1. 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

2. 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

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

7. 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 .

8. 5-chest wall deformity (pectus excavatum, carinatum)
6-scars (thoracotomy, pacemaker)
7-dilated veins

9. Palpation
باطنية / د.فاخر
2016//3/9

10. 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.

11. :
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.

12. 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 .

13. 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 .

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

16. 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)

17. 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

18. 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

19. 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) .

20. 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,

21. 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).

22. 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

23. 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

24. Systole LA AO LV RV

25. Diastole LA AO LV

26. 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

27. 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
S S S1

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

29. 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

30. 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

32. Mitral Regurgitation after MI

33. 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.

34. Aortic Stenosis

36. 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

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

38. 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

39. Left lateral decubitus

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

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

44. AR easily missed

45. 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.

46. 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)

47. 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