258.1 🎓 醫學生版

258.1.0.1 📌 一頁重點

258.1.0.1.1 History — 70-80% of Diagnosis

• Chief complaint + onset + duration + character + severity + radiation + provocation + relief (OPQRST)
• Cardiac risk factors (age, sex, family hx, smoking, DM, HTN, dyslipidemia, obesity)
• Past medical hx: prior MI, HF, arrhythmias, surgeries, devices
• Medications: statins, BB, ACEi, anticoagulants, antiarrhythmics
• Family hx: premature CAD, sudden death, cardiomyopathy
• Social hx: tobacco, alcohol, drugs, exercise, occupation
• Review of systems

258.1.0.1.2 Physical Examination

258.1.0.1.2.1 Vital Signs

• BP (both arms in initial; consider supine + standing for orthostasis)
• HR + rhythm
• Respiratory rate
• SpO2
• Temperature

258.1.0.1.2.2 Inspection

• General appearance (acute distress, cachexia, posture)
• Cyanosis (central vs peripheral)
• Clubbing (chronic hypoxia, congenital heart disease, endocarditis)
• JVP measurement
• Edema (peripheral, dependent)
• Skin changes (xanthomas, xanthelasma, splinter hemorrhages, Janeway lesions, Osler nodes)

258.1.0.1.2.3 JVP (Jugular Venous Pressure)

• Right internal jugular vein preferred
• Patient at 30-45° head elevation
• Measure vertical height above sternal angle + add 5 cm
• Normal: < 8-9 cm H2O total (3-4 cm above sternal angle)
• Elevated: HF, tamponade, constrictive pericarditis, RV failure, volume overload
• Hepatojugular reflux (sustained JVP rise with abdominal pressure) — HF
• Kussmaul sign (JVP rises with inspiration) — constrictive pericarditis, tamponade, severe RV failure, restrictive CMP

258.1.0.1.2.4 Arterial Pulse

• Rate + rhythm + amplitude + contour + symmetry
• Carotid most accurate for amplitude / contour
• Pulsus parvus et tardus: weak + delayed — aortic stenosis
• Water-hammer / Corrigan: large rapid + collapse — aortic regurgitation
• Pulsus alternans: alternating strong/weak — severe LV dysfunction
• Pulsus paradoxus: > 10 mmHg drop in SBP with inspiration — tamponade, severe asthma/COPD, severe pericarditis
• Pulsus bisferiens: bifid pulse — HOCM, severe AR
• Peripheral pulse asymmetry: aortic dissection, peripheral vascular disease

258.1.0.1.2.5 Precordium

• PMI (Point of Maximal Impulse) location + character
  • Normal: 5th ICS, midclavicular line, < 2 cm
  • Lateral displacement: LV enlargement / hypertrophy
  • Sustained / heaving: LV hypertrophy (HTN, AS)
  • Tapping: mitral stenosis (loud S1)
• Thrills (palpable murmurs): aortic stenosis (R 2nd ICS), VSD (left sternal border)
• Right ventricular heave: pulmonary HTN
• Apical impulse displacement

258.1.0.1.2.6 Auscultation

• 4 areas:
  • Aortic (R 2nd ICS) — aortic murmurs
  • Pulmonic (L 2nd ICS) — pulmonic + PDA murmurs
  • Tricuspid (L lower sternal border) — tricuspid + RV murmurs
  • Mitral / Apex (5th ICS midclav) — mitral murmurs + S3 / S4
• Listen at each with diaphragm (high-frequency) + bell (low-frequency)

258.1.0.1.3 Heart Sounds

258.1.0.1.3.1 S1

• Mitral + tricuspid valve closure (M1 + T1)
• Beginning of systole
• Loud in: mitral stenosis, hyperdynamic states (anemia, hyperthyroidism), short PR
• Soft in: severe MR, long PR, severely diseased mitral valve, decreased contractility

