Transcript Cardiac valve areas

The Physical Examination
of Heart
1st Affiliated Hospital
Liaoning Medical College
He Xin
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Anatomy
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一、Inspection
with tangential lighting
1、Thoracic deformity
2、Apical impulse
3、Abnormal pulsations of precardium
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1、Thoracic deformity
---protrusion of precordium
--Right ventricular hypertrophy (L3-5)
congenital heart disease( tetralogy of Fallot)
valvular heart disease( MS,PS)
--pericardial effusion (large , childhood)
--The second right intercostal space (2nd ICS-RS)
aneurysm of aortic arch
dilatation of ascending aorta
---flat chest
---pigeon chest/ funnel chest
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2 Apical impulse
---Normal
--Position : in the left fifth intercostal space about
0.5-1.0cm medial from the midclavicular line
--Range: no larger than 2.0-2.5cm in diameter
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---Abnormal
（1）Location





Posture
Diaphragm
Mediastinum
Enlargement of the heart
Dextrocardia(右位心): 5-ICS—RS
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
Posture:
---Recumbent(仰) position—upper
---left lateral(侧) position—to the left 2-3cm
---right lateral position—to the right 1.0-2.5cm
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
Diaphragm:
---“transverse position” upper,outward
obesity ,child, pregnacy
ascites; tumor of abdominal cavity
---“vertical position” inferior,inner
thin, high, emphysema
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
•
•
mediastinum:
one side pleural effusion or pneumothorax
---to the healthy side
one side atelectasis or pleural adhesion
---to the affected side
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
Enlargement of the heart
•
right ventricular dilatation – displaced
to the left or slightly upper
left ventricular dilatation— displaced to
the left inferior
LV &RV dilatation –left inferior (both
side dilatation)
•
•
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(2) Intensity and extent changes
decrease
increase
Physiological
Chest wall pachynsis,
Narrow intercostal space
Thin chest wall,
Broaden intercostal space,
Exertion, emotion
pathological
Myopathy (AMI, DCM),
Pericardial effusion,
Emphysema,
Constrictive pericarditis,
Left side massive pleural
effusion or pneumothorax
LVhypertrophy,
Hyperthyroidism,
Fever,
anemia
A feeble diffuse impulse ( more than 22.5cm in diameter) may
suggest dilation.
If the thrust is forcible, hypertrophy is suggested.
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(3)Inward impulse(负性心尖搏动):
apex excavation in the systole
--adhesive pericarditis
--prominent RV hypertrophy
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3、Abnomal pulsations of percardium
(1)left third-forth intercostal space lateral to
the sternum (3,4ICS-LS)
---RV hypertrophy
(2)xiphoid process
---RV hypertrophy
---Abdominal aorta (aneurysm)
(The pulsation of the abdominal aorta may often be felt in the
epigastric area. Also, the impulse from right ventricle can be
felt by the fingertips placed under the xiphoid process while
inspiration.)
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3、Abnomal pulsations of percardium
(3)basal part of the heart
---2 ICS-LS: dilatation of the pulmonary
artery or pulmonary hypertensin,
occasionally healthy young man
---2 ICS-RS: aneurysm of aortic arch or
dilatation of ascending aorta
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二、Palpation
1 Apical impulse and pulsation of
precardium
2 Thrill
3 Pericardial friction rub
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1、 Apical impulse and pulsation
of precardium
---Exact position of apex
---The beginning of systole of ventricle
first sound
---Heaving apex impulse: reliable of LV
hypertrophy
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2、Thrill
---Mechanism : the flow of blood→narrowed
orifice→vortices→vibration→chest wall
---One of characteristic signs of organic heart
disease：CHD or valvular stenosis, occasionally
insurficiency
---thrill - high frequency
murmurs - low frequency
---Key point: position, phase of cardiac cycle,
clinical significance
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Clinical significance of thrill
Location
phase
Disease
2 ICS-RS
2 ICS-LS
Systole
Systole
AS (RHD,CHD,senile)
PS (CHD)
3,4 ICS-LS
Systole
VSD (CHD)
Apex
Systole
MI (severe)
Apex
Diastole
MS (RHD)
2 ICS-LS
Continous
PDA
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3、 Pericardil friction rub
---Precardium -4th ICS-LS
---both phases of the cardiac cycle
---systolic period, sitting erect and leaning
forward, the end of expiration
---mechanism: rub of the visceral and
parietal layers of pleura
---seen: acute pericarditis
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三、Percussion
---Aim: to determine the size and
shape of the heart
---Absolute dullness: contain no gas
Relative dullness : real size
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1、maneuver of percussion
---patient in erect position
–the pleximeter is vertical with the
intercostal space
---patient in the recumbent position
–the pleximeter is parallel with the
intercostal space
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2、order :
---left—right ; upwards ; inward
---left margin : from 2-3 cm lateral to
the apex beat up to the 2nd ICS
---right margin : one intercostal space
higher than the border of liver dullness
up to the 2nd ICS
---size: vertical distance from margin to
the anterior midline
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Percussion of cardiac dullness border
starts tothe left on the chest, from 23cm
apart from theapical impulse towards
cardiac dullness (relativecardiac dullness).
