IM 3A: Cardiology Differential - isolated cyanosis affecting the lower but not the

Dr. Jumangit cyanosis upper extremities

August 4, 2016 - patient with large PDA secondary pulmonary
hypertension with R>L shunting at the great
PHYSICAL EXAMINATION OF THE CARDIOVASCULAR SYSTEM vessel level (reversal of shunting)
Malar telangiectasis - mitral stenosis and scleroderma
GENERAL PHYSICAL EXAMINATION
Hemochromatosis - hereditary iron overload
a. General appearance - a common cause of restrictive cardiomyopathy
b. Age Jaundice - with advanced right heart failure and congestive
c. Posture hepatomegaly or late-term cardiac cirrhosis
d. Demeanor Cutaneous - in patient taking Vitamin K antagonists or anti
e. Overall health status Ecchymoses platelet
Is the patient in pain or resting quietly, dyspneic or diaphoretic? Lipid disorders - subcutaneous xanthomas particularly along the
Does the patient choose to avoid certain body positions to reduce or tendon sheaths or over the extensor surfaces of
eliminate pain? the extremities
Chronically-ill appearing emaciated patient Palmar crease - specific for type III hyperlipoproteinemia
- long standing heart failure or another systemic disorder such as a xanthomas
malignancy Pseudoxanthoma - a disease associated with premature
Height and weight should be measured elasticum atherosclerosis
BMI should be calculated - axilla and neck creases
Measure waist circumference and the waist-to-hip ratio
HEAD AND NECK
Various genetic syndromes (often with cardiovascular involvemen)t:
a. Trisomy 21 (Down Syndrome)
b. Marfan Syndrome - dentition and oral hygiene should be assessed in every patient both as a
c. Holt-Oram Syndrome source of potential infection and as an index of general health
- high-arched palate- is a feature of Marfan syndrome and other connective
Evidence of congenital heart disease: tissue disease syndromes
hypertolerism High-arched palate a feature of Marfan syndrome and other
low-set ears connective tissue disease syndromes
micrognathia
Bifid uvula Loeys-Dietz syndrome
blue sclerae- feature of Osteogenesis Imperfecta
Funduscopic atherosclerosis
examination hypertension
SKIN - assess the DM
Skin> Pallor, cyanosis and jaundice microvasculature suspected endocarditis

Central Cyanosis - significant R> L shunting at the level of the CHEST

Peripheral cyanosis
or acrocyanosis
heart or lungs
- reduced extremity blood flow due to small vessel
constriction Midline sternotomy, left posterolateral thoracotomy, or infraclavicular scars
- severe heart failure at the site of pacemaker/defibrillator generator implantation
- shock Prominent venous collateral pattern- suggest subclavian or vena caval
- peripheral vascular disease obstruction

Cardiology: Physical Examination of the Cardiovascular System 1 of 12

 EXTREMITIES
Thoracic cage abnormalities- connective tissue disease syndromes like
Marfan syndrome Clubbing - presence of central right-to-left
pectus carinatum (pigeon chest)
shunting
pecuts excavatum (funnel chest) - patients with endocarditis
Evidence of Obstructive lung disease
barrel chest deformity (inc AP diameter)
- appearance can range from
Pursed-lip breathing cyanosis and softening of the root
use of accessory muscles !
of the nail bed, to the classic loss of
Ankylosing spondylitis the normal angle between the base
severe kyphosis and compensatory lumbar, pelvic, and knee flexion of the nail and the skin
should prompt careful auscultation for a murmur of aortic regurgitation Holt-Oram Syndrome - unopposable, "fingerized" thumb
(AR) - frequently associated with atrial
dilatation of aortic ring with valvular insufficiency
Straight Back syndrome septal defect (ASD)
loss of normal kyphosis of the thoracic spine
seen in MVP and its variants
PA may be compressed against the sternum gradient across
pulmonary outflow tract> ejection murmur
Respiratory rate and pattern should be noted during spontaneous breathing
depth !
audible wheezing Marfan Syndrome - arachnodactyly spider fingers -
stridor abnormally long and slender fingers
Lung examination can reveal adventitious sounds indicative of pulmonary - Positive "wrist" sign (overlapping of
edema, pneumonia, or pleuritis the thumb and fifth finger around
the wrist)
ABDOMEN - Positive "thumb" sign (protrusion of
the thumb beyond the ulnar aspect
Liver - frequently enlarged in patients with chronic of the hand when the fingers are
heart failure clenched over the thumb in a fist)
- systolic pulsations signify severe tricuspid ! sign.
regurgitation (TR) - Marfan syndrome are usually
Splenomegaly - may be a feature of infective endocarditis associated with MVP and aortic
Ascites - advanced chronic right heart failure aneurysm
- constrictive pericarditis
- hepatic cirrhosis Mnemonic:
- Intraperitoneal malignancy - (MARfan Mvp, AneuRysm)
Elevated JVP - implies cardiovascular etiology
Arterial bruit - suggest high grade atherosclerotic disease,
though precise localization is difficult !

