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Cardiovascular Examination

Cardiovascular Examination. Part 2. Cardiovascular Examination Part 2. Precordium. Inspection Palpation Percussion Auscultation. Inspection. Scars Sternotomy Valvotomy Thorocotomy Deformity Pectus excavatum kyphoscoliosis Pulsations Gynomastia Digoxin Spironolactone. Palpation.

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Cardiovascular Examination

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  1. Cardiovascular Examination Part 2

  2. Cardiovascular ExaminationPart 2

  3. Precordium • Inspection • Palpation • Percussion • Auscultation

  4. Inspection • Scars • Sternotomy • Valvotomy • Thorocotomy • Deformity • Pectus excavatum • kyphoscoliosis • Pulsations • Gynomastia • Digoxin • Spironolactone

  5. Palpation Apex position and character • Absent impulse • Emphysema • Obesity • Pericardial effusion • dextrocardia • Forceful impulse • LVH

  6. Palpation • Tapping impulse • Mitral stenosis • Dyskinetic impulse • Paradoxical ventricular wall movement in systole

  7. Palpation • Thrills (palpable murmur) • Parasternal Heaves • RV dilatation or hypertrophy • MV disease • Cor pulmonale

  8. Thrill

  9. Percussion • Percussion of cardiac dullness • Pleural effusion • Consolidation

  10. Auscultation • Time heart sounds and murmurs against the carotid impulse • The bell – low-pitched sounds • The diaphragm – high pitched sounds

  11. Auscultation • Area of auscultation • Apex • Upper LSB • Lower LSB • Upper RSB • Lower RSB • Under Clavicle • Over Carotids • In axilla • Listen at apex with patient rolled to the left side • Mitral stenosis • Listed at LSB with patient sitting forward, in expiration • Aortic incompetence

  12. Heart Sound • Listen individually to the S1 and S2 • Loud or soft • Splitting • Splitting increased or decreased with inspiration • Listen for added sounds • Note timing relative to S1 and S2

  13. Heart Sound • Listen for murmurs • Systolic/ diastolic • Duration (pan, early, mid or late} • Quality (harsh, soft) • Pitch (low or high) • Listen for prosthetic sound

  14. Heart Sounds • Loud S1 • High output states • Mitral stenosis • Split S1 • RBBB • Epstein’s Anomaly

  15. Heart Sounds • Loud S2 • Pulmonary hypertension (P2) • Systemic hypertension(A2) • Split S2(A2P2) • Normal in inspiration in the young • Delayed PV closure • RBBB • Prolonged RV systole • Massive PE • PHT • PS

  16. Heart Sounds • Reverse Split • Delayed AV closure • LBBB • RV paced rhythm • Prolonged LV systole • LVOT obstruction • Aortic stenosis • Systemic hypertension • Fixed Split • Medium or large ASD

  17. Added Sounds • Third heart sound • Fourth heart sound • Ejection Click • Opening Snap • Mid-systolic click • Prosthetic sound

  18. Third Heart Sound • Due to rapid ventricular filling • Occurs shortly after the S2 • Usually low-pitched

  19. Fourth Heart Sound • Due to atrial systole against a poorly compliant ventricle. • LVH • Occurs just before S1

  20. Ejection Click • High-pitched • Closely follow S1 • Occurs in • Bicuspid AV • AS • Valvular PS • Dilatation of PA

  21. Opening Snap • High-pitched sound • Occurs after S2 • Occurs as stenotic MV opens

  22. Mid-systolic Click • Due to MVP

  23. Prosthetic Sounds • Mechanical Valves – both opening and closing sounds • Absent sound may be a sign of valve dysfunction. • Thrombosis • Pannus encroachment • Valve disintegration

