ࡱ> }~`!F ǮZ^Ef9w3kMJ0Z0J xYs^Ɏ3iRihU(m%%ZFrbJr[h@RCo=4xrL/=䐿^z!}.!2G}{{c1vky9eq`t(vloQ_8]y*<}Ms,wo19vqls^ۀkx[hyl=ѕq緜 H<QC]?XbE/1>KL8̢ ˱<|n 2pU-X;˄#t^'+_YBFŕm%ZԼl<=zp8:ѠCiC0T2N3_Vavm+M/?7hoNYe}I4_> _вrl'8Gu] [}[ץ0/;4*^&m@!⃾Thu˓H߳zO̓&y5ӽsW%cݫ{Gm~}/'|u.?, <8ȄZ[gw=$vz_!.AV8^*@;~e!c爩9g|o<) ]%{5jqnLsfN<+_h9I%IQ)~k81oVߏB~O\>HtEy@ A ^(% *Bo (W󪼲65) =Dږl\I,x4C囎PYy6=hkre=.օn.aƑ*E2PNG  IHDR_^r_sRGB pHYs.> IDATx^O5 #xf ـî!` @ VmNrnI77Pt 9Y>f,A4 v!W55=ӣQij}_ս_r/Go)A-:e﮶>ol]y}t+{Hj?|t~?֙ӿ=zTkmWfhex[zFOmZ/H+o "+E4ǾGg0'sšj^otD \ Vngf?n?|(.:>ܬ$NΫ":yhIkXfs:2UGs3ޫ⋔~[CgR2oVv%({6fq# ܲzHZ2 1[uQ@OہV^j &/ o?x`}U S7̐JGTIœqɚm |t|aʘ+K{2e &vO͓w^fXq3R}00ٸpxJ_F t-.vI)ɄOrK@)Pƽ՛_Zp8, NNIde]^D:X|5&fq-a@GO tFCU]b6+:o]y~t4ϘPkLS1ՖMК"Rs3OCtdԕ)E[vHFK7Dy dgQ!lKw; GҀx:Ί|FG2̣\Y$|=t&er[:.JBFvJ'֥25Qaʭ BZ=Lz*:ʥA}T,\VKyR)$tndeDվĦ^a$tXY N+Xe"V 1а!gWb A< dL[f\OYZr0*\S mzJ3e:%glU:I^Cc4g|]&u_:Щ(q4hL:Mk9%d>q$6&ʶ$*H»WR|H" F#qt,Zv>ݥP}գAΉ St4 hZA'hZj`8$ŋAVW nȸZT@GD $+%JZД.e)_}{&ЉB`H[X8XWI"h8߬pW׬5HSZ)<\ڑt9=_>5Rwt\B?ru9=~''}wܣ;܇ 󳟯؝ ͋Ýkgxv|o~ ORf'Ĭ[b>{,aD|GyQڜyGZP# m;f,?U I{iKڌ0R;/yYiŒ?(1+ZF܊ [7RVF &n"/M;un:CYL@ B:(3^HgKvB|ndze>ShM[ Ll Ҭ7>4S b FUIQ-=9b7;bUdgњFǙ˧|wBA=檦ugLT7K-Tp"mVZ0[*,.R6U&qPs)hr2YJ3Cߘ@AcHJϯޓUج|V SbUpp_}T$@ (?^rL!eiXp;A.3 ~v9F˨H/y: T?l x}W O_}cF<$".J;\āx?#3mf2cTP!*]R$JJHswx|=^kk6B><< 9%RRxhUTZ9%K =ʗyNT度fF-]A6*+.gaU^ P4yRM!e,)i*SdJ|MesVR]Fa%Un/n<7ړ.F8T'C8c?؇;Mh>JZ i5֡\ 5hq ^|:n4\sd8Sqb0#p vI'bsw d xR,q"x!8k7Nc&t0 e\l;L m1ֶ޶v`;[ﵕv ^k.E=|cAs 4䘳i.AѐdN0q_4-y7q~x5L,*Wx>ÓA,p_ۂtU$h *7v,⡠k${ʶ~1K0ŬY&g8tsW[(41J74&x4I̠lePE3* FЮ` m "z+hMk·Һ\{,÷x]k귦KsAgBh'$ZBK)4O('R_~YT_@ rU:gMu5>3q~w莼Awl:t4׃8Zzw N':%7uu>ߡwq=}HƧ[PJUmtVtV~ 7U ^- .uX us_gbqۺm1B1nfLCUq(Ցju/FQEO ]()R6֧uX mq :%~YKbg D*(\ſԶZ@j^4XEf VY-ԧ"v @ʆ)=,NKԯH8]0>c ~&u΃/;gWx}%|SE+n?gV̈́4S 8N8#:` ' ^,M "l [(yH&w~Пc!D y1U0 |*N&8dS:NBGy!td2lz Rڊ쩊:G9zZW5 QXՑhC* T4R1tDGHC Q/½AF^{hNU4+i<һy]x7cQMo&?燽4ns-/IJ*WnZky>dtXS$8Q<:H7.Sk) 2h:L?0Z q єQ" ,)y-°hcY_mci>.wKJu*9,L䫘$/ᛸs$KWa Db=y͖=|y#n;ˍr-#Y3ܬ>\f+0TVR^$oY껽A"Pȕҝw"  ЩIs>xWy|O׶?{Zks4ZT QZUUEQXRcUUS W Tc$HLADd!!"BjܾwYk}ޫܲ^|ZyqdߋNO!