简介
"Despite the fact that more than half the patients seekingcare from an internal medicine specialist or a family physician will have either a primary or secondary cardiac problem, the teaching of cardiac auscultation, the physical examination of the heart, has been deteriorating since the advent of such modern diagnostic tools as 2D echocardiography and nuclear imaging. In The Art and Science of Cardiac Physical Examination: With Heart Soundsand Pulse Wave Forms on CD, veteran academic clinicians bring the art and science of cardiac physical examination to the bedside with a tour de force tutorial on techniquesneeded to elicit various physical signs and to interpret them in relation to the patient's symptoms and underlying cardiac condition. Drawing on twenty-five years of teaching and training physicians and physicians-to-be, theauthors integrate the physiology, pathophysiology, and mechanisms behind the various physical signs with a thorough and easy-to-use practical approach that makes a physician feel more comfortable and competent performing the cardiac physical examination. The authors pay particular attention to the interpretation of the jugular venous pulsations and contour and make the physiology and pathophysiology of the normal and abnormal arterial pulse interesting and relevant. They also clarify the apical impulse and its importance. Local and systemic manifestations relevant to cardiac diagnosis are also emphasized and illustrated. A unique and original companion video CD presents close to 140 clinical examplestaken from actual patients, complete with audio recordingsof various heart sounds and murmurs displayed in real timeas seen on an oscilloscope. Additional video recordings show both precordial pulsations and jugular pulsations from patients with a variety of cardiac lesions, and illustrate certain unusual clinical conditions through simultaneous echocardiographic images and recordings of heart sounds and murmurs."--BOOK JACKET.
目录
Preface p. vii
Acknowledgment p. x
Companion CD p. xv
Color Plates p. xvii
Approach to the Physical Examination of the Cardiac Patient p. 1
Reasons for Which Cardiac Assessment Is Sought p. 2
Cardiac Symptoms and Their Appraisal p. 2
Generation of Working List of Possible Diagnoses p. 4
Focused Physical Examination: Clinical Exercise p. 6
Focused Physical Examination: Practical Points p. 14
Arterial Pulse p. 15
Physiology of the Arterial Pulse p. 15
Assessment of the Arterial Pulse p. 34
Practical Points in the Clinical Assessment of the Arterial Pulse p. 44
References p. 46
Blood Pressure and its Measurement p. 49
Physiology of Blood Flow and Blood Pressure p. 49
Physiology of Blood Pressure Measurement p. 50
Points to Remember When Measuring Blood Pressure p. 52
Factors That Affect Blood Pressure Readings p. 53
Interpretation of Blood Pressure Measurements p. 54
Use of Blood Pressure Measurement in Special Clinical Situations p. 56
References p. 64
Jugular Venous Pulse p. 67
Normal Right Atrial Pressure Pulse Contours p. 68
Jugular Venous Inflow Velocity Patterns and the Relationship to the Right Atrial Pressure Pulse p. 70
Jugular Venous Flow Events and Their Relationship to Jugular Venous Pulse Contours p. 74
Normal Jugular Venous Pulse Contour and Its Recognition at the Bedside p. 81
Individual Components of the Right Atrial Pressure Pulse, Their Determinants, and Their Recognition in the Jugulars p. 82
Abnormal Jugular Venous Pulse Contours as Related to Abnormal Jugular Venous Flow Velocity Patterns p. 92
Abnormal Jugular Contours p. 96
Assessment of Jugular Venous Pressure p. 105
Clinical Assessment of the Jugular Venous Pulse p. 107
References p. 110
Precordial Pulsations p. 113
Mechanics and Physiology of the Normal Apical Impulse p. 113
Physical Principles Governing the Formation of the Apical Impulse p. 115
Normal Apical Impulse and Its Determinants p. 118
Assessment of the Apical Impulse p. 120
Left Parasternal and Sternal Movements p. 133
Right Parasternal Movement p. 134