Percussion is performed fromleft towards
cardiac dullness in the 4th, 3rd and2nd
intercostal spaces. Next, to the right of
thechest, percussion is done in the
midclavicularline down to a dull point (the
upper margin ofliver). Then, percuss from
right towards cardiacdullness in the 4th
(above the liver dullness), 3rd,and 2nd
intercostal spaces.
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一．
二．
三．
四．
Measure the vertical distances from each point of cardiac dullness
to the mid-sternal line with a stiff ruler
When the left border of cardiac dullness falls outside the
midclavicular line, it usually indicates that the left ventricle is
enlarged
If the left border of cardiac dullness goes out of left midclavicular
line (the left cardiac border towards left in the 5th intercostal
space), it suggests that the right ventricle enlarged
The cardiac dullness enlarged towards two sides: (1)both left and
right ventricles enlarged, (2) a large volume of fluid in the cavity of
pericardium. In this case, the cardiac borders will be changed
following the change of the patient's position
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④
②
③
①
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3、Normal heart borders
(area of relative dullness)
Right(cm)
SVC,SA
2~3
RA 2~3
RA 3~4
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ICS
Ⅱ
Left(cm)
2~3 PA
III
Ⅳ
Ⅴ
3.5~4.5 LA
5~6 LV
7~9 LV
4、The composition of various parts of the
border of the heart
Right
ICS
Left
SVC,SA
II
PA
RA
III
LA
RA
Ⅳ
LV
Ⅴ
LV
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---The upper border –the lower border of
the anterior end of the third rib↑
---The basal part —the second intercostal
space upward
left: aortic node and PA
---Concave part –between the aorta and
the left ventricle
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5、Changes in the area of cardiac
dullness and its significance
（1）body’s position:
1) recumbent position：widening of base
of the heart
2) erect position:“triangular shape”
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（2）Cardiac factors :
1)LV enlargement: “boot shape”
Seen:aortic valvular disease ,
hypertension heart disease
2)RV enlargement :
slightly↑--absolute dullness↑
Prominent↑--relative dullness↑
to the left side prominently
Seen:PHD, MS
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3)Two ventricle ↑:
“generally enlarged heart”
seen:DCM , Kashan cardiomyopathy
4)LA and/or pulmonary artery:
“pear shape”
LA:concave part disappear
LA+PA:2,3 ICS-LS outwards
Seen: MS--- “mitrial type”
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5)pericardial effusion:
enlargement of both sides of the border
6)dilatation of the aorta /ascending aortic
aneurysm:
widening if the dull area of first and
second intercostal space (with systolic
pulsation)
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（3）Extacardial factors :
1)large pleural effusions and
pneumothorax → to the healthy side
2)atelectasis /pleural pachynsis →to the
affected
3)a large amount of ascites or big
abdominal tumor:
diaphragm elevated→transverse position
→left side enlargement
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四、Auscultation
1、Cardiac valve areas for precordial
auscultation
2、Order
3、Contents
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1、cardiac valve areas for
precordial auscultation
1)ausclutatory mitral area: apical area
2)auscultatory pulmonary area:2 ICS-LS
3)ausclutatory aortic area: 2 ICS-RS
4)second ausclutatory aortic area: 3rd ICS
LS—Erb area
5)tricuspid area :4,5 ICS-LS
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Pulmonic
valve area
Aortic
valve
areas
Mitral
valve area
Tricuspid
valve area
Cardiac valve areas
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2、Order:
Apical area
Pulmonary valve area
Aortic valve area
2 nd aortic
valve area
Tricuspid valve area
MV---PV---AV1---AV2---TV
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3、Contents :
1) rate
2)rhythm
3)heart sound
4)extra heart sound
5)murmurs
6)pericardial friction sound
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(1)heart rate
Normal heart rate is 60-100/min (adult)
above 100/min
(below 3 years old)
Tarchycardia : above 100/min (adult)
above 150/min (infant)
