Three Brothers Plus One Book VI Medical/Surgical

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Size: 6x9. Buy This Book E-Book. The absence of a click in patients with prosthetic valves may indicate valve failure! Sounds produced by the turbulent flow of blood within the heart ; are known as murmurs. They are described based on the location and radiation of the murmur , timing, intensity, configuration, frequency, and response to maneuvers. Murmurs can be classified as either functional or pathological.

Functional murmur physiological or innocent. A mid- systolic murmur in an asymptomatic individual is most likely physiological! Unlike systolic murmurs , diastolic murmurs are almost always pathological! Diastolic murmurs may require that certain maneuvers be performed to make them more apparent.

The intensity refers to the loudness of the murmur on auscultation grades I—VI. While most murmurs of grade III and above are pathological, the intensity of a murmur does not always correlate to the severity of the underlying lesion! For example, a larger VSD produces a softer murmur than a small VSD and a murmur of severe aortic stenosis may disappear if a patient develops left heart failure!

All diastolic murmurs and any systolic murmurs of grade II and above require further echocardiographic evaluation! The configuration of a murmur describes the change in intensity of the murmur.

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A murmur may be auscultated at a site that does not lie directly over the heart. Certain maneuvers may be performed to elicit a change in the intensity of a murmur. Hand grip. References: [11] [12]. Clinical science Cardiovascular examination is a central tool for assessing the cardiovascular system.

History Dyspnea Chest pain Palpitations Syncope Hemoptysis Edema General examination Appearance Level of consciousness altered mental status Skin and mucous membrane color changes, temperature, dehydration Central cyanosis see features of congenital heart defects and congestive heart failure Pallor e. Approach The patient should be in supine position , torso elevated to 45 degrees, and the head extended backward and turned to the left the neck veins should not be visible and collapse in this position.

Identify the venous pulsation of the internal jugular vein. Determine the height of the internal jugular venous filling pressure. The hepatojugular reflux may be tested if the JVP cannot be visualized properly. Signs of elevated jugular venous pressure Jugular venous distention Hepatojugular reflux Conditions associated with elevated JVP : e.

Approach The patient should be sitting for several minutes before measuring blood pressure. Use correct cuff size. Record the pressure in both arms and legs and note any differences.

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Determine the systolic and diastolic blood pressure value. Repeat measurement. Ambulatory blood pressure measurement 24 hours may be helpful in establishing the average and peak blood pressure values during daily activities. Approach Three finger method: palpation with 2 nd —4 th fingertips Palpation of the common carotid artery , radial artery , abdominal aorta , femoral artery , popliteal artery , tibialis posterior artery , and dorsalis pedis artery.

Arterial hypertension Low-tension pulse : The vessel wall is either soft or not palpable between beats and is easily compressible. Low blood pressure Systemic vasodilatation e. Approach The patient is initially requested to remove their upper body attire to identify: Scars e. Apex impulse The apex impulse apex beat is the outermost and lowermost cardiac impulse on the chest wall that is definitely palpable.

The examiner places their flat hand on the cardiac apex to locate the apex beat; it is further localized and assessed by palpating with 2—3 fingers. Other impulses Parasternal heave : a heaving motion felt over the left parasternal area palpate with right hand and straightened elbow Suggests RV hypertrophy e. Approach Performed in the supine position with slight elevation of the torso Politely ask the patient to refrain from speaking while the heart sounds are being assessed.

The pulse should be simultaneously palpated during auscultation mainly the radial artery. If heart sounds are weakly audible, request that the patient holds their breath for a moment after expiration respiratory rest position. Assess the following: Location, timing, changes in intensity, and splitting of heart sounds Abnormal heart sounds Murmurs. Location and timing The first S1 and second S2 heart sounds are physiological sounds that are heard in all healthy individuals.

The third S3 and fourth S4 heart sounds may be physiological particularly in young adults, pregnant women, and the elderly or indicate an underlying pathology. Heart sound Origin Timing Occurrence Primary heart sounds 1st heart sound S1 Closure of the mitral valve and tricuspid valve Best heard in the 5 th left intercostal space in the midclavicular line cardiac apex Onset of systole Heard just before the carotid pulsation is felt Always 2nd heart sound S2 Closure of the aortic and pulmonary valve Two components: A2 : closure of the aortic valve louder P2 : closure of the pulmonary valve softer Best heard in the aortic region A2 and pulmonary region P2 Transition from systole to diastole Heard immediately after the carotid pulsation Always See splitting of S2 below.

Extra heart sounds gallops 3rd heart sound S3 Ventricular filling sound Rapid ventricular filling Sudden deceleration of blood when the ventricle reaches its elastic limit.

Three Brothers Plus One Book VI Medical/Surgical

Splitting of heart sounds If the aortic and pulmonary valves do not close simultaneously, an apparent splitting of S2 can be heard upon auscultation. Description Cause Splitting of S2 Physiological split During inspiration : The sound of aortic valve closure A2 precedes the sound of pulmonary valve closure P2. The split is especially pronounced among young individuals.

Wide split An exaggerated physiological split, i. Ejection sounds Clicks Clicks are crisp sounds produced by the movement of abnormal valves. Mechanism Timing Technique of auscultation Aortic ejection click Opening of a stiff aortic valve in aortic stenosis Early- systolic sound immediately after S1 Best heard with the diaphragm of a stethoscope at the aortic region with the patient seated and leaning forward Mitral valve opening snap Opening of a stiff mitral valve in mitral stenosis Early- diastolic sound immediately after S2 Best heard with the bell of a stethoscope at the mitral region with the patient in a left lateral position Mitral valve prolapse click Mitral valve prolapse into the left atria during systole Midsystolic sound Best heard with the diaphragm of a stethoscope at the mitral region with the patient in left lateral position Mechanical valve clicks S1 and S2 sounds that are produced by prosthetic valves sound like clicks.

Appropriate see S1 and S2 above With the diaphragm of a stethoscope The presence of an aortic ejection click can be used to differentiate a pathological systolic murmur of aortic stenosis from a flow murmur! Other abnormal heart sounds See pericardial friction rub.

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See pericardial knock. Auscultatory locations Region Site at which a murmur is heard best Pathology Erb's point cardiology 3 rd left parasternal intercostal space Diastolic murmurs : aortic regurgitation , pulmonic regurgitation Systolic murmurs : HCOM Aortic region 2 nd right parasternal intercostal space Aortic stenosis Aortic regurgitation Coarctation of the aorta Pulmonary region 2 nd left parasternal intercostal space Pulmonary stenosis Pulmonary regurgitation ASD Mitral region 5 th left intercostal space in the midclavicular line Mitral stenosis Mitral regurgitation Mitral valve prolapse Tricuspid region 4 th left parasternal intercostal space Tricuspid stenosis Tricuspid regurgitation Gibson's point Left infraclavicular region Continuous murmur of a PDA is heard best at this point.

Intensity The intensity refers to the loudness of the murmur on auscultation grades I—VI. Manny, Diego and the rest of the gang must rescue Sid from an underground world after Sid steals some dinosaur eggs. Nickelodeon Sun. Manny, Sid and Diego reunite to warn their friends about the danger to their homes posed by swiftly melting ice. Icebox Anthony Gonzalez, Omar Leyva. A Denver man tracks down the Florida woman who stole his identity, financed a luxurious lifestyle, and destroyed his credit. FXX Wed. Members of a dysfunctional family react differently to the suicide of the eldest son.

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