1. Cardiac Exam

2. Arterial Pulses Paradoxus - tamponade, asthma Bisferiens - aortic insufficiency, HCM Alternans - severe LV dysfxn, bigemminy Parvus et Tardus - aortic stenosis Asymmetric - aortic dissection Diminished or absent - PAD, coarctation

3. Normal carotid upstroke

4. Pulsus parvus et tardus

5. Bisferiens Pulse

6. Venous Waveforms Giant A waves - RVH/PHTN, TS, PS Cannon A waves - AV dissociation, pacing Rapid X decent - tamponade Large V wave - severe TR, septal rupture Rapid X & Y - constrictive pericarditis and restrictive cardiomyopathy Slow Y decent – Tricuspid stenosis

7. Large V waves (Severe TR)

8. Giant A waves

9. Constrictive pericarditis

10. Exam maneuvers Recumbency - increases venous return Squatting - increases venous return Inspiration - increases venous return Standing - decreases venous return Valsalva - decreases venous return Hand Grip - increases afterload (BP) Amyl Nitrate - vasodilator, decreases BP increases cardiac output

11. Heart Sounds S1 - closing of mitral and tricuspid valves –Incr with short PR, MS, hyperdynamic LV S2 - closing of aortic and pulmonic valves –splitting S3 - increased early diastolic filling pressure –Can be normal in kids and athletes S4 - decrease ventricular compliance –Never normal, ie LVH, ischemia, AS

13. Splitting of S2 Physiologic split –Splits during inspiration Widened split –RBBB (Late P2), MR (early A2) Fixed split –ASD Paradoxic split (delayed A2) –LBBB, AS, HCM

14. Murmurs All murmurs get louder with increased flow (ie recumbency, squatting) and softer with decreased flow (ie valsalva, standing) except MVP and HCM Distinguish between MVP (louder) and HCM (softer) with sustained handgrip Right sided murmurs are louder during inspiration, left sided louder during expiration All diastolic murmurs are abnormal (echo)

16. Murmurs Systolic –Flow murmurs, AS, PS, MR, TR, VSD Diastolic –AI, PI, MS, TS Continuous –Patent ductus arteriosus

18. Murmurs with names Austin Flint –Late diastolic murmur in aortic insufficiency of jet causing vibration of anterior mitral valve leaflet or antero-apical wall Graham Steell –Early diastolic murmur of pulmonic insufficiency in the setting of pulmonary HTN Carey-Coombs –Mid-diastolic apical murmur of inflammation of the mitral leaflets in the carditis of rheumatic fever