Cardiovascular Examination Part 2

7/27/2019 Cardiovascular Examination Part 2

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Cardiovascular Examination

Part 2


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Cardiovascular Examination

Part 2


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Precordium

Inspection

Palpation

Percussion

Auscultation


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Inspection

Scars

Sternotomy

Valvotomy

Thorocotomy

Deformity

Pectus excavatum

kyphoscoliosis

Pulsations

Gynomastia

Digoxin

Spironolactone


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Palpation

Apex position and character

Absent impulse

Emphysema

Obesity Pericardial effusion

dextrocardia

Forceful impulse

LVH


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Palpation

Tapping impulse

Mitral stenosis

Dyskinetic impulse

Paradoxical ventricular wall

movement in systole


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Palpation

Thrills (palpable murmur)

Parasternal Heaves

RV dilatation or hypertrophy

MV disease

Cor pulmonale


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Thrill

Location of Thrill Associated Disorder

Over the base of the heart at the

2nd intercostal space, just to the

right of the sternum, duringsystole

Aortic stenosis

At the apex during systole Mitral regurgitation

To the left of the sternum at the

2nd intercostal space

Pulmonic stenosis

At the 4th intercostal space Small muscular ventricular

septal defect (Roger's

disease)


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Percussion

Percussion of cardiac dullness

Pleural effusion

Consolidation


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Auscultation

Time heart sounds and murmurs against the

carotid impulse

The belllow-pitched sounds

The diaphragmhigh pitched sounds


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Auscultation

Area of auscultation Apex

Upper LSB

Lower LSB

Upper RSB

Lower RSB Under Clavicle

Over Carotids

In axilla

Listen at apex with patient rolled to the left side

Mitral stenosis

Listed at LSB with patient sitting forward, in

expiration

Aortic incompetence


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Heart Sound

Listen individually to the S1 and S2

Loud or soft

Splitting

Splitting increased or decreased withinspiration

Listen for added sounds

Note timing relative to S1 and S2


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Heart Sound

Listen for murmurs

Systolic/ diastolic

Duration (pan, early, mid or late}

Quality (harsh, soft)

Pitch (low or high)

Listen for prosthetic sound


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Heart Sounds

Loud S1

High output states

Mitral stenosis

Split S1 RBBB

Epsteins Anomaly


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Heart Sounds

Loud S2

Pulmonary hypertension (P2)

Systemic hypertension(A2)

Split S2(A2P2) Normal in inspiration in the young

Delayed PV closure

RBBB

Prolonged RV systole

Massive PE PHT

PS


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Heart Sounds

Reverse Split Delayed AV closure

LBBB

RV paced rhythm

Prolonged LV systole LVOT obstruction

Aortic stenosis

Systemic hypertension

Fixed Split

Medium or large ASD


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Added Sounds

Third heart sound

Fourth heart sound

Ejection Click

Opening Snap

Mid-systolic click

Prosthetic sound


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Fourth Heart Sound

Due to atrial systole against a poorly

compliant ventricle.

LVH

Occurs just before S1


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Ejection Click

High-pitched

Closely follow S1

Occurs in

Bicuspid AV

AS

Valvular PS

Dilatation of PA


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Opening Snap

High-pitched sound

Occurs after S2

Occurs as stenotic MV opens


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Mid-systolic Click

Due to MVP


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Prosthetic Sounds

Mechanical Valvesboth opening and

closing sounds

Absent sound may be a sign of valve

dysfunction. Thrombosis

Pannus encroachment

Valve disintegration


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Murmurs

Timing

Duration

Quality

Pitched

Location

Accentuation

Radiation

Grading


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Timing

Systolic

AS

PS

MR

TR

Diastolic

MS

TS AI

PI


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Duration

Systolic

Pansystolic

MR

TR

VSD

PDA

Ejection Systolic

AS

AV calcification

PS


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Duration

Early systolic

Severe MR

Late systolic

MVP


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Duration

Early Diastolic

AR

PR with PHTN Graham Steel murmur


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Duration

Mid-diastolic

MS

TS

Severe MR

AR

Austin Flint Murmur

PR

Late diastolic MS in sinus rhythm

TS in sinus rhythm


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Quality

Harsh

VSD

AS

PS

Soft

AI

TR

Rumbling

MR (blowing)


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Pitch

Low-Pitched

MS and TS (low-pitched

rumbling)

High-Pitched

Regurgitant murmurs

Chronic AI and PI (high-pitched

decrescendo)


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Location

Know the areas where the murmurs are heard best

Aortic stenosis Aortic area

Pulmonary stenosis Pulmonary area Tricuspid stenosis Tricuspid area

Mitral stenosis Mitral area (apex)


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Location

Aortic insufficiency** Left sternal edge

Pulmonary insufficiency Pulmonary area

Tricuspid insufficiency Tricuspid area Mitral insufficiency** Mitral area, axilla, rarely to aorta

** Not where expected


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Accentuation

Louder on Inspiration

TR

TS

Louder in Expiration

AI (patient sitting forward)

Pre-systolic

MS and TS


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Maneuver that Aid in the Diagnosis of

Murmurs

Maneuver Effect on Blood Flow Effect on Heart Sounds

Inspiration Simultaneously

increases venous flow

into the right heart,

decreases venous flow

into the left heart

Augments right heart sounds (eg,

murmurs of tricuspid stenosis and

regurgitation, those of pulmonic

stenosis* [immediately] and

regurgitation [usually]); reduces left

heart sounds

*Patient may need to be standing for effect on pulmonic stenosis to be heard.


