Internal Medicine

Insider CLINICAL
The following notes are based upon the widely
known Jam’ El-Majam’ clinical series, So you will find Part II
nothing new except for organization and
simplification. The aim is to offer it in a more Cardiology sheet
concise way easily to remember and handle. That is E x a m - o r i e n t e d
to say it’s the “Skimmed Jam’ El-Majam’”.
Internal Medicine | Cardiology sheet Internal Medicine | Cardiology sheet
1
Examine the Heart: II. Cardiac:
I. Inspection AND Palpation: - Dextrocardia.
- RVH → Outwards; LVH → Downwards AND outwards.
1. Pericardial bulge:
III. Chest:
Congenital HD; Rheumatic HD.
Pericardial effusion; RVH. - PE; Pneumothorax → Push; Fibrosis; Collapse → Pull.
I.
2. Apex: IV. Abdominal:
Site: - ↑ IAP (Ascites; Pregnancy) → Shifted up.
- Normally in left 5th ICS just inside MCL.
Extent: V. Misc.→ Kyphoscoliosis.
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- Localized → Normally AND LVH.
- Diffuse → RVH. Difference () RVH AND LVH:
- Double → MI.
LVH RVH
- Bifid → BBB.
Apex:
Character: Normally no special character.
Thrill : Only low frequency murmurs are palpable. Site Downwards AND outwards. More outwards.
Relation to systole: Retraction OR Bulge. Extent Localized. Diffuse.
3. Pulsations. Character 1. Volume overload: Slapping.
4. Thrill. Hyperdynamic.
5. State of the skin: 2. Pressure over:
Dilated vessels (SVC Thrombosis); Pigmentation; Scar. Heaving.
II. Percussion. Relation Bulge Retraction
to systole (Parasternal retraction) (Parasternal bulge)
III. Auscultation:
Misc.:
For Heart sounds; Added sounds; Murmurs; Pericardial rub.
Pulsation 1. Epigastric pulsation.
‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬

2. Parasternal pulsation:
Cause of Abnormal site of the apex: If RVE + LAE:
-
I. Physiological: - Uplift pulsation.
If RVE only:
- Long thin person : 6th ICS.
- Heaving pulsation.
- Children > 2 years : 4th ICS.
Dullness 1. Lower ⅓ of sternum.
- During inspiration : More down. -
2. Widened bare area.
- Position : More down in sitting; laterally in left side.
Internal Medicine | Cardiology sheet Internal Medicine | Cardiology sheet
2
Causes of Absent (Invisible OR Not palpable) Apex: Causes of Dullness:
1. Obesity. (Thick chest wall) I. Pulmonary area (2nd left ICS):
2. Behind a rib. - Pulmonary artery dilation; LAE.
3. Pleural effusion; Pericardial effusion; Emphysema. - Aortic artery aneurysm.
4. Advanced HF. (weak) II. Aortic area (2nd right ICS):
5. Dextrocardia. - Ascending aortic artery dilation.
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III. Cardiac waist (3rd left ICS):
Causes of Pulsations: - LAE.
I. Suprasternal pulsation: IV. Right of the sternum:
- Short obese with short neck and High diaphragm. - RAE; Huge LAE.
- Hyperdynamic cir. (AR) V. Outside the apex:
- Coarctation of the aorta.
- Pericardial effusion; Ventricular aneurysm.
- High Aortic Arch.
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- Aneurysm of aortic arch.
II. Epigastric pulsation: Causes of ↓ Bare area:
- RVH. 1. Pneumothorax.
- Hepatic pulsations → TR (Systolic); TR AND TS (Diastolic). 2. Emphysema.
- Abdominal Aorta. ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬

III. Pulsation to right of the sternum: (Fingers Tips) Causes of ↑ Bare area:
- RAE; Huge LAE. 1. RVE.
- Aortic Aneurysm.
2. Pericardial effusion.
- Internal mammary artery in lactating female.
3. Fibrosis; Collapse.
IV. Parasternal pulsation: (By Paroxysmal part of a palm)
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- RVH → Uplift OR Heaving.
Causes of Huge (Bovine) heart:
V. Pulmonary area pulsation: (Fingers Tips; Left hand ulnar border)
- Pulmonary artery dilation or aneurysm; LAE. 1. Multivalvular disease.
VI. Aortic area pulsation: (Fingers Tips) 2. Pericardial effusion.
3. Dilated cardIomyopathy.
- Aortic artery dilation.
4. Long standing hypertensive HF.
 ‫‪Internal Medicine | Cardiology sheet‬‬ ‫‪Internal Medicine | Cardiology sheet‬‬
‫‪3‬‬
‫‪Causes of Small heart:‬‬ ‫‪Difference () Wide and Reversed splitted S2:‬‬
‫‪1. COPD.‬‬ ‫‪Wide splitted S2‬‬ ‫‪Reversed splitted S2‬‬
‫‪2. Addison’s disease; Senile cardiac atrophy.‬‬ ‫‪Haemodynamics‬‬ ‫‪Delayed closure of‬‬ ‫‪Delayed closure of Aortic‬‬
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‫‪Causes of Accentuated AND Weak S1:‬‬ ‫‪Causes‬‬ ‫‪ASD.‬‬ ‫‪PDA.‬‬
‫‪PS.‬‬ ‫‪AS.‬‬
‫‪Accentuated S1‬‬ ‫‪Weak S1‬‬ ‫‪RBBB.‬‬ ‫‪LBBB.‬‬
‫‪MS.‬‬ ‫‪1. Loss of valvular component:‬‬ ‫‪Effect of deep‬‬ ‫↑‬ ‫‪Disappear‬‬
‫‪Hyperdynamic circulation.‬‬ ‫‪MR.‬‬ ‫‪inspiration‬‬
‫‪Tachycardia.‬‬ ‫‪Calcified MS.‬‬
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‫‪Exercise; Emotion.‬‬
‫‪2. Loss of Muscular component:‬‬
‫‪Children.‬‬
‫‪Myocarditis.‬‬
‫‪Causes of Single S2:‬‬
‫‪Thin chest wall.‬‬
‫‪Cardiomyopathy.‬‬ ‫‪1. TOF; Pulmonary atresia.‬‬
‫‪3. Misc.:‬‬ ‫‪2. Truncus arteriosus; Very large VSD.‬‬
‫‪Bradycardia.‬‬ ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
‫‪Absent apex.‬‬
‫‪Causes of S3 (Protodiastolic sound):‬‬
‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬

‫‪Abnormalities of S2:‬‬ ‫‪1.‬‬ ‫‪MR.‬‬

‫‪Rapid Ventricular filling‬‬

‫‪2.‬‬ ‫‪TR.‬‬
‫‪1.‬‬ ‫‪Accentuated splitted S2.‬‬ ‫‪3.‬‬ ‫‪ASD.‬‬
‫‪2.‬‬ ‫‪Weak splitted S2.‬‬ ‫‪4.‬‬ ‫‪VSD.‬‬
‫‪3.‬‬ ‫‪Wide and Reversed splitted S2.‬‬ ‫‪5.‬‬ ‫‪PDA.‬‬
‫‪4.‬‬ ‫‪Single S2.‬‬ ‫‪6.‬‬ ‫‪Hyperdynamic circulation.‬‬
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‫‪7.‬‬ ‫)‪HF; Cardiomyopathy. (Flabby myocardium‬‬
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‫‪Causes of Accentuated AND Weak S2:‬‬
‫)‪Causes of S4 (Presystolic sound): (↑ ventricular pressure‬‬
‫‪Accentuated S2‬‬ ‫‪Weak S2‬‬
‫‪↑ atrial cont.‬‬ ‫‪1.‬‬ ‫‪AS; PS.‬‬
‫‪Dilatation and Hypertension of‬‬ ‫‪AS; PS.‬‬
‫‪Pulmonary artery and Aorta.‬‬ ‫‪Hypertension.‬‬
‫‪2.‬‬ ‫‪Hypertension (Pulmonary; Systemic).‬‬
‫‪Shock.‬‬ ‫‪3.‬‬ ‫‪Pulmonary embolism.‬‬
‫‪Absent apex.‬‬ ‫‪4.‬‬ ‫‪Coarctation of Aorta.‬‬
Internal Medicine | Cardiology sheet Internal Medicine | Cardiology sheet
4
5. Rapid and early atrial contraction. (Against resistance) Enumerate Diastolic murmurs:
6. MI. (↓ Compliance). Over the base Over the apex
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AR; PR. 1. Mitral valve:
Added heart sounds: Coarctation of the aorta. MS (Organic; functional).
PDA. Carey Coomb’s murmur.
1. Opening snap. (MS; TS) Venous hum. Austin Flint murmur.
2. Ejection click. (AS; PS) Left atrial myxoma.
3. Pericardial knock. (Constrictive pericarditis) Cor triatriatum.
4. Gallop: 2. Propagated murmurs:
AR.
- S3 Gallop → S3 + Tachycardia.
- S4 Gallop → S4 + Tachycardia. ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬

- Summation Gallop → S3 + S4 + Tachycardia. Enumerate Continuous murmurs:

5. Mid-systolic click. (Mitral valve prolapse) 1. PDA.
6. Tumor plops. (Left atrial myxoma) 2. Coarctation of the aorta.
‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬ 3. Venous hum.
Value of hearing opening snap: 4. Systemic (Pulmonary; Coronary) fistula.
5. Bronchial collaterals.
1. Absence of calcification; NO MR; NO AF.
6. Broncho-pulmonary stenosis.
2. The nearer the opening snap to S2, The more severity of MS.
7. Rupture aneurysm of Valsalva (Aortic) sinus into Rt. side of the Ht.
3. Differentiate () Rh. MS AND Left atrial myxoma (Absent).
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‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬

Difference () Continuous AND To-Fro murmurs:

Enumerate Systolic murmurs:
Continuous murmur To-Fro murmurs
Over the base Over the apex
AS; PS. 1. Mitral valve: Gap () the 2 phases
NO Gap Gap
MR (Organic; functional). (Systole AND Diastole)
Aortic OR Pulmonary aneurysm.
Coarctation of the aorta. Mitral valve prolapse. Flow direction One direction Opposite direction
ASD. 2. Propagated murmurs: Causes PDA Severe AR + AS
VSD; PDA. TR. Coarctation of aorta
Venous hum. AS; PS. Venous hum.
Still’s murmur. VSD; PDA. (See before...)
Internal Medicine | Cardiology sheet Internal Medicine | Cardiology sheet
5
Types of murmurs: VSD:
Time and - Pansystolic harsh murmur which is maximum at 3rd and 4th ICS with
Character Site Propagation Misc. propagation all over the pericardium.
duration
PDA:
MR Axilla
- Continuous machinery murmur which is maximum at left infraclavicular

lateral position

Left side murmurs ↑ with expiration

Soft Max. OR The
Pansystolic area with propagation to apex AND neck.

↑ in left
Blowing AT Apex heart base

With propagation to
[in Pt. leaflet Innocent murmurs:

Murmur which is
regurge]
- Early systolic soft murmurs.
MS Mid- Localized - Best heard over P area AND Left sternal edge.
Rumbling -
Diastolic TO Apex
- ↑ with standing and respiration.
AR Max. Apex - Causes: Hyperdynamic circulation; Minimal organic lesions; Chest
OVER A1

↑ with leaning
Early Soft Neck deformities.
OR Max.

forward
Diastolic Blowing ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬

OVER A2
[in Rh. AR]
AS Ejection Max. Apex
Harsh OVER A1
Systolic Neck
The End
TR Max. Apex Part II: Cardiology sheet
Soft
Pansystolic OVER Clinical sheets of Internal medicine
Blowing

Right side murmurs ↑ with

T Area

inspiration [Carvallo sign]

Exam-oriented
With propagation to

TS Max. -
Murmur which is

First edition 2009

Mid-
Rumbling OVER -
Diastolic
T Area
PR Max.
Early Soft dя isιaaм
OVER -
Diastolic Blowing
P Area
Any comment by email is to: islamuhamad@live.com
-

PS Max. Apex
Ejection
Harsh OVER Neck
Systolic
P Area

NB:
- Severity of the lesion depends on the duration (which is determined by
pressure gradient) NOT the intensity of the murmur.