Presentation on theme: "Virginia Joslin, PA-C, MPH"— Presentation transcript:
1 Virginia Joslin, PA-C, MPH A Workshop: Review Your Knowledge and Build your Skills INTERPRETATION OF HEART SOUNDSVirginia Joslin, PA-C, MPHandKaren Newell, PA-C, MMScEmory DFPMContact information:Virginia Joslin, PA-CDirector, Emory University PA Program(404)Karen Newell, PA-CAcademic CoordinatorEmory University PA Program(404)Website:
2 Workshop Goals:To enhance the learner’s knowledge and skills in heart sounds interpretation for improved clinical practice and performance on the Board Certification exam a) using physical exam techniques focusing on auscultation effectively and b) critically analyzing a narrative description of heart exam findings
3 Learner ObjectivesBy the end of the workshop, the learner will be able to:Describe the critical cardiac anatomy and physiology as it relates to heart sounds.Utilize the stethoscope properly to maximize your ability to pick-up subtle sounds.Recognize the common causes of heart murmurs.Interpret heart sounds based on timing, location, radiation, pitch, and changes in quality with specific exam techniques.Provide a differential diagnosis for the etiology of extra heart sounds.Identify the heart abnormality or diagnosis, given a classic description of case presentation with risk factors, history and physical exam findings.
4 Organize your critical thinking skills! Case Presentation Mr. N. Trouble is a 64 y.o. homeless man with a history of worsening chest pain and DOE for the last 3 months. He has developed a nonproductive cough and orthopnea without fever. On exam of the heart you note:an enlarged, hyperdynamic PMI displaced infero-laterally, a thrill over the apex, an S4, S3, and a grade IV/VI holosystolic murmur heard best with the diaphragm at the apex.
5 Case PresentationWhat is the most likely diagnosis?What is the likely cause of this condition in this patient?
6 Surface Anatomy: Key Landmarks MCLSternal Angle2Erb’s Point5 L. MCLBickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens
7 Heart wall layers and pericardium Other Relevant Cardiac AnatomyHeart wall layers and pericardiumInter-atrial and Inter-ventricular SeptumValvesChordae Tendineae and Papillary musclesCardiac conduction systemThree layers: Endocardium, Myocardium, EpicardiumSeptum between atria, or between ventricles may have an opening ( ASD, VSD) which may cause a murmurNormally heart valves open in one direction Valves allowing backward flow of blood are incompetent and cause regurgitant murmurs. Stiff, narrow valves cause valvular stenosis.Chordae Tendinae act as ligaments between the papillary muscles and the A/V valves ( Tricuspid and Mitral).Conduction System serves to organize the physiological events of the heart: Sinoatrial(SA) node to Atrioventricular(AV) node, to Bundle of His to Right and Left Bundle Branches and Perkinje Fibers. The Left Bundle Branch has septal, anterior and posterior fascicles.
8 Cardiac Conduction System Organizer of the cardiac physiological events
9 Emory University Physician Assistant Program A & P Valves Open M & T Valves ClosedMitral Valve is closedTricuspid Valve is closedEmory University Physician Assistant Program
10 Emory University Physician Assistant Program M & T Valves Open P & A Valves ClosedAPEmory University Physician Assistant Program
11 1 2 3 4 5 6 M & T close A & P open A & P close #1 Left ventricular pressure exceeds left atrial pressure as the full ventricle begins to contract. The mitral valve is pushed closed = S1#2 The left ventricular pressure exceeds that pressure in the aorta, pushing the aortic valve open. Normally no sound is heard. If the aortic valve is stiff, an ejection click may be heard.#3 The pressure in the aorta exceeds the pressure in the left ventricle, pushing the aortic valve closed, causing S2#4The pressure in the left atrium exceeds the pressure in the left ventricle, pushing the mitral valve open. Normally no sound is heard. If the mitral valve is stiff, an opening snap may be heard.#5 Early in diastole the blood flows by gravity from the left atrium into the left ventricle. If the inferior septal wall of the ventricle is stiff, an early diastolic sound may be heard = an S3.#6 At the end of diastole, the left atrium contracts, increasing the pressure in the left atrium..Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens with permission456M & T open
