Cardiovascular Examination

Part 2

Cardiovascular Examination Part 2

Precordium

Inspection Palpation Percussion Auscultation

Inspection
Scars Sternotomy Valvotomy Thorocotomy Deformity Pectus excavatum kyphoscoliosis Pulsations Gynomastia Digoxin Spironolactone

Palpation
Apex position and character
Absent impulse Emphysema Obesity Pericardial effusion dextrocardia Forceful impulse LVH

Palpation
Tapping impulse Mitral stenosis
Dyskinetic impulse Paradoxical ventricular wall movement in systole

Palpation

Thrills (palpable murmur) Parasternal Heaves RV dilatation or hypertrophy MV disease Cor pulmonale

Thrill
Location of Thrill Associated Disorder

Over the base of the heart at the 2nd intercostal space, just to the right of the sternum, during systole
At the apex during systole

Aortic stenosis

Mitral regurgitation

To the left of the sternum at the 2nd intercostal space

At the 4th intercostal space

Pulmonic stenosis
Small muscular ventricular septal defect (Roger's disease)

Percussion

Percussion of cardiac dullness Pleural effusion Consolidation

Auscultation

Time heart sounds and murmurs against the

carotid impulse
The bell low-pitched sounds The diaphragm high pitched sounds

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

Heart Sound
Listen individually to the S1 and S2 Loud or soft Splitting Splitting increased or decreased with inspiration Listen for added sounds Note timing relative to S1 and S2

Heart Sound

Listen for murmurs Systolic/ diastolic Duration (pan, early, mid or late} Quality (harsh, soft) Pitch (low or high)
Listen for prosthetic sound

Heart Sounds
Loud S1 High output states Mitral stenosis Split S1 RBBB Epsteins Anomaly

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

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

Added Sounds
Third heart sound Fourth heart sound Ejection Click Opening Snap Mid-systolic click Prosthetic sound

Third Heart Sound

Due to rapid ventricular filling
Occurs shortly after the S2

Usually low-pitched

Fourth Heart Sound

Due to atrial systole against a poorly

compliant ventricle.
LVH Occurs just before S1

Ejection Click
High-pitched
Closely follow S1

Occurs in Bicuspid AV AS Valvular PS Dilatation of PA

Opening Snap

High-pitched sound Occurs after S2 Occurs as stenotic MV opens

Mid-systolic Click

Due to MVP

Prosthetic Sounds
Mechanical Valves both opening and

closing sounds
Absent sound may be a sign of valve

dysfunction.
Thrombosis Pannus encroachment Valve disintegration

Murmurs
Timing Duration Quality

Pitched
Location Accentuation Radiation Grading

Timing
Systolic AS PS MR TR

Diastolic MS TS AI PI

Duration
Systolic
Pansystolic MR TR VSD PDA Ejection Systolic AS AV calcification PS

Duration

Early systolic Severe MR Late systolic MVP

Duration

Early Diastolic AR PR with PHTN

Graham Steel murmur

Duration
Mid-diastolic MS TS Severe MR AR
Austin Flint Murmur

PR Late diastolic MS in sinus rhythm TS in sinus rhythm

Quality
Harsh VSD AS PS

Soft AI TR
Rumbling MR (blowing)

Pitch

Low-Pitched
MS and TS (low-pitched

rumbling)

High-Pitched
Regurgitant murmurs Chronic AI and PI (high-pitched

decrescendo)

Location
Know the areas where the murmurs are heard best

Aortic stenosis Pulmonary stenosis Tricuspid stenosis Mitral stenosis

Aortic area Pulmonary area Tricuspid area Mitral area (apex)

Location

Aortic insufficiency** Pulmonary insufficiency Tricuspid insufficiency Mitral insufficiency**

Left sternal edge Pulmonary area Tricuspid area Mitral area, axilla, rarely to aorta

** Not where expected

Accentuation
Louder on Inspiration TR
TS

Louder in Expiration AI (patient sitting forward)

Pre-systolic MS and TS

Maneuver that Aid in the Diagnosis of Murmurs

Maneuver Inspiration Effect on Blood Flow Simultaneously increases venous flow into the right heart, decreases venous flow into the left heart Effect on Heart Sounds 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.