#X[Q`3(   !3Bitmap Image Paint.Picture0Bitmap Image03Clip (MS_ClipArt_Gallery.20,Microsoft Clip Galleryhttp://130.14.32.45/cgi-bin/VERSION_B/IGM-client?12653+records+810Z/Document Word.Document.80.Microsoft Word Document/ 0LDTimes New Roman$63bb0bWo 0 ` .  @n?" dd@  @@``  P$IJ !    `$2$2$2$2$22$ǮZ^Ef9w3kMN 2b$aƑ*E26N 22$껽A"Pȕҝw 2c $@{uʚ;2Nʚ;g4CdCd0b ppp@ <4!d!d 0b73b<4dddd 0b73b<4BdBd 0b73b ? %i Palpation  6Feel for diagnosis ( Palpation 0By the time you put stethoscope to chest you should know what you are going to hear If you don t hear what you expect,explain it (Palpation-PulsesRhythm, rate, regularity Contour Water hammer pulse-AR Brachial-radial delay AS Pulsus paradoxus Tamponade COPD Pulsus alternans LV dysfunction\aZZZZa,P Carotid ExaminationCarotid upstroke brisk, normal or delayed bisferiens or anacrotic volume: normal, increased or decreased Carotid auscultation Bruit Transmitted murmur A2 audible in neck? Presence excludes severe AS YIY -,+  ! Palpation - Precordium KParasternal: Palpable P2-pulmonary HTN Thrill VSD/HCM RV lift RVH Severe MR   "Precordium-PalpationParasternal Lift: RVE or severe MR Thrill: VSD, HOCM (IHSS) Palpable P2 (ULSB): pulmonary hypertension Medial retraction LVE Lateral retraction RVE #Palpation - ApexApex: Palpable in 1 of 5 adults age 40 Best felt with fingertips or finger pads Normal Location: No more than 10 cm from mid-sternal line in the supine position Left decubitus position not reliable for apical location Normal Size: No larger than 3 cm (about 2 finger breadths) ZJZZzZ Z/ZZZ J / i$Apex-Dynamic QualitiesLV impulse outward movement like a ping pong ball were protruding between the ribs Apex moves outward for the first third of systole and falls away rapidly Lasts for no more than 2/3 of systole%4Apex Dynamic Abnormalities(Sustained Apex: correlates with pressure overload ( > 2/3 systole-hangs out to S2) AS, LVH or LV systolic dysfunction Hyperdynamic Apex: correlates with volume overload AR/MR palpable S4 (atrial kick) palpable S1 (MS) palpable non-ejection click (MVP) ZgZZsZZZ!