Two seconds or less is normal

Cholesterol build up and may be due to familial hypercholesterolemia

• Osler's nodes are thought to be immunological-mediated, cause pain when palpated
• Janeway lesions are thought to be caused by septic micro-emboli (e.g. infective endocarditis)

Sign of infective endocarditis

Note the rate and rhythm

Delay suggests aortic dissection

Volume and character

Collapsing pulse/water hammer pulse associated with aortic regurgitation

Associated with mitral valve stenosis

• Risk factor for infective endocarditis
• Specifically viridans streptococci

• A heave can be a sign of right ventricular hypertrophy
• Feels like an abnormally large beating of the heart

• A thrill is a palpable murmur
• Suggests quite severe valvular abnormalities

• You may hear a heart murmur in multiple locations
• Pathology is likely to be in the location where it is loudest

• Aortic stenosis will radiate to the neck unlike aortic sclerosis (as it does not significantly obstruct flow)
• Hearing a murmur here is a key way to differentiate between aortic and pulmonary stenosis
• Remember to listen before you palpate the carotids
• Remember not to palpate (obstruct) both carotids at the same time

Mitral valve pathologies radiate to the apex

• Pulmonary oedema may suggest (left-sided) heart failure
• In severe aortic stenosis there's an obstruction of outflow from the left-side of the heart
• This may result in a 'backing up' of blood and result in heart failure and lung-related issues

• Similar to lung oedema, sacral oedema is a sign of peripheral oedema (rather than lung)
• Suggests right-sided congestion if present

• The murmur is in line with the first heart sound (S1) suggesting a systolic murmur
• Ejection suggests the murmur is in the early phase of the heart sound (as opposed to throughout e.g. pansystolic).

• A high-pitched crescendo-decrescendo sound is characteristic of an aortic stenosis
• Heard loudest in the aortic region (2nd intercostal space right side of the chest)
• Loudest on expiration (ask the patient to breath out and hold their breath whilst listening)
• Importantly and often an important sign to pick up in an exam is radiation to the carotids which is unique to aortic stenosis (lack of carotid radiation differentiates aortic stenosis from aortic sclerosis)

• Brief obstruction of blood flow from the heart to the brain due to narrowing of the valves may cause syncope

• Reduced blood flow to the heart
• Inadequate oxygen supply to meet metabolic demands of the cardiac muscle

• Due to reduced functioning of the heart
• Blood backs up into the lungs increasing capillary hydrostatic pressure
• Fluid moves from capillaries into surrounding tissues