Dr.

Rene Manalo | August 9, 2016 (B), August 13, 2016 (A)

PRELIM QUIZ 1

Blue Audio | Violet OT | Red - Emphasized Important to pinpoint the exact location of the PMI
(which is both a finding of Inspection and Palpation)
To palpate - use the entire palm to screen for the PMI
PHYSICAL EXAMINATION: CARDIOVASCULAR SYSTEM and then switch to the base of the fingers (most
Four Basic Maneuvers: IPPA sensitive part of the palm, then use the finger to
Inspection pinpoint the exact location
Observe precordium distinguish acquired from S3 is better picked up by palpation rather than
congenital conditions auscultation especially in cases of pulmonary
o Precordial bulges: hypertension and arterial hypertension.
- Asymmetrical chest wall
- Precordial bulging on the left side due to Percussion
accommodation of the heart as the child Least important
grows, indicates a congenital condition Areas of relative and absolute cardiac dullness may be
Point of maximal impulse (PMI): influenced by the degree of pulmonary tissue that
o Point in the precordium where the cardiac impulse overlaps the cardiac structure
is most intense Important if trying to assess the presence of effusion or
o Normally located at the 5th ICS Left MCL determine roughly the size of the heart
o Should be differentiated from the APEX BEAT (AB)
Apex Beat (AB) Auscultation
o Most lateral and most inferior pulsation of the Very important maneuver
heart Indirect auscultation - more civilized way, started by
o Does not necessarily mean that it should be the the french physician Ren-Thophile-Hyacinthe
most intense pulsation Lannec
o 90% (9 out of 10) of individuals have the same AB Most important is to note for:
location 1. Transients
- Heart sounds S1 to S4
Left Ventricular Hypertrophy: - Opening snaps
- PMI is displaced laterally and - Clicks
inferiorly/downward, usually 1 ICS below 2. Murmurs - result of Turbulence and Vortex Shedding
the normal location a. Diastolic murmur - always abnormal
Right Ventricular Hypertrophy: b. Systolic murmur - may or may not be
- PMI is displaced laterally and abnormal
superiorly/upward, usually 1 ICS above the i.e. Hemic murmur in cases of anemia
normal location and thyrotoxicosis
2 main causes of Murmurs
Jugular Pulse Waves or Jugular Venous Palpation 1. Turbulence: due to increased flow
Very strong current or jet stream
High output states
AV fistulas
Beri-beri
2. Vortex shedding or EDDYING
Represent a constriction or
disruption in the normal laminar
flow which sends a vortex
Creates a vibration which is
appreciated as a murmur

Clinical Heart Valve Areas

A wave: Right atrial contraction/systole
1. Mitral: 5th ICS L MCL
C wave: Right Ventricular Contraction with closed tricuspid valve
2. Tricuspid: Subxyphoid
X-descent: Atrial diastole
3. Pulmonic: 2nd L ICS PSL
V wave: Right Atrial filling
4. Aortic: 2nd ICS R PSL
Y descent: Right Atrial emptying
Palpation