&4Apex Dynamic Abnormalities(oAtrial kick: Palpable S4 Loss of LV compliance LVH 2o Hypertension Aortic Stenosis Hypertrophic Cardiomyopathy f  V : 'Non-invasive ejection fractionxPalpable S4/ apex not sustained EF > 50% Palpable S4/ Apex sustained EF 40-50% S4 not palpable/ Apex sustained EF < 40% X    y!(Non-invasive ejection fraction/"#$%&'p  ` ` ̙33` 333MMM` ff3333f` f` f` 3>?" dd@,|?" dd@   " @ ` n?" dd@   @@``PR    @ ` ` p>> rj (    N8j1 ))?"` 1 T Click to edit Master title style! !$  01 " 1 RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S  01 "`` 1 >   0  "`  1 >   0 "`  0 ^*  T32 @1?"`  T  @1?"x   <A ??"`X n   c $A ??"- B  s *޽h ? ̙33 THow to Examine the Heart Website Slideshow 0 zr (    0X* P   * P*    0*    * R*  d  c $ ?  *  0*  @ * RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S  6X* `P  * P*    6 * `  * R*  H  0޽h ? ̙33 z(  x  c $d*p * x  c $*p`   *   N* ))?` \0 H  0޽h ? ̙33  0(  x  c $`   x  c $\*  H  0޽h ? ̙33  6(  ~  s **`  * x  c $/* * H  0޽h ?   6(  ~  s *1`  1 x  c $1 1 H  0޽h ?   <(  ~  s **`  * ~  s *01 * H  0޽h ?   06(  ~  s *1`  1 x  c $L1 1 H  0޽h ?   P6(  x  c $*`  * ~  s *1 @ * H  0޽h ? ̙33  `0(  x  c $10  1 x  c $\0 1 H  0޽h ? ̙33n  p (   ~   s * 0      0e0e ))?`   H   0޽h ? ̙33  0(  x  c $ 0`   x  c $t%0 0 H  0޽h ? ̙33  qi(  ~  s *g00   0 x  c $D0 0   <pk01?  9TITLE: The apical impulse in coronary heart disease. AUTHORS: Ranganathan N; Juma Z; Sivaciyan V SOURCE: Clin Cardiol 1985 Jan;8(1):20-33 0` Z=     </1? @  Bhttp://130.14.32.45/cgi-bin/VERSION_B/IGM-client?12653+records+81 C 2C 0AH  0޽h ?   0(  ~  s *0/`  / r  6A ?1?  H  0޽h ?  0 4(  d c $   1 s *ȑ1 @  1  H  0޽h ? ̙33  0 4(  d c $   1 s *81 @  1  H  0޽h ? ̙33! 0  4(  d c $   1 s *1 @  1  H  0޽h ? ̙33" 0 @4(  d c $   1 s *P1 @  1  H  0޽h ? ̙33' 0 4(  d c $   0 s *E۟v}s$"y$H$9KCH~Dc#)H&9Or$ϐ\$ɳ$-6$#(El(,U?.