  24. Murmurs • Timing • Duration • Quality • Pitched • Location • Accentuation • Radiation • Grading

  25. Timing • Systolic • AS • PS • MR • TR • Diastolic • MS • TS • AI • PI

  26. Duration Systolic • Pansystolic • MR • TR • VSD • PDA • Ejection Systolic • AS • AV calcification • PS

  27. Duration • Early systolic • Severe MR • Late systolic • MVP

  28. Duration • Early Diastolic • AR • PR with PHTN • Graham Steel murmur

  29. Duration • Mid-diastolic • MS • TS • Severe MR • AR • Austin Flint Murmur • PR • Late diastolic • MS in sinus rhythm • TS in sinus rhythm

  30. Quality • Harsh • VSD • AS • PS • Soft • AI • TR • Rumbling • MR (blowing)

  31. Pitch Low-Pitched • MS and TS (low-pitched rumbling) High-Pitched • Regurgitant murmurs • Chronic AI and PI (high-pitched decrescendo)

  32. Location • Know the areas where the murmurs are heard best • Aortic stenosis Aortic area • Pulmonary stenosis Pulmonary area • Tricuspid stenosis Tricuspid area • Mitral stenosis Mitral area (apex)

  33. Location • Aortic insufficiency** Left sternal edge • Pulmonary insufficiency Pulmonary area • Tricuspid insufficiency Tricuspid area • Mitral insufficiency** Mitral area, axilla, rarely to aorta ** Not where expected

  34. Accentuation Louder on Inspiration • TR • TS Louder in Expiration • AI (patient sitting forward) Pre-systolic • MS and TS

  35. Maneuver that Aid in the Diagnosis of Murmurs *Patient may need to be standing for effect on pulmonic stenosis to be heard.

  36. Maneuver that Aid in the Diagnosis of Murmurs

  37. Maneuver that Aid in the Diagnosis of Murmurs

  38. Maneuver that Aid in the Diagnosis of Murmurs

  39. Maneuver that Aid in the Diagnosis of Murmurs

  40. Maneuver that Aid in the Diagnosis of Murmurs

  41. Radiation • Aortic area and carotids • AS • AV calcification (not carotids) • Posteriorly and to Pulmonary area • PS • Axilla • MR • RSB • VSD • AR

  42. Grading

  43. Valves Positions • In systole (ventricles ejecting blood) • AV and PV are open and • the MV and TV are closed • In diastole (ventricles being filled) • MV and TV are open while • the AV and PV are closed

  44. Ejection Murmurs • Ejection murmurs are always systolic (blood is ejected in systole) • Ejection murmurs peak and (almost) always fall in intensity • This means they begin after S1 and end (almost) always before S2 • Ejection murmurs arise from the aortic valve or pulmonary valve (or less commonly from the LV or RV outflow tracts)

  45. Regurgitant Murmurs • Regurgitant murmurs are high pitched (the flow is from an area of high pressure to an area of much lower pressure)

  46. Regurgitant Murmurs • Systolic regurgitant murmurs are (almost) always holosystolic (= pansystolic) and begin with S1 and end with S2 • Examples are: • mitral insuffiency • tricuspid insufficiency. • A VSD is another cause.

  47. Diastolic Murmurs • Diastolic murmurs can be • “Decrescendo”: high pitch, intensity decreasing during diastole, due to insufficiency of AV or PV • “Rumbles”: low pitched, localized, heard with bell, related to low pressure flow across a narrowed valve, (mitral stenosis, tricuspid stenosis)

  48. Case 1 • You hear a systolic ejection murmur loudest in the upper right sternal border • Ejection murmurs come when a valve is not opened properly (stenotic) • This is the aortic area • This is the murmur of aortic stenosis

  49. Case 2 • You hear a systolic murmur loudest in the apex which is regurgitant. • What valves should be closed in systole? • What area is this? • This is the murmur of mitral insufficiency

  50. Case 3 • You hear a diastolic murmur loudest at the apex which is low pitched, and localized. • What does it imply? • What valves should be open in diastole? • What area is this? • This is the murmur of mitral stenosis

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