12 A complete cycle of physiologic cardiac events Aortic PressureVentricular PressureAtrial PressureS1EjClS4S1#7 At the end of diastole the left atrium contracts, ejecting the last bolus of blood into the left ventricle. . Normally no sound is heard. If the inferior septal wall of the left ventricle is stiff, and S4 gallop may be heard.Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& WilkensA complete cycle of physiologic cardiac events
13 Quiz Which valves are normally closed during systole? Aortic and PulmonicTricuspid and MitralAortic and MitralTricuspid and Pulmonic
14 Answer: B T&M valves During Systole: the Aortic and Pulmonic valves are OPENThe Tricuspid and Mitral valves are CLOSED
15 Cardiac Exam Inspect Palpate Auscultate The exam is inadequate, if the precordium is covered.No more than one pulsation should be visible (PMI).No more than one pulsation should be palpable:Location: Normally in the MCL, 5th ICS or just medialPulse should be palpable no longer than 2/3 of systole as auscultated simultaneouslySize: No larger than 2.5 cm.PMI that is enlarged, displaced, sustained suggests LVHAuscultation should include, at a minimum, use of the bell and diaphragm in all four valve location
16 Normal Heart Sounds Valve Closure S1 (closure of Mitral and Tricuspid valves)S2 (closure of the Aortic and Pulmonic valves)High pitched: heard best with the DiaphragmWhich is S1? S2? (location where best heard, rhythm, timing compared to the carotid pulse and JVP waves )S1 due to closure of the Tricuspid and Mitral ValvesS2 due to closure of the Aortic and Pulmonic valvesBoth are high pitched sounds, best heard with the diaphragmMethods to differentiate S1 from S2:1) Systole (between S1 and S2) is shorter than Diastole2) S2 usually loudest at the base (Aortic and Pulmonic areas); S1 is usually loudest at the apex (Mitral area)3) Carotid pulsation is palpable immediately after S14) S1 is audible immediately after the “a” wave of the JVP (the highest wave when looking at the JVP in profile) by observation5) S2 occurs almost simultaneously with the “v” wave of the JVP
17 S2 = A P valves Base Apex S2 S2 S1 S1 = M T valves S2 (A P) is loudest at the base of the heart, while S1(M T) is loudest at the apex. LET’s listen to Karen reproduce the normal Heart Sounds.S1 = M T valvesApexAdapted from Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens
18 Normal Splitting of S2 with Inspiration ExpirationInspirationPhysiologic splitting, the splitting of the Aortic and Pulmonic components of S2 with inspiration, is frequently present in healthy patients. Inspiration causes an increase in return of blood to the heart (right heart initially), slowing the timing of contraction of the right ventricle and closure of the pulmonic valve .Think of inspiration as having a vacuum effect on blood in the venous system, increasing the amount of venous blood entering the right heart.Split S2 with inspiration, heard best with diaphragm near 2nd and 3rd ICS at the LSBBickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams & Wilkens
19 QuizUpon auscultation of heart sounds, where is S2 normally heard the loudest?BaseApexErb’s Point2nd the LSB
20 **Answer: BS2 is loudest at the base of the heart since this sound results from the closure of the Aortic and Pulmonic valvesThe pressures on the left side of the heart are higher than on the right, thus the Aortic valve closure sound predominates ( A/PBaseS2S2S2= A&P valve closureS1S2 (A P) is loudest at the base of the heart, while S1(M T) is loudest at the apex. LET’s listen to Karen reproduce the normal Heart Sounds.S1 = M&T valve closureApexAdapted from Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens
21 Which of the following best describes the normal splitting of S2? S2 is split into 2 components with expirationS2 is split into 2 components with inspirationSplit S2 is heard best at the apexSplit S2 is heard best at the aortic valve region
22 Answer: BIf present, a split S2 is best heard near Erb’s Point (3rd LSB or over the Pulmonic valve area (2nd andDuring Inspiration, venous return of blood to the right side of the heart, slows the right-sided physiologic events, causing a delay in the closure of the pulmonic valve.A Split S2 during expiration is pathological !