Endocarditis lesions: Janeway lesions:

- nontender, slightly raised
hemorrhages on the palms and
soles

Cardiology: Physical Examination of the Cardiovascular System 2 of 12


Pre sacral edema in the
setting of an elevated JVP
Lower extremity edema in the
absence of jugular venous
hypertension
CARDIOVASCULAR EXAMINATION
JUGULAR VENOUS PRESSURE AND WAVE FORM
Jugular venous pressure
Internal jugular vein
External jugular vein
Venous pressure
Cardiology: Physical Examination of the Cardiovascular System
Oslers node:
- tender, raised nodules on the pads
of the fingers or toes
Splinter hemorrhages:
- linear petechiae in the mid position
of the nailed
- constrictive pericarditis
- lymphatic or venous obstruction
- venous insufficiency
- the single most important bedside
measurement from which to estimate the
volume status
- preferred because the external jugular
vein is valved and not directly in line with
the superior vena cava and right atrium.
- has been used to discriminate between
high and low central venous pressure
(CVP)
- the vertical distance between the top of
the jugular venous pulsation and the
sternal inflection point (angle of Louis)
- A distance >4.5 cm at 30elevation is
considered abnormal
a-c-v waves
x-y descents
A WAVE
- right atrial presystolic contraction
- occurs just after ECG P wave
- precede the first heart sound
Prominent a wave - seen in reduced right ventricular
compliance
- cannon a wave occur with atrioventricular
(AV) dissociation and right atrial contraction
against a closed tricuspid valve
- wide ventricular tachycardia
Atrial fibrillation - not present
X DESCENT
- defines the fall in right atrial pressure after inscription of the a wave
C WAVE
- interrupts this x descent and is followed by a further descent
- may reflect the carotid pulsation in the neck and/or an early systolic
increase in right atrial pressure as the right ventricle pushes the
closed tricuspid valve into the right atrium
V WAVE
- represents atrial filling (atrial diastole) during ventricular systole and
peaks at the second heart sound
- height determined by:
right atrial compliance
volume of blood returning to the right atrium either anterograde
from the cavae or retrograde through an incompetent tricuspid
valve
3 of 12
Tricuspid regurgitation ASSESSMENT OF BLOOD PRESSURE
- v wave accentuates
- subsequent fall in pressure (y Accurate measurement depends on
descent) is rapid
body position place of measurement
- arm size device
with progressive degrees of TR, time of measurement device size
v wave merges with the c wave
the right atrial and jugular vein Blood pressure is best measured
waveform become - in the seated position
ventriculized - with the arm at the level of the heart
- using an appropriately sized cuff:
the length and width of the blood pressure cuff bladder should be 80%
Y DESCENT and 40% of the arm's circumference, respectively
- follows peak of the v wave - after 510 min of relaxation
- can become prolonged or blunted with obstruction to right ventricular
inflow, as may occur with tricuspid stenosis or pericardial tamponade Common source of error in practice
Inappropriately SMALL - marked overestimation of true BP
Kussmaul sign cuff
- due to the impaired filling if right ventricle - underestimation of true BP
- either a rise or a lack of fall of the JVP with inspiration Inappropriately LARGE
- associated with: cuff
constrictive pericarditis
restrictive cardiomyopathy - The cuff should be inflated to 30 mmHg above the expected systolic
massive pulmonary embolism pressure and the pressure released at a rate of 23 mmHg/s.
advanced left ventricular systolic heart failure - Systolic and diastolic pressures are defined by the first and fifth Korotkoff
* normally the venous pressure should fall by at least 3 mmHg with sounds, respectively.