Bradycardia:
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below 60/min
(2)cardiac rhythm:
sinus arrythmia—affected by breath
premature beat—frequently:＞6 bpm
occasionally: ＜6 bpm
atrial fibrillation: —absolute irregular rhythm
S1 intensity inequality
Pulse deficit
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(3) cardiac sound
Cycle
Nature
Isovolumetric
Blunt
contraction phase
Duration
S2
Isovolumetric
relaxation phase
S3
S4
S1
0.1″
Site
Apical
area
Mechanism
Closure of the
MV and TV
Distinct
0.08″
Basal
part
Closure of the
AV and PV
The end of
ventricular rapid
filling phase
Weak
Blunt
0. 04″
after S2
0.12~0.18″
Apex
(innerupper)
Ventricular
vibration
The end of
ventricular
diastolic phase
Weak
0. 1″
forward S1
Apex
Atrium
contraction
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(4)Abnormal cardiac sound
1)Intensity:
cardiac sound is influenced by a
number of factor
---position of the atrioventricular valve
---Ventricular contractility and output
---Valvular integrity and activity
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S1 Accentuation:
---MS
---HR↑contractility↑
fever,anemia,hyperthyroidism
---complete AVB →cannon sound
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S1 attenuation :
---MI
---P-R interval enlong
---AI
---myocarditis,myopathy,MI,HF
S1 inequality:
---AF
---III°-AVB
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S2---A2+P2
S2 ↑ ---pressure and flow of blood ↑
A2 : hypertensin, arterisclerosis
P2 : PHD,CoHD(L--R),LVF
S2 ↓ ---pressure↓ flow ↓
Seen:hypotension,AS/AL,PS/PI
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2)Quality
mono rhythm
pendular rhythm---embryocardia
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3)Splitting of heart sound
S1 splitting:
seen—RBBB, right heart failure
Ebetein malformation ,MS
LA myxoma
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S2 splitting:
physiological splitting :end of inspiration
general splitting : most commonly
seen: CRBBB, PS, MS,MI ,VSD
fixed splitting :ASD
paradoxical splitting(reversed splitting) :
pathological
seen: CLBBB ,AS, hypertension
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(5)extra cardiac sound
1)Diastolic period
①gallop rhythm:
--protodiastolic gallop: S1+S2+S3 the third
sound gallop (sign of organic heart disease)
seen : HF（AMI, severe myocarditis , myopathy
-- late diastolic gallop: atrial gallop S1+S2+S4
seen : HBP ,HCM ,AS ,CHD
-- summation gallop: quadruple rhythm
seen:HF,cardiomyopathy
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②opening snap :MS
③pericardial knock: constrictive
pericarditis
④tumor plop: LA myxoma
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2)Systolic period
①early systolic ejection sound(click)
---pulmonary :pulmonary hypertension;
pulmonary artery dilatation，PS, ASD,
VSD
---Aortic: hypertension, aneurysm ,
AS, AI ,aorta constriction
②mid and late systolic click:
S1----mid＜0.08″ late＞0.08″
seen: mitral prolapse
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3)iatrogenic
① prosthetic valvular sound
② pacemaker
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（6） Cardiac murmurs
1）Mechanism
---acceleration of blood flow
--- Blood viscosity
--- Valve: narrowed or incompetent; organic
or relative
---abnormal passage
---foreign body
---dilatation of vessles(aneurysm)
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2）characterization of murmur and
ausclutatory key points
①Location and Transmission
②Timing
③Quality
④Intensity
⑤Effect of position, respiration and exercise
on intensity of murmurs
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①Location and Transmission
---location: where it is audible most significantly
L3,4 –VSD
L2,3—PDA
---transmission: which direction it come from
MI ---left axilla
AS---neck
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②Timing
---Murmurs are timed according to the
phase of cardiac cycle during which
they occur.
---SM, DM , CM.
---Early, middle, late
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③Quality
---Depend on: frequency and intensity of
sound wave
---Related to: pathology and hemodynamic
changes of the heart
---Soft，harsh, musical.
---SM: blowing, harsh, musical (seagull)
---DM: blowing, sigh-like, rumbling.