 Erbs point Heard by applying the rim of the diaphragm
Area of importance between 3rd and 4th ICS L PSL of the stethoscope touching the
usually cardiac events felt and heard here precordium
corresponds to a congenital lesion (VSD) Presence of thrill
Some place in their physical examination LLSB (left VI/VI loud murmur
lower sternal border) in their report Heard even when chest piece 1-2 mm above
the chest wall
Cardiac Cycle Associated with thrill
In auscultating it is important to establish the cardiac cycle
Two valvular heart disease that are surgical
emergencies because both would lead to pulmonary
edema within hours to days:
S1 Systolic S2 Diastolic S1 1. Acute Aortic Regurgitation
2. Acute Mitral Regurgitation
Systolic time
o Never affected by increase in heart rate
o Starts with the closure of the AV valves (S1) to Location clinical valve areas
closure of Semilunar valves (S2) Transmission where it is radiated to
Diastolic time Character or Quality i.e. Rumbling
o Always longer than systolic time
o Important - phase where ventricles fill up and Holosystolic Murmurs/Pansystolic Murmurs
coronary arteries fill up Murmurs heard during the entire systole
o Important for patients with CAD because the Three differential diagnoses:
coronary arteries are compromised, a longer Mitral Regurgitation (MR):
diastolic time would profuse the coronary arteries o Hear murmur at any part of the head/ trunk of
better and fill up the ventricle fully if you have a the patient (pakawala murmur)
longer diastolic time o LV hypertrophies backward and hits the
o Shortens when heart beats faster vertebral column and this promotes bone
conduction
Murmur (TILT-C) Tricuspid Regurgitation (TR):
Timing o Subxyphoid and apex of the heart
Systolic o (+) Carvallo sign deep inhalation causes an
o Early phase increase in the intensity of the murmur; used
o Middle phase to differentiate it from MR
o Late phase Ventricular Septal Defect (VSD)
o Holosystolic or pansystolic o Only heard at ERBs point
Diastolic
o Early phase (protodiastolic) Rule:
o Middle phase(mesodiastolic) If the murmur is Systolic and in the Semilunar
o Late phase (pre systolic) valve it is Stenosis
Intensity it is inversely proportional to the size of the If the murmur is Systolic and in the AV valve it is
defect Regurgitation or insufficiency
Freeman Williams Grading of Murmurs
Grade Features If the murmur is Diastolic and in the Semilunar
Faint murmur valve it is Regurgitation
I/VI 5P MEDICINE 2: Valvular Heart Disease 1
Appreciated after patient is asked to If the murmur is Diastolic and in the AV valve it is
exercise or perform activity Stenosis
II/VI Faint murmur
No exertion from the patient Remember your SSS. Systolic-Semilunar-Stenosis
III/VI Moderately loud murmur Semilunar
Stenosis
valve
Not associated with thrill Systolic
IV/VI Moderately loud murmur AV valve Regurgitation
Associated with thrill (palpatory component
of a loud murmur) Semilunar
Regurgitation
V/VI Loud murmur valve
Diastolic
AV valve Stenosis

P age 2|6
 VALVULAR HEART DISEASES Wide and strong pulse that suddenly
collapses or rapidly disappear
Kinds of Valvular Heart Disease Mullers sign To-and-fro movement of the uvula
1. Congenital Examination of the throat
2. Acquired Traubes sign Also known as Pistol shot murmur
Loud booming systolic murmur heard
Heart Valves (according to relative involvement) upon deep pressure on the femoral artery
1. Mitral most commonly affected Duroziezs sign To-and-fro (systolic-diastolic-diastolic)
2. Aortic murmur on the femoral artery on light
3. Tricuspid auscultation/ soft pressure at the
4. Pulmonic: rarest femoral artery
Hills sign Wide difference in the popliteal and
Mitral + aortic 75% of VHD due to pressure brachial pressure greater than 30 mmHg
present in the left side of the heart especially in Quinckes sign or Alternating blanching and erythema
RHD capillary upon application of pressure on the nail
Tricuspid + pulmonic 25% of VHD pulsations beds
Applying pressure in the distal phalanx
I. AORTIC REGURGITATION (AR) Austin Flint Apical diastolic murmur usually
murmur mistaken as mitral stenosis
Relative mitral stenosis but absolute
aortic insufficiency
Mimics mitral stenosis
Landorffs sign Only seen in females: difference
To-and-fro movement of the cervix

