minute for adults. Rhythm should be regular Rhythm should be regular Sinus arrhythmias occur normally in young adults and children and varies with respiration. Rhythm increases at peak of inspiration, slows with expiration. Sinus arrhythmias occur normally in young adults and children and varies with respiration. Rhythm increases at peak of inspiration, slows with expiration. Premature beat – an early beat. May be isolated or patterned – occurs every 3 rd or 4 th beat. Premature beat – an early beat. May be isolated or patterned – occurs every 3 rd or 4 th beat. Pulse deficit – the beats at the apex are not the same as at a peripheral pulse. May occur with atrial fibrillation, premature beats, heart failure. Pulse deficit – the beats at the apex are not the same as at a peripheral pulse. May occur with atrial fibrillation, premature beats, heart failure. Apical rate – Radial rate = Pulse deficit

29 Developmental Considerations in Assessment - Infants Fetal shunts normally close within hours, but may take up to 48 hours. Fetal shunts normally close within hours, but may take up to 48 hours. Cyanosis signals oxygen desaturation and congenital heart disease Cyanosis signals oxygen desaturation and congenital heart disease Heart rate may range from bpm after birth, then stabilize bpm Heart rate may range from bpm after birth, then stabilize bpm Tachycardia – greater than 200 bpm in newborns and greater than 150 bpm in infants Tachycardia – greater than 200 bpm in newborns and greater than 150 bpm in infants Bradycardia – less than 90 in newborns, less than 60 in older infants and children Bradycardia – less than 90 in newborns, less than 60 in older infants and children Expect sinus arrhythmia – varied heartbeat with respiration Expect sinus arrhythmia – varied heartbeat with respiration

30 Developmental Considerations in Assessment - Children Slowing of heart rate Slowing of heart rate Physiologic S3 is common Physiologic S3 is common Innocent heart murmurs are common Innocent heart murmurs are common Venous hum (turbulence of blood flow in jugular venous system) is also common Venous hum (turbulence of blood flow in jugular venous system) is also common

31 Developmental Considerations in Assessment - Pregnancy Increase in pulse rate of bpm Increase in pulse rate of bpm Decrease of blood pressure in 2 nd trimester, rise again in 3 rd trimester Decrease of blood pressure in 2 nd trimester, rise again in 3 rd trimester Increase loudness of S1, S3 heard Increase loudness of S1, S3 heard Possible appearance of heart murmurs, which disappear after pregnancy Possible appearance of heart murmurs, which disappear after pregnancy

32 Developmental Considerations in Assessment - Aging Rise in systolic BP – arteriosclerosis and atherosclerosis Rise in systolic BP – arteriosclerosis and atherosclerosis Orthostatic hypotension Orthostatic hypotension Increase in AP diameter of chest Increase in AP diameter of chest Systolic murmurs become more common Systolic murmurs become more common Be careful when palpating carotid artery due to the carotid autonomic reflex causing bradycardia! Be careful when palpating carotid artery due to the carotid autonomic reflex causing bradycardia!

33 S1 and S2 S1 is the start of systole and is the reference point for other cardiac sounds S1 is the start of systole and is the reference point for other cardiac sounds Distinguishing S1 from S2 Distinguishing S1 from S2 1 st sound of the “LUB – dup” except in tachyarrhythmias 1 st sound of the “LUB – dup” except in tachyarrhythmias S1 is louder than S2 at the apex. S2 is louder than S1 at the base S1 is louder than S2 at the apex. S2 is louder than S1 at the base Erb’s point – S1 and S2 heard equally Erb’s point – S1 and S2 heard equally S1 coincides with carotid artery pulse S1 coincides with carotid artery pulse S1 coincides with R wave on ECG monitor S1 coincides with R wave on ECG monitor Auscultation Assistant

34 S1 Caused by closure of the AV valves Caused by closure of the AV valves Abnormalities Abnormalities Accentuated (loud) S1 Accentuated (loud) S1 Hyperkinetic states such as exercise, fever, anemia, hyperthyroidism Hyperkinetic states such as exercise, fever, anemia, hyperthyroidism Calcification of AV valves - requires increasing ventricular pressure to close valves against increased atrial pressure Calcification of AV valves - requires increasing ventricular pressure to close valves against increased atrial pressure Diminished S1 Diminished S1 First degree heart block – prolonged PR interval on ECG due to delayed conduction from atria to ventricles First degree heart block – prolonged PR interval on ECG due to delayed conduction from atria to ventricles Extreme calcification of valves, limiting their mobility Extreme calcification of valves, limiting their mobility Split S1 Split S1 Mitral and tricuspid components are heard separately Mitral and tricuspid components are heard separately Normal but uncommon Normal but uncommon

35 S2 Caused by closure of semilunar valves (aortic and pulmonic) Caused by closure of semilunar valves (aortic and pulmonic) Abnormalities Abnormalities Accentuated S2 Accentuated S2 Higher closing pressure due to systemic hypertension Higher closing pressure due to systemic hypertension Pulmonary hypertension Pulmonary hypertension Aortic or pulmonic stenosis – calcification, still mobile Aortic or pulmonic stenosis – calcification, still mobile Diminished S2 Diminished S2 Fall in systemic BP – shock Fall in systemic BP – shock Aortic and pulmonic stenosis – calcification, decreased mobility Aortic and pulmonic stenosis – calcification, decreased mobility Split S2 Split S2 Normal. Due to the aortic valve closing 0.06 seconds before the pulmonic valve during inspiration Normal. Due to the aortic valve closing 0.06 seconds before the pulmonic valve during inspiration Heard only in the pulmonic valve area Heard only in the pulmonic valve area Paradoxical split – opposite of what you’d expect. Split on expiration Paradoxical split – opposite of what you’d expect. Split on expiration