---CM: machine-like, hum
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④Intensity
Six-point scale of for grading the intensity of
heart murmur
Grade
Grade
Grade
Grade
Grade
Grade
Ⅰ: basely audible
Ⅱ: usually readily heard
Ⅲ: loud
Ⅳ: quite loud
Ⅴ: even most pronounced
Ⅵ: can be heard with thestethoscope
removed from the chest wall
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⑤Effect of position, respiration and
exercise on intensity of murmurs
---body position:
MS--left lateral position
AI--sitting erected and forward
MI,TI,PVS--lie on one’ back
Lie → stand: HCM
---breath:
expiration--LV murmurs
inspiration --RV murmurs
valsalva--HCM
---exercise: HR↑murmurs ↑
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3） The clinical value of heart murmur
① systolic murmurs
② Diastolic murmurs
③continuous murmurs
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① systolic murmurs
Mitral valve area ：
functional:exercise,fever,anemia,pregnanc
y,hyperthyroidism
Soft, blowing SM, Grade II/VI well
localized wethout transmission. S1
normal.
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① systolic murmurs
Mitral valve area ：
relative:HBP,CHD,DCM,anemia
Dilatation of LV and mitral valve relative
insufficiency
---blowing SM
---Grade II-III/VI with or without transmission
---S1 usually normal.
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① systolic murmurs
Mitral valve area ：
organic：MI(RHD),mitral prolapse
Pansystolic murmur, blowing or harsh,
Grade III/VI or more, transmited toward
axilla or left back, S1 masked, the SM can
be intensified by lying on left lateral
position.
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① systolic murmurs
Aortic valve areas ：
Organic： aortic stenosis
---harsh ejection SM
---Grade III-IV/VI, often accompanied by a thrill
---crescendo-decrescendo type (diamond shaped)
---transmitted toward neck and apex
---A2 diminished or absent
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① systolic murmurs
Aortic valve areas ：
Functional：due to relative aorticstenosis
( dilatation of aorta , severe
hypertension atherosclerosis of aorta)
---Soft
---A2 accentuated
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① systolic murmurs
Pulmonary valve areas ：
Physiology：(children)
---Soft blowing SM
---Grade II/VI
---shorter
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① systolic murmurs
Pulmonary valve areas ：
relative：MS、ASD
Dilatation of pulmonary artery
( pulmonary hypertension or large
outflow from RV)
---Soft blowing SM
---Grade II/VI,well location
---Shorter
---P2 accentuated
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① systolic murmurs
Pulmonary valve areas ：
organic：pulmonary stenosis
---harsh ejection SM,
---Grade III-IV/VI, often accompanied
by a thrill
---crescendo-decrescendo type
(diamond shaped)
---P2 diminished or absent.
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① systolic murmurs
Tricuspid valve areas ：
relative ：RV enlarged
---Soft blowing SM
---Grade III/VI
organic ：rare
other location:
3-4nd I.c.s left to sternum
(VSD,ventricular septal defect)
---Loud, harsh SM, ejection
---accompanied by a thrill
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② Diastolic murmurs
mitral valve area
Organic： rheumatic mitral stenosis
---S1 loud and snappy OS audible
---well localized to the apex
---rumbling in quality in middle-late
of diastole crescendo characte
---In many instances, it is
accompanied by a thrill.
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② Diastolic murmurs
mitral valve area
relative MS ：Austin Flint murmur: In severe aortic
insufficiency, reduced overload of left
ventricular in diastolic there may be heard a
rumbling DM over the apex which can be
distinguished from the organic MS by
following points
--- not accompanied by a loud snappy S1 , or a thrill
---(There are unequivocal fingings compatible with
AR,i.e.blowing DM of AR over aortic valve
areas，lift ventricular enlargement, peripheral
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② Diastolic murmurs
Aortic valve areas. aortic insurfficiency
---decrescendo, sighing DM
---best heard in sitting position, leaning
forward,holding breath in expiration
---transmitted downward along both sides of
sternum
---A2 diminished
---In cases of severe degree of AR, there may be
present: DM (Austin Flint) over apex and peripheral
vascular signs
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② Diastolic murmurs
pulmonary valve areas
Relative：Graham Steel murmur:dilate of
pulmonary artery relative pulmonary
insufficiency
---decrescendo
---Blowing,soft
---P2 accentuated
---Seen in mitral stenosis
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③continuous murmurs
PDA (patent ducuts arteriosus)
---Continuous murmur PDA, characteristic
murmur of PDA is a comtinuous , machinary
murmur
---at 2 nd i.c.s. Left to sternum
---with an accentuated P2
---A systolic thrill may be present
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（7）pericardial friction sound
---both phases , unaffected by
respiration
---seen: pericarditis
RHD ,AMI ,renal failure
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