A site for medical students - Practical,Theory,Osce Notes

What is Gallop rhythm

3 sounds heard during each cardiac cycle produce triple rhythm

Triple rhythm with sinus tachycardia produce Gallop rhythm imitating the sounds of galloping horse.
LV S3 gallop - is an important auscultatory sign of Left ventricular failure.
LVS3 is a sign of systolic dysfunction of ventricle.
Early S3 is heard in RVEMF -this is due to sudden limitation of ventricular filling.
Pericardial knock - An early S3 in constrictive pericarditis as in RV EMF.

S3 gallop is common in:
  1. Dilated cardiomyopathy.
  2. Decompensated aortic valve disease.
  3. Decompensated hypertensive heart disease.
RV S3 is always pathological
It is heard at LLSB.
Inspiratory augmentation is  present.
This is  associated with tricuspid regurgitation.
Atrial gallop S1,S2, S4
Ventricular gallop S1, S2, S3

Quadruple Rhythm
Quadruple rhythm is the presence of 4 heart sounds
(S1, S2, S3 and S4).

Summation Gallop
Summation is the presence of S1,S2 with merged S3 and S4

Causes of Striae over the abdomen

Striae is due to stretching of the abdominal wall that is severe enough to cause rupture of the elastic fibres in the skin and produces pink linear marks with a wrinkled appearance indicates recent change in the size of abdomen.

Striae types:
White striae or striae albicans  is seen in 

  • Obese persons who lost weight suddenly
  • Following pregnancy 
  • Relieving ascites
Purple striae usually represent the rupture of subepidermal connective tissue seen in
  • Recent or past abdominal distension
  • Cushing's syndrome
  • Prolonged steroid therapy
Broad silvery lines (striae gravidarum) are seen after repeated pregnancies.

Types of continuous murmur

 Continuous murmur with cyanosis

  • TOF with PDA
  • Pulmonary atresia with bronchopulmonary anastomoses
  • Pulmonary AVF
Continuous murmur with systolic > diastolic component
  • PDA
  • Peripheral Pulmonaryartery stenosis
  • Broncho pulmonary anastomoses
Continuous Murmurs with Diastolic Accentuation
  • Rupture of sinus of Vakalva (RSOV)
  • Coronary arteriovenous fistula
  • Anomalous origin of left coronary artery from pulmonary artery (ALCAPA)
  • Pulmonary arteriovenous fistula

Inspection for shape and movement of the chest

Looking from above (standing behind the patient), over the shoulders or the upper part of the chest.If standing or sitting is not possible for the patient, inspect the chest in Iying down position, patient lies absolutely straight in the bed in supine position) inspect from the

  • Top.
  • Foot end of the bed.
  • The sides in profile.
  • Head end.
  • Back (try to turn the patient to any one side).
The following are the points to note :
  1. Any deformity, fullness or depression (i.e. shape of the chest), apical impulse etc.
  2. Back (winging of the scapula, drooping of the shoulder, kyphoscoliosis, gibbus. skin changes).
  3. Whether both the sides of the chest arc moving simultaneously and symmetrically.
  4. Classically  winged scapula is found in paralysis of nerve to serratus anterior (C 6 ,7) and sometimes in facio-scapulo-humeral muscular dystrophy.
  5. Assessment of the expansion of the upper lobes is better achieved by inspection
  6. From behind the patient, looking down at the clavicles during moderate respiration.
  7. Equal on both sides - normal
  8. Reduced movement on one side -  pleural disease ,pulmonary disease
  9. Bilaterally reduced movement - in emphysema.

History taking in cardiovascular disorders

Presenting symptoms in chronological order include
  1. Dyspnoea
  2. Palpitation
  3. Chest pain
  4. Cyanosis
  5. Edema
  6. Syncopal attack
  7. Cough and hemoptysis
  8. Fatigue.
History of Presenting complaint
  1. Detailing of each symptom
History of past illness
  1. Enquire about the presence of Diabetes mellitus, Dyslipidemia Hypertension etc.
  2. Rheumatic fever
  3. Sexually transmitted diseases
  4. Other illness.
Family history
  1. Hypertension
  2. CAD
  3. Diabetes mellitus
  4. Obesity
  5. Rheumatic and congenital heart disease
  6. Dyslipidemia.
Personal history
  1. Alcoholism
  2. Smoking
  3. Occupation
  4. Exercise
  5. Diet
Treatment history
  1. Drugs fo - CAD.hypertension,
  2. Diabetes mellitus dyslipidemia.

Causes of fourth heartsound

 LV S4  causes

  1. Systemic hypertension
  2. AS (left ventricular hypertrophy)
  3. LV myocardial infarction
RVS4  causes
  1. Pulmonary hypertension
  2. Pulmonary stenosis (Right Ventricular hypertrophy)
  3. RV myocardial infarction.
Features of RVS4
  1. Heard at LLSB
  2. Inspiratory augmentation present
  3. Associated with  a wave in JVP
  4. Seen in PAH and pulmonary stenosis
Triple rhythm

Quadruple rhythm
S1,S2 + S3 + S4.

Seen In:
  • Cardiomyopathy
  • Coronary artery disease
Summation gallop
S, S3 with merged S, & S4.

Causes of pathological S4
  1. Hypertrophic cardiomyopathy
  2. Systemic hypertension
  3. Coronary artery disease
  4. Myocardial infarction
  5. Ventricular aneurysm.
S3 -Ventricular distension sound.
S4 -Atrial contraction sound.

LV : Left Ventricular
AS : Aortic Stenosis
RV : Right Ventricular

S1 - First Heart Sound
S2 - Second Heart Sound
S3 - Third Heart Sound
S4 - Fourth Heart Sound

Assessment of position of Trachea

Trail's sign

Shift of trachea produces prominence of sternal head of sternocleidomastoid on the side to which the trachea is shifted. It is called Trail's sign.

The pretracheal fascia encloses the clavicular head of stemomastoids muscle on both sides. When the trachea is shifted to one side, the pretracheal fascia covering the stemomastoid muscle on that side relaxes, producing the clavicular head more prominent on the side of tracheal deviation.

Causes of tracheal shift

Pleural disease - Shift to opposite side
  • Pleural effusion
  • Pneumothorax
Pulmonary disease-Shift to same side
  • Fibrosis and collapse of lung
Goiter - Shift of trachea to opposite side.

Position of the Trachea and Trail's sign