瓣膜性心臟病(Valvular Heart Disease)

Physical examination(S1234-> Pitch-> murmur-> 如何加強減弱 -> 脈搏)

1. 心音
   1. S1: MV/TV 關閉
      1. S1 loud: Tachycardia, MS, AS(TSS-> 大聲S1)
      2. S1 soft: Bradycardia, MR, AR
   2. S2: AV/PV關閉=> A2(左心, 早)/P2(右心, 晚)-> 見最下方圖
      1. 生理性split: 吸氣時
      2. Fixed split
         1. 右心收縮晚(RVOT阻塞): Pulmonary stenosis(PS), Pulmonary embolism(PE), RBBB(傳導慢), ASD!!!(一考再考)
         2. 左心收縮早: LV VPC
      3. Reversed split: P2比A2早
         1. 左心收縮晚(LVOT阻塞): Aortic stenosis(AS), HCM, Systolic HTN, LBBB, LV failure
         2. 右心收縮早
   3. Pitch
      1. High: Preesure gradient↑: AS, AR, MR
      2. Low: Preesure gradient↓: MS, S3, S4
   4. Systolic murmur(只討論左心): AS, MR
      1. MVP會有Midsystolic clicks
   5. Diastolic murmur(只討論左心): AR, MS
      1. MS會有Opening snap=> MS越嚴重, A2到OS時間越短
   6. S3: Ventricular filling: HF
   7. S4: Atrial contraction(左心compliance變差, LV無法單靠本身舒張以獲取血液): HCM, IHD, AS, HTN
   8. 心音變化
      1. 呼吸(區別左右murmur)
         1. 吸氣: 右心回血增加: 右心murmur↑
         2. 呼氣: 左心離心血增加: 左心murmur↑
      2. 姿勢(區別大小聲, 區別HCM)
         1. 站立: 回心血減少: murmur↓, 但HCM/MVP的murmur↑
         2. 蹲踞: 回心血增加: murmur↑, 但HCM/MVP的murmur↓
      3. 特殊動作
         1. Valsava: 等同站立
         2. 手握緊: 等同蹲踞
         3. HCM: Digoxin(增加Contraction), NTG(減少Preload)=> 以上兩者藥物皆可使HCM murmur↑
2. 中心靜脈導管(CVC): 監測RA!!!

1. 三個上升段: A, C, V, 兩個下降段: x, y2. EKG的R對在a, c之間a: 心房收縮=>(1) Af時出現disminished A wave(2) AV dissociation時出現canon A wave(3) PS, Pulmonary HTN, TS, Pericardial temponade: Contiunous large A wave(RA收縮受阻)c: 心室早期收縮:(1) TR時c波變明顯(blood 漏回去RA)x descent : 心室晚期收縮:(1) TR時 x波消失(2) Constrictive pericarditis: x波變明顯v: 心房舒張(1) TR時v波變明顯y descent: 心室舒張(1) TS, RA myxoma(阻礙RA/RV之間血流): slow y descent(2) TR, Right HF, constrictive pericarditis: sharp y descent

Constrictive pericarditis(Restrictive cardiomyopathy也是)1. Steep x/y wave2. Sharp c/v wave3. Disminished a wave4. 可見dip-and-plateau(又叫做"Square root sign"(平方根的形狀) Pericardial temponade1. Sharp a wave2. Blunted y descent **Kussmal's sign(吸氣時JVP↑): 常出現在CP, PT較少

1. 動脈壓脈搏(VHD只牽涉到AV)
   1. AS: Pulsus tardus, Pulsis parvus(搏動有阻力)
   2. AR: Pulsus bisferiens, Bounding pulse(Water-Hammer)
   3. HCM: Pulsus bisferiens
   4. Cardiac temponade: Pulsus paradoxus(吸氣時, SBP↓>10mmHg, 因為右心回血↑壓迫到左心)
   5. HF: Pulsus alternance (累了... 一快一慢)

AR("彈跳"的瓣膜)	AS	MR	MS
BP: 150/40mmHg(Pulse presure widening)
S1: softHigh pitch diastolic murmur in RUSB/LUSB=> 加強: 呼氣 蹲踞, 手握拳, 前傾Austin-Flint murmur: Diastolic mumur(AR jet與Mitral flow互相干擾)	S1: loud; S2: Reverse split; S4High pitch systolic murmur in RUSB=> 加強: 呼氣 蹲踞, 手握拳; 減弱: 吸氣 站立, Valsava	S1: soft; S2: Wide splitHigh pitch systolic murmur in LLSB=> 加強: 呼氣 蹲踞, 手握拳	S1: loudLow pitch diastolic murmur in LLSB=>加強: 呼氣 蹲踞, 手握拳, 左側躺; 減弱: 吸氣 站立, ValsavaOpening snap: Severity↑, A2/OS間隔越短Rumbling murmur
Pulsus bisferiensBounding pulse(Water-Hammer, Corrigan's sign)Fermoral a.a(1) Doroziez's sign: to-and-fro pulse(2) Pistol shot sound: 手槍音(3) Traube's sound: double soundde Masset's sign: 頭會跟著beat點頭Muller's sign: uvula會跟著搏動Quincke's pulse: 指甲床可見搏動	Pulsus tardusPulsus parvus

**ASD: Fixed S2 split, Systolic murmur

**PDA: Continuous machinery murmur