258.1.0.1.3.2 S2

• Aortic + pulmonic valve closure (A2 + P2)
• End of systole
• Splitting:
  • Physiologic splitting (inspiratory increase in P2 delay): normal
  • Fixed splitting: ASD (right-sided volume overload — atrial septal defect)
  • Wide splitting: RBBB, pulmonary HTN, pulmonic stenosis, RV failure
  • Paradoxical splitting (reverses with inspiration): LBBB, severe AS, HOCM
• Loud A2: HTN, aortic root dilation
• Loud P2: pulmonary HTN

258.1.0.1.3.3 S3 (Ventricular Gallop)

• Early diastole (rapid ventricular filling)
• Low-frequency — heard with bell
• Physiologic in young (< 35), pregnancy, hyperdynamic
• Pathologic in adult: HF, MR, AR, VSD, severe TR

258.1.0.1.3.4 S4 (Atrial Gallop)

• Late diastole (atrial contraction into stiff ventricle)
• Heard before S1
• Low-frequency — heard with bell
• Pathologic: LV hypertrophy (HTN, AS, HCM), acute MI, ischemia, diastolic dysfunction
• Disappears in AF (no atrial contraction)

258.1.0.1.3.5 Additional Heart Sounds

• Opening snap: mitral stenosis (high-frequency, early diastole)
• Ejection click: bicuspid aortic valve, pulmonic stenosis
• Mid-systolic click: mitral valve prolapse
• Pericardial friction rub: pericarditis (scratchy, 1-3 components, position-dependent)
• Pericardial knock: constrictive pericarditis

258.1.0.1.4 Murmurs

258.1.0.1.4.1 Systematic Description

1. Timing: systolic vs diastolic vs continuous
2. Location: where loudest
3. Radiation: where heard elsewhere
4. Intensity: graded I-VI (Levine)
5. Character / quality: harsh, blowing, rumbling, musical
6. Pitch: high vs low frequency
7. Configuration: crescendo-decrescendo, holosystolic, late systolic
8. Dynamic maneuvers: how it changes

258.1.0.1.4.2 Grading (Levine Scale)

• I: very soft, requires concentration
• II: soft but easily audible
• III: moderately loud, no thrill
• IV: loud with thrill
• V: very loud with thrill, heard with stethoscope edge on chest
• VI: heard without stethoscope on chest

258.1.0.1.4.3 Systolic Murmurs

Murmur	Location	Character
Aortic stenosis (AS)	R 2nd ICS → carotid radiation	Crescendo-decrescendo harsh; late peaking in severe
Mitral regurgitation (MR)	Apex → axilla	Holosystolic, blowing
Tricuspid regurgitation (TR)	L lower sternal border	Holosystolic; increases with inspiration (Carvallo sign)
VSD	L lower sternal border	Holosystolic, harsh
HOCM	L lower sternal border	Crescendo-decrescendo; decreases with squat, increases with Valsalva
MVP (mid-late systolic)	Apex	Mid-systolic click + late systolic murmur; earlier with Valsalva
Innocent / functional	L sternal border	Soft, vibratory; varies with position; in absence of structural disease

258.1.0.1.4.4 Diastolic Murmurs

Murmur	Location	Character
Aortic regurgitation (AR)	L sternal border 3rd-4th ICS	Decrescendo; high-pitched blowing; patient sitting + leaning forward + breath held in expiration
Mitral stenosis (MS)	Apex (with bell)	Opening snap + diastolic rumble + presystolic accentuation (if sinus rhythm)
Pulmonary regurgitation	L 2nd ICS	Similar to AR but L-sided; PHTN (Graham Steell murmur)

258.1.0.1.4.5 Continuous Murmurs

• Patent ductus arteriosus (PDA): “machinery” murmur, L 2nd ICS, throughout cardiac cycle
• Coronary AV fistula
• Aortopulmonary window

