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The Big Heart Disease Lie

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Abdominal angina, 276 Abdominal aortic aneurysm, 58 Abdominal compression test, 71-73

hepatojugular reflux, 70-73 Abdominal murmurs, 265-266 Acrocyanosis, 279

Stokes-Adams attack. Akinetic areas, definition and S4, 179 Amyl nitrate administration method 224 in AS vs MR and HOCM, 205 cardiovascular effects, 224 mitral stenosis murmur effects, 248 murmur differential diagnosis, 224 Amyloid disease, skin signs, 19

history in, 6 Anemia, 5

symptoms and flow murmur in, 195 Anacrotic shoulder, 30 Aneroid manometer, 43 Aneurysm, 267

apex beat in, and S3, 105 dissecting and mycotic, 267 ventricular, 267 and parasternal movement, 99 Angina abdominal, 207 equivalent, 8

history taking and differential diagnosis, 11-13

NY Heart Association classification 14, 15

Prinzmetal's, 12 vasospastic, 12 Angioid streaks, 25

Angle of Louis, 65, 279 Ankylosing spondylitis and AR, 254 Anomalous pulmonary venous connection, 267

Annular calcium and MR, 216 Aortic area, 201

Aortic-coronary bypass murmur, 211 Aortic ejection sound , 124 and aortic stenosis, 124, 125 and bicuspid aortic valve, 125 and valvular abnormalities, 123 Aortic isthmus, 273 A2P2vs 20S, 160

and split S1, 123-125 Aortic regurgitation. See also Regurgitation, aortic bicuspid valve in, 125 bisferiens pulse in, 37 bounding pulse in, 35, 36 causes of, 254, 255 Corrigan's pulse in, 36 diastolic pressure, 35 and dissection , 254 and Durozier's murmur, 36 and Hill's sign, 53 and left ventricular impulse in, 105 leg blood pressure in, 53, 55 luetic and ostial stenosis, 23 murmurs,

Austin Flint, 249-51 Cole-Cecil, 257 dove-coo, 257 loudness of 256, 257 maneuvers to increase, 256 musical, 257 pitch and quality, 256

right sided, 256 shape and timing, 255 site of, 257 vs venous hum, 240 pistol-shot sounds, 36 Quincke's sign, 58 Traube's sign, 36 S2 features, 141 sudden and severe onset, 141 water-hammer pulse in, 36 Aortic sclerosis flow murmur, 199, 200 Aortic stenosis aortic ejection sound in, 124, 125 auscultatory clues for diagnosis of severity, 202, 203 A2 loudness in, 141 arterial pulse in, 31, 32 bisferiens 37 calcific, 99

and carotid murmurs, 31, 188 chordae rupture imitating, 221 and S4, 183

discrete subvalvular aortic stenosis, 206 ejection sound in, 125 gradient peak site, 188 history in, 3

and hypertrophic obstructive cardiomyopathy murmurs in, 204

differentiation from aortic stenosis and pulmonary stenosis, 203209

loudness and site, 201, 202 shape, duration, and quality, 200, 201

supravalvular murmurs, 206 Aortic valve bicuspid calcification of, 125 ejection sound, 123 incidence of, 254 fenestration of, 237 rupture of, 257 sclerosis of, 188 Apex beat in aortic regurgitation, 105 and A wave, 105

chest position for finding, 91 definition of, 89 left ventricular apex beat, 89 in left ventricular hypertrophy, 104, 105 normal site, 93 palpability of, 91, 92 in pericardial absence, 105 vs PMI, 89-90 sustained, 104 Arcus, 23

