Essentials of Bedside Cardiology: A Complete Course in Heart Sounds and Murmurs on CD

305 Pages·2003·7.39 MB·English

by  Jules Constant MD

Essentials of Bedside Cardiology
CONTEMPORARY CARDIOLOGY
CHRISTOPHER P. CANNON, MD
SERIES EDITOR
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Essentials of
Bedside Cardiology
WITH
A Complete Course
in Heart Sounds and Murmurs on CD
SECOND EDITION
Jules Constant,
MO, FACC
Clinical Associate Professor of Medicine
State University of New York at Buffalo School of Medicine
Buffalo, NY
*-
Humana Press Totowa, New Jersey
© 2003 Humana Press Inc.
Softcover reprint of the hardcover 1 st edition 2003
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10987654321
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Additional material to this book can be downloaded from http://extras.springer.com.
Constant, Jules, 1922-
Essentials of bedside cardiology: with a complete course in heart sounds and murmurs on CD 1
by Jules Constant.--2nd ed.
p. ; cm. --(Contemporary cardiology)
Rev. ed. of: Essentials of bedside cardiology for students and house staff. 1st ed. c1989.
Includes bibliographical references and index.
ISBN 978-1-4684-9754-0 ISBN 978-1-59259-338-5 (eBook)
DOI 10.1007/978-1-59259-338-5
I. Heart--Examination. 2. Heart--Diseases--Diagnosis. 3. Heart--Sounds. 4. Medical history taking. I.
Constant, Jules, 1922-Essentials of bedside cardiology for students and house staff. II. Title. III. Contem
porary cardiology (Totowa, N.J. : Unnumbered)
[DNLM: I. Heart Diseases--diagnosis. 2. Heart Sounds. 3. Physical Examination. WG 141 C757ea 2002]
RC683.C593 2002
616.1'2--dc21
2002190222
To Elizabeth my wife, without whom this book might
never have been published
Preface
Essentials of Bedside Cardiology, Second Edition, like the first edition,
is designed for those who wish to balance technological advances with increased
personal skill in history taking and physical examination.
It is important to teach physicians that all technologies now in use for
diagnosing cardiovascular disorders, such as echocardiography, can have false
positive and false negative results. It is not always wise to rely on these
technologies alone; indeed, they may not even be available in some settings.
Even when the full panoply of up-to-date techniques is at the physician's
disposal, the patient may not be a good candidate for an echocardiogram, or
the technician or reader may not be well qualified, or the equipment itself may
be substandard. Technology must be combined with physical examination to
decide what is true and what is false.
The practice of expert history taking and physical examination returns
the physician to the actual patient, where the physician can feel like a "real
doctor" rather than a mere interpreter of laboratory data.
Essentials of Bedside Cardiology, Second Edition, strives to teach and
not simply to tell the facts, relying on three basic methods derived from the
psychology of teaching and learning:
1. Explain the facts.
2. Use a question and answer format-the Socratic method.
3. Provide tricks or mnemonics to help the reader remember the facts.
The value of the Socratic method is its ability to focus attention and
stimulate thinking. The format of Essentials of Bedside Cardiology, Second
Edition, supports this goal by allowing the reader to cover up the answer and
so use the book as a programmed learning tool.
A demonstration of all the heart sounds and murmurs with detailed
explanations of what is being heard is provided on the enclosed CD. No
simulators have been used. In addition, the use of phonocardiograms and pulse
tracings for teaching is encouraged throughout the text.
vii
viii Preface
The index also is a learning tool, having been compiled by me, based on
40 years of teaching experience, with the goal of efficiently guiding the reader to
the information needed. The glossary, too, is designed for all levels of readers,
constituting a virtual encyclopedia of terms for the cardiologist, student, and
noncardiologist alike. Terms that are fully explained in the glossary are typeset
in boldface throughout the text as one more pedagogical aid.
Essentials of Bedside Cardiology, Second Edition, is the only book that
teaches how to recognize normal jugular waves using updated terminology,
how to measure jugular pressure accurately, how to record auscultation findings
with an auscultogram, how to tell cardiac function by the blood pressure cuff
and Val salva method, how to diagnose cardiomegaly on an X -ray without using
the outdated cardiothoracic ratio, and how to tell whether the apex beat is due
to the right or left ventricle. It also gives the latest explanation for the changing