inspiration - Blood pressure is best assessed at the brachial artery level, though it can
be measured at the radial, popliteal, or pedal pulse level.
ABDOMINOJUGULAR REFLEX - In general, systolic pressure increases and diastolic pressure decreases
- elicited with firm and consistent pressure over the upper portion of the when measured in more distal arteries.
abdomen preferably over the right upper quadrant, for at least 10 s. - Blood pressure should be measured in both arms, and the difference
- Positive response: sustained rise of more than 3 cm in JVP for at least should be less than 10 mmHg.
15 s after release of the hand. - A blood pressure differential that exceeds this threshold may be
- useful in predicting a pulmonary artery wedge pressure in excess of 15 associated with
mmHg in patients with heart failure. atherosclerotic or inflammatory subclavian artery disease
supravalvular aortic stenosis
ELEVATED JVP aortic coarctation
- prognostic significance in patients with both symptomatic heart aortic dissection
failure and asymptomatic left ventricular systolic dysfunction. - Systolic leg pressures are usually as much as 20 mmHg higher than
- associated with a higher risk of subsequent hospitalization for systolic arm pressures.
heart failure, death from heart failure, or both. - Greater legarm pressure differences
chronic severe AR extensive and calcified lower extremity peripheral
arterial disease.
- The ankle-brachial index
lower pressure in the dorsalis pedis or posterior tibial artery divided by
the higher of the two brachial artery pressures
powerful predictor of long-term cardiovascular mortality
Cardiology: Physical Examination of the Cardiovascular System 4 of 12
- The blood pressure measured in an office or hospital setting may not
accurately reflect the pressure in other venues. PERIPHERAL ARTERIAL PULSES
- subclavian, brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and
WHITE COAT HYPERTENSION" posterior tibial.
- at least 3 separate clinic-based & In patients in whom the diagnosis of either temporal arteritis or polymyalgia
- at least 2 non-clinic-based measurements <140/90 mmHg in the absence rheumatica is suspected, the temporal arteries also should be examined.
of any evidence of target organ damage Although one of the two pedal pulses may not be palpable in up to 10% of
- may not benefit from drug therapy normal subjects, the pair should be symmetric.
- may be more likely to develop sustained hypertension over time A weak and delayed pulse (pulsus parvus et tardus) defines severe aortic
stenosis (AS).
ORTHOSTATIC HYPOTENSION
- a fall in systolic pressure >20 mmHg or in diastolic pressure >10 mmHg in PULSE IN AORTIC REGURGITATION
response to assumption of the upright posture from a supine position - With chronic severe AR, the carotid upstroke has a sharp rise and rapid
within 3 min. fall-off (Corrigan's or water-hammer pulse).
common cause of postural lightheadedness/syncope - Some patients with advanced AR may have a bifid or bisferiens pulse,
exacerbated by advanced age, dehydration, certain meds, food, in which two systolic peaks can be appreciated.
deconditioning, and ambient temperature
BIFID PULSE
ARTERIAL PULSE Described in patients with easily appreciated in patients on
hypertrophic obstructive intra-aortic balloon counterpulsation
- character and contour of the arterial pulse depend on the cardiomyopathy (HOCM) (IABP), in whom the second pulse is
- stroke volume diastolic in timing
- ejection velocity
- vascular compliance
- systemic vascular resistance
- best appreciated at the carotid level
- A weak and delayed pulse (pulsus parvus et tardus) defines severe aortic
stenosis (AS).
- The pulses should be examined for their
Symmetry
Volume
Timing
Contour
Amplitude
Duration

