Clinical Examination:

Pulse

Define pulsus alterans

Variation in pulse volume with alternate beats due to change in systolic blood pressure

Give an important cause of pulsus alterans

Left ventricular failure

Which valvular pathology may cause pulsus alternans?

Aortic regurgitation (severe)

In a healthy adult how does the timing of the radial and femoral pulse upstrokes compare with each other?

Simultaneous

In coarctation of the aorta how does the femoral pulse upstroke compare to the radial pulse?

Delayed onset usually with reduced volume

Describe ‘Corrigan’s pulse’, also called water hammer pulse

Abrupt and rapid upstroke followed by a rapid collapse

How is ‘Corrigan’s pulse’ / water hammer pulse best palpated?

Suddenly raising the arm while palpating the radial and/or brachial pulse

In which valvular condition may Corrigan’s pulse occur?

Chronic aortic regurgitation (may not occur in acute)

Describe the character of the pulse which may be palpated in aortic stenosis

Slow rising with delayed upstroke

Clinical Examination:

Blood Pressure

What term is given to the difference between the systolic and diastolic pressures?

Pulse pressure

How is systolic arterial pressure normally affected by inspiration?

Reduced – maximum 8 to 12 mmHg

Define pulsus paradoxus

Reduction in systolic arterial pressure more than 10 mmHg during inspiration

Which respiratory condition can lead to pulsus paradoxus?

Chronic obstructive pulmonary disease (COPD)

Define postural hypotension

Drop in systolic BP of more than 20 mmHg or diastolic BP of more than 10 mmHg after standing for 3 minutes from a lying position

Clinical Examination:

Jugular Venous Pressure

Which vein is represented by examination of the jugular venous pressure (JVP)?

Right internal jugular vein

The JVP assesses the pressure in which chamber of the heart?

Right atrium

What is the ideal position for the patient when examining the JVP?

Seated at 45 degrees, head turned to the left, neck relaxed

In the healthy JVP waveform how many ‘waves’ are there?

3 – ‘a’ wave, ‘c’ wave and ‘v’ wave

In the healthy JVP waveform how many ‘descents’ are there?

2 – ‘x’ descent and ‘y’ descent

What physiological process does the JVP ‘a’ wave correspond to?

Atrial systole

What physiological process does the JVP ‘c’ wave correspond to?

Tricuspid valve closure (wave not visible)

What physiological process does the JVP ‘x’ descent correspond to?

Reduction in atrial pressure during ventricular systole

What physiological process does the JVP ‘v’ wave correspond to?

Atrial filling with a closed tricuspid valve

What physiological process does the JVP ‘y’ descent correspond to?

Tricuspid valve opening

What abnormal JVP waveform is typically seen in tricuspid regurgitation?

Giant ‘c-v’ waves (Lancisi’s sign) – due to systolic regurgitation into the right atrium

What abnormal JVP waveform is typically seen in constrictive pericarditis?

Sharp and steep y descent (Friedreich’s sign)

How may superior vena cava (SVC) obstruction affect JVP waveform?

Absent – JVP is raised and fixed

In which valvular condition can large ‘a’ waves seen in the JVP?

Pulmonary stenosis

Describe the JVP waveform which may be seen in pulmonary hypertension

Large ‘a’ waves

Describe the JVP waveform which may be seen in complete heart block

Cannon ‘a’ waves

Describe the JVP waveform which may be seen in atrial fibrillation

Absent ‘a’ waves

Describe the JVP waveform which may be seen in tricuspid regurgitation

Large ‘v’ waves

Describe the JVP waveform which may be seen in constrictive pericarditis

Steep ‘x’ and ‘y’ descents

Clinical Examination:

Praecordium

What is the landmark for palpation of the apex beat in a healthy adult?

5th intercostal space mid-clavicular line

What cardiac abnormality does a palpable ‘heave’ correspond to?

Enlarged right ventricle

In what region of the praecodium may a parasternal ‘heave’ be palpated?

Left sternal edge

Which valvular condition may cause a ‘tapping’ apex beat on palpation?

Mitral stenosis

Which condition may cause a ‘double impulse’ apex beat on palpation?

Hypertrophic obstructive cardiomyopathy (HOCM)

Which valvular condition may produce a ‘heaving’ apex beat on palpation?

Aortic stenosis

Which two valvular conditions may produce a ‘thrusting’ apex beat on palpation?

1) Mitral regurgitation

2) Aortic regurgitation

Clinical Examination:

Heart Sounds

When in relation to the first and second heart sound is a third heart sound (S3) heard?

Immediately after the second heart sound

When in relation to the first and second heart sound is a fourth heart sound (S4) heard?

Immediately before the first heart sound

Which valvular condition may cause a loud first heart sound?

Mitral stenosis

Which valvular condition may cause a quiet/soft first heart sound?

Mitral regurgitation

Which 2 valvular conditions may cause a quiet/soft second heart sound?

1) Aortic stenosis

2) Pulmonary stenosis

How is the intensity of the first heart sound affected in dilated cardiomyopathy?

Quiet/soft

How is the intensity of the first heart sound affected with a pericardial effusion?

Quiet/soft

What additional heart sound may be auscultated in the high-output state of thyrotoxicosis?

Third heart sound (S3)

What additional heart sound may be auscultated in the high-output state of pregnancy?

Third heart sound (S3)

Which valvular pathology may produce an ejection systolic click?

Bicuspid aortic valve

What additional sound may be heard on auscultation in mitral valve prolapse?

Mid-systolic click

What additional sound may be heard on auscultation in mitral stenosis?

Opening snap – precedes murmur

How do the intensity of artificial heart valve sounds compare to normal heart valve sounds?

Artificial heart valve sounds are louder

The sound of a prosthetic mitral valve click may be auscultated during which heart sound?