258.1.0.1.5 Dynamic Maneuvers

258.1.0.1.5.1 Valsalva (Strain Phase)

• Decreases venous return (decreases LV preload)
• MOST murmurs decrease with Valsalva
• HOCM increases: less LV volume → more LVOT obstruction
• MVP: click and murmur earlier (less LV volume → MVP earlier)

258.1.0.1.5.2 Squatting

• Increases venous return + afterload
• MOST murmurs increase
• HOCM decreases: more LV volume → less LVOT obstruction
• MVP: click and murmur later

258.1.0.1.5.3 Inspiration

• Increases R-sided murmurs (TR — Carvallo sign, PR, PS, pulmonic flow murmur)
• Decreases L-sided murmurs typically

258.1.0.1.5.4 Hand Grip

• Increases afterload
• MR / AR / VSD murmurs increase (more regurg / shunt)
• AS murmur decreases or unchanged

258.1.0.1.5.5 Amyl Nitrate (Older Test)

• Decreases afterload
• HOCM, AS murmurs increase; MR, AR murmurs decrease

258.1.0.1.6 Lungs + Abdomen

• Crackles: pulmonary edema (HF)
• Wheeze: pulmonary congestion / asthma
• Pleural effusion: HF, malignancy
• Hepatomegaly + ascites: right HF
• Pulsatile liver: severe TR

258.1.0.1.7 Extremities

• Edema (peripheral, dependent — pitting)
• Capillary refill
• Peripheral pulses (radial, femoral, popliteal, dorsalis pedis, posterior tibial)
• Cyanosis + clubbing
• Cool / cold limbs (low CO)
• Stigmata: splinter hemorrhages, Janeway lesions, Osler nodes (endocarditis)

---

258.1.0.2 1️⃣ JVP Detail

258.1.0.2.1 Measurement

• Patient at 30-45°
• Find right IJV (lateral neck, between sternal head + clavicular head of SCM)
• Identify pulsations (vs arterial — IJV inward-moving, biphasic)
• Measure vertical height above sternal angle (Louis)
• Add 5 cm (sternal angle to RA distance approximately)
• Normal: < 8-9 cm H2O total (< 3-4 cm above sternal angle)

258.1.0.2.2 JVP Waveform

• a-wave: atrial contraction
• x descent: atrial relaxation
• c-wave: tricuspid valve bulging into RA (RV contraction)
• v-wave: RA filling (passive)
• y descent: RA emptying into RV

258.1.0.2.3 Abnormal JVP Findings

• Elevated: HF, tamponade, RV failure, pulmonary HTN
• Hepatojugular reflux positive: HF
• Kussmaul sign (JVP rises with inspiration): constrictive pericarditis, severe RV failure, restrictive cardiomyopathy
• Giant a-waves: tricuspid stenosis, pulmonary HTN, RVH
• Cannon a-waves: AV dissociation (3rd degree block, junctional rhythm, VT)
• Absent a-waves: atrial fibrillation
• Large v-wave + sharp y descent: severe tricuspid regurgitation

---

258.1.0.3 2️⃣ Arterial Pulse Detail

258.1.0.3.1 Normal Pulse

• Rapid upstroke
• Smooth single peak
• Gradual downstroke

258.1.0.3.2 Pathologic Pulse Patterns

258.1.0.3.2.1 Pulsus Parvus et Tardus

• Weak (parvus) + delayed (tardus)
• Severe aortic stenosis
• Carotid most sensitive
• Sign of significant outflow obstruction

258.1.0.3.2.2 Water-Hammer / Corrigan Pulse

• Large rapid rise + abrupt collapse
• Aortic regurgitation (severe chronic) — wide pulse pressure
• Also: hyperdynamic states, PDA, A-V fistula

258.1.0.3.2.3 Pulsus Alternans

• Alternating strong + weak beats with regular rhythm
• Severe LV dysfunction
• Best appreciated with sphygmomanometer

