Pleural effusion (LVF)

Rhonchi (pulmonary edema)

Gastrointestinal tract Tender hepatomegaly (right heart failure)

Splenomegaly (infective endocarditis)

Ascites (right heart failure)

Dysphagia (due to large left atrium)

Nervous system Stroke (hemiplegia/Horner’s syndrome, cranial nerve palsies)

PULSATILE LIVER

Examination of Pulsatile Liver

Patient in 45° recumbent position

Two methods are described

Bimanual palpation (Fig. 4E.31): Place one palm over the anterior surface of the right lower

chest and other palm on the posterolateral surface of the right lower chest. Pulsations of the liver

are felt between the two palms.

Make fist of the right hand and placing the knuckles and fingers in the right lower intercostal

spaces and feel for the pulsatile liver as shown in Figure 4E.32.

Systolic pulsation Diastolic pulsations (presystolic)

TR

AR

TS

(AR: aortic regurgitation; TR: tricuspid regurgitation; TS: tricuspid stenosis)

Valsalva Maneuver

The Valsalva maneuver is a forceful attempted exhalation against a closed glottis.

Instruction:

Take a deep breath, close your mouth and pinch your nose with the thumb and index finger and attempt

to breathe out gently, keeping your cheek muscles tight, not allowing the air to escape by keeping the

lips pursed.

Fig. 4E.31: Bimanual method of palpation of pulsatile liver.

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Fig. 4E.32: Examining the pulsatile liver by making fist and placing the knuckles and fingers in the

intercostal spaces.

“Standard” or “quantitative”:

Blowing out with an open glottis into a tube of a sphygmomanometer against the pressure of 40 mm Hg.

Phases of Valsalva Maneuver

Physiological effects on blood pressure, heart rate and phases of Valsalva maneuver are presented in

Figure 4E.33.

Phases of Valsalva maneuver

Phase

1

The onset of blowing.

The pressure within the chest and abdomen increases and presses upon the arteries in the chest, which results in an

increase in mean arterial blood pressure (Fig. 4E.33). This activates the baroreceptor reflex, which results in an

increase in parasympathetic (vagal) activity and hence in a drop in heart rate.

The increased intrathoracic pressure also reduces the amount of blood that comes into the right atrium (decreased

venous return or preload)

Phase

2

A decrease of venous return results in a lower amount of blood that is ejected from the heart, which results in a decrease

of central venous pressure and consequently in a decrease of mean arterial blood pressure. This activates the

baroreflex, which results in a decrease of the parasympathetic (vagal) activity and consequent increase of the heart rate,

and in an increase in sympathetic activity, which constrict the arteries (an increase of peripheral resistance) and results

in a slight rise of the blood pressure at the end of phase 2 (2b).

Phase

3

Relaxation—the end of the maneuver. The intrathoracic pressure decreases, so the intrathoracic arteries widen, which

results in a brief drop in blood pressure. At the same time, the venous blood fills the heart

Phase

4

The heart ejects the blood into the arterial system against increased peripheral resistance (which has developed in

phase 2), so the blood pressure rises again (blood pressure overshoot). This activates the baroreflex, which results in a

drop in heart rate (bradycardia). Eventually, both the blood pressure and heart rate normalize

Uses

Eustachian tube dysfunction

Heart murmurs: Valsalva increases murmurs in hypertrophic cardiomyopathy and mitral valve

prolapse and decreases them in atrial septal defects and aortic stenosis.

Congestive heart failure: Valsalva responses lost.

Function of the autonomous nervous system:

An abnormal blood pressure response (for example, an absence of the blood pressure rise in

phase 4) suggests an abnormality of the sympathetic system.

An abnormal heart rate response suggests an abnormality of the parasympathetic system.

Valsalva maneuver that can be used as a provocative test to check for neurogenic orthostatic

hypotension, Chiari malformation, the Valsalva maneuver (coughing) triggers a headache at the

back of the head.

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Diagnosis of inguinal hernia, prolapse of the uterus, bladder or vagina, varicocele and intrinsic

sphincter deficiency in stress urinary incontinence system.

Valsalva maneuver can help: Equalize the pressure between the middle ear and the ambient pressure

during scuba diving, driving from a steep hill, elevator descending, parachuting or plane landing or in

individuals with Eustachian tube dysfunction.

Modified Valsalva Maneuver

Modified Valsalva maneuver is used to terminate an attack of supraventricular tachycardia (SVT); it

includes blowing against a closed glottis followed by lying down face up and raising legs with the help of

an assistant, may be effective in 19–54% of cases.

Fig. 4E.33: Mean arterial blood pressure and heart rate changes during the Valsalva maneuver.

Various phases of Valsalva maneuver and its associated changes:

Phase 1 2a 2b 3 4

Intrathoracic pressure ↑ ↑ ↑ N N

Mean arterial blood pressure ↑ ↓ ↑ ↓ ↑

Heart rate ↓ ↑ ↓ ↑ ↓

Sympathetic activity ↓ ↓ ↑ ↑ ↑

Parasympathetic (vagal) activity ↑ ↑ ↓ ↓ ↑

Reversed Valsalva—Müller’s maneuver

Muller’s maneuver is the opposite of the Valsalva maneuver and includes forced exhalation followed by

an attempted forceful inhalation with a closed mouth and nose or just with a closed glottis. The test can

be used to evaluate weakness of the soft palate and throat walls in individuals with obstructive sleep

apnea.