۝6.6Ri tԥQ*J|T_b&f"c![*vWV>[M̿҈Hٚ4Mmi>ɭc]41(ΩT6(xXi u>ؔF;`e՞WؽZK(]c=CrbRDQ&m^LNr0gDI(,#fGF8I{p(gEOMc5A|`i RC[кG }[it.o;,=[+QYME1lxl`ӵ'hDjM|TAt%BĮ? &Qe#_&Kc8J+(<9Ih!>r2;ߣˀE[˃F; aФ`k?KRk 嵣.[RГbu|l4.^,2%x^SNZ*%QKX)ƈu/bŽj_h^X-bSRQTYlwG՚bWrZ ]VpZIG5+LtfGtoi>XY+5eHs3U8|6u0Er،-D<||d57_ 6`W EwfRdTiGL1CΧ=T R,2YE>RY>Y$.ZTpo8jHѮBl|pmAjQ| 4| rhß!W;/'a"|QGÇCDW}Mll< Ux`C)97G8c) |f0g&-X|`%>y ,#G;'_n8O+ᡝ| 4:!|W=秣~|0|xn_[2OYAfϿt@>³=pq|u,{d#t8L|0p>(k >T>")_'չ'/vSCϧ "ˇgdM OsC|Xm*M|&58\Okjbc|rsLsO CʝχC8o͍R,)>fؤ?< <[h_0>yfG)-EAO$Vzö·'eG͖ )Vӛ|O2!Ay?#?XwOV(g ä,Gn^&"<ؐ{L*nONj{'.O)D)b|$^|7Q8{!P,򢄷mD(oȶ|p>G=;yRNfeOeٯ{c<9־o>Ir{G粋|\옇V;V{àS=:v|3K[74C'O뺇6Msm{h3V .|k%M,p@ň§l~olhHKf2CԅJ2WDҲC.Cہ=lpmѠd ħ馘qm{hsm&Dpm,^*M6:E>R'wmm|P4tm >{hsmЖ{hk3v{hk==c"6===ř{hkmڒtmmqڢ{hkM===%c6C[kj{hKƙ{hk-Kg-YЖ{hkK=c /(C[,qЖ{hk-g-S Ѱ|9{hkBʋ={x3Py>@F|! xytVER/,a4 (""BXfX!aI! !"a_$, jLPEmQDADļj:Nӧg[uWサT>rzI'`0bR2&TS9BeB9\AR CdHy)RC"Ƶԍ-~ֹ!o4 ݋3FM&돁$kOjob&Y7FA_yQ0Zn_javKX~+Y7D`oWj7/@;JP@(qeUP1P{# w !B};pbBcTWh&4Z?Z  mB 06GBMxT%A;% -4nDr)!㒺$􈊏V_1.w/b`ʥc8qzND" ,HH ^NQU(28*IМ"k{ΐIǝx([Ce.5v>.3qMt@٦mmU:XG^rgG/볐*}2 ӵI&8B{aWaxu *8i? xď=@&Q\ťx[⁊q;] _:Tt7jpz.G1Kõ Nw,F p(AO=z9O }?KX:菢~8?N/miXtMW Ge^y DWtkD{m$ ^4}SBG4zӛB;gi7 BNC'֛EQ o VﮣWw7]p7qiKB_ts[)ۓ_sF7Fq;xnwtgn7qW]AqI,7uVnjSf^UTk7^t'&B⾨;T[{P]+@}STS)un? ?؍`ءv|> =t\ݢpWLMzwUnO$n--s]_ ܳ߸^_o$v}N#$?џ*e^Z3(KfgU*=O ?W(PxNL˙~eܯn6-y߯jNy?A&Xn"i0QXljf,Lno'r=جq:df^l _1G:sNo0WuqFsd fl1v3ʼf.3ռkbYn., vg3maH`כ9vYjs mcd^]k~[ξkkgoCz2v8@cZmaC_[Am_>g}r)6ڙgH;lNm.:.;#4؜6b}ڎ)Nwy٧><3{1sqXcĹBLj%w`CyuQceZV!jET |K= N+_pqa+3XU9>k1WMc-K[l-Z|`,pjȄqSe_O}~,Ux9sMGD)Rh̠b`# .S(Ph};C <&\+aożG( uUp27Ér(Ap-O<EBVZFl^5 UoaT8XJ;Z4T5 ū4A)ZFI*h:!FB N9iH1N%8hEM4O)Ye9ٹ>gG:8ܙO:agrIeOL@-巅W^lKJ)j-'Up]>3#*L5RTkMuRmc UU?UF=`uBHϨMVdstRiR9_MCj2SEj.w28Dh^tLygX^DNӝ_s=NSNy~ϹJGalwv83([j':q4ApyOxD-Q"cXV%Ihz]Uij8U4!S{0A-,|T-Ŗj C-X8 ,4'HE[_u6ϗ > = ɛ!_6lX$'B*B$OM]IlW) >ɰm4Vl-?C"XQ"( *!u-*p]Qr'~Ei;$ 9UNܭ) ɩ԰ Ҿ+ԥ|`T<9iMx\,H̨Ha ͗s{:kVK>,7S+V$/}݆,ԺQIAoǨ䔈QI )#ƍHLy_Whh[}E8ʴ??5Yb[㕩;b?BU"/Ψp=!M~*2 Rx\_l3BIJ&bc I">`cG#۽5{RUj!*yT*JH+Uji<4RyRK<$R73MHPVo۽[OjBkVW H(_jaqM _})<5vPUWgA=@A@At3!