Argyll Robertson pupil, 23 Arrhythmia, differential diagnosis, 13 Arteriosclerosis, 268

aortic stenosis pulse rate of rise in, 30 definition, 268 retinal signs, 24 arterial flow murmurs carotid murmur, 210 in coarctation, 210 in hyperthyroidism, 210 nomenclature of, 210 supraclavicular vs valvular murmur, 109, 210 Arterial-venous fistula, 233, 265 Arthritis and aortic regurgitation, 254 Ascites, diagnosis of, 25 ASD. See Atrial septal defect Atrial fibrillation (AF), jugular pulse contours, 87, 88 Atrial gallop, 175 Atrial myxoma clinical signs in, 268 definition, 268 giant A wave in, 82 history in, 6

vs tricuspid stenosis, 253 Atrial septal defect (ASD) and absent murmur in 196 and anterior chest bulge, 27 chest palpation for right ventricular enlargement, 97, 99 and diastolic flow murmur, 195, 253 in Down's syndrome in Epstein's anomaly, 274 gradient through defect, 196 hemodynamics of , 268 Holt-Oram syndrome, 27

jugular pulse contours in, 84 and prolapsed mitral valve, 226 and rubella, 6

post Valsalva effect in, 147 primum defect, 269-70 S2 features, 141 and sinus venous defect, 270 skeletal abnormalities in, 27 and tricuspid opening snap, 162 Atrioventricular block, 271 capillary pulsation in, 58 and mitral diastolic inflow murmur, 252 S1in, 129, 131 S4 features, 184, 185 syncope in, 7 Atrioventricular dissociation, 271 and cannon waves, 83 and P-R interval, 131, 132 S1 changing in, 129, 131 Auscultatory gap, Auscultogram, 117-119 Austin Flint murmur, 249-250 vs mitral stenosis murmur, 252 presystolic accentuation in, 251 A wave. See Jugular wave contours; Apex beat

Barlow's syndrome. See Prolapsed mitral valve syndrome Bell chest piece. See Stethoscope Beriberi, 20, 271 Bernoulli effect, definition, 272 Bicuspid aortic valve and aortic ejection sound, 125. See also Aortic valve, bicuspid Bisferiens pulse, 37 Blood pressure accuracy of recording, 46-49I arm differences, 40 circadian rhythm, 46 cuff size, 43

diastolic blood pressure measurement, 45 Doppler methods, for, 45, 53 equipment error sources, 43 inflation rates and degree, 41, 47, 48 inspiratory fall of 56-57

in leg and aortic regurgitation, 53, 55 in coarctation of the aorta, 53-55 comparison with arms, 51, 52 infant measurement of, 53 method of measurement, 52, 53 normal levels, 40 by palpation, 39, 42 and pulsus alternans, 50 pulsus paradoxus, 55, 56 recording methods to the nearest 5 or 0, 46

and stethoscope pressure, 42 systolic blood pressure errors in measurement, 44, 45 estimation by palpation, 39, 40 Valsalva maneuver response, 58-61 Bounding pulse, 35 Breath holding time, 27, 277 Brockenbrough effect, 34 Bronchopulmonary anastomoses and continuous murmurs, 240 Bruit vs murmur, 210

Cannon waves, 82, 83 Capillary pulsations, 58 Carcinoid, 272 history in, 6 skin signs, 19, 20 Cardiomyopathy, 272 Cardiorespiratory murmur, 210 Cardiothoracic (C/T) ratio vs height and weight, 101, 102 Cardiovocal syndrome, 7 Carey Coombs murmur, 253 Carotid pulse vs jugular pulsations, 68, 69, 80, 81 rates of rise anacrotic shoulder, 30 in aortic stenosis, 31, 32 normal, 30

rapid rise with increased pulse pressure, 35, 36 rapid rise with normal pulse pressure, 32, 34

Carvallo's sign, 229

Cataract and rubella, 23 Chagas' disease, 6 Checklist, advantages of Chest X-ray, cardiac size estimation, 101, 102

Chest pain, differential diagnosis, 11-13 Chest palpation, and A wave, 107

for dilatation in left lateral position, 9496

for left parasternal movement, 99, 100 for thrills, 120

for ventricular enlargement. See Apex beat for right ventricular enlargement, 9699

Cheyne-Stokes respiration, 272 Chordae, 221 rupture of and aortic stenosis imitation, 221 causes of, 223 floppy valve syndrome, 223 murmurs and S4in, 221, 222 Chordal snap theory, 226 Chorea, 3