NOTES

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F. SUMMARY OF FINDINGS IN COMMON CARDIOVASCULAR DISEASES

Findings MS MR AS AR TR ASD V

Pulse Low volume,

Irregularly

irregular (if

associated

with AF)

High volume,

Irregularly

irregular (if

associated

with AF)

Low volume,

Pulsus

parvus et

tardus

Anacrotic

pulse

Apico-carotid

delay—severe

AS

High volume,

Collapsing

pulse Water

hammer pulse

Pulsus

bisferiens

Normal Normal

Irregularly

irregular (if

associated

with AF)

High

Blood Pressure Low BP

Mean of 3

readings to

be taken if

atrial

fibrillation is

present

Wide pulse

pressure

Mean of 3

readings to

be taken if

atrial

fibrillation is

present

Low BP

Systolic

decapitation

Coanda

effect: Right

upper limb BP

>left upper

limb BP

(supravalvular

AS)

Wide pulse

pressure

Hills sign—

Lower limb BP

>20 mm of

upper limb BP

Normal Normal Wid

pres

JVP Raised in

heart failure

Prominent a waves—

pulmonary

hypertension

without atrial

fibrillation

Absence of

a wave—

atrial

fibrillation

Prominent v waves (c-v

waves) and

rapid y

descent →

tricuspid

regurgitation

Raised in

heart failure

Prominent a waves—

pulmonary

hypertension

without atrial

fibrillation

Absence of

a wave—

atrial

fibrillation

Prominent v waves (c-v

waves) and

rapid y

descent →

tricuspid

regurgitation

Usually normal

Raised in

heart failure

Rarely

prominent a

wave—

Bernheim

effect

Usually normal

Raised in heart

failure

Raised

with most

prominent

‘giant’ v

wave in the

jugular

venous

pulse (a cv wave

replaces

the normal

x descent).

Earlobe

pulsations

(Lancisi’s

sign)

“M” pattern-- a

and v waves

have equal

height, a wave

becomes taller

when

pulmonary

hypertension

develops or

associated mitral stenosis

(MS).

Raised

failure

Apex Tapping apex Hyperdynamic

Down and out

apex

Heaving Hyperdynamic

Down and out

apex

Normal Normal Mild d

down

Parasternal

heave

Present (RVH

or left atrial

enlargement)

Present (RVH

or left atrial

enlargement)

No No Present Prese

Thrills Diastolic thrill at

apex

Systolic thrill at

apex in acute

or severe MR

Systolic thrill

over the aortic

and carotid area

Diastolic thrill in

aortic/neoarotic

area

Systolic thrill

in left lower

sternal edge

nil Left 4-

parast

Heart

sounds

S1 Loud Soft Normal Soft Soft Loud Soft

S2 Loud P2

(pulmonary

hypertension)

Narrow split

(pulmonary

hypertension)

Loud P2

(pulmonary

hypertension)

Narrow split

(pulmonary

hypertension)

Soft A2 (valvular

AS)

Loud A2

(bicuspid aortic

valve)

Normal

Tambour A2 in

syphilitic AR

Loud P2 with

narrow split

(pulmonary

hypertension)

P2 loud

Wide fixed split

P2 lou

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Paradoxical split

(severe AS)

S3 RVS3 (present

in failure)

RV/LVS3

(present in

failure)

LVS3 in failure LVS3 in severe

AR

RVS3 RVS3 +/-

S4 Never Present in

acute MR

Present.

indicates severe

AS

+/- -- RVS4

(Eisenmenger’s)

RVS4

(Eisen

Others Opening snap OS in 10% AEC in bicuspid

aortic valve

--- -- PEC

(Eisenmenger’s)

PEC

(Eisen

Murmurs MDM at mitral area

PSM at

tricuspid area

ESM at

pulmonary

area

EDM

(Graham

Steel) at

pulmonary

area

PSM in mitral area

radiation to

axilla/base

Flow MDM

at mitral area

PSM at

tricuspid

area

ESM at

pulmonary

area

EDM

(Graham

Steel) at

pulmonary

area

ESM in aortic

area

conducting to

carotid

Systolic murmur at mitral area

(Gallavardain

Phenomenon)

EDM in

aortic/neoarotic

area

Flow ESM in

aortic area

MDM at mitral

area (Austin

Flint)

Diastolic murmur in left

axilla (ColeCecil murmur)

Blowing

PSM: At the

lower-left

sternal

border that is

increased

during

inspiration

and reduced

during

expiration

(deCarvallo’s

sign).

ESM in

pulmonary area

and MDM in

tricuspid area. Once

Eisenmenger’s —EDM in

pulmonary area

and PSM in

tricuspid area

PSM h

at the

sterna

(3rd, 4

5th int

space

Other features Palpable P2

(diastolic

shock)

Palpable P2

(diastolic

shock)

-- Peripheral signs Pulsatile liver Precordial bulge Aortic

insuffic

approx

5%

(AR: aortic regurgitation; AS: aortic stenosis; ASD: atrial septal defect; ESM: ejection–systolic murmur;

EDM: early diastolic murmur; MDM: mid-diastolic murmur; MR: mitral regurgitation; MS: mitral stenosis;

PS: pulmonary stenosis; PDA: patent ductus arteriosus; PSM: pansystolic murmur; TR: tricuspid

regurgitation; VSD: ventricular septal defect)

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P

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