ào ?t+16v' _/fqTm n[|>h눊KD}]6ŽK?Eƪd֣z{Vn}P4޶ ρ$羕u!n_2U Avo""o㷍"S~߄I3:󎫳 Y^"1x>^O ѧÿ=U4SX zp'D/~iD0?4̑2Xi&*hm4%G?RUhYA[~Fg(~iE| iuY!bfۃNMEekxɠI/I9:A@z&qc;(6Ch4t"k8F̆%ZP^9v&k&Hrj:D: ѶXk,Kw,0̠y3E(bhdM[4&h]Gc&pqD>.wF9DAlO~/*Fl;3bY+tw-[(VaxҚ tݻnb5CY)((((((((((=ǻ+H/_iX,(8t.ZOѧB 7P3B? w7i<[)y)Vȏyos 8N1hǭ;Ȥ3GGXh0l4r f,縎UV44gg$X3cXin:ǎhށ#{wX:̤Mt 'ө68{?<Ey \XP03QWf{f9 4ٮW|iX+\rJ YN, T)LK>tyuYa#f:t`n"&oRXYZk'4"Q\% !bz ļe^BKnrPv};':ZcWs2 1;ve ĀR| 3Ŋ'f*| QcezJݑ0|h)&W e?/mLz2tQjBA98Lavx澳d'S4ƓG&fjטS,ZWk@<]ݾi*( X)ܓʁ^1OV7uuC;V׿ +9Dj.駇#ȹOsWyVcgƶ#z@w[i;5P>9\/?Xi'F123$cn|#\ %OSzWI3ps>"`L d>w 䆚<mJ,N@ٖy.֡1C< 'G/O? R8zMAAAAAAAAAAAAr^x_Pk(;nk~k"5{$O, {Α\ɵ$?2ɽoZu܅GJB9W|=-\FKЖʷ |—іKt/eL2(\ ;u= r yw8Nxx:`Qԏ Mhݔ1L{=n+}8A{E{~ݮpTrl j&0Sw`0m,,/02468:<h?`A)F!H JKMOQv'(   Bi Oh+'0" hp ( H T `lt'Pulses & Precordium Dr J Niznickord\C:\Program Files\Microsoft Office\Templates\Presentation Designs\CMI copyright template.pot xxxx xxxx F7xxMicrosoft PowerPointoso@O7@8Ysr@O=NG.!PICT!& HH HH  /z|H u)e~~~{Kh2& W~~Y hK|:G~~rB^_Ici۴|+7~~ڱ~0 |~c u峧1(w~~@-'}i[w)d~𒠔9n~~[I~ »׹~Ob~u dyptmӰ t Ӌ{ČjSo0~ ҄~dNz4j ;cptu+8l dz˻Ҙ{ıu*| ~~Ʊȹғ~{/Pw1scp}n˝Km{ Q̿θŨ~p~@~~ɿͷŤ~8>Rhp~"~诊߯nm n^ںù̈wa`k:nnƞ~׹øˁ~z~nF,;t潰 ԏZ"vo~wz~҉~{o~win[( K` gM2 R>onǸ~~ }ߌ|nG$);\ѣ}gX†Ӿ`p~{nq~Ѻp~{nqٴ嵒疔|}9Ɵ{TVonq~̾ɾŚ|onqI=f(5Ѯx]UiY4W=925@amQ3𾲯!Kprz~Pprz82FWI=fI6¤*!,5 1(J)Ș%Bk{t|~Ɠ~k{ruI;UHfN+ȯr}8 @%<+,X8)de%׹(7~յ濙~~:8_;]VMz3p/]JX,6@/⺛8-~Ḙ~~H*??іA9K&(9 ̣  *E}~~ʠ~~ɿ}}EGK?v53*(B:84#-C) nbICMWaqџ~~~|3:cFA4Q<  4;-'4 ~~~~~~Q 9  ~~~~~,6AN]n}}n^OA6,6AN]n}}n^OA6,,6AN]n}}n^OA6,6AN]n}}n^OA6,(9K_tt`M9((9K_tt`M9(&3BReyyfTB3&7fḎ偀局CfM!L]L]f fDUff fDffD2fwLf D wLf D 0ffffUfffffff0n0nf-LL]ULLL]LL]fL-LL]ULLL]LL]fLffLLf LULfLLLLLLLf LULfLLLLL f f++*fUffUfff+LULUf+LULUffDUffD!ff{f{!{f{!uww*LUw*LLUwLwwLLwwwwww*LUw*LLUwLwwLLwwww€rL]3ULL]3*nLLL]3ULL]3*nLL€рwwЀwwЀVˀƀFʀˁʀʀ΁ ʀ  Ȁׁʀɀс ʀ  ʀ ˀ  ɀ"ҀЀˀ΀ˀ π π ππeۀ€ˀ€stBBBBBBBBBBBBBBBBkBkBkBkkkkkkkkkkkkkkkkkkkkBkBkBBBkBBBBBBBBBBBBBBBBBBBkBBBkBkBkBkBkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkBkBkBkBkBBBkBBBBBppp␐»⑹»⺼⻺޻ݝpqqq⑁qpp⼻pppqqq»pppppp⑺qp񻻻pqpqpq "--&TNPP &&s tbpC5UHEf0]6#(|Kf<3(JjcvaZcRss4䒿@C}sta%4Ȅf%3M f0'LgFs41BMGA7X:JxJxA;xEa%:bJ<~R0E8F~UKVC}X(=>~!e8SF20Ha,rΒ8U s- ? |T*46GX؎E8qX,&"Ꮻ0 }q舻Dc+`uD{Ǹ)e wpK8/~v!