CAROTID PULSE
- Occurs just after the ascending aortic pulse PULSUS PARADOXUS
- simultaneous auscultation of the heart can help identify a delay in the - a fall in systolic pressure of >10 mmHg with inspiration
arrival of an arterial pulse - Seen in patients with:
- The carotid upstrokes should NEVER be examined simultaneously or pericardial tamponade severe obstructive lung
before listening for a bruit massive pulmonary disease
- Light pressure should always be used to avoid precipitation of carotid embolism tension pneumothorax
hypersensitivity syndrome and syncope in a susceptible elderly individual. hemorrhagic shock
AORTIC PULSE
- best appreciated in the epigastrium
- just above the level of the umbilicus
Cardiology: Physical Examination of the Cardiovascular System 5 of 12
 - measured by noting the difference between the systolic pressure at A visible right upper parasternal pulsation may be suggestive of ascending
which the Korotkoff sounds are first heard (during expiration) and the aortic aneurysm disease.
systolic pressure at which the Korotkoff sounds are heard with each
heartbeat, independent of the respiratory phase.
- Between these two pressures, the Korotkoff sounds are heard only PALPATION OF HEART
intermittently and during expiration. - begins with the patient in the supine position at
- The cuff pressure must be decreased slowly to appreciate the finding 30
- It can be difficult to measure pulsus paradoxus - can be enhanced by placing the patient in the
Tachycardia left lateral decubitus position.
Atrial fibrillation - Thrill: palpable heart murmur felt
Tachypnea as a 'shudder' under the hand
- A pulsus paradoxus may be palpable at the brachial artery or femoral - best felt with distal palm
artery level when the pressure difference exceeds 15 mmHg - Heave: thrusting sensation often
used to describe large area
PULSUS ALTERNANS and amplitude with sustained
- defined by beat-to-beat variability of pulse amplitude. movement
- present only when every other phase I Korotkoff sound is audible as the
cuff pressure is lowered slowly LV IMPULSE
- typically in a patient with a regular heart rhythm - less than 2 cm in diameter and moves quickly away
- independent of the respiratory cycle. from the fingers
- seen in severe left ventricular systolic heart failure - better appreciated at end expiration, with the heart
- closer to the anterior chest wall.
Auscultation for carotid, subclavian, abdominal aortic, and femoral artery - enlargement of the LV cavity is manifested by a leftward and downward
bruits should be routine. displacement of an enlarged apex beat.
Cervical bruit = weak indicator of the degree of carotid artery stenosis; - Palpable presystolic impulse corresponds to the fourth heart sound (S4)
- the absence of a bruit does not exclude the presence of significant indicative of reduced left ventricular compliance and the forceful
luminal obstruction. contribution of atrial contraction to ventricular filling.
The likelihood of significant lower extremity peripheral arterial disease - Palpable third sound (S3)
increases with presence of: indicative of a rapid early filling wave in patients with heart failure
Claudication may be present even when the gallop itself is not audible.
Cool skin - Ventricular systole is defined by the interval between the first (S1) and
Abnormalities on pulse examination second (S2) heart sounds
Presence of a vascular bruit
HEART SOUNDS
ABNORMAL PULSE OXIMETRY
- a >2% difference between finger and toe oxygen saturation
- used to detect lower extremity peripheral arterial disease
- comparable in its performance characteristics to the ankle-brachial index.

