258.4 📌 章末速記

258.4.0.0.1 History

• 70-80% of CV diagnosis
• OPQRST + risk factors + PMH + meds + family + social

258.4.0.0.2 Physical Exam

• JVP: volume + RV / HF
• Pulse: vascular tone + AS / AR
• PMI: LV enlargement / hypertrophy
• Heart sounds:
  • S1 + S2 (splitting)
  • S3 (HF, MR, AR) — pathologic in adult
  • S4 (LVH, AS, HCM) — pathologic
  • Opening snap (MS), ejection click (bicuspid AV), mid-systolic click (MVP)

258.4.0.0.3 Murmurs

• Timing + location + radiation + intensity + character + maneuvers
• Systolic: AS, MR, TR, HOCM, MVP, VSD, innocent
• Diastolic: AR, MS
• Continuous: PDA

258.4.0.0.4 Dynamic Maneuvers

• HOCM: Valsalva ↑, squat ↓ (unique)
• AS: opposite (Valsalva ↓, squat ↑)
• TR: inspiration ↑ (Carvallo)
• MR / AR / VSD: hand grip ↑

258.4.0.0.5 Critical Signs

• Pulsus paradoxus (> 10 mmHg drop inspiration): tamponade
• Pulsus parvus et tardus: AS
• Water-hammer Corrigan: AR
• Kussmaul sign (JVP rises inspiration): constrictive pericarditis
• Cannon a-waves: AV dissociation (3° block, VT)
• S2 fixed splitting: ASD

258.4.0.0.6 盧醫師 hint

• 心音 + 雜音 systematic approach essential
• HOCM vs AS dynamic maneuvers (Valsalva, squat)
• TR Carvallo sign (inspiration ↑)
• AR peripheral signs (multiple eponyms)
• Pulsus paradoxus → think tamponade
• Echo doesn’t replace physical exam — they complement