CLINICAL INTRODUCTORY

COURSE- WEEK2
Rawan Sami

THIS IS A NOTE FOR MCLEOD BUT EVERY THING FROM ANY OTHER SOURCE OR AT
WHICH THE BOOK IS NOT REALLY HELPFUL IS MENTIONED RIGHT HERE!

GOOD LUCK 

MAY THE LORD BLESS YOUR SOULS WITH PASSION

I’ll mention here which figures or paragraphs we can to omit from McLeod 13

Page102 Figure 6.4

Page 103 Figure 6.6

Page 104 Figure 6.7, 6.8

Page106 Figure 6.10,6.11

Page 110 Figure 6.12

Page 114-116 JVP ( I WROTE IT DOWN HERE )

Page 117-126 Heart Sounds and murmurs (THRY”RE RIGHT DOWN

HERE WAITING FOR US!)
Page 129-130 Carotid artery and vertebrobasilar territories
Page 131 Figure 6.38
Page 133 Figure6.40
 HEART SOUNDS

S1- The pressure applied against at closure of tricuspid and mitral valves-LUB (onset of ventricular systole)

S2- The pressure applied against closure of pulmonary and aortic valves- DUB It is best heard at left sternal edge
(end of ventricular systole)

S3- rapid ventricular filling after opening of atrioventricular valves (mitral and tricuspid) - early diastolic seen in
young adults and pregnancy. Hear with bell on the apex

S4- ALWAYS PATHOLOGICAL – due to forceful atrial contraction against stiff ventricle in left ventricle hypertrophy
(due to hypertrophic cardiomyopathy or hypertension for instance)

ABNORMALITIES
S1
Quiet
Rheumatic mitral regurgitation
Decreased cardiac output

Loud
Increased cardiac output
Large stroke volume
Mitral stenosis( due to increased atrial pressure )
Atrial myxoma (rare)

Variable
Atrial fibrillation
Extrasystoles
Complete heart block
S2
THE IDEA OF SPLITTING

Left ventricle contracts just a bit before right so aortic valve closes before pulmonary. At end-inspiration venous
filling increases at the right which delays the pulmonary valve closure even more. This does not happen in
expiration

Heard at the left sternal edge

Inspiration – lub/d/dub

Expiration- lub/dub
Occurs in RV BBB

Pulmonary stenosis

Pulmonary HTN

VSD

Quiet Aortic regurgitation

Loud Pulmonary/Systemic Hypertension

In reversed splitting the pulmonary closure comes before aortic and occurs during expiration

These conditions are met when left ventricular emptying is delayed ex:

 LV BBB
 RV pacing
 Aortic stenosis

 HOCM

In a specific case _ASD: atrial septal defect- the splitting is FIXED (i.e. in inspiration and expiration)

S3
After the age of 40: early sign of mitral regurge due to volume loading of the ventricle

S3v with tachycardia gives us a GALLOP (note that S4 also can cause a gallop but either sounds without tachycardia
is not considered a gallop)

ADDED SOUNDS
 Click syndrome – mitral prolapse and regurge

 Mitralization - A straightening of the left heart border in a chest x-ray

because of increased prominence of the convexity formed by the main
pulmonary artery and its left main branch or the left atrial appendage or both.
Mechanical valve sounds

High-pitched
Metallic
S1- mitral valve replacement
S2- aortic valve replacement

Opening snap-

Mitral stenosis (heard by diaphragm)

Diastole

Pericardial rub

Systolic and diastolic

Heard best by diaphragm at holding

of breath
Acute viral pericarditis 24-72 hours
post-MI

Ejection Clicks –
Mid-systolic mitral valve prolapse
Late systolic murmurs (heard by
diaphragm)
High-pitched
Heard at apex

Murmurs :
Heart murmurs are produced by turbulent flow across an abnormal valve, septal defect or outflow obstruction.
‘Innocent’ murmurs caused by increased volume or velocity of flow through a normal valve occur when stroke volume is increased

ex:
 During pregnancy
 In athletes with resting bradycardia
 Children with fever
Systole Diastole
Atrial contraction Early: Closure of pulmonary and aortic valves till the
opening of mitral and tricuspid valves
Mitral and tricuspid valve closed Mid: ventricular filling(Pressure in atria>ventricles)
Cause aortic and pulmonary valves open Presystolic: atrial systole
Ends with closure of aortic and pulmonary valves
NOW WHY THIS IS IMPORTANT???