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Murmurs

Valsalva

maneuver

Reduces size of left

ventricle (LV); decreases

venous return to the rightheart and subsequently to

the left heart

Augments murmur of hypertrophic

obstructive cardiomyopathy and

diastolic murmur of mitral stenosis;reduces murmurs of aortic stenosis,

mitral regurgitation, and tricuspid

stenosis


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Murmurs

Release of

Valsalva

maneuver

Increases volume of LV Augments murmur of aortic stenosis,

that of aortic regurgitation (after 4 or

5 beats), and those of pulmonic

regurgitation or pulmonic stenosis*

(immediately); reduces murmur of

tricuspid stenosis


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Murmurs

Isometric

handgrip

Increases afterload and

peripheral arterialresistance

Reduces murmurs of aortic stenosis

and hypertrophic obstructivecardiomyopathy; augments murmurs

of mitral regurgitation and aortic

regurgitation and diastolic murmur of

mitral stenosis


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Murmurs

Squatting Simultaneously decreases

venous return to the right

heart and increases

afterload and peripheral

resistance

Augments murmurs of aortic

regurgitation, aortic stenosis, mitral

valve prolapse, and mitral

regurgitation and diastolic murmur

of mitral stenosis; reduces murmur

of hypertrophic obstructive

cardiomyopathy


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Murmurs

Amyl nitrite Causes intense venodilation,

which reduces venousreturn to the right heart

Augments murmurs of hypertrophic

obstructive cardiomyopathy andmitral valve prolapse; reduces

murmur of aortic stenosis


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Radiation

Aortic area and carotids

AS

AV calcification (not carotids)

Posteriorly and to Pulmonary area PS

Axilla

MR

RSB

VSD

AR


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Grading

Grade I Just audible in quiet room with patient holding

breath.

Grade II Quiet

Grade III Easy to hear, no accompanying thrill

Grade IV Loud, with thrill

Grade V Very loud, with thrill

Grade VI Audible without stethoscope


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Valves Positions

In systole (ventricles ejecting blood)

AV and PV are open and the MV and TV are closed

In diastole (ventricles being filled)

MV and TV are open while

the AV and PV are closed


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Ejection Murmurs

Ejection murmurs are always systolic (blood isejected in systole)

Ejection murmurs peak and (almost) always fall inintensity

This means they begin after S1 and end (almost)always before S2

Ejection murmurs arise from the aortic valve orpulmonary valve (or less commonly from the LVor RV outflow tracts)


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Regurgitant Murmurs

Regurgitant murmurs are high pitched (the flow is

from an area of high pressure to an area of muchlower pressure)


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Regurgitant Murmurs

Systolic regurgitant murmurs are (almost)always holosystolic (= pansystolic) and beginwith S1 and end with S2

Examples are:

mitral insuffiency

tricuspid insufficiency.

A VSD is another cause.


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Diastolic Murmurs

Diastolic murmurs can be

Decrescendo: high pitch, intensity decreasing

during diastole, due to insufficiency of AV orPV

Rumbles: low pitched, localized, heard withbell, related to low pressure flow across a

narrowed valve, (mitral stenosis, tricuspidstenosis)


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Case 1

You hear a systolic ejection murmur loudest in

the upper right sternal border

Ejection murmurs come when a valve is notopened properly (stenotic)

This is the aortic area

This is the murmur of aortic stenosis


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Case 3

You hear a diastolic murmur loudest at the apex which

is low pitched, and localized.

What does it imply?

What valves should be open in diastole?

What area is this?

This is the murmur of mitral stenosis


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Describe the murmurs for the following

lesions

Pulmonary stenosis

Pulmonary insufficiency

Tricuspid stenosis

Tricuspid insufficiency


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Question 1

Aortic insufficiency produces a:

1. Systolic ejection murmur

2. Diastolic ejection murmur

3. Diastolic rumble

4. Diastolic decresendo murmur


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Question 3

Pulmonary stenosis produces a:

1. Systolic ejection murmur

2. Diastolic decrescendo murmur

3. Diastolic rumble

4. Systolic regurgitant murmur


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Question 4

Mitral stenosis produces a

1. Diastolic rumble

2. Systolic rumble

3. Systolic regurgitant murmur

4. Diastolic decrescendo murmur

Cardiovascular Examination Part 2

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Transcript of Cardiovascular Examination Part 2