Pulsations Over the Clavicular Heads p. 134
Pulsations Over the Second and/or Third Left Intercostal Spaces p. 135
Subxiphoid Impulse p. 135
Practical Points in the Clinical Assessment of Precordial Pulsations p. 136
References p. 138
Heart Sounds p. 141
Principles of Sound Formation in the Heart p. 141
First Heart Sound (S1) p. 142
Clinical Assessment of S1 and Components p. 156
Second Heart Sound (S2) p. 158
Normal S2 p. 159
Abnormal S2 p. 162
Clinical Assessment of S2 p. 174
Opening Snap (OS) p. 179
Third Heart Sound (S3) p. 185
Clinical Assessment of S3 p. 198
Fourth Heart Sound (S4) p. 200
Clinical Assessment of S4 p. 204
References p. 206
Heart Murmurs: Part I p. 211
Principles Governing Murmur Formation p. 211
Hemodynamic Factors and Cardiac Murmurs p. 214
Frequencies of Murmurs p. 214
Grading of Murmurs p. 216
Systolic Murmurs p. 216
Ejection Murmurs p. 217
Regurgitant Systolic Murmurs p. 232
Mitral Regurgitation p. 233
Tricuspid Regurgitation p. 253
Ventricular Septal Defect (VSD) p. 258
Clinical Assessment of Systolic Murmurs p. 265
References p. 269
Heart Murmurs: Part II p. 275
Diastolic Murmurs p. 275
Diastolic Murmurs of Mitral Origin p. 275
Diastolic Murmurs of Tricuspid Origin p. 282
Semilunar Valve Regurgitation p. 283
Aortic Regurgitation p. 283
Pulmonary Regurgitation p. 290
Clinical Assessment of Diastolic Murmurs p. 292
Continuous Murmurs p. 294
Persistent Ductus Arteriosus p. 296
Aorto-Pulmonary Window p. 298
Sinus of Valsalva Aneurysm p. 298
Coronary Arteriovenous Fistulae p. 299
Venous Hum p. 300
Mammary Souffle p. 300
Clinical Assessment of Continuous Murmurs p. 300
Pericardial Friction Rub p. 302
Innocent Murmurs p. 303
References p. 304
Elements of Auscultation p. 309
The Stethoscope p. 309
Auscultation Method p. 310
References p. 318
Pathophysiological Basis of Symptoms and Signs in Cardiac Disease p. 321
Pathophysiology of Mitral Regurgitation p. 321
Pathophysiology of Aortic Regurgitation p. 325
Pathophysiology of Mitral Stenosis p. 329
Pathophysiology of Aortic Stenosis p. 331
Pathophysiology of Myocardial Ischemia/Infarction p. 334
Pathophysiology of Hypertensive Heart Disease p. 336
Pathophysiology of Dilated Cardiomyopathy p. 338
Pathophysiology of Hypertrophic Obstructive Cardiomyopathy p. 340
Pathophysiology of Atrial Septal Defect p. 342
Pathophysiology of Diastolic Dysfunction p. 345
Pathophysiology of Constrictive Pericarditis p. 347
Pathophysiology of Cardiac Tamponade p. 348
Appendix p. 351
References p. 356
Local and Systemic Manifestations of Cardiovascular Disease p. 361
General Observations p. 361
Congenital Syndromes/Diseases p. 364
Vascular Diseases p. 369
Valvular Heart Disease p. 372
Endocrine and Metabolic Diseases p. 373
Inflammatory Diseases p. 377
Diseases of Connective Tissue and Joints p. 377
Pharmacological Agents p. 381
Musculoskeletal Diseases p. 384
Tumors p. 386
Synopsis p. 386
Acknowledgment p. 390
References p. 390
Index p. 397
About the Authors p. 413
Acknowledgment p. x
Companion CD p. xv
Color Plates p. xvii
Approach to the Physical Examination of the Cardiac Patient p. 1
Reasons for Which Cardiac Assessment Is Sought p. 2
Cardiac Symptoms and Their Appraisal p. 2
Generation of Working List of Possible Diagnoses p. 4
Focused Physical Examination: Clinical Exercise p. 6
Focused Physical Examination: Practical Points p. 14
Arterial Pulse p. 15
Physiology of the Arterial Pulse p. 15
Assessment of the Arterial Pulse p. 34
Practical Points in the Clinical Assessment of the Arterial Pulse p. 44
References p. 46
Blood Pressure and its Measurement p. 49
Physiology of Blood Flow and Blood Pressure p. 49
Physiology of Blood Pressure Measurement p. 50
Points to Remember When Measuring Blood Pressure p. 52
Factors That Affect Blood Pressure Readings p. 53
Interpretation of Blood Pressure Measurements p. 54
Use of Blood Pressure Measurement in Special Clinical Situations p. 56
References p. 64
Jugular Venous Pulse p. 67
Normal Right Atrial Pressure Pulse Contours p. 68
