Cardiac Physical exam

Imagine there’s no Echo

It’s easy if you try…

Arterial Pulses

• Paradoxus - tamponade, asthma

• Parvus et Tardus - aortic stenosis

• Asymmetric - aortic dissection

• Diminished or absent - PAD, coarctation

• Bisferiens - aortic insufficiency, HCM• Alternans - severe LV dysfxn, bigemminy

The Neck Veins

http://www.youtube.com/watch?v=tJzBKdKg2k0

Abdominal Jugular Test

• Press firmly for 10 seconds

• If CVP > 4 cm for 10 seconds (or falls > 4 cm with release of pressure) POSITIVE

• Pos AJR is an accurate sign of elevated LEFT ATRIAL PRESSURE (LR = 8.0)

Sustained Left lower parasternal movements (i.e. Heave)

• Can be caused by RV volume overload, MR

• If they are excluded, can be associated with degree of pulmonary HTN– RV pressure > 50 (+LR 3.6)

Heart Sounds

• S1 - closing of mitral and tricuspid valves– Incr with short PR, MS, hyperdynamic LV

• S2 - closing of aortic and pulmonic valves– splitting

• S3 - increased early diastolic filling pressure– Can be normal in kids and athletes– Depressed EF (LR – 3.8; not very sensitive, very

specific)

• S4 - decrease ventricular compliance– Never normal, ie LVH, ischemia, AS

How to Describe a Murmur

• Intensity

• Pitch

• Quality

• Configuration

• Location

• Timing

Intensity

• I/VI : Faint, only heard with special effort• II/VI : Immediately identified• III/VI : Moderately loud• IV/VI : Loud with a palpable thrill• V/VI : One edge of stethoscope on chest• VI/VI : No stethoscope required

Pitch

• High– MR, AI

• Low– MS, Gallops

Quality

• Harsh

• Rumbling

• Scratchy

• Blowing

• Musical

• Squeaky

Configuration

• Crescendo– Severe AS, MVP

• Decrescendo– AI

• Crescendo-decrescendo (diamond shaped)– Innocent murmur

• Plateau– MR

Location

• Apex

• Bases

• Parasternal– Right or left– Which ICS

• Does it radiate?

Timing

• Systolic/Diastolic– Early– Mid– Late– Holo

• Continuous

Murmurs

• Systolic– Flow murmurs, AS, PS, MR, TR, VSD

• Diastolic– AI, PI, MS, TS

• Continuous– Patent ductus arteriosus

Aortic Stenosis

Mitral Regurgitation

Aortic Regurgitation

Exam Maneuvers

• Respiration

• Standing

• Squatting

• Valsalva

• Hand Grip

• Post Ectopic Beats

• Amyl Nitrate

Murmurs

• All murmurs: – louder with increased flow (ie recumbency, squatting) – and softer with decreased flow (ie valsalva, standing) – except MVP and HCM

• MVP vs HCM – sustained handgrip: MVP louder HCM softer

• Right sided murmurs increase with inspiration • Left sided murmurs louder during expiration• All diastolic murmurs are abnormal (echo)

Respiration

• Inspiration increases venous return to the right heart, and decreases return to the left heart

• Inspiration increases the split of S2– P2 moves farther away from A2

• Inspiration increases the intensity of right sided Murmurs and Gallops– TR Carvallo’s sign

Standing

• Decreases venous return, stroke volume, arterial blood pressure– AS decreased– MR/TR decreased– VSD decreased– MVP earlier click, longer murmur– HCM INCREASED

Squatting

• Increases preload, afterload, and arterial pressure– MR/TR increased– VSD increased– AI increased– AS variable– MVP delayed click, shorter increased murmur– HCM DECREASED

Valsalva

• Decreased venous return, ventricular volumes, stroke volumes, arterial pressure– AS/PS decreased– AI/PI decreased– MR/TR decreased– MS/TS decreased– MVP earlier click, longer murmur– HCM INCREASED

20-30 Sec Handgrip

• Increased SVR, arterial pressure, cardiac output, LV volume– AS DECREASED– MR/MS increased– AI increased– VSD increased– MVP later click, shorter murmur– HCM decreased

Post ectopic beat

• Increased ventricular volume and contractility (effect of increased contractility > increased volume)– MR NO CHANGE– AS/AI increased– HCM increased– TR increased– MVP earlier click, longer murmur

• Effect of contractility > volume

Murmurs with names

• Austin Flint– Late diastolic murmur in aortic insufficiency of jet

causing vibration of anterior mitral valve leaflet or antero-apical wall

• Graham Steell– Early diastolic murmur of pulmonic insufficiency in the

setting of pulmonary HTN

• Carey-Coombs– Mid-diastolic apical murmur of inflammation of the

mitral leaflets in the carditis of rheumatic fever

Extra Heart Sounds

Splitting of S2

• Physiologic split– Splits during inspiration

• Widened split– RBBB (Late P2), MR (early A2)

• Fixed split– ASD

• Paradoxic split (delayed A2)– LBBB, AS, HCM