Maneuver that Aid in the Diagnosis of Murmurs

Valsalva maneuver

Reduces size of left ventricle (LV); decreases venous return to the right heart 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

Maneuver that Aid in the Diagnosis of 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

Maneuver that Aid in the Diagnosis of Murmurs

Isometric handgrip

Increases afterload and peripheral arterial resistance

Reduces murmurs of aortic stenosis and hypertrophic obstructive cardiomyopathy; augments murmurs of mitral regurgitation and aortic regurgitation and diastolic murmur of mitral stenosis

Maneuver that Aid in the Diagnosis of 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

Maneuver that Aid in the Diagnosis of Murmurs

Amyl nitrite

Causes intense venodilation, which reduces venous return to the right heart

Augments murmurs of hypertrophic obstructive cardiomyopathy and mitral valve prolapse; reduces murmur of aortic stenosis

Radiation
Aortic area and carotids AS AV calcification (not carotids) Posteriorly and to Pulmonary area PS Axilla MR RSB VSD AR

Grading
Grade I Grade II Grade III Grade IV Grade V Just audible in quiet room with patient holding breath. Quiet Easy to hear, no accompanying thrill Loud, with thrill Very loud, with thrill

Grade VI

Audible without stethoscope

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

Ejection Murmurs

Ejection murmurs are always systolic (blood is

ejected in systole)
Ejection murmurs peak and (almost) always fall in

intensity
This means they begin after S1 and end (almost)

always before S2
Ejection murmurs arise from the aortic valve or

pulmonary valve (or less commonly from the LV or RV outflow tracts)

Regurgitant Murmurs

Regurgitant murmurs are high pitched (the flow is

from an area of high pressure to an area of much lower pressure)

Regurgitant Murmurs

Systolic regurgitant murmurs are (almost)

always holosystolic (= pansystolic) and begin with S1 and end with S2

Examples are:

mitral insuffiency tricuspid insufficiency. A VSD is another cause.

Diastolic Murmurs

Diastolic murmurs can be

Decrescendo: high pitch, intensity decreasing during diastole, due to insufficiency of AV or PV Rumbles: low pitched, localized, heard with bell, related to low pressure flow across a narrowed valve, (mitral stenosis, tricuspid stenosis)

Case 1
You hear a systolic ejection murmur loudest in

the upper right sternal border

Ejection murmurs come when a valve is not

opened properly (stenotic)

This is the aortic area This is the murmur of aortic stenosis

Case 2
You hear a systolic murmur loudest in the

apex which is regurgitant.

What valves should be closed in systole? What area is this? This is the murmur of mitral insufficiency

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

Case 4
You hear a diastolic murmur loudest at the left

sternal border which is high pitched and decreases in intensity during diastole.
What is another name this type of murmur? What

does it imply?
What valves should be closed in diastole? What area is this? This is the murmur of aortic insufficiency

Describe the murmurs for the following lesions

Pulmonary stenosis Pulmonary insufficiency Tricuspid stenosis Tricuspid insufficiency

Question 1
Aortic insufficiency produces a:
1. 2. 3.

4.

Systolic ejection murmur Diastolic ejection murmur Diastolic rumble Diastolic decresendo murmur

Question 2
Tricuspid insufficiency produces a:
1. 2. 3. 4.

Systolic ejection murmur Systolic rumble murmur Diastolic rumble Systolic regurgitant murmur

Question 3
Pulmonary stenosis produces a:
1. 2. 3. 4.

Systolic ejection murmur Diastolic decrescendo murmur Diastolic rumble Systolic regurgitant murmur

Question 4
Mitral stenosis produces a
1. 2. 3. 4.

Diastolic rumble Systolic rumble Systolic regurgitant murmur Diastolic decrescendo murmur