Jugular Venous Inflow Velocity Patterns and the Relationship to the Right Atrial Pressure Pulse p. 70
Jugular Venous Flow Events and Their Relationship to Jugular Venous Pulse Contours p. 74
Normal Jugular Venous Pulse Contour and Its Recognition at the Bedside p. 81
Individual Components of the Right Atrial Pressure Pulse, Their Determinants, and Their Recognition in the Jugulars p. 82
Abnormal Jugular Venous Pulse Contours as Related to Abnormal Jugular Venous Flow Velocity Patterns p. 92
Abnormal Jugular Contours p. 96
Assessment of Jugular Venous Pressure p. 105
Clinical Assessment of the Jugular Venous Pulse p. 107
References p. 110
Precordial Pulsations p. 113
Mechanics and Physiology of the Normal Apical Impulse p. 113
Physical Principles Governing the Formation of the Apical Impulse p. 115
Normal Apical Impulse and Its Determinants p. 118
Assessment of the Apical Impulse p. 120
Left Parasternal and Sternal Movements p. 133
Right Parasternal Movement p. 134
Pulsations Over the Clavicular Heads p. 134
Pulsations Over the Second and/or Third Left Intercostal Spaces p. 135
Subxiphoid Impulse p. 135
Practical Points in the Clinical Assessment of Precordial Pulsations p. 136
References p. 138
Heart Sounds p. 141
Principles of Sound Formation in the Heart p. 141
First Heart Sound (S1) p. 142
Clinical Assessment of S1 and Components p. 156
Second Heart Sound (S2) p. 158
Normal S2 p. 159
Abnormal S2 p. 162
Clinical Assessment of S2 p. 174
Opening Snap (OS) p. 179
Third Heart Sound (S3) p. 185
Clinical Assessment of S3 p. 198
Fourth Heart Sound (S4) p. 200
Clinical Assessment of S4 p. 204
References p. 206
Heart Murmurs: Part I p. 211
Principles Governing Murmur Formation p. 211
Hemodynamic Factors and Cardiac Murmurs p. 214
Frequencies of Murmurs p. 214
Grading of Murmurs p. 216
Systolic Murmurs p. 216
Ejection Murmurs p. 217
Regurgitant Systolic Murmurs p. 232
Mitral Regurgitation p. 233
Tricuspid Regurgitation p. 253
Ventricular Septal Defect (VSD) p. 258
Clinical Assessment of Systolic Murmurs p. 265
References p. 269
Heart Murmurs: Part II p. 275
Diastolic Murmurs p. 275
Diastolic Murmurs of Mitral Origin p. 275
Diastolic Murmurs of Tricuspid Origin p. 282
Semilunar Valve Regurgitation p. 283
Aortic Regurgitation p. 283
Pulmonary Regurgitation p. 290
Clinical Assessment of Diastolic Murmurs p. 292
Continuous Murmurs p. 294
Persistent Ductus Arteriosus p. 296
Aorto-Pulmonary Window p. 298
Sinus of Valsalva Aneurysm p. 298
Coronary Arteriovenous Fistulae p. 299
Venous Hum p. 300
Mammary Souffle p. 300
Clinical Assessment of Continuous Murmurs p. 300
Pericardial Friction Rub p. 302
Innocent Murmurs p. 303
References p. 304
Elements of Auscultation p. 309
The Stethoscope p. 309
Auscultation Method p. 310
References p. 318
Pathophysiological Basis of Symptoms and Signs in Cardiac Disease p. 321
Pathophysiology of Mitral Regurgitation p. 321
Pathophysiology of Aortic Regurgitation p. 325
Pathophysiology of Mitral Stenosis p. 329
Pathophysiology of Aortic Stenosis p. 331
Pathophysiology of Myocardial Ischemia/Infarction p. 334
Pathophysiology of Hypertensive Heart Disease p. 336
Pathophysiology of Dilated Cardiomyopathy p. 338
Pathophysiology of Hypertrophic Obstructive Cardiomyopathy p. 340
Pathophysiology of Atrial Septal Defect p. 342
Pathophysiology of Diastolic Dysfunction p. 345
Pathophysiology of Constrictive Pericarditis p. 347
Pathophysiology of Cardiac Tamponade p. 348
Appendix p. 351
References p. 356
Local and Systemic Manifestations of Cardiovascular Disease p. 361
General Observations p. 361
Congenital Syndromes/Diseases p. 364
Vascular Diseases p. 369
Valvular Heart Disease p. 372
Endocrine and Metabolic Diseases p. 373
Inflammatory Diseases p. 377
Diseases of Connective Tissue and Joints p. 377
Pharmacological Agents p. 381
Musculoskeletal Diseases p. 384
Tumors p. 386
Synopsis p. 386
Acknowledgment p. 390
References p. 390
Index p. 397
About the Authors p. 413
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