ޤ9eb_(N CLbNp#S%L4̢(w2#șM+pgP:_mْ8kRJ9-{7b&(u,Q&L]dYgx"ʉ;yQ *\QAdDD"y"B{bs[: α;E+DcQF_5xYY<#W V|Ϙr7EEx]$ D"( 1N\9_"PqUb Sl" dx(d[Ve}/ߗC);\UH~*5^5U+\!'Udc*<, 7u^VW&BJܬ걌 SuYyRS<[3֟'yN\'u|3W/"PP9}MՅ7n*F?T FtSW_%uռ ;iJLO Rz`~*?XE8fב&Ҍ焊#YY9qf@)˜[b6 )~Ṉ7N;OECA T D-c۳z 2~|_V6*rM :&,цK1T+b=d#gxInd,7{2Rk#XLtFȎ@v[-;rj.n#VSeC^x젎˞*[P(D/55X-ed$O7dn*3uGe1ĺXɚWny]u:[KE]b[0zp>\_U5+7jSuԐ:m*n؉MKutc]|QIr?>Ԇ4Cm6 A -e`166`_/!vQp? G`m`?t'.ٸ`,7xMO+! !Ts4|μOpqRoot EntrydO)݆UoPictures@Current User)SummaryInformation(N`R x !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwyz{| IGM-client?12653+records+81pcgi-bin/VERSION_B/IGM-client?12653+records+81!_ CTxxxx xxxxckma\$2T|WK/b:LshW5Tƥ |+ :Y/d5-%}uݙ^pRjT_?C'RݢΪz\Be_)geq%MT)4Q>ni۬ 1Oy r9Q0nzم?(8W& 6uS 9 1C"׆c[f؈C1E+!!XlC57yywf`H;Z>e eO΃b({;< _Y @GRДx,աM\fug-7YMc% ƘFLg5èǵHwIPOӄ>3hy6/wh~@㸮U#>P/BCq|y>E:Sm'hlCTKϞG9c/;6߸6Է6I37SmosJNMk&mo wv6݅bnS7 ʸP5Ѐњnrc`1O`Wz9 ޗ,nJ u^4l~/RdR;^*8;ӼD݋Mv>o {k0[)LL8~N5.&{0n滱XGB7ʻTc#FW4]KrΣn Mwlw "9֣\_Z향)EZfQ=Cgm:]iؓE{ھmV6yv'{.gZaSl w|[W=S;ulWo3^ly{ [D2]7fm%(:h^Lti2sއgזޡ[m:b1%PKMYNiW:HiM%:VjL ZK/ LC? R;^X ft,;c!cNcs> c0^› . 0p3Őp Qly+pN%8p9&sG9Td[86?=i9@L4)`ߘ aQ3сw(Tݼ_EB_$J2*s=Y=֓m;H^L\%lmt=y]l/`TeϨ֞2lmSdnf,7fL[ĹLqhsʝbιw6 @n8Tp@uzwa|Fwnu/w"coʱ.{EkzXs>ţxW| |^^x ۲4bTcx1 \8p7A*.*$ck_>8 ! HL 7){ op|?E| _c d<X15ס%sp^# g,l|J-Lo,Vc ЩIs>l x}W O_}cF<$".J;\āx?#3mf2cTP!*]R$JJHswx|=^kk6B><< 9%RRxhUTZ9%K =ʗyNT度fF-]A6*+.gaU^ P4yRM!e,)i*SdJ|MesVR]Fa%Un/n<7ړ.F8T'C8c?؇;Mh>JZ i5֡\ 5hq ^|:n4\sd8Sqb0#p vI'bsw d xR,q"x!8k7Nc&t0 e\l;L m1ֶ޶v`;[ﵕv ^k.E=|cAs 4䘳i.AѐdN0q_4-y7q~x5L,*Wx>ÓA,p_ۂtU$h *7v,⡠k${ʶ~1K0ŬY&g8tsW[(41J74&x4I̠lePE3* FЮ` m "z+hMk·Һ\{,÷x]k귦KsAgBh'$ZBK)4O('R_~YT_@ rU:gMu5>3q~w莼Awl:t4׃8Zzw N':%7uu>ߡwq=}HƧ[PJUmtVtV~ 7U ^- .uX us_gbqۺm1B1nfLCUq(Ցju/FQEO ]()R6֧uX mq :%~YKbg D*(\ſԶZ@j^4XEf VY-ԧ"v @ʆ)=,NKԯH8]0>c ~&u΃/;gWx}%|SE+n?gV̈́4S 8N8#:` ' ^,M "l [(yH&w~Пc!D y1U0 |*N&8dS:NBGy!td2lz Rڊ쩊:G9zZW5 QXՑhC* T4R1tDGHC Q/½AF^{hNU4+i<һy]x7cQMo&?