By Donald N. Ross B.Sc., M.B., Ch.B., F.R.C.S. (auth.)
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Additional info for A Surgeons’Guide to Cardiac Diagnosis: Part 1: The Diagnostic Approach
This is best heard to the left of the sternum in the "pulmonary valve area". Where there is a high pulmonary artery pressure the pulmonary eomponent of the second sound is loud and ringing. In the presence of collateral elinical evidence of pulmonary hypertension a loud pulmonary component of the second sound is helpful in confirming this feature. In severe pulmonary hypertension the shoek of the pulmonary valve closure may be so marked as to be feIt as an appreeiable impulse with the flat of the hand held over the "pulmonary area" (po 34).
C) The loudness 01 the two eomponents 01 the seeond sound. The splitting of the seeond sound into two components indieates the presenee of two funetional valve units. But the loudness with whieh they elose is an indication of the diastolic elosing pressure in the aorta or pulmonary artery elosing the valve leaflets. Thus, in essential hypertension with an aortie diastolic pressure of, say, 140 mm, there is a loud ringing closure of the aortic valve, best heard to the right of the sternum. In the evaluation of cardiac cases for surgery one is eoncerned with the presenee of "pulmonary hypertension" so that we listen critically to the loudness of the pulmonary valve closure.
There is an increase in the volume of the soft tissue digital pulp in addition to the above features. Grade IV. This is an exaggerated stage of the above, with swelling of the tissues on each side of the nail-bed. Grade V. This is revealed as gross "drum-stick" formation of the ends of the digits, and may be associated with clubbing of the nose. Oedema. During the general inspection and assessment of the patient before examining the cardiovascular system more specificaIly, it is convenient to feel for pitting oedema of the ankles as a sign of raised systemic venous pressure or right heart decompensation.
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