Echocardiogram long axis parasternal view

Regurgitant jet stream yellow or turbulence
1. Acute Aortic Regurgitation End diastolic volume blue
Sudden severe dyspnea, orthopnea and weakness Stroke volume red
Would eventually lead to acute pulmonary edema
Always a surgical emergency - requires prompt
surgical intervention (sodium nitroprusside andbeta 4 degrees of regurgitation:
blockers) - Trivial
Absence of typical peripheral signs of chronic aortic - Mild
regurgutation (Absence of classic pimp signs) - Moderate
Associated with acute aortic dissecting aneurysm - Severe
Usually 9/10 cases of acute aortic regurgitation Moderate to severe
will happen in te presence of an acute aortic clinically significant or
dissecting aneurysm evident
Trivial to mild seen on
2. Chronic Aortic Regurgitation echo, not clinically
Long asymptomatic period then presents as CHF or significant
angina pectoris
Most typical sign wide pulse pressure Treatment:
Always remember: dental procedure, ob-gyne
Wide pulse pressure >/= 100 mmHg 5P MEDICINE 2: Valvular Heart Disease 1
180/20 mmHg or 200/0 mmHg procedure or endoscopy
Diastole - cut off at phase 4 korotkoff sounds always subject the patient to antibiotic
Associated with classic pimp signs prophylaxis; usually given 3 days before the
Males 14 signs procedure extending 3-4 days after the procedure
Females 15 signs to avoid infective endocarditis
1. Vasodilators
CLASSIC PIMP SIGNS - Calcium channel blockers
Sign Features - ACE inhibitors
De Mussets sign To-and-fro movement of the head with - ARBs
each heartbeat 2. Antibiotic prophylaxis
Corrigans pulse Also known as Water hammer pulse - A must for all patients with valvular conditions
and congenital heart disease who undergo:
- Dental procedures
P age 3|6
 - Deliver babies/ OB-GYN procedures Natural history
- Endoscopy / Surgical Mild to moderate Aortic Stenosis - prognosis is
- 3-4 days before and after excellent
3. Avoid competitive sports - Statins are the agent of choice due to its pleotropic
4. Aortic valve replacement effect which delays the progression of valve defect
- For patients symptomatic LVEF (left ventricular - Stabilizes the coronary lesion in ACS and
ejection fraction) >25% prevents the lesion from progressing from
- For patients asymptomatic and LVEF 25-50% mild to moderate to severe in VHD
Severe Aortic Stenosis
II. AORTIC STENOSIS (AS) - Mean survival for AS:
- 45 months: (+) angina
- 27 months: (+) repeated syncope
- 11 months: (+) LVF/ Heart failure

Treatment:
Severe aortic stenosis requires surgical correction
Valve replacement( choice for severe AS):
- When symptomatic and/or
- AVA is <0.8 cm2
Regurgitation can happen acutely, while stenosis is always
chronic Appearance of symptoms of severe AS, indicates that
the patient needs to undergo surgical repair
Classic triad of symptoms (SAD) in its severe form Patient may suddenly die from arrhythmia or heart
Syncope SV is compromised and patient may have failure
seizures due to low cerebral perfusion Never give vasodilators and beta blockers because they
Angina Left ventricular hypertrophy would dilate the post stenotic area, which could cause
Dyspnea Heart failure hypotension
Common causes
Senile calcific degeneration PEARL: If vasodilators and beta-blockers MUST be
Calcific degeneration of congenital bicuspid aortic used with extreme caution (ICU) in patients with
valve severe aortic stenosis even in the presence of CHF
Rheumatic heart disease most common
Methysergide a component of appetite stimulants, III. MITRAL REGURGITATION (MR)
serotonin agonist, can iatrogenically cause Aortic
Stenosis (in contrast to Phen-Fen which iatrogenically 1. Acute Mitral Regurgitation
causes Mitral Regurgitation) Acute volume problem
Essentials for diagnosis:
Physical Examination findings Sudden severe dyspnea/orthopnea in evidence
LVH of pulmonary congestion
MURMUR Systolic murmur, 2nd RICS, Evidence of pulmonary edema
PSL Apical holosystolic murmur
PULSUS PARVUS ET TARDUS Weak and delayed pulse due Most common cause chordal rupture from a
Parvus: weak or small in to constriction massive acute myocardial infarction
volume Contrast - Corrigans Pulse

5P MEDICINE 2: Valvular Heart Disease 1
Tardus: delayed or slow (abrupt rise and sudden Treatment:
collapse) Stabilization with vasodilators
GALLAVARDIN Contrast Austin Flint Intraaortic balloon pump
PHENOMENON Murmur Urgent surgical repair/replacement
Apical systolic murmur
mistaken as mitral
regurgitation which is
actually an aortic stenosis
Relative mitral regurgitation
Absolute aortic stenosis