INSPECTION AND PALPATION OF THE HEART

The left ventricular apex beat may be visible in the midclavicular line at the
fifth intercostal space in thin-chested adults.
Visible pulsations anywhere other than this expected location are
abnormal.
The left anterior chest wall may heave in patients with an enlarged or
hyperdynamic left or right ventricle.
Cardiology: Physical Examination of the Cardiovascular System 6 of 12
 NORMAL SOUNDS FIXED - secundum atrial defect
SPLITTING OF
S2
NORMAL SOUNDS - pathologic delay in aortic
- S1 Closure of MV and TV; loudest at apex REVERSE
- S2 Closure of AV and PV; loudest at base PARADOXICAL valve closure
SPLITTING left bundle branch block
FIRST HEART SOUND (S1) (the individual right ventricular apical
component of S2 are pacing
The intensity of S1 is determined by:
audible at end severe AS
the distance over which the anterior leaflet of the mitral valve must
travel to return to its annular plane,
expiration and HOCM
intervals narrow with acute myocardial
leaflet mobility, inspiration) ischemia
left ventricular contractility
PR interval
THE THIRD HEART SOUND (S3)
SPLIT S1 - young patients - occurs during the rapid filling phase of ventricular diastole
- right bundle branch block - can be a normal finding in children, adolescents, and young adults
- tricuspid valve closure is relatively delayed - in older patients it signifies heart failure
LOUD S1 - early phases of rheumatic mitral stenosis Left-sided S3 - low pitched sound best heard over the left ventricular
- hyperkinetic circulatory states apex
- short PR intervals
Right-sided S3 - usually better heard over the lower left sternal border
SOFT S1 - ater stages of MS when the leaflets are rigid and calcified and becomes louder with inspiration
- after exposure to
- -adrenergic blockers
- long PR intervals THE FOURTH HEART SOUND (S4)
- left ventricular contractile dysfunction - occurs during the atrial filling phase of ventricular diastole
- indicates left ventricular presystolic expansion
- more common among patients who derive significant benefit from the
SECOND HEART SOUNDS (S2)
atrial contribution to ventricular filling
Aortic and pulmonic valve closure constitutes the second heart sound - in chronic left ventricular hypertrophy or active myocardial ischemia,
NORMAL OR - the A2P2 interval HOCM
PHYSIOLOGIC increases with inspiration - An S4 is not present with atrial fibrillation.
SPLITTING and narrows during
expiration.
EJECTION SOUNDS
WIDE - In right bundle branch
block because of the
- a high-pitched early systolic sound that corresponds in timing to the
PHYSIOLOGIC upstroke of the carotid pulse
further delay in pulmonic
SPLITTING OF
valve closure
- associated with congenital bicuspid aortic or pulmonic valve disease;
S2
- In severe MR because of
Figure 1: normal physiologic - isolated aortic or pulmonary root dilation and normal semilunar valves
the premature closure of
splitting
Figure 2: wide physiologic splitting Bicuspid Aortic Valve - becomes softer and then inaudible as the
the aortic valve valve calcifies and becomes more rigid.
UNUSUALLY - featre of pulmonary Pulmonic Stenosis - moves closer to the first heart sound as
NARROWLY hypertension the severity of the stenosis increases.
SPLIT OR - It is the only right-sided acoustic event
EVEN A that decreases in intensity with
SINGULAR S2 inspiration

Cardiology: Physical Examination of the Cardiovascular System 7 of 12

 NON EJECTION SOUNDS (CLICKS)
Pericardial - high-pitched
knock - occurs slightly later than the
- related to mitral valve prolapse opening snap, corresponding in
- may be single or multiple timing to the abrupt cessation of
- may introduce a murmur ventricular expansion after
tricuspid valve opening and to an
BEHAVIOR OF THE NONEJECTION CLICK (C) AND SYSTOLIC MURMUR exaggerated y descent seen in
OF MVP the jugular venous waveform in
- With standing, venous patients with constrictive
return decreases, the pericarditis.
heart becomes Tumor - a lower-pitched sound that rarely
smaller, and prolapse plop can be heard in patients with
occurs earlier in atrial myxoma
systole
- The click and murmur
move closer to S1.

CARDIAC MURMURS
- With squatting,
venous return
increases, causing an
- Heart murmurs result from audible vibrations
increase in left that are caused by increased turbulence and
ventricular chamber are defined by their timing within the cardiac
size. cycle
- The click and murmur
- The duration, frequency, configuration, and
occur later in systole intensity of a heart murmur are dictated by the
and move away from magnitude, variability, and duration of the
S1 responsible pressure difference between two
cardiac chambers, the two ventricles, or the
ventricles and their respective great arteries.
DIASTOLIC SOUNDS
- The high pitched opening snap (OS) of mitral stenosis (MS)
INTENSITY OF HEART MURMURS
Opening
Snap of
MS

- After the 2nd sound, there is a distinct, crisp extra sound

which is the opening snap (OS) of the stenotic mitral valve
- can be emulated saying "lup butter," adding an additional
syllable to the normal heart's "lup dup."

