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|High output e.g. post exercise, thyrotoxicosis, fever, Hyperdynamic circulation, severe Paget's disease
|Aortic regurgitation or AV fistula. Low diastolic pressure. Wide pulse pressure.
|Slow rising small "pulsus parvus" seen with Aortic stenosis. Narrow pulse pressure.
|Hypertrophic obstructive cardiomyopathy
|Mixed collapsing and plateau pulse with mixed aortic valve disease
|Alternating large and small beats and suggests severe LV dysfunction
|caused by a premature beat before every QRS complex
|Normal BP fall with inspiration is exaggerated > 10 mmHg. Feel pulse weakens with inspiration. Consider Cardiac Tamponade, pericardial constriction and acute severe asthma where inspiration will affect cardiac filling. Pulse weakens during inspiration.
|dissection if aorta with ipsilateral subclavian involved, arterial thrombosis or embolism in subclavian or brachial or may be seen post catheterisation (angiography now done via radial artery), Takayasu's disease
|Suggests Coarctation of aorta. Be sure to check blood pressure at arm and leg if suspicious.
|Sinus Rhythm, Sinus tachycardia, Sinus bradycardia, Atrial flutter with 2:1 or 3:1 block, Complete heart block (slow!)
|Bigemini (normal beat followed by ectopic), Mobitz type II block
|Atrial fibrillation (commonest abnormality) , SR with multiple ectopics
Listening to murmurs -Traditionally these are the areas but do not really take into account different chest anatomy and physiology and jets of turbulence can be heard outside these areas. Instead of these 4 areas, one can just start in the apex and slide the stethoscope across to the tricuspid area, up the LSE to the pulmonary area and over into the aortic areas listening as you go. A sort of sigmoidal shape. Remember to have one finger on a pulse at all times.
|Characteristics of Apex beat and chest wall palpation
|Thrusting and Dynamic
|Aortic regurgitation, Post exercise, Dynamic circulation
|Pericardial effusion,Emphysema, Obesity
|produced by the mitral valve slamming shut in Mitral Stenosis " palpable S1"
|Ventricular aneurysm. Place palm of hand flat on chest and feel a sort of rocking sensation
|obesity, emphysema and barrel chested, pericardial effusion, dextrocardia
|Right ventricular heave
|Place palm of hand over left sternal edge and see if one can feel the RV lift which suggests RV Hypertrophy. Consider RV to reflect RV dynamics as apex does for the LV apex beat.
|Thrills "Palpable murmurs"
|Place flat of hand across praecordium and see if one can feel any abnormal pulsations or thrills. Time them with pulse.
|First Heart sound
|Caused by closure of mitral and tricuspid valves.
|Loud S1: Usually caused by ventricular systole occurring when the cusps of the mitral valve are far apart and snapped closed by a rapidly rising left ventricular pressure - a bit like a gust of wind catching an open door. Causes the tapping apex beat. Causes: Mitral Stenosis, Hyperdynamic circulation e.g. anaemia, fever, Left to right shunt, Atrial ectopics, Short PR, thin people
Soft S1 Mitral Cusps are close at the time of systole or reduced output. Causes Mitral regurgitation, Severe heart failure, shock, LBBB, Long PR , Aortic stenosis
|Second Heart sound
|Produced by the Aortic valve and then pulmonary valve closing. Louder if shuts more forcefully due to increased pressure gradient e.g. ? BP or fast drop in pressure in ventricle e.g. VSD or MR. Softer if reduced flow e.g. severe aortic stenosis
|Third heart sound
|Rapid LV filling into a stiff ventricle but physiological in those under 30
|Sounds like "KENTUCKY" with the S1---PULSE--------- S2--S3 . The causes are Heart failure, Mitral regurgitation, Ventricular septal defect, Dilated cardiomyopathy
|Fourth Heart sound
|Atrial systolic kick produces the sound
Sounds like "TENNESSEE" with S4 S1 ------PULSE-------S2
Diastolic murmurs are never innocent">