Circulation time, 273

Clicks, causes of, 226, 227 vs ejection sound, 122 Clubbing, 273

in atrial myxoma, 268 and cyanosis, 17, 18 without cyanosis, 273 differential diagnosis of, 18, 19 in endocarditis, 18 Coarctation, 273

with aortic regurgitation and bicuspid valve, 55 arterial flow murmurs in, 210 and continuous murmurs, 240 infantile and preductal, 273 leg pulses and blood pressure, 53-55 and radial-femoral lag, 54, 55 Turner's syndrome, 27, 28, 282 Cole-Cecil murmur, 257 Collagen disease symptoms, 5 Complete A-V block. See Atrioventricular block

Compliance, 273

Congenital heart disease, history in, 6, 7 Constrictive pericarditis. See also Friction rubs and atrial retraction, 98, 99 definition, 273, 274 edema vs dyspnea in, 10 effusive-constrictive, 57, 281 jugular pulse contours in, 84, 87 Kussmaul's sign, 73 pulsus paradoxus in, 55 S4 absence in, 179 Continuous murmurs, 235-240 in AV fistulas, 235, 240 bronchopulmonary, 240 causes of 235, 236, 240 in coarctation, 210, 240 definitions of, 214, 234 mammary souffle, 240, 241 persistent ductus, 236-238 in pulmonary atresia, 240 and venous hum, 238-240 Corneal arcus, 22, 23 Cor pulmonale, 275

history in, 4, 5 Corrigan's pulse, 36I Crackles and lung diagnosis, 28 Cryoglobulinemia and livido reticularis, 19 Cushing's syndrome, 13 Cyanosis in carcinoid 19, 272 central vs peripheral, 17 and clubbing, 17, 18 differential, 18, 19 in Ebstein's 2741, in transposition, 7, 282 and viscosity, 188

DaCosta's syndrome, skin signs in, 20. See also Neurocirculatory asthenia DeMusset's sign, 21 Dextrocardia and levocardia, 276 Diastolic blood pressure. See Blood pressure

Diastolic murmurs. See specific murmurs Dicrotic wave, 38 Digitalis side effects, 2

Dilated cardiomyopathy, 272 Dissection, 12, 254 Diuretics, side effects of, 2 Dizziness, etiologies of, 10 Dove-coo murmur, 257 Down syndrome, 20, 21

hand signs in, 27 Dressler's syndrome, 278. See also

Postmyocardial infarction syndrome Drop attacks, 11 Duroziez' double murmur, 36 Dyskinetic area and S4, 179 Dyspnea, differential diagnosis of, 7, 8

Earlobe crease, 21 Ebstein's anomaly, 274

ASD, cyanosis, and tricuspid regurgitation in, 274 sail sound in, 131 split S1 in, 123

and tricuspid opening snap, 162 and tricuspid regurgitation, 230 Eccentric hypertrophy, 103 Eddy sounds and persistent ductus, 237 Edema, differential diagnosis of, 9, 10 noncardiac causes in leg, 25 slow vs fast, 25 Effort syndrome, 277 Effusive-constrictive pericarditis, 57, 281 Ehlers-Danlos sclera, 25 Eisenmenger's complex definition, 232 Eisenmenger syndrome, definition 232, 274 differential cyanosis, 18, 19 ejection sound in. 128 onset age, 283 S2 features in, 150 Ejection fraction, 274

normal, 59 Ejection murmur. See also Aortic and Pulmonary stenosis definition, 188, 191 loudness crescendo-decrescendo, 189, 191 factors affecting, 192 and gradient, 192

long diastole effects, 190 phonocardiogram, characteristics, 188 pitch characteristics of soft murmurs, 190 flow murmurs in arteries, 209, 211 types of, 193 Ejection sounds aortic, 123-125 causes of, 123 vs click, 122

in pulmonary idiopathic dilatation, 128 in pulmonary hypertension, 128 in pulmonary stenosis, 125-127 Endocarditis. See Infective endocarditis Enlargement vs hypertrophy, 89, 103 Epilepsy vs cardiac syncope, 10, 11 Ewart's sign, 28 Exophthalmos, 23