36 S3 Physiologic S3 Physiologic S3 Heard frequently in children and young adults, disappears when the person sits up. Heard frequently in children and young adults, disappears when the person sits up. Pathologic S3 (ventricular gallop) Pathologic S3 (ventricular gallop) Persists when sitting up and heard after age 40 Persists when sitting up and heard after age 40 Occurs because the left ventricle is not very compliant Occurs because the left ventricle is not very compliant At the beginning of diastole the rush of blood into the left ventricle causes vibration of the valve leaflets and the chordae tendinae At the beginning of diastole the rush of blood into the left ventricle causes vibration of the valve leaflets and the chordae tendinae Occurs with heart failure due to volume overload, such as mitral, aortic, or tricuspid regurgitation Occurs with heart failure due to volume overload, such as mitral, aortic, or tricuspid regurgitation KEN - TUCK - Y SHLOSH - ING IN

37 S4 Physiologic S4 Physiologic S4 May occur in older adults after exercise May occur in older adults after exercise Pathologic S4 (atrial gallop) Pathologic S4 (atrial gallop) Caused by the relatively rapid filling rate against a relatively stiff ventricle Caused by the relatively rapid filling rate against a relatively stiff ventricle Occurs with: Occurs with: Decreased compliance of ventricles (coronary artery disease, cardiomyopathy) Decreased compliance of ventricles (coronary artery disease, cardiomyopathy) Systolic overload (afterload) Systolic overload (afterload) Aortic stenosis Aortic stenosis Systemic hypertension Systemic hypertension TEN - NES - SEE‘ A - STIFF Heart

38 Extracardiac Sounds Pericardial friction rub Pericardial friction rub High pitched, scratchy sound as a result of inflammation of the pericardium High pitched, scratchy sound as a result of inflammation of the pericardium Heard best at apex and lower sternal border Heard best at apex and lower sternal border This sound is usually continuous, and heard diffusely over the chest. This sound is usually continuous, and heard diffusely over the chest. If the rub completely disappears when the patient holds his breath it is more likely due to pleural, not pericardial, origin. If the rub completely disappears when the patient holds his breath it is more likely due to pleural, not pericardial, origin. Common during the 1 st week following a myocardial infarction Common during the 1 st week following a myocardial infarction

39 Question 5 The examiner wishes to listen for a pericardial friction rub. Select the best method for listening: 1. W ith the diaphragm, patient sitting up and leaning forward, breath held in expiration 2. U sing the bell with the patient leaning forward 3. A t the base during normal respiration 4. W ith the diaphragm, patient turned to the left side

40 Congenital Heart Defects

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45 Listening for Murmurs Loudness Loudness Grade i – barely audible Grade i – barely audible Grade ii – clearly audible, but faint Grade ii – clearly audible, but faint Grade iii – moderately loud, but easy to hear Grade iii – moderately loud, but easy to hear Grade iv – loud, associated with a thrill palpable on the chest wall Grade iv – loud, associated with a thrill palpable on the chest wall Grade v – very loud, heard with one corner of stethoscope lifted off Grade v – very loud, heard with one corner of stethoscope lifted off Grade vi – loudest, heard with entire stethoscope lifted off the chest wall Grade vi – loudest, heard with entire stethoscope lifted off the chest wall Pitch – high, medium, low. Depends on pressure and rate of blood flow Pitch – high, medium, low. Depends on pressure and rate of blood flow Pattern Pattern Quality – musical, blowing, harsh, rumbling Quality – musical, blowing, harsh, rumbling Location Location Radiation Radiation Posture Posture

46 Murmurs Systolic Systolic Occur during the ventricular ejection phase of the cardiac cycle Occur during the ventricular ejection phase of the cardiac cycle Most caused by obstruction of the outflow of the semilunar valve (aortic, pulmonic) or by incompetent AV valves (mitral, tricuspid). Most caused by obstruction of the outflow of the semilunar valve (aortic, pulmonic) or by incompetent AV valves (mitral, tricuspid). Diastolic Occur in the filling phase of the cardiac cycle Caused by incompetent semilunar valves or stenotic AV valves Early diastolic murmurs usually result from insufficiency of a semilunar valve or dilation of the valvular ring. Mid-and late diastolic murmurs are generally caused by narrowed, stenosed mitral and tricuspid valves that obstruct blood flow.

47 Midsystolic Ejection Murmurs Due to forward flow through semilunar valves

48 Midsystolic Ejection Murmurs

49 Pansystolic Regurgitant Murmurs Due to backward flow of blood from area of higher pressure to one of lower pressure

50 Pansystolic Regurgitation Murmurs

51 Diastolic Rumbles of AV Valves Filling murmurs at low pressures, best heard with bell lightly touching skin

52 Diastolic Rumbles of AV Valves

53 Early Diastolic Murmurs Due to semilunar valve incompetence

54 Early Diastolic Murmurs

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