loudness of the first heart sound with changing P-R intervals and updates
methods for recording and taking an accurate blood pressure.
lules Constant,
MD, FACC
Contents
Preface ........................................................................................ vii
A Complete Course in Heart Sounds
and Murmurs on CD ...................................... Inside Back Cover
1 THE CHECKLIST IN HISTORY TAKING ................................................ 1
Advantages of a Checklist 1
Reminder List History 2
Etiologies 3
Follow-Up Questions 7
New York Heart Association Functional and Therapeutic Classification 14
2 CARDIAC CWES FROM PHYSICAL ApPEARANCE .......................•......•.. 17
Skin 17
Congenital and Acquired Facies 20
Eyes 22
Edema 25
Extremities 26
Chest and Respiration 27
3 ARTERIAL PULSES AND PRESSURES .................................................. 29
Method of Arm Palpation 29
Rates of Rise and Pulse Volume 30
Pulsus Bisferiens 37
Palpation of the Leg Pulses 38
Estimating Systolic Blood Pressure by Palpation Alone 39
Accurate Blood Pressure Measurement 40
Korotkoff Sounds 41
Chest Piece Placement and Choice 42
Equipment Sources of Error 43
Systolic Pressure Measurement 44
Diastolic Blood Pressure Recording 45
Accuracy of Blood Pressure Recording 46
ix
x Contents
Summary of How to Take Ann Blood Pressures by Listening for Korotkoff Sounds 48
Pseudohypertension 49
Pulsus Alternans 49
Blood Pressure and Pulses in the Legs 51
Pulsus Paradoxus 55
Capillary Pulsation 58
Abdominal Aortic Aneurysm (AAA) 58
How to Tell Cardiac Function by Blood Pressure Response to a Valsalva Maneuver 58
4 JUGULAR PRESSURE AND PULSATIONS ............................................. 63
Venous Pressure by Jugular Inspection 63
How to Use the Internal Jugulars as a Manometer 65
Method of Obtaining an Accurate Measurement of Venous Pressure 66
How to Tell Jugular from Carotid Pulsations 68
The Abdominal Compression Test (Hepatojugular Reflux) 70
Jugular Pulse Contours 73
5 INSPECTION AND PALPATION OF THE CHEST ..................................... 89
Ventricular Enlargement from Examination of the Chest 89
Cardiac Dilatation Signs in the Left Lateral Decubitis Position 94
Right Ventricular Enlargement 96
Left-Sided Causes of Left Parasternal Movement 99
X-ray Evaluation of Cardiac Size 101
Diagnosis of Ventricular Hypertrophy by Physical Examination of the Precordium 103
6 THE STETHOSCOPE ................................................................... 111
The Bell Chest Piece III
The Smooth Diaphragm 113
The Tubing 114
Air Leaks and Ear Tips 115
Summary of Good Stethoscope Characteristics 116
7 DIAGRAMMING AND GRADING HEART SOUNDS AND MURMURS ....... 117
The Auscultogram 117
Grading of Heart Sounds and Murmurs 119
8 THE FIRST HEART SOUND (S) .................................................. 121
Physiology of the First Sound Components 121
The Ml Plus Aortic Ejection Sound as the Cause of a Split Sl 123
The Pulmonary Ejection Sound 125
Loudness of the M, 129
Contents xi
9 THE SECOND HEART SOUND (S) .............................................. 133
Physiology and Nomenclature for the S2 133
Explanation of Normal Splitting Sequence of S, J3 4
Physiology of the Normally Moving Split 136 .
Loudness of the Components of S2 137
The Widely Split S2 143
The A2-P2 in Pulmonary Stenosis 144
ASDs with Narrow Splits 146
Differential Diagnosis of the Fixed Split 147
The Narrowly Split S2 148
The S2 Split in Pulmonary Hypertension 149
The Reversed or Paradoxically Split S2 150
laTHE OPENING SNAP ................................................................ 155
Mechanism and Timing 155
Relation Between the 2-0S Interval and the Severity of Mitral Stenosis 156
The Loudness of the Opening Snap 159
How to Tell an A2-P2 from an A2-OS 160
11 THE THIRD HEART SOUND (S) ................................................. 163
Nomenclature 163
Timing 163
Mechanism of Production 165
The Physiological S3 166
Loudness of the S, 167
The Exaggerated Physiological S, 169
The Pathological S, 170 .
The Physiological Versus the Pathological S,170
The Right Versus the Left Ventricular Sl 17i
The S3 Versus the Opening Snap 172
12 THE FOURTH HEART SOUND (S4) .............................................. 175
Nomenclature 175
Mode of Production 175
Recognizing the Rhythm of the S4 Gallop 177
The Physiological S4 177
The Pathological S 4 178
Loudness and Audibility of the S 180
4
Differentiation of the S4 from the S3 181
Differentiation of an S4-S1 from a Split Sl (M1-A1 or M1-T1) 182
Severity of Cardiac Dysfunction and Presence of an S4 183
The S4-S1 Interval and Severity of Dysfunction 184
Summation and Augmented Gallops 184
The Pacemaker S4-Like Click 186