Extremities, cardiac clues from, 26, 27 Eyes, cardiac clues from, 22-25

Fallot's tetralogy. See Tetralogy of Fallot Facies, cardiac clues from, 20-22 Femoral pulse in coarctation of the aorta, 55 Fenestrations of semilunar valves, 254 Fetal circulation, 277 Filling pressure, definition, 275

and ejection fraction, 171 First heart sound. See S1 Fixed output symptoms, 3 Fixed splitting. See Atrial septal defect Floppy valve syndrome, 225

vs prolapsed valve, 225 Flow murmurs in arteries, 209, 211 causes of, 252 vs mitral stenosis, 252 tricuspid, 253 in VSD, 235 Friction rubs, 242-244

in Dressler's syndrome, 263 and pleuralpericardial rub, 262

Gallop atrial. See S4 augmented, 185

definition, 163 double, 182 summation, 185 Gallavardin phenomenon, 200 Gibson murmur, 236 Gradient, definition, 275

and pitch, 217 Grading heart sounds and murmurs, 117-120 Graham Steell murmur, 258 Growing pains, 3

Heart sounds. See Opening snap; S1; S2; S3:

Height and weight tables, 102 Hemic murmur, 195 Hemochromatosis, skin signs in, 19 Hepatojugular reflux. See Abdominal compression test Hereditary hemorrhagic telangiectasia, 7 High output failure symptoms, 4 Hill's sign, 53

Hoarseness from the heart, 7 HOCM. See Hypertrophic obstructive cardiomyopathy Hollenhorst plaques, 24 Hold-Oram syndrome, 27 Hypertelorism, 20, 275

with pulmonary stenosis and ASD, 275 and Turner's syndrome, 282 Hypertension pulmonary

A wave in, 82 ejection sound in, 128 history in, 79 hyperkinetic and S3, 159 obstructive, 149 and orthopneia, 9 and parasternal impulse, 109 primary, 141, 279 split S1in, 141, 279 split S2 in, 144 vasoactive, 141 systemic, aortic regurgitation in, 254 differential diagnosis in, 14

retinal signs in, 24 reversed split in, 150 Hypertrophic obstructive cardiomyopathy (HOCM) cause of the obstruction, 203 mid-systolic dip in, 108 mitral regurgitation with, 206 murmurs in differentiation from aortic stenosis,

204-206 origins, 203, 204 pulse rate of rise, 33 symptoms in, 211 Hypertrophic subaortic stenosis, definition, 275

Hypertrophy. See also Left ventricular hypertrophy; Right ventricular hypertrophy concentric vs eccentric, 103 definition, 89, 103

precordium examination for detection of, A wave, 105-107 left ventricular impulse, 104, 105 mid-systolic dip, 108 right ventricular enlargement, 109 Hypertrophic osteoarthropathy and

Eisenmenger's, 7 Hyperventilation and breath holding time,

27, 277 Hypophosphatemia, 5 H wave, 78, 88

Idiopathic dilatation of pulmonary artery ejection sound in 128 flow murmur in, 193 and pulmonary regurgitation, 259 IHSS vs HOCM, 275 Incisura, 122 Infarction history in, 131 S4in, 179 Infective endocarditis vs atrial myxoma changing murmurs in, 275 chordae rupture etiologies, 221, 223

etiologies, 275 eye signs, 23

and prolapsed mitral valve, 227 skin signs in, 19 symptoms of, 5, 6 Inflow murmur. See Mitral diastolic murmur Inflow tract, 207 Infundibulum, definition, 276 Innocent murmur definition, 195

humming ejection murmur, 197, 199 Intermittent claudication, 276 as coronary risk factor, 12 Iridodonesis and cardiac lesions, 24 Ischemic heart disease, risk factors, 4 Isovolumic contraction, 122, 156

vs isometric, 276 Isovolumic relaxation, 163, 243, 276 Isthmus and coarctation, 273

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