Cardiology: Physical Examination of the Cardiovascular System 8 of 12

 OTHER CAUSES:
TIMING OF HEART MURMURS pulmonic valve stenosis (with or without an ejection sound)
Systolic Murmurs (Ventricular Diastolic Murmurs (Ventricular Filling) Hypertrophic obstructive cardiomyopathy
Pumping) increased pulmonary blood flow in patients with a large ASD and
Restricted flow through narrow outflow Restricted filling through stenotic A-V left-to-right shunting
tract or vessel, or high flow through valve or disturbed or high volume inflow accelerated blood flow in the absence of structural heart disease
normal channel (fever, thyrotoxicosis, pregnancy, anemia, and normal
mid-diastolic/presystolic adolescence)
mid systolic
Regurgitation (backflow) through A-V Regurgitation through semilunar valve B. LATE SYSTOLIC MURMURS
valve (MV,TV) (Aortic, Pulmonic Valve) heard best at the apex, indicates MVP
holosystolic may or may not be introduced by a non-ejection click
early diastolic/holodiastolic
(occ. early or late systolic)
Flow through intracardiac defect(VSD) C. HOLOSYSTOLIC MURMURS
plateau in configuration
holosystolic reflect a continuous and wide pressure gradient
Continuous (Shunt) Between the left ventricle and left atrium (chronic MR)
Between the left ventricle and right ventricle (VSD)
SYSTOLIC MURMURS Between the right ventricle and right atrium (TR)
can be early, mid-, late, or holosystolic in timing
MR - best heard over the cardiac apex.
- intensity of the murmur increases with maneuvers that increase
left ventricular afterload, such as sustained hand grip.
VSD - The murmur of VSD (without significant pulmonary hypertension)
is holosystolic and loudest at the mid-left sternal border, where a
thrill is usually present.
TR - loudest at the lower left sternal border
- increases in intensity with inspiration (Carvallo's sign)
- accompanied by visible cv waves in the jugular venous wave
form and, on occasion, by pulsatile hepatomegaly

Mnemonic:
HOlocystolic MURmur (HOMUR)
HOMUR (Hammer)- VeSiDe (VSD), MisteR(MR)., ThoR (TR)

A. MID-SYSTOLIC MURMURS Normal - S1, S2, no murmurs

begins after S1 and ends before S2 MVP - mid systolic click, late systolic murmur of MR
typically crescendo-decrescendo in configuration.
Aortic stenosis - most common cause of a midsystolic murmur in an adult Acute MR - loud S1, initiates explosive systolic murmus
- Severe AS - would include parvus et tardus carotid upstrokes, - S3 with mid-diastolic murmur
- a late-peaking grade 3 or greater midsystolic murmur, a soft A2, a
sustained LV apical impulse, and an S4. Chronic MR - blowing holosystolic murmur
- Inspection in AS: Carotid pulse peak is weak and delayed (parvus (compensation) - mid diastolic rumble
et tardus)
- Auscultation in AS: murmur is mid systolic, murmur ends before S2,
ejection sound at 3rd right ICS
Cardiology: Physical Examination of the Cardiovascular System 9 of 12
DIASTOLIC MURMURS CHRONIC SEVERE AR
In contrast to some systolic murmurs, diastolic heart murmurs ALWAYS Austin flint murmur:
signify structural heart disease low-pitched mid- to late apical
Usual causes of Diastolic murmurs: diastolic murmur that sometimes
Semilunar valve incompetence: A-V valve obstruction: can be confused with MS
Aortic insufficiency Mitral stenosis Due to mitral inflow
(regurgitation) Best heard at apex
Apical diastolic rumble imitating the
Pulmonic valve insufficiency Tricuspid stenosis
murmur of organic MS but is due to
aortic regurgitation (AR) stream that
prevents the mitral valve from
opening fully
PR (Pulmonic Regurgitation)
MS
Listening at base:
- abnormally loud S1 at base
- shorter S2-OS interval indicates MS
Listening at apex:
- relatively soft and of short
ACUTE AR - crescnedo, pre systolic murmur
Inspection: duration - loud S1
- rapid rise in left ventricular
bounding (Corrigans) pulse - S2, OS
head bobbing (Mussets sign) diastolic pressure and the - mid-diastolic murmur
Auscultation progressive diminution of the
Inspection:
to-fro murmus aortic-left ventricular diastolic
pressure gradient
- JVP is a wave dominant
Mid systolic murmur (Aortic outflow) - a wave occurs with loud S1
Early diastolic murmur (Aortic
regurgitation)
3RICS (To-FRO) FUNCTIONAL" MITRAL OR TRICUSPID STENOSIS
2RICS (TO-fro) - generation of mid-diastolic murmurs that are created by increased and
accelerated transvalvular diastolic flow, even in the absence of valvular
obstruction
severe MR,
severe TR,
large ASD with left-to-right shunting
- classically heard as a
decrescendo, blowing
diastolic murmur
- along the left sternal border in
patients with primary valve
pathology
- along the right sternal border
in patients with primary aortic
root pathology.
- pulse pressure is wide and the
arterial pulses are bounding in
character.
- heard along the left sternal
border
- most commonly due to
pulmonary hypertension and
enlargement of the annulus of
the pulmonic valve
- S2 is single and loud and may
be palpable
- right ventricular/parasternal lift
that is indicative of chronic
right ventricular pressure
overload.
- classic cause of a mid- to late
diastolic murmur,
- best heard over the apex in the
left lateral decubitus position
- low-pitched or rumbling and is
introduced by an OS in the
early stages of the rheumatic
disease process.

