1. 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

3. 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

4. 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.

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

6. 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

7. 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

8. 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) .

9. 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.)

10. 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.

11. 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

12. 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

13. Systole LA AO LV RV

14. Diastole LA AO LV

15. 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

16. 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

17. 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

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

19. Left lateral decubitus

20. 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

22. 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

23. Aortic Stenosis

25. 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 mm Hg

26. 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

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

30. 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

31. Mitral Regurgitation after MI

32. 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)

33. Left lateral decubitus

34. 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

35. 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

37. AR easily missed

38. 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)

39. Marfan Syndrome