258.1.0.3.2.4 Pulsus Paradoxus

• > 10 mmHg drop in SBP with inspiration
• Caused by:
  • Cardiac tamponade
  • Severe asthma / COPD exacerbation (large negative intrathoracic pressure)
  • Severe pericarditis
  • Massive PE
• Measurement: inflate cuff above SBP; deflate slowly; note pressure when Korotkoff sounds heard only on expiration (level 1); then when heard throughout (level 2); difference = pulsus paradoxus

258.1.0.3.2.5 Pulsus Bisferiens

• Bifid pulse (2 peaks per systole)
• HOCM (early peak from ejection, mid-systolic dip from obstruction, late peak)
• Severe AR

258.1.0.3.2.6 Asymmetric Pulses

• Aortic dissection (different SBP between arms > 20 mmHg, or absent pulse in extremity)
• Subclavian steal
• Peripheral vascular disease
• Coarctation of aorta (femoral delay, weak)

---

258.1.0.4 3️⃣ Heart Sounds — Detailed

258.1.0.4.1 S1 (Mitral + Tricuspid Closure)

• Beginning of systole
• M1 + T1 (usually fused; sometimes split)
• Loud: mitral stenosis (tense leaflets), hyperdynamic states, short PR
• Soft: severe MR (leaflets don’t coapt), long PR, severe leaflet pathology

258.1.0.4.2 S2 (Aortic + Pulmonic Closure)

• End of systole
• A2 + P2
• Splitting with respiration:
  • Physiologic: inspiratory increase in P2 delay (more venous return, longer P2 ejection)
  • Fixed: ASD (atrial septal defect — equalized R+L atrial pressure)
  • Wide: RBBB, pulmonic stenosis, PHTN, RV failure
  • Paradoxical (reversed): LBBB, severe AS, HOCM (A2 delayed)
• A2 loud: HTN, aortic root dilation
• P2 loud: pulmonary HTN (key clinical sign!)

258.1.0.4.3 S3 (Ventricular Gallop)

• Early diastole (rapid ventricular filling)
• “Kentucky” — S1, S2, S3 (S3 = “tucky”)
• Low-pitched — heard with bell at apex
• Physiologic in young (< 35), pregnancy, athletes
• Pathologic in adult: HF, MR, AR, severe TR, VSD
• Sensitive but not specific for HF in older adults
• Often disappears with HF treatment

258.1.0.4.4 S4 (Atrial Gallop)

• Late diastole (atrial contraction into stiff ventricle)
• “Tennessee” — S4, S1, S2 (S4 = “ten”)
• Low-pitched — heard with bell
• Pathologic: LV hypertrophy (HTN, AS, HCM), acute MI, severe ischemia, diastolic dysfunction
• Disappears in AF (no atrial contraction)

258.1.0.4.5 Additional Sounds

258.1.0.4.5.1 Opening Snap

• Mitral stenosis
• High-frequency, early diastole (after S2)
• Caused by tense stenotic mitral leaflets snapping open
• Distance from A2 to opening snap inversely proportional to severity (closer = more severe MS)

258.1.0.4.5.2 Ejection Click

• Early systolic, high-pitched
• Aortic ejection click: bicuspid aortic valve, aortic root dilation
• Pulmonic ejection click: pulmonic stenosis, PHTN

258.1.0.4.5.3 Mid-Systolic Click

• Mitral valve prolapse (MVP)
• Mid-systolic click + late systolic murmur
• Position-dependent (Valsalva makes click + murmur earlier)

258.1.0.4.5.4 Pericardial Friction Rub

• 1-3 components (atrial systole, ventricular systole, ventricular diastole)
• Scratchy, leather-rubbing
• Position-dependent (best when patient leans forward, breath held in expiration)
• Pericarditis classic

258.1.0.4.5.5 Pericardial Knock

• Constrictive pericarditis
• Early diastole, sharper than S3
• Sudden ventricular filling halted by constrictive pericardium

