Cardiac Exam
Inspection Palpation Percussion AuscultationInspection : Apex beat . left parasternal movement due to right ventricular hypertrophy. pulsation in 2d left ICS 2ry to enlarged PA. epigastric pulsation 2ry to expanded abdominal aorta
By PALPATION:
Apex beat: Site (the most lateral and most inferior; normally in the 5th left intercostals space in the mid clavicular line) Displaced or not Character (heaving, double impulse, tapping) Parasternal impulse: By the heel of the hand rested just to the left of the sternum. Palpable murmurs (thrills): Start at the apex then the left sternal edge then the base of the heart.Auscultation: bell to detect low-pitched sounds , press lightly against the skin diaphragm detect high-pitched sounds press firmly against the skin
Cont. auscultation
Normally audible heart sounds: 1st & 2nd HS Added sounds: 3rd & 4th HS, pericardial friction rub (pericarditis), opening snap (m.s), mitral click(m.v.p) murmersAUSCULTATION
S1 – closure of mitral and tricuspid valvesS2 – closure of aortic and pulmonic valvesLow pitched sounds S3, S4, mitral stenosis, S1 systole S2 diastole S1Murmurs
Turbulent blood flow caused by diseased valve or if a large amount of blood flows through a normal valve. characteristics of murmurs suggest the cause of it (site, radiation, pitch, timing gradig and the intensity) .
Cont.
Cont.Grading of Murmurs: Grade 1 - only a staff man can hear Grade 2 - audible to a resident Grade 3 - audible to a medical student Grade 4 - associated with a thrill or palpable heart sound Grade 5 - audible with the stethoscope partially off the chest Grade 6 - audible at the bed-side
I. Auscultatory Valve Area
1. MV: apex, fifth left intercostal space, medial to the midclavicular line 2. PV: second left intercostal space 3. AV: second right intercostal space 4. AV2: left third intercostal space 5. TV: lower part of sternalLA
LV
AO
Systole
RV
LA
LV
AO
Diastole
Cardiac Physiology 101
Regurg/ Insuff – leaking (backflow) of blood across a closed valveStenosis – Obstruction of (forward) flow across an opened valve Systole AV/PV – opens-------Aortic StenosisS1-S2MV/TV – closes------Mitral RegurgDiastoleAV/PV – closes------Aortic Regurg S2-S1MV/TV – opens-------Mitral Stenosis These concepts are set in stone, it can’t occur any other way, It would be anatomically impossibleCommon Murmurs and Timing (click on murmur to play)
Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosisS1 S2 S1
Mitral Stenosis
Opening snap Loud S1, loud P2 if pulmonary hypertension present Rumbling diastolic murmur heard at apex with stethoscope bell, patient in L lateral decubitus Palpate carotid to identify diastole Presystolic accentuation unless AFib present Exercise, maneuvers to increase flow make murmur louderMitral Stenosis
“always” rheumatic in originTurbulent, high velocity flow occurs during diastoleAlways look for MS in patient with new Atrial fibrillationLeft lateral decubitus
Mitral stenosis (MS) is a narrowing of the inlet valve into the left ventricle that prevents proper opening during diastolic filling. Patients with mitral stenosis typically have mitral valve leaflets that are thickened, commissures that are fused, and/or chordae tendineae that are thickened and shortened
Mid-systolic Murmurs
Mid-systole is the EJECTION PERIODMSM are therefore “Ejection Murmurs”Ejection starts after S1, peaks soon after, and diminishes before S2Ejection murmurs MUST be crescendo-decrescendoHolosystolic murmurs are NOT ejection murmursAortic Stenosis
Pulmonic StenosisUsually congenital, may be associated with other abnormalities Causes a mid-systolic ejection murmur similar to AS but does NOT radiate to carotids Radiates to left infraclavicular area Murmur intensity and ejection sound vary with respiration Widened S2 split Balloon valvuloplasty when gradient exceeds 30-50 mm Hg
Holosystolic Murmurs
“Pansystolic Murmurs”Begin with S1 and end after S2Caused by flow from high pressure area to much lower pressure areaVentricle to atriumLeft ventricle to right ventricleHarsh, “blowing,” well-heard with diaphragmHolosystolic Murmurs
Atrioventricular valve leakage Mitral Regurgitation Tricuspid Regurgitation Interventricular shunt Ventricular septal defectChronic Mitral Regurgitation
Progressive Mitral Valve Prolapse most common cause LV dilatation, rheumatic, congenital, endocarditis, infarction Results in chronic volume overload of left ventricle Acute MR may have very brief murmur due to rapid equilibration of pressures
Mitral Regurgitation after MI
MRRadiates to axilla or back in most casesMay radiate to the base if posterior leaflet prolapseWell heard with diaphragm but listen with bell also for S3 or diastolic “flow” rumbleDue to high volume flowing back from LANo change in intensity after a PVC but increases with isometric exercise and squatting (increases afterload)
Left lateral decubitus
Aortic Regurgitationcongenital, endocarditis, age, aortic disease, collagen vascular, syphillis Early diastolic, decrescendo murmur best heard at LLSB with diaphragm subtle, have pt lean forward, breathe out associated with wide pulse pressure
Aortic regurgitation findings
S3 Soft S1 and A2 Blowing decrescendo diastolic murmur Begins immediately with A2 High frequency (diaphragm) Press firmly & concentrate Inconsistent relationship between duration and severity Associated murmurs Often has systolic ejection flow murmur Austin-Flint murmur at apex sounds like mitral stenosisAR easily missed