Cardiac Examination Inspection Palpation Percussion Auscultation باطنية / د.فاخر Cardiac Examination 2016//3/9 Inspection Palpation Percussion Auscultation specti The cardiac exam includes: Inspection of jugular venous pressure Inspection, palpation, and auscultation of the 4 cardiac areas with the diaphragm Auscultation over the tricuspid and mitral areas with the bell Special maneuvers If the PMI is not readily palpable with the patient supine, palpate in the left lateral decubitus position Ausculate for aortic insufficiency (regurgitation) - diaphragm at the left lower sternal border with the patient sitting and fully exhaled Ausculate for mitral stenosis - left lateral decubitus with bell

Cardiovascular Anatomy 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

باطنية / د.فاخر 2016//3/9 Assessment of the Heart, Great vessels of the neck, and Peripheral Vascular system

Inspection : Apex beat . left parasternal movement due to right ventricular hypertrophy. pulsation in 2d left ICS 2ry to enlarged PA. epigastric pulsation 2ry to expanded abdominal aorta .

5-chest wall deformity (pectus excavatum, carinatum) 6-scars (thoracotomy, pacemaker) 7-dilated veins

Palpation باطنية / د.فاخر 2016//3/9

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.

: 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: By the heel of the hand rested just to the left of the sternum.

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 .

Palpable murmurs (thrills): 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 .

Auscultation: bell to detect low-pitched sounds , press lightly against the skin diaphragm detect high-pitched sounds press firmly against the skin

Cardiovascular: Heart Sounds باطنية / د.فاخر 2016//3/9 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)

S1 – closure of mitral and tricuspid valves 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

Cont. auscultation 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

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) .

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,

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 mid-systolic (AS), pansystolic (MR). Diastolic; time between 2nd and the 1st HS, can be divided into tow phases. Early (AR), Mid-diastole (MS).

Grading of Murmurs: Grade 1 - only a staff man can hear باطنية / د.فاخر 2016//3/9 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

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

Systole LA AO LV RV

Diastole LA AO LV

Cardiac Physiology 101 Systole AV/PV – opens-------Aortic Stenosis Regurg/ Insuff – leaking (backflow) of blood across a closed valve Stenosis – Obstruction of (forward) flow across an opened valve Systole AV/PV – opens-------Aortic Stenosis S1-S2 MV/TV – closes------Mitral Regurg Diastole AV/PV – closes------Aortic Regurg S2-S1 MV/TV – opens-------Mitral Stenosis These concepts are set in stone, it can’t occur any other way, It would be anatomically impossible

Common Murmurs and Timing (click on murmur to play) باطنية / د.فاخر 2016//3/9 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

Holosystolic Murmurs Atrioventricular valve leakage Mitral Regurgitation Tricuspid Regurgitation Interventricular shunt Ventricular septal defect

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

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

Mitral Regurgitation after MI

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.

Aortic Stenosis

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

Mitral Stenosis “always” rheumatic in origin Turbulent, high velocity flow occurs during diastole Always look for MS in patient with new Atrial fibrillation

Mitral Stenosis Loud S1, present - normal S2 Opening snap . Rumbling mid-diastolic murmur heard at apex with stethoscope bell, patient in L lateral decubitus Palpate carotid to identify diastole

Left lateral decubitus

Aortic Regurgitation congenital, endocarditis, age, aortic disease, collagen vascular, syphillis Early diastolic, decrescendo murmur best heard at LLSB with diaphragm

Aortic regurgitation findings Soft S1 and A2 Blowing decrescendo diastolic murmur Begins immediately with A2 High frequency (diaphragm) Press firmly & concentrate

AR easily missed

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.

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)

JUGULAR VENOUS DISTENTION باطنية / د.فاخر 2016//3/9 JUGULAR VENOUS DISTENTION Top line – level of the higest visible point of distention Bottom line – level of the sternal angle Measure: the vertical distance between the sternal angle and the highest level of jugular distention