23 Abnormal Heart Sounds Discrete sounds: Split S2 (pathological) Gallops (S3 and S4)Clicks (ejection)Snaps (opening)Continuous sounds:MurmursFriction RubsPDAThe Symphony! Listen for just the violin! Just the drums!, Just the harp!Be sure to take the time to listen in all four valve areas with both the diaphragm and bell, try to stay focused on each individual normal heart sound, listen for the normally quiet spaces between S1 and S2 (Systole), and S2 and S1(Diastole)
24 Paradoxical Splitting ExpirationInspirationInspirationS2Expiration1Wide splitting2Fixed splitting3P2 A2Pathologic Splitting of S2 means that there are two distinct audible components (A and P) during expiration. The split S2 in expiration may also occur in inspiration.The A and P components of S2 may be due to:delay of the pulmonic valve closure - Wide splitting (#1 illustration)Pulmonic StenosisRight Bundle Branch Blockearly closure of the aortic valveMitral RegurgitationAtrial Septal Defect- Fixed splitting (#2 illustration)delay in the closure of the aortic valveLeft Bundle Branch Block- Paradoxical splitting (#3 illustration)S2 is usually a single sound in inspiration with LBBBNote: S1 may be split in RBBB, and in normal healthy peopleParadoxical SplittingAdapted from Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens
25 Ejection Clicks Extra Sounds in Systole: An Ejection Click is a high pitched, early systolic sound associated with the opening of an abnormal valve, sometimes followed by a murmurAortic Stenosis - 2nd R the SBPulmonic Stenosis- 2nd L the SBWhat physiologic event normally occurs early in Systole?Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens
26 Extra Sounds in Diastole: SnapsAn Opening Snap is a high-pitched diastolic sound associated with the opening of an abnormal valve, sometimes followed by a murmurTricuspid valve the LLSBMitral valve the apexWhat physiologic events normally occur early in Diastole?Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens
27 Extra sounds in early in Diastole: Gallops S3 and S4 are called Gallops, occur in diastole as a result of blood hitting a non-compliant, stiff ventricular wall. These are low-pitched sounds, heard best with the bell near the apex.S3 is an early diastolic sound (blood passively entering the ventricle) associated with Heart Failureheard at the LLSB or Apex with Left Heart Failureheard over the lower sternum/ epigastric area with Right Heart FailureNote: S3 can be heard normally in childrenEarly Diastolic Sound: S3Heard best with the BellBickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens
28 Late Diastolic Sound: Gallop S4 is a late diastolic sound associated with the active ejection of blood from the atria into the ventricles when the atria contract.S4 may be normal with an enlarged healthy heart in an athletic, or abnormal with ventricular hypertrophy.Late diastolic sound: S4Best heard with the BellSummation Gallop ( S3+S4)Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens
29 Which of the following best describes an ejection click? QuizWhich of the following best describes an ejection click?Occurs early in diastole and is best heard with the diaphragmOccurs late in diastole and is best heard with the bellOccurs early in systole and is a high pitched soundOccurs early in systole and is a low pitched soundA normal heard sound that occurs when the A&P valves open
30 Answer: CAn ejection click is an abnormal heart sound, classically described as high-pitched, which occurs early in systole, when a stiff aortic or pulmonic valve opensSystole
31 Identify the Extra Heart Sound ! Is the extra sound continuous (murmur) or discrete(clicks, snaps, split S1or S2, Gallops, rubs)Is the extra sound in systole or diastole?Systole (between S1 and S2)Carotid pulse quickly follows S1“A” wave (atrial kick) in the JVP is quickly followed by S1Systole is shorter than diastoleWhich valve(A/P/T/M) location do you hear the sound best?Do you hear it better with the bell or the diaphragm (high [click, snap, split S1 or split S2] or low pitched [S3,S4])?
32 Discrete SoundsABABWhich space between the heart sounds represents Systole ?Which bars represent S1?
33 Extra Sounds Systolic vs. Diastolic DiastoleSystoleS2S1S2“A” waveCarotid pulse“V” wave
34 Systolic Extra Sounds Diastole Systole S2 S1 S2 Where heard best? Bell or diaphragm?Constant or varies with respiration?Apex/ diaphragm = Split S1
35 Systolic Extra Sounds Diastole Systole S2 S1 S2 Where heard best? Where heard best?Bell or diaphragm?Constant or varies with respiration?Base / diaphragm = Ej. click (A or P)
36 Diastolic Extra Sounds DiastoleSystoleS2S2S1Where heard best? Bell or diaphragm?Constant or varies with respiration?Opening snap (location/pitch) vs. split S2 (location/pitch/varies with respiration) vs. S3 vs. S4 (location/pitch)
