Transcript Cardiac Auscultation

Cardiac Examination
•Inspection
• Palpation
• Percussion
• Auscultation
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Cardiovascular Anatomy
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Heart : is shaped like “Cone”
“top” of the heart is the base
“bottom” is the apex
Heart size = clenched fist
Precordium: area on anterior chest that
covers heart and great vessels
• Atria : are tilted slightly toward the back
and ventricles :extend to left and toward
anterior chest wall
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Assessment of the Heart, Great vessels of
the neck, and Peripheral Vascular system
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• Inspection :
1. Apex beat .
2. left parasternal movement due to right
ventricular hypertrophy.
3. pulsation in 2d left ICS 2ry to enlarged
PA.
4. epigastric pulsation 2ry to expanded
abdominal aorta .
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• 5-chest wall deformity (pectus excavatum,
carinatum)
• 6-scars (thoracotomy, pacemaker)
• 7-dilated veins
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Palpation
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By PALPATION
• Explain the procedure to the patient
• - Ensure the patient is in a supine position
at an angle of 45 degs.
• - Ask the patient to breathe normally.
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:
➡Apex beat:It is primarily due to recoil of the
heart’s apex as blood is expelled during systole.
➡Site (the most lateral and most inferior; normally
in the 5th left intercostals space in the mid
clavicular line)
Displaced or not
Character
( tapping ,thrusting ,heaving)
➡Parasternal impulse:
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By the heel of the hand rested just to the
left of the sternum.
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• Palpation :
• Left parasternal heave : at the left sternal
border due to right ventricle hypertrophy
• Palpable second heart sound at the
base of the heart (2nd intercostal space )
due to loud s2 ex: pulmonary
hypertension .
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➡Palpable murmurs (thrills):
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Start at the apex then the left sternal
edge and the base of the heart.
• Either systolic or diastolic thrills according
• to timing with carotid or apex beat .
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Auscultation:
bell to detect low-pitched sounds ,
press lightly against the skin
– diaphragm detect high-pitched
sounds
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press firmly against the skin
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Cardiovascular: Heart Sounds
• Heart sounds: lub dub
• SYSTOLE: lub= S1 (closing of AV valves)
• DIASTOLE: dub = S2 (closing of semilunar
valves)
• During the cardiac cycle, valves are opening
and closing, causing different heart sounds
(S1 and S2).
• Sometimes abnormal heart sounds are
heard due to improper opening or closing of
the valves.(murmurs)
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AUSCULTATION
• S1 – closure of mitral and tricuspid valves
• S2 – closure of aortic and pulmonic valves
• Low pitched sounds S3, S4, mitral stenosis,
• S1 systole S2 diastole S1
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Cont. auscultation
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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)
murmers
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Murmurs
• 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) .
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Cont.
• Site; area over which a murmur is best
heared depends upon the valve of origin
and the direction of the blood flow.
(Mitral m.at apex, aortic m.at right 2nd ICS)
• Radiation; occurs along line of blood flow.
(MR radiate to the axilla … AS» neck,
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Cont.
• Pitch; high pitch murmurs MR &AR
• Low pitch murmurs MS & AS
• Timing; in relation to the1st and the 2nd HS
Systolic;
time between 1st and the 2nd HS, could be midsystolic (AS), pansystolic (MR).
Diastolic;
time between 2nd and the 1st HS, can be divided
into tow phases. Early (AR), Mid-diastole (MS).
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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
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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 sternal
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Systole
LA
AO
LV
RV
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Diastole
LA
AO
LV
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Cardiac Physiology 101
Regurg/ Insuff – leaking (backflow) of blood across a closed valve
Stenosis – Obstruction of (forward) flow across an opened valve
Systole
S1-S2
Diastole
S2-S1
AV/PV – opens-------Aortic Stenosis
MV/TV – closes------Mitral Regurg
AV/PV – closes------Aortic Regurg
MV/TV – opens-------Mitral Stenosis
These concepts are set in stone, it can’t occur any other way,
It would be anatomically impossible
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Common Murmurs and
Timing (click on murmur to play)
Systolic Murmurs
• Aortic stenosis
• Mitral insufficiency
• Mitral valve prolapse
• Tricuspid insufficiency
Diastolic Murmurs
• Aortic insufficiency
• Mitral stenosis
S1
S2
S1
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Holosystolic Murmurs
• Atrioventricular valve leakage
– Mitral Regurgitation
– Tricuspid Regurgitation
• Interventricular shunt
– Ventricular septal defect
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Holosystolic Murmurs
• “Pansystolic Murmurs”
• Begin with S1 and end after S2
• Caused by flow from high pressure area to
much lower pressure area
– Ventricle to atrium
– Left ventricle to right ventricle
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MR
• Radiates to axilla or back in most cases
• May radiate to the base if posterior leaflet
prolapse
• Well heard with diaphragm but listen with
bell also for S3 or diastolic “flow” rumble
– Due to high volume flowing back from LA
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Mitral Regurgitation after MI
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Aortic Stenosis
• The typical murmur of aortic stenosis is
harsh, similar to the sound of clearing
one’s throat. Aortic events are usually well
heard at the apex.
• The murmur of aortic stenosis
characteristically radiates up into the
supraclavicular area of the neck, over the
carotids, and the suprasternal notch.
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Aortic Stenosis
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Pulmonic Stenosis
• Usually 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
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Mitral Stenosis
• “always” rheumatic in origin
• Turbulent, high velocity flow occurs during
diastole
• Always look for MS in patient with new
Atrial fibrillation
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Mitral Stenosis
• Loud S1, present
• - normal S2
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Opening snap
• . Rumbling mid-diastolic murmur
– heard at apex with stethoscope bell, patient in L
lateral decubitus
– Palpate carotid to identify diastole
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Left lateral decubitus
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Aortic Regurgitation
• congenital, endocarditis, age,
aortic disease, collagen vascular,
syphillis
• Early diastolic, decrescendo
murmur best heard at LLSB with
diaphragm
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Aortic regurgitation findings
• Soft S1 and A2
• Blowing decrescendo diastolic
murmur
– Begins immediately with A2
– High frequency (diaphragm)
• Press firmly & concentrate
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AR easily missed
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Aortic Regurgitation
• Positions and techniques for auscultation:
• The murmurs of aortic regurgitation are
generally heard when the patient is sitting
upright, leaning forward, breath held in
deep expiration.
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Additional findings
• Wide pulse pressure with low diastolic
– “Water hammer pulses”
• Durrosiez’s sign
– To and fro bruit at femoral artery
• Quinke’s sign
– Nailbeds flush with systole
• de Musset's sign (Head nodding in time
with the heart beat)
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JUGULAR VENOUS DISTENTION
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