258.1.0.4.5.6 Tumor Plop

• Atrial myxoma
• Diastolic; pre-systolic

---

258.1.0.5 4️⃣ Murmurs — Systematic Approach

258.1.0.5.1 Approach to Murmur Patient

1. Listen at all 4 areas + apex + sternal border
2. Determine timing (systolic vs diastolic vs continuous)
3. Identify loudest location + radiation
4. Grade intensity (I-VI)
5. Describe character + pitch
6. Apply dynamic maneuvers (Valsalva, squat, inspiration, handgrip)
7. Combine with other findings (S1, S2, S3, S4, JVP, PMI, peripheral)
8. Consider echocardiography if pathologic

258.1.0.5.2 Key Murmur Patterns

258.1.0.5.2.1 Aortic Stenosis (AS)

• Crescendo-decrescendo systolic
• R 2nd ICS, radiates to carotids
• Late-peaking + soft S2 → severe AS
• Pulsus parvus et tardus carotid
• Confirmed: echo

258.1.0.5.2.2 Mitral Regurgitation (MR)

• Holosystolic (begins with S1, extends through systole)
• Apex, radiates to axilla
• Blowing high-pitched
• S3 if severe + acute
• Echo confirmation + severity

258.1.0.5.2.3 Aortic Regurgitation (AR)

• Decrescendo diastolic, high-pitched blowing
• L sternal border 3rd-4th ICS (sometimes R)
• Patient sitting, leaning forward, breath in expiration
• Wide pulse pressure (Corrigan)
• Eponyms:
  • Quincke (pulsations in capillaries)
  • Duroziez (to-and-fro femoral murmur with light pressure)
  • Hill (BP lower extremity > upper)
  • de Musset (head bobbing)
  • Muller (pulsating uvula)

258.1.0.5.2.4 Mitral Stenosis (MS)

• Diastolic rumble + opening snap
• Apex, with bell
• Presystolic accentuation if sinus rhythm (atrial contraction)
• Often soft (low-frequency)
• Loud S1
• Confirmed: echo (rheumatic fish-mouth deformity)

258.1.0.5.2.5 Hypertrophic Cardiomyopathy (HOCM)

• Crescendo-decrescendo systolic
• L lower sternal border / 3rd-4th ICS
• Decreases with squat / handgrip (more LV volume → less LVOT obstruction)
• Increases with Valsalva (less LV volume → more obstruction)
• Bisferiens pulse
• S4 common (LVH)

258.1.0.5.2.6 Tricuspid Regurgitation (TR)

• Holosystolic at L lower sternal border
• Carvallo sign: increases with inspiration (more RV return)
• Pulsatile liver + JVP large v-wave

258.1.0.5.2.7 Innocent / Functional Murmur

• Soft (grade I-II)
• Systolic ejection
• Position-dependent
• No structural heart disease on echo
• Common in children + pregnant + anemia + hyperdynamic states

---

258.1.0.6 5️⃣ Dynamic Maneuvers Summary

Maneuver	Physiology	HOCM	MVP	AS	MR	AR
Valsalva (strain)	↓ preload	↑	Earlier click, longer murmur	↓	↓	↓
Squatting	↑ preload + ↑ afterload	↓	Later click, shorter murmur	↑	↑	↑
Inspiration	↑ R-sided return	minimal	minimal	↓ L	↓ L	↓ L; ↑ R-sided (TR, PR, PS, pulm flow)
Hand grip	↑ afterload	minimal	minimal	↓ or =	↑	↑
Amyl nitrate	↓ afterload	↑	minimal	↑	↓	↓

258.1.0.6.1 Key Differentiations

258.1.0.6.1.1 HOCM vs AS

• Both: crescendo-decrescendo systolic
• HOCM: Valsalva ↑, squat ↓, hand grip ↓
• AS: Valsalva ↓, squat ↑, hand grip ↓ or =

258.1.0.6.1.2 TR vs MR

• TR: inspiration ↑ (Carvallo), L lower sternal border
• MR: inspiration ↓, apex

---