38 Assessment of Murmurs Timing of the murmur Systolic Events Diastolic EventsS1 _________S2_______________ S1Systolic Physiologic Events:Normal Direction of Blood FlowEjection through the Aortic and Pulmonic Valves (AS, PS)Through a septal defect flow from high pressure to lower pressure (ASD, VSD)Flow against billowing mitral valve leaflets (MVP)Abnormal Direction of Blood Flow:Backwards flow through an incompetent valve (MR,TR)Diastolic Physiologic Events:flow through the Mitral and Tricuspid valves (MS,TS)Abnormal Direction of Blood Flowflow backwards through a leaking incompetent valve ( AR, PR)SystoleDiastole
39 Location of the Murmur A P T M Best heard where ? Aortic Pulmonic TricuspidMitral (Apex)Radiates to where?R. Neck, L. NeckL. AxillaBackSound follows thedirection of flowAPTMAortic Valve murmurs are heard best at the 2nd R the SB.Pulmonic Valve murmurs are heard best at the 2nd L SB.Tricuspid Valve murmurs are heard best at the LLSB.Mitral Valve murmurs are best heard at the apex ( PMI).Radiation of the sound follows the path of the flow of blood:Aortic Stenosis- murmur radiates to the right clavicle or neck.Pulmonic Stenosis - murmur radiates to the left clavicle or neck.Mitral Regurgitation - murmur radiates to the left axilla or left scapulaAortic Regurgitation - murmur radiates downward toward the LLSB and apex
40 Other Qualities of Murmurs Intensity (Grade I – VI)Soft to loud (if thrill present, Grade is =/> IV)Pitch (high, medium, low)Musical QualityRumblingCooingBlowing (Regurgitant murmurs)Shape (change in intensity)CrescendoDecrescendoIntensity: Graded on a scale of I - VIGrade I - barely audible; examiner must concentrate to hear thisGrade II - soft, but audibleGrade III - loudGrade IV - louder and associated with a thrillGrade V - very loud, it can be heard with the stethoscope head 1/2 off the chest, and is associated with a thrillGrade VI - so loud it can be heard without a stethoscopePitch: High, medium, low determined by which head of the stethoscope hears the murmur best ( low-pitched murmurs heard best with the bell).In general, flow murmurs are low to medium pitched, regurgitant murmurs are high-pitchedMusical Quality:Regurgitant murmurs usually described as “ blowing”Mitral Stenosis- rumblingMVP- cooingPDA- machinery-likeShape :Crescendo- increasing in intensityDecrescendo - decreasing in intensityCrescendo- Decrescendo - increasing then decreasing.
41 Shape Crescendo Decrescendo Crescendo- decrescendo Plateau 1 2 3 4 #3 crescendo-decrescendo ( classic ejection murmur) Aortic and Pulmonic Stenosis#4 plateauPlateauBickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams & Wilkens
42 Factors Changing Murmurs Respiration (increase venous return with inspiration; ↑ in intensity of the murmurs of T.S. and P.S., but ↓ in intensity with T.R. and P.R.Exercise (increase flow>>>> increased intensity)Positiondecubitus brings out mitral murmursleaning forward brings out the murmur of ARValsalva or Standing (decreases venous return)Squatting (increases venous return)Maneuvers are often used to differentiate murmurs:Inspiration increases the intensity of right heart flow murmurs.Exercise increases the intensity of most murmurs and may help to better assess a soft (low grade) murmur.Position changemitral valve murmurs are best heard or only heard in the left lateral decubitus positionthe murmur of aortic regurgitation becomes more intense with the patients leaning forward with expirationinnocent murmurs are often heard only with the patient supineStanding vs. SquattingSquatting increases the venous return to the heart and increases left ventricular volumeincreases the intensity of the murmur of Aortic Stenosisdecreases the intensity of the murmur of IHSSdecreases the intensity of the murmur of MVP, click is delayed, if present, and the murmur is shortenedStanding and the Valsalva maneuver decreases venous return and left ventricular volumedecreases the intensity of ASincreases the intensity of the murmur of IHSSincreases the intensity of the murmur of MVP and moves the click and murmur earlier (lengthens the murmur)
43 Emory University Physician Assistant Program Physical Exam PulsesPulses: : slow and delayed carotid pulse with severe AS; bounding with AR;Emory University Physician Assistant Program
