1. Cardiac Physical exam

2. Imagine there’s no Echo It’s easy if you try…

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

4. The Neck Veins http://www.youtube.com/watch?v=tJzBKdKg2k0

5. Abdominal Jugular Test Press firmly for 10 seconds If CVP > 4 cm for 10 seconds (or falls > 4 cm with release of pressure) POSITIVE Pos AJR is an accurate sign of elevated LEFT ATRIAL PRESSURE (LR = 8.0)

6. Sustained Left lower parasternal movements (i.e. Heave) Can be caused by RV volume overload, MR If they are excluded, can be associated with degree of pulmonary HTN –RV pressure > 50 (+LR 3.6)

8. 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 –Depressed EF (LR – 3.8; not very sensitive, very specific) S4 - decrease ventricular compliance –Never normal, ie LVH, ischemia, AS

9. How to Describe a Murmur Intensity Pitch Quality Configuration Location Timing

10. Intensity I/VI : Faint, only heard with special effort II/VI : Immediately identified III/VI : Moderately loud IV/VI : Loud with a palpable thrill V/VI : One edge of stethoscope on chest VI/VI : No stethoscope required

11. Pitch High –MR, AI Low –MS, Gallops

12. Quality Harsh Rumbling Scratchy Blowing Musical Squeaky

13. Configuration Crescendo –Severe AS, MVP Decrescendo –AI Crescendo-decrescendo (diamond shaped) –Innocent murmur Plateau –MR

14. Location Apex Bases Parasternal –Right or left –Which ICS Does it radiate?

15. Timing Systolic/Diastolic –Early –Mid –Late –Holo Continuous

16. Murmurs Systolic –Flow murmurs, AS, PS, MR, TR, VSD Diastolic –AI, PI, MS, TS Continuous –Patent ductus arteriosus

17. Aortic Stenosis

18. Mitral Regurgitation

19. Aortic Regurgitation

20. Exam Maneuvers Respiration Standing Squatting Valsalva Hand Grip Post Ectopic Beats Amyl Nitrate

21. Murmurs All murmurs: –louder with increased flow (ie recumbency, squatting) –and softer with decreased flow (ie valsalva, standing) –except MVP and HCM MVP vs HCM –sustained handgrip: MVP louder HCM softer Right sided murmurs increase with inspiration Left sided murmurs louder during expiration All diastolic murmurs are abnormal (echo)

22. Respiration Inspiration increases venous return to the right heart, and decreases return to the left heart Inspiration increases the split of S2 –P2 moves farther away from A2 Inspiration increases the intensity of right sided Murmurs and Gallops –TR  Carvallo’s sign

23. Standing Decreases venous return, stroke volume, arterial blood pressure –AS decreased –MR/TR decreased –VSD decreased –MVP earlier click, longer murmur –HCM  INCREASED

24. Squatting Increases preload, afterload, and arterial pressure –MR/TR increased –VSD increased –AI increased –AS variable –MVP delayed click, shorter increased murmur –HCM  DECREASED

25. Valsalva Decreased venous return, ventricular volumes, stroke volumes, arterial pressure –AS/PS decreased –AI/PI decreased –MR/TR decreased –MS/TS decreased –MVP earlier click, longer murmur –HCM  INCREASED

26. 20-30 Sec Handgrip Increased SVR, arterial pressure, cardiac output, LV volume –AS DECREASED –MR/MS increased –AI increased –VSD increased –MVP later click, shorter murmur –HCM decreased

27. Post ectopic beat Increased ventricular volume and contractility (effect of increased contractility > increased volume) –MR  NO CHANGE –AS/AI increased –HCM increased –TR increased –MVP earlier click, longer murmur Effect of contractility > volume

29. 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

31. Extra Heart Sounds

32. 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