cardiac exam pdf - كل السمنارات PDF

Cardiac Examination

•Inspection

• Palpation

• Percussion

• Auscultation

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

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

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 (2

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 .

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. AV

: left third intercostal space

5. TV: lower part of sternal

–

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

• 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)

AUSCULTATION

• S

– closure of mitral and tricuspid valves

• S

– closure of aortic and pulmonic valves

• Low pitched sounds S

, S

, mitral stenosis,

• S

systole S

diastole S

Cont. auscultation

•

Normally audible heart sounds:

& 2

•

Added sounds: 3

& 4

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 2

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 the1

and the 2

Systolic;

time between 1

and the 2

HS, could be mid-

systolic (AS), pansystolic (MR).

Diastolic;

time between 2

and the 1

HS, can be divided

into tow phases. Early (AR), Mid-diastole (MS).

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

Systole

Diastole

Cardiac Physiology 101

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

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

• 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

• 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