CLINMED – CVS NOTES – 2017
CONCENTRIC ECCENTRIC
 Strong forceful
pulsation/impulse
 5th ICS MCL/10cm
 Thick wall
 Small cavity
Seen in Patient with : Seen in Patient with :
 Chronic HPN  Chronic HPN
ECCENTRIC WITH LIFT LVH DILATATION
 Displaced apical  Very strong pulsation
beat horizontally  Pushes the
 5th ICS LAAL/12cm steth/Hands up
 Thick wall  Displaced
 Thick septum Horizontally/Vertically
Seen in Patient with :
 Volume overload
due to vulvular
disease
 Mitral regurgitation
 Aortic regurgitation
 Congenital Heart
Disease Seen in patient with :
 Eg. Patent Ductus
Arteriosus (PDA)
Symptomatic patients:
 DOB
 Orthopnea
 Peripheral edema
w/ jugular vein
distention
 On ECG
o Small QRS-
Hypokinetic
 On Xray
o Markedly
enlarged heart
RVH
 Not palpable  Apical Beat that retracts during
*turn pt. on lateral systole
decubitus-bring
nearer to the chest
wall* Symptomatic patients:
 5th/6th ICS  Mitral stenosis
 Very faintly palpable  Congested heart disease
beat on the middle  Cor pulmonale
of axilla  Pulmonary embolism
 Rheumatic heart disease
 *Global hypokinesia o Left atrial enlargement
moving in 2D echo o Right ventricular
hypertrophy
 Cardiomyopathy
 CAD
 Chronic Ischemia
Heart Disease
 Coronary Bypass
 Cox Virus
 Echo virus-viral
cardiomyopathy
 Use of alcohol
 Taking illicit drugs
FRANZ MIKKAEL AGAS, MD (FMAMD) 1
 CLINMED – CVS NOTES – 2017

PULSUS ALTERRANS PULSUS PARVUS ET TARDUS PULSUS BIGEMINUS/ CORRIGAN’S PULSE PULSUS PARADOXICUS
BISFRIENS

 Alternating strong  Small and late pulse  Premature  Very Strong pulse  Not a pulse
weak pulse ventricular  Collapsing pulse  Take pt BP and Deep breath
contraction -More than 10mm lowering in
*CHF *Aortic stenosis systolic BP
*Aortic stenosis + *Chronic Aortic
Regurgitation Regurgitation *Chronic Constrictive Pericarditis

Carvallos’s sign – Tricuspid regurgitation Ebstein Anomaly – Sail Sound

Kussmauls sign – Constrictive pericarditis and Pericardial effusion Graham Steele – Pulmonary regurgitation

Hepatojugular – CHF Carey Coombs – Rheumatic heart Disease

Austin Flint – Chronic Aortic regurgitation Coartation of Aorta – BP elevated in UE and low in LE

Gallavardin’s sign – Aortic Stenosis ASD – Fixed Splitting of S2

Machinary like – PDA VSD – Holosystolic murmur at the Left parasternal area to right sternal
border
Intermittent Claudication – pain in the right calf upon walking can be
relieve by rest

Addtion: RAA tables

Dynamic heart – LVH

Bigeminy - continuous alternation of long and short heart beats, premature ventricular contraction (PVC), aortic stenosis

FRANZ MIKKAEL AGAS, MD (FMAMD) 2

CLINMED – CVS NOTES – 2017

BEST HEARD:

2nd RIGHT ICS PSL 2nd LEFT ICS PSL 3rd LEFT ICS 4th LEFT ICS PSB 5th LEFT ICS MAL
(AORTIC) (PULMONIC) (ERB’S POINT) (TRICUSPID) (MITRAL)

1. Paradoxical 1. Physiologic 1. Mitral Valve Prolapse 1. Tricuspid 1. Mitral Regurgitation

Splitting of S2 Splitting of S2 (MVP) Regurgitation 2. Mitral Stenosis
2. Aortic Stenosis 2. Persistent Splitting 2. Vetricular Septal 2. ASD 3. S3
3. Aortic Aneurysm of S2 - Defect (VSD) 3. Physiologic 4. S4
3. Pulmonic 3. Aortic Regurgitation Splitting of S1 5. Dilated Cardiomyopathy
Aneurysm 4. Quadruple Rhythm 4. Ebstein Anomaly
4. Pulmonary 5. Hypertrophic
Stenosis Cardiomayopathy
5. PDA
6. ASD

A. HEART SOUNDS

S1 S2

LOUD S1 (TIM)
LOUD A2 (LA-SA) LOUD P2 (LP-PA)
Tachycardia
Systemic HPN Pulmonary HPN
Increased Temp
Aortic Dilatation ASD
Mitral Stenosis

SOFT S1 (VAMCC) SOFT A2 SOFT P2

Vol. Overload Aortic Stenosis Pulmonary Stenosis

A-FIB
Mitral Regurgitation
CHF
CAD

FRANZ MIKKAEL AGAS, MD (FMAMD) 3

CLINMED – CVS NOTES – 2017

B. HEART SOUND

S1 S2
SPLITTING  1st-Closure of mitral valve  1st – Aortic
 2nd – Pulmonic

WIDENING  Complete RBBB  RBBB

 Delayed onset of RV pressure pulse  Delayed closure of PV
 Mitral regurgitation

REVERSED  Severe mitral stenosis

 LBBB
 Left atrial myxoma
PHYSIOLOGIC  Delayed closure not vary with
pulmonic valve
 ASD
 RBBB