1) Knowing that mitral and tricuspid valves are closed during systole= means that a failure to close either
results in systolic murmur
This failure to close is REGURGE
SYSTOLIC MURMURS
Mitral regurge
Tricuspid regurge

2) As aortic and pulmonary valves open during a systole : narrowing of the valves and failure to open results
also in systolic murmur
This failure to open is STENOSIS

SYSTOLIC MURMURS
Aortic Stenosis
Pulmonary Stenosis

3) In Early diastolic pulmonary and aortic valves close .The failure of which would cause a regurge

4) In mid diastole ,the mitral and tricuspid valves are supposed to be open If not , which is the case in mitral
and tricuspid stenosis, we’d hear a murmur

Systolic murmur Pansystolic(all Early Diastolic Mid-diastolic Murmur Continuous

through the Murmur ( loudest at murmur
systole) the early diastole but
lasts all through)
Caused by Mitral Aortic Regurge Mitral Rare in adult
increased systolic regurge(loud Stenosis(Rumbling)
volume and blowing) Remember ; MITRAL
STENOSIS CAUSES
MALAR RASH)
Aortic ( harsh, Tricuspid Graham-Steell Lup S1 PDA- connection
high-pitched, Regurge murmur( pulmonary Tata S2 between upper
audible all over) regurge due to Rru S3 descending aorta
or pulmonary dilatation of and pulmonary
stenosis pulmonary artery in artery that is
case of pulmonary obliterated after
HTN) birth
HOCM ,ASD VSD Austin-Flint( Machinery-like
accompanies aortic
regurge due striking of
anterior mitral leaflet
which restricts inflow
of LV)
NOTE: MITRAL PROLAPSE CAUSES MID_SYSTOLIC MURMUR
EXAMINATION SEQUENCE:

1) Timing
Palpate the patient’s carotid pulse while listening – if the murmur is too far from the pulse it is diastolic

2) Duration
There are some murmurs that are pansystolic- last all through the systole (mitral and tricuspid regurge)
while others just start at a certain point (mid diastolic-mitral stenosis and late systolic mitral prolapse
murmurs)

3) Character and Pitch

High-pitched Low-ptched
Aortic regurge Mitral stenosis
S2 S1
S3,S4

Low pitch sounds are heard with BELL

4) Intensity

GRADIND MURMURS
Grade 1 Heard by an expert in optimum conditions
Grade 2 Heard by a non-expert in optimum conditions
Grade 3 easily heard; no thrill
Grade 4 A loud murmur, with a thrill
Grade 5 Very loud, often heard over wide area, with thrill
Grade 6 extremely loud, heard without stethoscope

5) Location – more helpful in diastolic murmurs

MURMUR BEST HEARD AT
Mitral regurgitation Left axilla (radiation)
Mitral Stenosis Apex
Pulmonary murmurs Upper left sternal edge
Aortic Stenosis Upper right sternal edge
Aortic and Tricuspid Regurgitation Lower left sternal edge

6) Radiation

JVP- JUGULAR VENOUS PRESSURE

 JVP = Central venous pressure = Rt atrial pressure
 JVP is normally less than 7 mmHg/ 9 cm H2O
 The sternal angle is 5 cm above the right atrium so the
normal JVP should be no more than 4 cm above this
angle when the 450
 EXAMINATION SEQUENCE:

Position the patient starting at 45o

Rest the patient head on a pillow

Head slightly tilted to the left

Measure
Measure height
heightof ofJVP:
JVP:
the
the JVP
JVP isis the
the vertical
vertical
height
heightinin centimeters
centimeters
 Identify the wavy pulsations: between
between the the top
top of
of
venous
venous pulsation
pulsation and and
Diffuse Inward movement the
the sternal
sternalangle
angle (+5cm
(+5cm
water)
water)
Two waves per pulse

 By palpation:

Impalpable

Disappears with compression at root of neck

Rises with abdominal pressure

 Special maneuvers:

Varies with respiration

Varies with patient position

 The JVP level reflects right atrial pressure (normally<7 mmHg/9 cmH2O). The sternal angle is
approximately5 cm above the right atrium, so the JVP in health should be ≤4 cm above this angle when
the patient lies at 45°. If right atrial pressure is low, the patient may have to lie flat for the JVP to be
seen; if high, the patient may need to sit upright

 Right jugular veins extend in an almost straight line to superior vena cava, thus favoring transmission of
the hemodynamic changes from the right atrium .
Elevated JVP:
-Fluid overload

The single most important sign of fluid overload

-In HF, Right ventricular dilatation (acute PE & COPD)

-SVC obstruction: nonpalsatile & it no longer reflects Right atrial pressure, abdominojugular reflex:
negative

Kussmaul Sign: paradoxical rise in JVP on inspiration- cardiac temponade-constrictive pericarditis –

RCM(restrictive cardiomyopathy)

JVP WAVEFORM
 a’ wave: Right atrial contraction, just before s1

 ‘v’ wave: atrial filling during ventricular systole (

tricuspid valve is closed )= peak pressure in right atrium
immediately before opening of tricuspid .

 ‘c’ wave: rare 3rd peak :closure of the tricuspid valve

 A-x descent: downward displacement of the

tricuspid ring during systole
 V-y descent at commencement of ventricular filling
Abnormalities of the jugular venous pulse

Condition Abnormalities

Heart failure Elevation, sustained abdominojugular reflux more than 10 seconds

Pulmonary embolism Elevation

Pericardial effusion Elevation, flattened y (impeded right atrium emptying and ventricular filling)

Pericardial constriction Elevation, Küssmaul's sign

Superior vena caval obstruction Elevation, loss of pulsation

Atrial fibrillation Absent 'a' waves( no atrial contraction)

Tricuspid stenosis Giant 'a' waves ( atrial contraction over a narrowed valve)

Tricuspid regurgitation Giant 'v' waves aka cv wave( if liver is pulsatile-NOT REALLY IMPORTANT TO KNOW
FOR THE TIME BEING)

Complete heart block Irregular Cannon' a waves ( atrial contraction against a closed valve)
IF THE RADIAL ARTERY IS NOT
COMPRESSIBLE : WE SHALL THINK ABOUT
ATHEROSCLEROSIS
 Abnormal character

:::: PULSES ::::

Collapsing pulse: rapid fall..the

peak arrives early followed by rapid
descend

Slow rising pulse: gradual upstroke

with a reduced peak occurring late in
systole – aortic stenosis

Bisferiens pulse: two systolic peaks

separated by midsystolic dip (concomitant
aortic stenosis & regurge, & HOCM)

Alternans pulse: beat to beat

variation in pulse volume with a normal
rhythm.
It occurs in advanced systolic heart failure
and aortic insufficiency

 BiGEMINUS Pulse:
Regular alteration of pulse amplitude due
to premature ventricular contraction that
follows regular beat- AV BLOCK

Frank Starling law

(Higher End-diastolic volume>> more
REGARDING BP
Keep in mind that we have plenty of guidelines. According to the doctor, JNC 7 is the most recent while
we still have a new guideline on the way JUST HAVE A LOOK
RESPIRATORY RATE RANGES

DONE
DON’T FORGET TO REFER TO THE VIDEOS FOR PHHYSICAL EXAMINATION