First heart sound (S1)

The sound of a prosthetic aortic valve click may be auscultated during which heart sound?

Second heart sound (S2)

In which condition may a ‘pericardial knock’ be auscultated?

Constrictive pericarditis

At which stage is a ‘pericardial knock’ typically auscultated?

Early diastole

In which condition may the additional sound of a ‘tumour plop’ be auscultated?

Atrial myxoma (left and right)

During which phase of respiration is a pericardial rub best heard on auscultation?

Held inspiration

What patient position is a pericardial rub best heard on auscultation?

Leaning forward

Describe the sound of a pericardial rub

‘Scratchy’ sound

Over which region of the precordium is a pericardial rub best heard on auscultation?

Left sternal border

What effect may right bundle branch block have on the second heart sound?

Wide splitting

What effect may left bundle branch block have on the second heart sound?

Reversed splitting

At which location of the praecordium is splitting of the second heart sound best heard on auscultation?

2nd intercostal space left of the manubrium – pulmonary area

Clinical Examination:

Murmurs

What is the underlying reason for a cardiac murmur?

Turbulent blood flow

What term is given to palpable murmur?

Thrill – palpable as a vibration

What grade denotes an extremely loud murmur audible without the stethoscope on the chest?

Grade 6

What grade denotes a murmur that is easily detected on auscultation with a palpable praecordial thrill?

Grade 4

What grade denotes a murmur which is soft but readily detectable on auscultation?

Grade 2

What grade denotes a murmur which is the faintest sound which is detectable on auscultation?

Grade 1

What grade denotes a murmur which is very loud audible when the stethoscope is placed lightly on the chest?

Grade 5

What grade denotes a murmur which is loud on auscultation but not associated with a palpable precordial thrill?

Grade 3

During what stage of the cardiac cycle do benign ‘flow’ murmurs typically occur?

Systolic – ejection or mid-systolic

What kind of murmur may occur in anaemia?

Systolic ‘flow’ murmur

What kind of murmur may occur in pregnancy?

Systolic ‘flow’ murmur

What kind of murmur may occur in thyrotoxicosis?

Systolic ‘flow’ murmur

Describe the murmur of aortic stenosis

Ejection systolic (high-pitched) murmur

In which region is the murmur of aortic stenosis best heard on auscultation?

2nd intercostal space right sternal border

Where does the murmur of aortic stenosis typically radiate?

Into the neck over both carotid arteries

Describe the murmur of aortic regurgitation

Early diastolic (soft) murmur

In which region is the murmur of aortic regurgitation best auscultated?

Lower left sternal edge

What is the best patient position for the auscultation of the murmur in aortic regurgitation?

Sitting and leaning forwards

During which phase of respiration is the murmur of aortic regurgitation best heard on auscultation?

Breath held in full expiration

Describe the murmur of mitral regurgitation

Pan-systolic (high-pitched) ‘whistling’ murmur

In which region is the murmur of mitral regurgitation best heard on auscultation?

5th intercostal space mid-clavicular line (apex)

List 3 sites to which the murmur of mitral regurgitation may radiate

1) Left axilla

2) Inferior angle of the left scapula

3) Over the thoracic spine

Which position can the patient be placed to accentuate the murmur of mitral stenosis?

Left side

Describe the murmur of mitral stenosis

Mid-diastolic (low-pitched) ‘rumbling’ murmur

How is the murmur of mitral stenosis affected by exercise?

Accentuated

Describe the murmur of mitral valve prolapse

Late systolic murmur

What is a Graham Steell murmur?

Early diastolic murmur where pulmonary regurgitation occurs secondary to pulmonary hypertension due to mitral stenosis

What murmur is typical of a ventricular septal defect (VSD)?

Pan-systolic murmur (harsh)

In which region is the murmur of a ventricular septal defect (VSD) best heard on auscultation?

Lower left sternal edge

Describe the Austin Flint murmur

Rumbling diastolic murmur at the apex

Describe the murmur of a prosthetic aortic heart valve

Short systolic murmur

Clinical Examination:

Miscellaneous

Which valvular condition may cause pulsatile hepatomegaly?

Tricuspid regurgitation

What skin abnormality may be seen with mitral stenosis?

Malar flush

In which condition may Roth spots be seen on fundoscopy?

Infective endocarditis

Describe Quincke’s sign

Capillary pulsation in the nailbed of the fingers or the lips

In which valvular pathology may Quincke’s sign be seen

Aortic regurgitation

Describe de Musset’s sign

Head bob occurring in time with the pulse

In which cardiac condition may de Musset’s occur?

Chronic aortic regurgitation

Describe Müller’s sign

Pulsation of the uvula during systole

In which cardiac condition may Müller’s sign occur?

Chronic aortic regurgitation

Describe Corrigan’s sign

Visible pulsation of the carotid artery

In which cardiac condition may Corrigan’s sign occur?

Chronic aortic regurgitation

Describe Traube’s sign

‘Pistol shot’ shot sound during systole and diastole heard on auscultation over the femoral artery

In which cardiac condition may Traube’s sign occur?

Chronic aortic regurgitation

Describe Duroziez’s sign

Systolic and diastolic bruit heard on auscultation during partial compression of the femoral artery

In which cardiac condition may Duroziez’s sign occur?

Chronic aortic regurgitation

Describe Becker’s sign

Visible pulsation of the retinal arteries

In which cardiac condition may Becker’s sign occur?

Chronic aortic regurgitation

Describe Landolfi’s sign

Pupil constriction and dilatation in time with the pulse

In which cardiac condition may Landolfi’s sign occur?

Chronic aortic regurgitation

Describe Gerhard’s sign

Systolic pulsations of the spleen

In which cardiac condition may Gerhard’s sign occur?

Chronic aortic regurgitation