44 Other PE CluesPulses:bounding carotid pulse (AR)decreased, delayed carotid pulse(AS)decreased with outlet obstruction or weak(heart failure)Pulsus alternans with L.Ventricular failureFundus: Roth spots, splinter hemorrhages (Endocarditis)Lungs: crackles (heart failure)General: Head bobbing: Severe Aortic RegurgitationBP: Wide pulse pressure ( Systolic-Diastolic > 40 ): Aortic RegurgitationNarrow pulse pressure ( Systolic- Diastolic < 40: Aortic StenosisJVP abnormalities:Tricuspid Stenosis may be associated with a giant “a” waveTricuspid Regurgitation may be associated with a large “v” waveJVP may be elevated with Pulmonic StenosisJVP elevated with Left Heart Failure, with some Cardiomyopathies, and with Constrictive PericarditisPulses: delayed upstroke or diminished intensity of the Carotid pulse may be a clue to AS.Bisferiens pulse (double systolic peak) is seen with Hypertrophic Cardiomyopathy, and AR.Pulsus Alternans (pulse amplitude varies beat to beat) is seen with left ventricular failure.Bounding, Corrigan’s or Water hammer carotid pulse: ARDiminished femoral pulse or radial-femoral pulse delay and BP lower in the legs than in the arms may be seen with Coarctation of the aorta.Paradoxical Pulse: Decrease in pulse amplitude on inspiration and/or decrease in systolic BP > 10 mm Hg with inspiration is seen in cardiac tamponade, constrictive pericarditisFundus: Only place to directly visualize blood vessels; Roth spots with endocarditisLungs: Crackles and wheezing with heart failure (Cardiomyopathy)Skin and extremities: edema with heart failure, petechiae in the skin and nails, Janeway lesions and Osler nodes with EndocarditisAbdomen: hepatomegaly and pulsatile liver may be due to Right Heart Failure
45 Emory University Physician Assistant Program Physical Exam: PulsesParadoxical pulse with constrictive percarditis/tamponadeFemoral pulse delay and BP in legs < in arms (Coarctation of the aorta)Rib notchingEmory University Physician Assistant Program
46 Emory University Physician Assistant Program Physical ExamSkin, NailsNail clubbing (chronic hypoxia)Petechiae, splinter hemorrhages – EndocarditisOsler’s nodes- finger tips - EndocarditisJaneway lesions- palms and soles- EndocarditisPedal edema- Right heart failureJaneway LesionOsler Nodeaapredbook.aappublications.orgEmory University Physician Assistant Program
47 Other PE Clues General appearance: Vitals: Jugular veins: Tall, thin with long limbs (Marfan’s);Willowy, thin chest wall (Mitral Valve Prolapse)Head bobbing (Severe AR)Pale (Anemia)Blue (anoxia with congenital heart defects)Vitals:Low BP with dehydration, Severe Heart Failure, MIPulse pressure wide (AR); narrow(AS)Tachycardia with infectionBradycardia with AV blocksJugular veins:distended, elevated JVP (R heart failure, PericardialTamponade)Giant A wave (TS)Large v wave (TR)Point of maximal intensity(PMI):enlarged, displaced, hyperdynamic, sustained (L. Heart Failure, LVH, AS, AR, MR)General: Head bobbing: Severe Aortic RegurgitationBP: Wide pulse pressure ( Systolic-Diastolic > 40 ): Aortic RegurgitationNarrow pulse pressure ( Systolic- Diastolic < 40: Aortic StenosisJVP abnormalities:Tricuspid Stenosis may be associated with a giant “a” waveTricuspid Regurgitation may be associated with a large “v” waveJVP may be elevated with Pulmonic StenosisJVP elevated with Left Heart Failure, with some Cardiomyopathies, and with Constrictive PericarditisPulses: delayed upstroke or diminished intensity of the Carotid pulse may be a clue to AS.Bisferiens pulse (double systolic peak) is seen with Hypertrophic Cardiomyopathy, and AR.Pulsus Alternans (pulse amplitude varies beat to beat) is seen with left ventricular failure.Bounding, Corrigan’s or Water hammer carotid pulse: ARDiminished femoral pulse or radial-femoral pulse delay and BP lower in the legs than in the arms may be seen with Coarctation of the aorta.Paradoxical Pulse: Decrease in pulse amplitude on inspiration and/or decrease in systolic BP > 10 mm Hg with inspiration is seen in cardiac tamponade, constrictive pericarditisFundus: Only place to directly visualize blood vessels; Roth spots with endocarditisLungs: Crackles and wheezing with heart failure (Cardiomyopathy)Skin and extremities: edema with heart failure, petechiae in the skin and nails, Janeway lesions and Osler nodes with EndocarditisAbdomen: hepatomegaly and pulsatile liver may be due to Right Heart Failure
48 Emory University Physician Assistant Program Physical Exam JVPJVP reflects RA pressure : ↑ JVP with R. Heart Failure, Constrictive Pericarditis, Cardiac Tamponade;Large A wave-with Tricuspid Stenosis, large V wave with Tricuspid RegurgitationEmory University Physician Assistant Program
49 Emory University Physician Assistant Program Physical ExamAbdomen(ascites , pulsatile liver, hepatomegaly- R Heart Failure)Extremities –pedal/lower extremity edema(R heart failure), pale distally (Arterial Insufficiency)Emory University Physician Assistant Program
50 Quiz Which of the following valve abnormalities may cause an enlarged displaced PMI Mitral StenosisPulmonic StenosisAortic StenosisTricuspid StenosisVentricular Septal Defect