P age 4|6
 Do not add anxiety to the patients
2. Chronic Mitral Regurgitation
Causes: Treatment
Myxomatous changes Very common and rarely requires treatment
Rheumatic fever most common cause in Asia If palpitations become uncontrollable give beta-
Libman-Sacks endocarditis blockers
Phenteramine-fenfluramine (Phen-Fen) Antibiotic prophylaxis in all dental procedures, ob-
o A drug that keeps patient awake, destroys gyne procedures, surgical procedures and endoscopy
sleep and decreases appetite
o Causes iatrogenic MR - DexFenfluramine V. MITRAL STENOSIS (MS)
o Still available in the Philippines
Variable natural history Essential for diagnosis:
Mild to moderate MR good prognosis 1. Exertional dyspnea and paroxysmal nocturnal
Relatively benign dyspnea in most cases
The first chamber that enlarges is the left atrium
Treatment Left ventricle does not receive enough blood so it
Infective endocarditis/Rheumatic Fever remains normal in size
prophylaxis LA would throw the problem to the lungs causing
Treatment of heart failure PND there is pulmonary arterial hypertension
o Decongest the heart with diuretics secondary that develops, producing right
o If kidney overload: induce diarrhea ventricular hypertrophy (backward failure)
Oral anticoagulation of AF in cases of atrial 2. Classic auscultatory changes (4)
fibrillation a. Exaggerated S1
Mitral valve replacements in severe types b. Opening snap pathognomonic of MS
c. Mid-diastolic rumbling murmur
IV. MITRAL VALVE PROLAPSE (MVP) d. Pre-systolic accentuation of mid-diastolic rumble
Lub-da-rrrrrrrr-rap mitral learns to rap

Heart is perfectly normal according to size and structure

Excellent natural history
Mitral valve is extra-large and usually the anteromedial
leaflet is affected
MV closes in a higher position and prolapses into the LA
Click murmur syndrome (lubb-click-dubb) 3. Right ventricular hypertrophy (RVH), giant atrium or
Heard more in left lateral decubitus position left atrium enlargement (LAE) with normal left
Associated with mid-systolic click - pathognomic of ventricle (LV)
MVP This is a result of backward failure
Most common symptoms: The only condition wherein LV will be preserved
o Palpitation
5P MEDICINE 2: Valvular Heart Disease 1
as to size and thickness because blood flow from
o Dyspnea on exertion LA to LV is decreased caused by the stenosis
o Panic attacks Burden lies on the LA resulting to LA enlargement
Treatment - reassurance
Barlows syndrome PEARL: Severe mitral stenosis can present as hemoptysis
due to rupture of bronchial arterial vessels due to
Most common manifestations:
pulmonary hypertension) in 2 10% of cases
o Frequent Palpitations most common
manifestation
o Dyspnea on exertion
o Panic attacks
LUTEMBACHER SYNDROME: MS + ASD
Especially among thin and tall females (9/10 of
S2 splitting and opening snap
cases)
Congenital lesion
Female: male ratio is 8:1
Treatment reassurance that the problem is benign
P age 5|6
 Treatment:
1. Rheumatic fever/infective endocarditis prophylaxis
2. Diuretics
3. Warfarin
4. Digitalis, Beta-blockers, Calcium Channel Blockers
Symptomatic patients with moderate-severe mitral
stenosis
1. Percutaneous mitral balloon valvuloplasty
2. Open or closed surgical commisurotomy
3. Mitral valve replacement

Richard Gorlin Formula for Mitral Valve Area

EF >40%- asymptomatic
EF<40%- symptomatic

The most important part when auscultating would be

the area that is in between the ears, coz you may have
the best stethoscope and still cannot interpret what
youre hearing

5P MEDICINE 2: Valvular Heart Disease 1

NOTETAKERS: GAMBOA | LEE

PROOFREADER: mmbp, egdg

Mini Quiz at the end of 6P

P age 6|6