燽4ns-/IJ*WnZk 2/3 systole-hangs out to S2) AS, LVH or LV systolic dysfunction Hyperdynamic Apex: correlates with volume overload AR/MR palpable S4 (atrial kick) palpable S1 (MS) palpable non-ejection click (MVP) ZgZZsZZZ!&4Apex Dynamic Abnormalities(oAtrial kick: Palpable S4 Loss of LV compliance LVH 2o Hypertension Aortic Stenosis Hypertrophic Cardiomyopathy f  V : 'Non-invasive ejection fractionxPalpable S4/ apex not sustained EF > 50% Palpable S4/ Apex sustained EF 40-50% S4 not palpable/ Apex sustained EF < 40% X    y!(Non-invasive ejection fraction/"#$%&'  ` ` ̙33` 333MMM` ff3333f` f` f` 3>?" dd@,|?" dd@   " @ ` n?" dd@   @@``PR    @ ` ` p>> "   (    NX ))?"`  T Click to edit Master title style! !$  0 "  RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S  0@ "``  >   0T "`   >   0 "`   D*  T32 @1?"`  T  @1?"x   <A ??"`X n   c $A ??"-   0* " T Continuing Medical Implementation & ...bridging the care gap Fi&O(@B  s *޽h ? ̙33 THow to Examine the Heart Website SlideshowrqwI&Mwq'.(   (M1*l/{|6{WC>y>dtXS$8Q<:H7.Sk) 2h:L?0Z q єQ" ,)y-°hcY_mci>.wKJu*9,L䫘$/ᛸs$KWa Db=y͖=|y#n;ˍr-#Y3ܬ>\f+ ՜.+,D՜.+,@    t'On-screen Show1Ottawacvcentre1Q $  Times New Roman+How to Examine the Heart Website Slideshow Palpation PalpationPalpation-PulsesCarotid Examination Palpation - PrecordiumPrecordium-PalpationPalpation - ApexApex-Dynamic QualitiesApexDynamic AbnormalitiesApexDynamic Abnormalities Non-invasive ejection fraction  Fonts UsedDesign TemplateEmbedded OLE Servers Slide Titles  8@ _PID_HLINKS'ABhttp://130.14.32.45/cgi-bin/VERSION_B/`Bitmap Image Paint.Picture0Bitmap Image`Clip (MS_ClipArt_Gallery.20,Microsoft Clip Galleryhttp://130.14.32.45/cgi-bin/VERSION_B/IGM-client?12653+records+81/ 0LDTimes New Romanl` 'j  ` .  @n?" dd@  @@``  X,JE!   `$`$`$`$`$`$`b$aƑ*E26N `B$껽A"Pȕҝw*#`c $@uʚ;2Nʚ;g4ZdZd Hppp@ <4!d!dP,@g`<4ddddP,@g`<4BdBdP,@g` ph___PPT2001D<4X? % Palpation  6Feel for diagnosis ( Palpation 0By the time you put stethoscope to chest you should know what you are going to hear If you don t hear what you expect,explain it (Palpation-PulsesRhythm, rate, regularity Contour Water hammer pulse-AR Brachial-radial delay AS Pulsus paradoxus Tamponade COPD Pulsus alternans LV dysfunction\aZZZZa,P Carotid ExaminationCarotid upstroke brisk, normal or delayed bisferiens or anacrotic volume: normal, increased or decreased Carotid auscultation Bruit Transmitted murmur A2 audible in neck? Presence excludes severe AS YIY -,+  ! Palpation - PrecordiumKParasternal: Palpable P2-pulmonary HTN Thrill VSD/HCM RV lift RVH Severe MR   "Precordium-PalpationParasternal Lift: RVE or severe MR Thrill: VSD, HOCM (IHSS) Palpable P2 (ULSB): pulmonary hypertension Medial retraction LVE Lateral retraction RVE #Palpation - ApexApex: Palpable in 1 of 5 adults age 40 Best felt with fingertips or finger pads Normal Location: No more than 10 cm from mid-sternal line in the supine position Left decubitus position not reliable for apical location Normal Size: No larger than 3 cm (about 2 finger breadths) ZJZZzZ Z/ZZZJ/ i$Apex-Dynamic QualitiesLV impulse outward movement like a ping pong ball were protruding between the ribs Apex moves outward for the first third of systole and falls away rapidly Lasts for no more than 2/3 of systole%4Apex Dynamic Abnormalities(Sustained Apex: correlates with pressure overload ( > 2/3 systole-hangs out to S2) AS, LVH or LV systolic dysfunction Hyperdynamic Apex: correlates with volume overload AR/MR palpable S4 (atrial kick) palpable S1 (MS) palpable non-ejection click (MVP) ZgZZsZZZ!&4Apex Dynamic Abnormalities(oAtrial kick: Palpable S4 Loss of LV compliance LVH 2o Hypertension Aortic Stenosis Hypertrophic Cardiomyopathy f  V : 'Non-invasive ejection fractionxPalpable S4/ apex not sustained EF > 50% Palpable S4/ Apex sustained EF 40-50% S4 not palpable/ Apex sustained EF < 40% X    y/"#$%&r' '