51 Answer: CAortic Stenosis will cause left ventricular hypertrophy, enlarging (>2.5 cm) and displacing the PMI leftward and inferiorly from the normal location (L. 5th ICS MCL)Mitral Stenosis will enlarge the left atriumPulmonic Stenosis will enlarge the right ventricle (sternal lift)Tricuspid Stenosis will enlarge the right atrium and cause abnormalities (elevated, giant “A” wave) of the JVPVSD causes enlargement of the right ventricle due to the higher pressures in the left ventricle resulting in a left to right shunting of blood and eventually RVH. (sternal lift)
52 Systolic Murmurs Innocent and Physiological Murmurs Anemia, Pregnancy, Fever, HyperthyroidismNormal Flow Direction through valvesAortic and Pulmonic StenosisIdiopathic Hypertrophic Subaortic StenosisHolosystolic MurmursBackward Flow through incompetent valves or a Ventricular septal defectMitral and Tricuspid RegurgitationVentricular Septal DefectBackward flow around billowing valve leaflets; but closed valveMitral Valve ProlapseTry to Categorize the Murmur:Systolic:Normal flow direction (AS, PS, IHSS )- “ejection” murmurPansystolic (MR, TR, VSD) - heard through out systolebackwards flow against a flaccid, but competent valve (MVP)- crescendo murmurDiastolic:Normal flow directionAbnormal direction of flow
53 Systolic Murmurs Low-grade flow murmurs Still’s murmur (innocent): child usually 3-6 years, mid-systolic, vibratory, heard at left sternal border to apex, disappears or ↓ with sitting/standingInnocent Murmurs tend to be soft (low grade), ejection-type in shape, heard best along the left sternal border, and in the supine position, and should not be associated with any abnormal exam findings.Physiologic Murmurs are ejection-type in shape. Look for other objective clues such as thyroidmegaly, pale conjunctiva, elevate temperature.Adapted from: Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens
54 Best heard at the Aortic area; Ejection shaped murmur, radiates to the right clavicle/ neck;May have EjCl, Narrowed Pulse Pressure, diminished delayed carotid upstroke, S4PMI abnormalitiesAS is classically:a systolic ejection murmur, sometimes preceded by an Ejection clickbest heard at the aortic regiondescribed as harshradiates to the right neckmay be associated with a narrow pulse pressuremay be associated with a delayed upstroke of the carotid pulse, or diminishedmay be associated with and enlarged, displaced PMImay have an S4, if significant hypertrophy resultsDDX:IHSS- squatting may decrease the intensity of this murmur; valsalva and standing may increase the intensity of this murmurAortic Sclerosis - usually no other abnormal objective findings; more common in the elderlyAdapted from: Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens
55 Split S2 with Inspiration Best heard at the Pulmonic area, ejection type murmur, radiates to the left neck, ↑ in intensity with inspirationMight have: Ej Cl over the pulmonic area, right-sided S4, sternal lift, JVP abnormalitiesPS is classically:a systolic ejection type murmur, sometimes proceeded by an Ejection clickheard best at the pulmonic regiondescribed as harshradiates to the left neckif severe, may be associated with a sternal lift and a right-sided S4if severe, may be associated with an elevated JVPmurmur should increase in intensity with inspirationSplit S2 with InspirationBickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens
56 IHSS subaortic hypertrophy Idiopathic Hypertrophic Subaortic Stenosis: An area of the ventricular septum located just beneath the aortic valve that can cause turbulent flow of blood and/or partial obstruction of blood flow out the aortic valve. The murmur is systolic and will vary in intensity with the volume of blood and the degree with which the septum is stretched.From: Mosby’s Guide to Physical Examination Seidel H, Ball J.Dains J, Benedict GW
57 Other generalized Cardiomyopathies Google images
58 The intensity of this murmur increases with the valsalva! IHSS:sounds like AS ( ejection-type, best heard near aortic region)increases with Valsalva and standing ( hypertrophic area bulges with less blood volume, causing more obstruction) , decreases with squattingThe intensity of this murmur increases with the valsalva!Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens
59 Other Systolic Murmurs mitral valve leafletsBackward direction of flow at a competent mitral valve, but the mitral leaflets billowMitral valve prolapseClick-murmur orClick alone orMurmur aloneConfirm by auscultating over the Mitral region while standing and squatting, or change with the valsalva maneuverValsalva/Standing lengthens the murmur;Squatting shortens itchordae tendinaeMVP classically:is associated with a high pitched click, followed by a systolic, crescendo murmur, heard best in the mitral region.Valsalva and standing moves the click or click/murmur earlier in systole, lengthening the murmur; squatting delays the click/murmur.
