Essentials of Bedside Cardiology CONTEMPORARY CARDIOLOGY CHRISTOPHER P. CANNON, MD SERIES EDITOR Aging, Heart Disease and Its Management: Facts and Controversies, edited by Niloo M. Edwards, MD, Mathew S. Maurer, MD, and Rachel B. Wellner, MD, 2003 Peripheral Arterial Disease: Diagnosis and Treatment, edited by Jay D. Coffman, MD, and Robert T. Eberhardt, MD, 2003 Essentials ofBedside Cardiology: With a Complete Course in Heart Sounds and Munnurs on CD, Second Edition, by Jules Constant, MD, 2003 Primary Angioplasty in Acute Myocardial Infarction, edited by James E. Tcheng, MD,2002 Cardiogenic Shock: Diagnosis and Treatment, edited by David Hasdai, MD, Peter B. Berger, MD, Alexander Battler, MD, and David R. Holmes, Jr., MD, 2002 Management of Cardiac Arrhythmias, edited by Leonard I. Ganz, MD, 2002 Diabetes and Cardiovascular Disease, edited by Michael T. 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Cannon, MD, 1999 Essentials of Bedside Cardiology WITH A Complete Course in Heart Sounds and Murmurs on CD SECOND EDITION Jules Constant, MO, FACC Clinical Associate Professor of Medicine State University of New York at Buffalo School of Medicine Buffalo, NY Humana Press *- Totowa, New Jersey © 2003 Humana Press Inc. Softcover reprint of the hardcover 1 st edition 2003 999 Riverview Drive, Suite 208 Totowa, New Jersey 07512 www.humanapress.com All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the Publisher. The content and opinions expressed in this book are the sole work of the authors and editors, who have warranted due diligence in the creation and issuance of their work. The publisher, editors, and authors are not responsible for errors or omissions or for any consequences arising from the information or opinions presented in this book and make no warranty, express or implied, with respect to its contents. Due diligence has been taken by the publishers, editors, and authors of this book to assure the accuracy of the information published and to describe generally accepted practices. The contributors herein have care­ fully checked to ensure that the drug selections and dosages set forth in this text are accurate and in accord with the standards accepted at the time of publication. Notwithstanding, since new research, changes in government regulations, and knowledge from clinical experience relating to drug therapy and drug reactions constantly occur, the reader is advised to check the product information provided by the manufacturer of each drug for any change in dosages or for additional warnings and contraindications. This is of utmost importance when the recommended drug herein is a new or infrequently used drug. It is the responsibility of the treating physician to determine dosages and treatment strategies for individual patients. Further, it is the responsi­ bility of the health care provider to ascertain the Food and Drug Administration status of each drug or device used in their clinical practice. The publishers, editors, and authors are not responsible for errors or omissions or for any consequences from the application of the information presented in this book and make no warranty, express or implied, with respect to the contents in this publication. This publication is printed on acid-free paper. ® ANSI Z39.48-1984 (American National Standards Institute) Permanence of Paper for Printed Library Materials. Cover design by Patricia F. Cleary. 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The fee code for users of the Transactional Reporting Service is: [1-58829- 142-1/03 $20.00]. 10987654321 Library of Congress Cataloging in Publication Data Additional material to this book can be downloaded from http://extras.springer.com. Constant, Jules, 1922- Essentials of bedside cardiology: with a complete course in heart sounds and murmurs on CD 1 by Jules Constant.--2nd ed. p. ; cm. -- (Contemporary cardiology) Rev. ed. of: Essentials of bedside cardiology for students and house staff. 1st ed. c1989. Includes bibliographical references and index. ISBN 978-1-4684-9754-0 ISBN 978-1-59259-338-5 (eBook) DOI 10.1007/978-1-59259-338-5 I. Heart--Examination. 2. Heart--Diseases--Diagnosis. 3. Heart--Sounds. 4. Medical history taking. I. Constant, Jules, 1922- Essentials of bedside cardiology for students and house staff. II. Title. III. Contem­ porary cardiology (Totowa, N.J. : Unnumbered) [DNLM: I. Heart Diseases--diagnosis. 2. Heart Sounds. 3. Physical Examination. WG 141 C757ea 2002] RC683.C593 2002 616.1'2--dc21 2002190222 To Elizabeth my wife, without whom this book might never have been published Preface Essentials of Bedside Cardiology, Second Edition, like the first edition, is designed for those who wish to balance technological advances with increased personal skill in history taking and physical examination. It is important to teach physicians that all technologies now in use for diagnosing cardiovascular disorders, such as echocardiography, can have false positive and false negative results. It is not always wise to rely on these technologies alone; indeed, they may not even be available in some settings. Even when the full panoply of up-to-date techniques is at the physician's disposal, the patient may not be a good candidate for an echocardiogram, or the technician or reader may not be well qualified, or the equipment itself may be substandard. Technology must be combined with physical examination to decide what is true and what is false. The practice of expert history taking and physical examination returns the physician to the actual patient, where the physician can feel like a "real doctor" rather than a mere interpreter of laboratory data. Essentials of Bedside Cardiology, Second Edition, strives to teach and not simply to tell the facts, relying on three basic methods derived from the psychology of teaching and learning: 1. Explain the facts. 2. Use a question and answer format-the Socratic method. 3. Provide tricks or mnemonics to help the reader remember the facts. The value of the Socratic method is its ability to focus attention and stimulate thinking. The format of Essentials of Bedside Cardiology, Second Edition, supports this goal by allowing the reader to cover up the answer and so use the book as a programmed learning tool. A demonstration of all the heart sounds and murmurs with detailed explanations of what is being heard is provided on the enclosed CD. No simulators have been used. In addition, the use of phonocardiograms and pulse tracings for teaching is encouraged throughout the text. vii viii Preface The index also is a learning tool, having been compiled by me, based on 40 years of teaching experience, with the goal of efficiently guiding the reader to the information needed. The glossary, too, is designed for all levels of readers, constituting a virtual encyclopedia of terms for the cardiologist, student, and noncardiologist alike. Terms that are fully explained in the glossary are typeset in boldface throughout the text as one more pedagogical aid. Essentials of Bedside Cardiology, Second Edition, is the only book that teaches how to recognize normal jugular waves using updated terminology, how to measure jugular pressure accurately, how to record auscultation findings with an auscultogram, how to tell cardiac function by the blood pressure cuff and Val salva method, how to diagnose cardiomegaly on an X -ray without using the outdated cardiothoracic ratio, and how to tell whether the apex beat is due to the right or left ventricle. It also gives the latest explanation for the changing loudness of the first heart sound with changing P-R intervals and updates methods for recording and taking an accurate blood pressure. lules Constant, MD, FACC Contents Preface .......................................................................................