FIXED  Does not vary with respiration

 ASD
 RVF

PARADOXICAL  Does not vary on expiration and

disappears on inspiration
 Delayed closure at AV
 Aortic stenosis
 LBBB
 Hypertropic Cardiomyopathy

SYSTOLIC SOUND

EJECTION SOUNDS NON-EJECTION SOUND/MIDSYSTOLIC CLICK

-HIGH PITCH SOUND (DAPE) MVP
Dilatation of Aorta Barlow’s Syndrome
Aortic Stenosis
Pulmonic Stenosis
Early Systole

FRANZ MIKKAEL AGAS, MD (FMAMD) 4

CLINMED – CVS NOTES – 2017

DIASTOLIC SOUND

OPENING SNAP S3 S4
- Brief high pitch - Low pitched - Low pitched
- LLSB - Normal in children - Pre-systolic sound
- Radiates to the base of heart

AV Stenosis Early Diastole Absent in AF

Cardiac tamponade Systemic HPN
Tricuspid regurgitation Aortic Stenosis
Constrictive pericarditis *vol. overload Hypertropic Cardiomyopathy
Ventricular Gallop After S2 Ischemic Heart Disease
Heart Failure Mitral Regurgitation
Aortic Regurgitation
Weak Contractility

REVIEW:

Normla
Apex: Loud S1 Soft S2
Based: Loud S2 Soft S1

The intensity of first heart sound is being affected by heart rate. In patient with very fast heart (FEVER, PREGNANCY, and HYPERTHYROIDISM –
S1 becomes loud all over

Physiologic Splitting of S2 in Normal Breathing

Persistent Splitting of S2 in Pulmonic Stenosism Atrial Septal Defect
Paradoxical Splitting: P2 Louder than A2 (in comparison to physiologic and persistent splitting which has louder A2 than P2)

S3
-Mitral Regurgitation
-Hypertropic Cardiomyopathy
-Restrictive in early diastole (ventricular filling)

FRANZ MIKKAEL AGAS, MD (FMAMD) 5

CLINMED – CVS NOTES – 2017

HEART MURMUR
Systolic Diastolic

MITRAL VALVE REGURGITATION STENOSIS

TRICUSPID VALVE (Holocystolic) (MID SYSTOLIC MURMUR)

AORTIC VALVE STENOSIS REGURGITATION

PULMONIC VALVE (Midsystolic/Systolic Ejection Murmur) (EARLY DIASTOLIC MURMUR)

SYSTOLIC DIASTOLIC
MIDSYSTOLIC (APAH) EARLY DIASTOLIC (APA)

- Aortic Stenosis - AORTIC REGURGITATION

- Pulmonic stenosis - PULMONIC REGURGITATION
- ASD - AUSTIN FLINT
- HOCM – Hypertropic Cardiomyopathy

HOLOSYSTOLIC (MTV) MID-LATE DIASTOLIC (MT)

- Miral Valve Regurgitation - Mitral Stenosis

- Tricuspid Regurgitation - Tricuspid Stenosis
- VSD

LATE SYSTOLIC

- MVP

CONTINOUS MURMUR VENOUS HUM – Loudest in Diastole : PERICARDIAL FRICTION RUB –

PDA- MACHINERY LIKE MURMUR Humming or Rearing Sound Scartchy, scraping sound at Erb’s
point

Austin Flint – Soft rumbling murmur. Late systolic

FRANZ MIKKAEL AGAS, MD (FMAMD) 6

CLINMED – CVS NOTES – 2017

POSITIONING

Valsalva  Increase hypertrophic cardiomyopathy murmur

Deep breathing  Right sided murmur
Hand grip  Left sided murmur
Standing from squatting  MVP
Squatting from standing  Decrease hypertrophic cardiomyopathy murmur

Squatting and leg raising  Increase venous return to the heart

AUSCULTATION
Sitting and leaning  Mild aortic regurgitation

HEART
Aortic Stenosis  Ejection systolic murmur transmitted into carotids
 Crescendo-decrescendo murmur
 Ejection click or sound
 Paradoxical splitting of S2
Aortic regurgitation  Diastolic blowing murmur
 Wide systolic pressure
Hypertrophic Cardiomyopathy 
Atrial septal defect  Fixed/persistent splitting of S2
Ventricular septal defect  Holosystolic murmur  Heard at Erb’s, transmitted to the right sternal border
Tricuspid regurgitation  4th ICS parasternal line
Pulmonic stenosis  RBBB
 Mid-diastolic murmur  radiates to left shoulder
 Crescendo-decrescendo
 Persistent splitting of S2
Pulmonic regurgitation 
Mitral stenosis  Opening snap
 Diastolic murmur
 Loud S1
Mitral regurgitation  Holosystolic murmur displaced to the left axilla/infrascapular
 Diminished S1
 Rumbling murmur
Mitral valve prolapse  Mid-systolic click
 Late systolic murmur
 Non-ejection sound
Coarctation of aorta  Greater BP in the UE compared to LE

FRANZ MIKKAEL AGAS, MD (FMAMD) 7