60 Holo/Pansystolic Murmurs Mitral Regurgitation (Apex, radiates to the L. axilla or scapula)Tricuspid Regurgitation (LLSB, JVP abnormalities)Ventricular Septal Defect (lower sternum, Sternal lift)Pansystolic = Holosystolic
61 radiation radiation Apex R sided Mitral Regurgitation classically:is a pansystolic murmurheard best at the apex, sometimes only in the decubitus position“blowing” in qualityradiates to the left axillamay be associated with PMI abnormalities, +S4may develop quickly S/P MI ( papillary muscle rupture)R sidedM&T areas close together, Both are “blowing”! Radiation direction!Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens
62 +/- Sternal lift R-sided S4 Ventricular Septal Defect classically: is a pansystolic murmurheard best over the lower sternumharsh in qualityradiates widelymay be associated with a sternal liftmay be associated with a right sided S4intensity decreases with inspiration and squattingNote: The intensity of the murmur and the size of the defect do not correlate!R-sided S4Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens
63 Which of the following conditions would cause a holosystolic murmur? MSASASDMRAR
65 Diastolic Murmurs Possibilities during ventricular filling: Normal direction of flow through narrowed valvesMitral and Tricuspid StenosisBackward flow through incompetent valvesAortic and Pulmonic InsufficiencyMTPA
66 Compare to Tricuspid Stenosis! Diastolic Decrescendo- Crescendo Murmur +/- Opening SnapMitral Stenosis classically:is a decrescendo-crescendo diastolic murmur, sometimes preceded by an Opening Snapmurmur is low-pitched (heard best with the bell)heard better in the left decubitus position, sometimes only heard in this positionTricuspid Stenosis classically:is a low-pitched murmurheard best at the LLSBintensity of the murmur increases with inspiration and squattingmay be associated with a giant “a” waveCompare to Tricuspid Stenosis!Both have low-pitched murmurs, may have an OSTS: murmur ↑ with inspiration/squatting, +/- giant A waveBickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens
67 Diastolic Decrescendo Murmur Aortic Regurgitation classically:is a decrescendo diastolic blowing murmurbest heard in the aortic regionradiates downward toward the apexincreases in intensity with leaning forward ( have patient exhale and hold their breath)may be associated with an S4; may cause heart failure eventually (+S3)PMI usually enlarged, displacedassociated with a wide pulse pressuremay be associated with a bounding “waterhammer” carotid pulsein severe cases the patients head may bobPulmonic Regurgitation classically:best heard in the pulmonic regionmay have an associated sternal lift, left sided S4decreases in intensity with inspirationBlowing murmur, heard from Aortic area to the apex, S4,+/- S3, PMI abnormalities, wide pulse pressure, bounding or pulsus alterans of the carotid pulse, +/- head bobbing. Murmur may intensify as the patient leans forward and exhalesBickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens
68 Sounds heard in both Systole and Diastole Pericardial Friction RubPatent Ductus ArteriosusVenous HumOther auscultated precordial sounds may be misinterpreted as murmurs as they will be heard in systole and diastole
69 High pitched, scratchy, LLSB & apex, 3 components (2 in diastole), best heard with patient leaning forwardPericardial Friction Rub:is high-pitched (best heard with the diaphragm) and “scratchy”usually heard along the left sternal border and apexheard best with the patient leaning forwardcharacterized by 3 components occurring as the heart and pericardium come in contactBickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens
70 PDA Machinery like, in neonates, S2 may be masked Patent Ductus Arteriosus is:usually found in neonateshas crescendo systolic and decrescendo diastolic components that mask S2usually described as harsh and “machinery-like”heard best in the pulmonic regionmay radiate to the left clavicleBickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott William s& Wilkens
71 Continuous hum heard over the Jugular vein above the clavicle; sound disappears when the Jugular is compressedA venous hum may initially be misinterpreted as a heart murmur thought to radiate to the neck, when the neck is auscultated before the heart.is continuousheard best above the clavicle over the jugular vein (could be bilateral)disappears with pressure over the jugular veinBickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens
72 QuizYou hear this extra systolic sound clearly at the 2nd & 3rd left ICS with the diaphragm, but only with inspiration. ____2. You hear this extra early diastolic sound only with bell at the apex in both inspiration and expiration in a healthy child._____You auscultate an ejection murmur at the 2nd ICS RSB, which radiates to the right neck. What is the timing of the murmur ?The intensity of a systolic murmur heard best at the 2nd ICS RSB seems to increase during the Valsalva maneuver. What is the likely heart abnormality? _____________
73 Answers1. Physiologic Split S2 2. S3 3. Systole 4. IHSS Note: Aortic Stenosis is also best heard at the 2nd ICS of the RSB, radiates to the right neck. valsalva maneuver decreases the blood flow back to the heart including to the Left Ventricle, ↓ ing the intensity of the murmur of AS, but ↑ ing the murmur of IHSS (area of hypertrophy bulges into the outflow tract causing turbulence
74 Case Presentations 33 y. o. pregnant female with a new systolic murmur Grade 2/6mid-peaking ejection murmurheard best at the left sternal borderunchanged during respirationno other abnormal heart findingsKEY CLUESThe female accountantPMI displaced leftward (big left ventricle)paradoxical split (LBBB)presystolic sound is low pitched (+S4)harsh crescendo-decrescendo systolic murmur at the aortic regionradiates to the R neckIV drug abuserfever, skin petechiae+ sternal lift (RVH)blowing systolic murmur at LLSB (Tricuspid area)decreases in intensity with inspiration (left heart problem,backward flow)JVP abnormalities, large “v” wave
75 Physiological MurmurIncrease blood volume and flow through the aortic valve with pregnancy
76 26 y.o. I.V. drug abuser with fever and a new systolic murmur AS, PSMR, TR (holosystolic), VSDMVPFever suggests infection! Look for Roth spots, petechea, splinter hemorrhages, Osler nodes, Janeway lesionsDrug abuse most commonly effects Right heart valves ( T/P) ( forward or backward flow?)The murmur increases with inspiration, is heard best at 2nd LICS at the SB, radiates to the Left clavicle/neck and is mid-peaking
78 18 y.o. basketball “phenom” with episodes of C/P associated with palpitations, SOB. You auscultate a systolic murmur !Systolic MurmurAS, PSMR, TR ( holosystolic), and MVPYou wisely auscultate at the apex and hear a click-murmur. You have the patient squat and the murmur decreases in intensity and shortens. Upon standing the murmurs gets louder and longer.Q: Would you like to order any additional test?
80 Neonate with a Holosystolic murmur Three causes of Holosystolic/Pansystolic MurmursMR (Heard best at the Mitral valve(apex) area, radiates to __?; may have an S4 and enlarged PMI)TR (Heard best at the Tricuspid area, decreases in intensity with inspiration) Check the JVP for elevation, large “v” waveVSD (radiates widely across the sternum, may have a sternal lift)
81 In a Neonate, VSD is most common ! Note:The size of the defect does not correlate with the intensity of the murmur
82 Mr. N. TroubleS: 64 y.o. homeless man with a history of worsening chest pain and DOE for the last 3 months. He has developed a nonproductive cough and orthopnea without fever. O: On PE of the heart you note: an enlarged, hyperdynamic PMI displaced inferiorly and leftward, a thrill over the apex, an S4, S3,and a grade IV/VI holosystolic murmur, heard best with the diaphragm at the apex.Mr. Runamuckenlarged PMIholosystolic/pansystolic, best heard at the apex DDX: MR, TR, VSD (all pansystolic)TR and VSD would not enlarge the PMI .Check to see if the murmur radiates to the left axilla
83 Mr. N. Trouble A: D.Dx. MR, TR, VSD Clues on history : homeless, C/P with DOE, orthopnea and nonproductive coughClues on physical exam: LVH, at least a Grade IV/VI holosystolic/pansystolic murmur heard best at the apex.Which of the three valves abnormalities in your D.Dx is most likely, and what condition is the result of the valve problem?Mr. Runamuckenlarged PMIholosystolic/pansystolic, best heard at the apex DDX: MR, TR, VSD (all pansystolic)TR and VSD would not enlarge the PMI .Check to see if the murmur radiates to the left axilla
84 Auscultate at the axilla to confirm! Mitral RegurgitationAuscultate at the axilla to confirm!He has developed CHF.
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