258.3 🩺 內科專科考前版

258.3.0.1 1⃣ Carvallo Sign for TR

  • Holosystolic murmur at L lower sternal border that increases with inspiration
  • Identifies tricuspid regurgitation
  • Inspiration increases venous return → more TR

258.3.0.2 2⃣ HOCM Murmur — Counterintuitive

  • Unlike most murmurs that decrease with Valsalva, HOCM increases
  • Reason: Valsalva reduces LV preload → smaller LV cavity → more LVOT obstruction (dynamic)
  • Squat increases preload + afterload → larger LV + less obstruction → murmur decreases
  • Hand grip increases afterload → larger LV → murmur decreases
  • Critical for differentiating HOCM from AS

258.3.0.3 3⃣ Pulsus Paradoxus Measurement

  • Inflate cuff above SBP
  • Slowly deflate while patient breathes normally
  • Note level when Korotkoff sounds heard only during expiration (Level 1)
  • Continue deflating; note when heard throughout (Level 2)
  • Difference = pulsus paradoxus

  • 10 mmHg = abnormal (tamponade, severe asthma, severe pericarditis)

258.3.0.4 4⃣ Murmur Maneuvers Quick

Murmur Squat Valsalva Hand Grip
AS ↑ ↓ ↓ or =
HOCM ↓ ↑ ↓
MR / AR / VSD ↑ ↓ ↑
MVP click + murmur Later Earlier minimal

258.3.0.5 5⃣ JVP Waveform Pearls

  • Cannon a-waves: AV dissociation (3rd degree block, junctional rhythm, VT)
  • Absent a-waves: AF
  • Giant v-wave: severe TR
  • Kussmaul sign + paradoxical pulse: cardiac tamponade
  • Steep y descent: constrictive pericarditis
  • Slow y descent: tamponade, restrictive cardiomyopathy

258.3.0.6 6⃣ AR Peripheral Signs (Many Eponyms)

  • Corrigan pulse (water-hammer)
  • Duroziez sign (to-and-fro femoral murmur)
  • Hill sign (BP lower extremity > upper)
  • de Musset sign (head bobbing)
  • MÃŒller sign (pulsating uvula)
  • Quincke pulse (capillary pulsations in nail bed)

258.3.0.7 7⃣ S3 vs S4

  • S3: early diastole (rapid filling); ventricular gallop; “Kentucky”
  • S4: late diastole (atrial contraction); atrial gallop; “Tennessee”
  • S3 in young = normal; S3 in adult = pathologic (HF)
  • S4 always pathologic in adult
  • S3 + S4: severe HF + LVH (“summation gallop”)

258.3.0.8 8⃣ Physical Exam vs Echo

  • Echo doesn’t replace physical exam — they’re complementary
  • Some findings (S3, S4, peripheral signs of AR) are not always seen on echo
  • Murmur localization + dynamic maneuvers + clinical context guide echo interpretation
  • Physical exam remains a key skill (less utilized in modern practice unfortunately)

258.3.0.9 9⃣ 健保 / Taiwan

  • 健保 echocardiography widely available for murmur evaluation
  • Primary care physician + cardiology coordination
  • Increasing use of point-of-care ultrasound (POCUS) in emergency / clinic

258.3.0.10 10. Modern Considerations

  • POCUS (point-of-care ultrasound): increasing role in volume + cardiac function assessment
  • AI-enabled stethoscopes: detect murmurs, AF, S3, S4 with high sensitivity
  • Smartphone-based ECGs + monitoring
  • Physical exam fundamentals remain key, augmented by technology