Cardiology: Physical Examination of the Cardiovascular System 10 of 12

Unusual causes of a mid-diastolic murmur
- include atrial myxoma,
- complete heart block, and
- acute rheumatic mitral valvulitis
E. STANDING & SQUATTING
CONTINUOUS MURMURS
- predicated on a pressure gradient that persists between two cardiac
chambers or blood vessels across systole and diastole.
- typically begin in systole, envelop the second heart sound (S2), and
continue through some portion of diastole.
Classic Example: Patent Ductus Arteriosus:
- usually heard in the second or third interspace at a slight distance from
the sternal border.
F. Post-PVC potentiation
OTHER CONTINUOUS MURMURS
- ruptured sinus of Valsalva aneurysm with creation of an aorticright atrial
or right ventricular fistula
- a coronary or great vessel arteriovenous fistula, and
- an arteriovenous fistula constructed to provide dialysis access.
- Mammary souffle of pregnancy
enhanced arterial blood flow through engorged breasts
diastolic component of the murmur can be obliterated with firm pressure
over the stethoscope.
Augments the murmurs of ventricular septal defects and of mitral and
aortic regurgitation.
Opposite happens to AS
Squatting and passive leg elevation increases both venous return and
peripheral arterial resistance.
Standing diminishes most murmurs
Squatting or leg elevation increase most murmurs.
Standing intensifies the murmur of HOCM and prolongs mitral prolapse
murmur earlier into systole.
Squatting and leg elevation have opposite effects.
Semilunar stenosis murmurs increase during the beat following a post
extrasystolic pause, or during beat following long RR interval in atrial
fibrillation.
Mitral regurgitant murmurs tend to remain unchanged, or even diminish.
PVCS stenosis increases

MURMUR EVALUATION MANEUVERS THAT INCREASE MURMUR INTENSITY

Maneuvers Interpretation
MANEUVERS THAT AFFECT MURMURS:
A. INSPIRATION (Mnemonic: R.I.ght- Inspiration; L.E.ft- Expiration) Inspiration Right-sided
Right-sided murmurs generally increase with inspiration. Valsalva HCM
Left-sided murmurs usually are louder during expiration Squat to stand HCM
Handgrip Mitral regurgitation, VSD
B. VALSALVA MANEUVER Transient arterial occlusion Mitral regurgitation, VSD
Most murmurs decrease in length and intensity except: MANEUVERS THAT RESULT IN DECREASED MURMUR INTENSITY
HOCM: systolic murmur which usually becomes much louder
MVP: longer and often louder
After release of the Valsalva maneuver, right-sided murmurs tend to return Maneuvers Interpretation
to control intensity earlier than do left-sided murmurs earlier into systole. Stand To Squat HCM
Leg elevation HCM
Handgrip HCM
C. HANDGRIP
Most murmurs increase with exercise.
Murmurs of aortic stenosis or obstructive cardiomyopathy tend to
decrease with peak handgrip.

D. ARTERIAL-OCCLUSION
Blood pressure cuff inflation to both arms increases peripheral vascular Believe that you can and youre halfway there
resistance. "

Cardiology: Physical Examination of the Cardiovascular System 11 of 12

Cardiology: Physical Examination of the Cardiovascular System 12 of 12