Cardiac Exam Inspection Palpation Percussion Auscultation 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

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

By PALPATION: Apex beat: Parasternal impulse: Site (the most lateral and most inferior; normally in the 5th left intercostals space in the mid clavicular line) Displaced or not Character (heaving, double impulse, tapping) Parasternal impulse: By the heel of the hand rested just to the left of the sternum. Palpable murmurs (thrills): Start at the apex then the left sternal edge then the base of the heart.

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

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

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

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. (AS» neck, AR» left sternal edge.)

Cont. Pitch; the greater the pressure gradient the higher the pitch(MS m.» low-pitched, AR m.» high-pitched) 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 three phases. Early (AR), Mid-diastole (MS), Presystole.

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) Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis S1 S2 S1

Mitral Stenosis Opening snap Loud S1, loud P2 if pulmonary hypertension present Rumbling diastolic murmur heard at apex with stethoscope bell, patient in L lateral decubitus Palpate carotid to identify diastole Presystolic accentuation unless AFib present Exercise, maneuvers to increase flow make murmur louder

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

Left lateral decubitus

Mitral stenosis (MS) is a narrowing of the inlet valve into the left ventricle that prevents proper opening during diastolic filling. Patients with mitral stenosis typically have mitral valve leaflets that are thickened, commissures that are fused, and/or chordae tendineae that are thickened and shortened

Mid-systolic Murmurs Mid-systole is the EJECTION PERIOD MSM are therefore “Ejection Murmurs” Ejection starts after S1, peaks soon after, and diminishes before S2 Ejection murmurs MUST be crescendo-decrescendo Holosystolic murmurs are NOT ejection murmurs

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 Balloon valvuloplasty when gradient exceeds 30-50 mm Hg

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 Harsh, “blowing,” well-heard with diaphragm

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

Chronic Mitral Regurgitation Progressive Mitral Valve Prolapse most common cause LV dilatation, rheumatic, congenital, endocarditis, infarction Results in chronic volume overload of left ventricle Acute MR may have very brief murmur due to rapid equilibration of pressures

Mitral Regurgitation after MI

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 No change in intensity after a PVC but increases with isometric exercise and squatting (increases afterload)

Left lateral decubitus

Aortic Regurgitation congenital, endocarditis, age, aortic disease, collagen vascular, syphillis Early diastolic, decrescendo murmur best heard at LLSB with diaphragm subtle, have pt lean forward, breathe out associated with wide pulse pressure

Aortic regurgitation findings Soft S1 and A2 Blowing decrescendo diastolic murmur Begins immediately with A2 High frequency (diaphragm) Press firmly & concentrate Inconsistent relationship between duration and severity Associated murmurs Often has systolic ejection flow murmur Austin-Flint murmur at apex sounds like mitral stenosis

AR easily missed

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)

Marfan Syndrome