CARDIOVASCULAR EXAMINATION

INSPECTION PALPATION PERCUSSION AUSCULTATION

- Manoz marwin

PERCUSSION

It is done to see the enlargement of the dullness of the cardiac region

Left border APEX Right border RIGHT STERNAL

MARGIN

Useful in :

Cardiac causes – Cardiomegaly, pericardial

effusion, pulmonary artery dilatation, dilated

cardiomyopathy, etc.

* See if the dullness extends beyond the apical impulse as in case of Pericardial effusion.

Useful in :

Respiratory causes : Pleural effusion, hydropnemothorax,

collapse, fibrosis.

* To find the cause of displaced heart due to lung conditions

• Presence of diaphragmatic hernia and eventration of diaphragm can be suspected.

Auscultation

Auscultatory areas

1. Mitral area – 5th left ICS in mid-clavicular line

(corresponds to apex beat)

2. Tricuspid area – 4th left ICS just lateral to the lower end of the sternum

3. Aortic area

• First aortic area – 2nd right ICS close to sternum• Second aortic area or ERB’S area – 3rd left ICS close to

sternum

* The early diastolic murmur of AR and pansystolic murmur of VSD are best heard at ERB’S AREA

4. Pulmonary area – 2nd left ICS close to sternum

5. Gibson’s area – 2nd left ICS away from sternum

* The murmur of patent ductus arteriosus is best heard at gibson’s area

Other areas of Auscultation

Carotids Supraclavicular region Infraclavicular region Axillary region Back – interscapular and infrascapular

regions, bruits in the back

Check for

Heart sounds Heart murmurs Gallops Opening snap Ejection click Pericardial knocks Pericardial rub Diastolic knock Prosthetic valve sounds

Heart sounds

The heart sounds are audible vibrations of variable intensity, frequency and quality generated by beating of heart, closure of heart valves and the resultant blood flow through it.

Four heart sounds• S1

• S2

• S3

• S4

First heart sound (S1)

Produced by closure of AV valves Best audible at apex Indicates the beginning of ventricular

systole Split is not normally heard but heard in

phonocardiogram.

Factors that affect intensity of S1

Position of AV valve cusps at the onset of ventricular systole

Heart rate Pliability of the valve cusps

* S1 may be normal, soft, loud or variable intensity.

Soft S1

Mitral regurgitation Tricuspid regurgitation Ventricular dysfunction Calcified, stenosed mitral valve Calcified, stenosed tricuspid valve Aortic regurgitation Conditions associated with prolonged PR

interval Miscellaneous conditions

Loud S1

Mitral stenosis Tricuspid stenosis Atrial septal defect Mechanical prosthetic valve High output states Short PR interval, tachycardia Atrial myxoma In normal children

Varying intensity of S1

Atrial fibrillation Complete heart block Extra systoles

Canon sound(bruit de canon) Loud S1 heard intermittently in complete

heart block and in interference, dissociation when the ventricles contract shortly after atria.

Associated with short PR interval

Splitting of S1

Components – M1 and T1

Appreciated when

Causes

• Early closure of mitral valve• Delayed closure of tricuspid valve

• Right bundle branch block• Pulmonary hypertension• Left ventricular pacing• Ectopic beats• Idioventricular rhythm of left ventricle

Reverse splitting of S1

Delayed mitral component Tricuspid component is heard earlier

than mitral component Causes

• Right ventricular pacing• Ectopic beats• Idioventricular rhythm of right ventricle

Second heart sound(S2)

Produced by closure of pulmonary and aortic valve

Indicates the beginning of diastole Normal splitting• Two components – A2 and P2

• A2 louder than P2

• Appreciable during inspiration

Abnormalities of aortic component

Intensity – Accentuated or diminished

Timing – Early or late

Accentuated diminished

• Systemic hypertension• Aortic regurgitation

• When aortic valve is immobile as in fibrosis or calcification• If absent as in aortic valve atresia

Early Delayed

• VSD• MR• Constrictive pericarditis

• When left ventricular ejection is prolonged as in aortic valvular or subvalvular stenosis, PDA with large L R shunt, AR, left bundle branch block and LVF

Abnormalities of pulmonic component

Intensity – Accentuated or diminished or absent

Timing – Delayed

Pulmonary arterial hypertension

Pulmonic stenosis

Pulmonary valvar atresia

• Pulmonic stenosis• ASD• Right bundle branch block• Total anomalous pulmonary venous congestion• Type A WPW syndrome

Abnormalities in splitting of S2

Wide splitting of S2 splitting during expiration

If interval increases during inspiration Wide variable split

If interval increases in both inspiration and expiration Wide and fixed second sound

Early A2

Late P2

A2 – P2 interval ≥ 0.03 sec during expiration

Wide variable splitting of S2

Pulmonic stenosis due to delay in P2

Mitral regurgitation VSD

due to early A2

Wide and fixed splitting of S2

ASD Right bundle branch block Total anomalous pulmonary venous

connection

* In these conditions, splitting is due to delay in P2

Delay in A2 results in closely split, single or paradoxically split S2.

In paradoxically split S2, the split is wide in expiration, but narrows during inspiration

A single second sound

Either A2 or P2 or a combination of both The decision whether it is aortic or

pulmonary or a combination is based on clinical profile

Tetrology of fallot A2

VSD with pulmonary hypertension Combination

* Interpretation of single second sound is not dependant on auscultation alone

Third heart sound (S3)

Protodiastolic sound or ventricular gallop, produced by intial passive filling of ventricles

Heard best with bell at the apex Normally present in children and athletes Pathological causes :• High output states

• Congenital heart diseases• Regurgitant lesions• HOCM• Systemic hypertension

Fourth heart sound (S4)

Presystolic gallop/atrial gallop, produced by rapid emptying of atrium into a non-compliant ventricle

Confused with ejection click Always pathological :• HOCM

• Systemic hypertension• Ventricular failure• Pulmonary hypertension

Added sounds

Gallop rhythm

Opening snap Ejection click

1. Triple rhythm2. Quadruple rhythm3. Summation gallop

Murmurs

Turbulence caused by increased flow through normal/stenosed valve or a normal flow through a stenosed valve/orifice

Ausculation should be done over precordium, back and over the carotids

Note :

Changing murmurs

• Various charecteristics of the murmer• Position of the patient in which the murmur is best heard

Site

Note the site of maximum intensity of murmur

VSD – Murmur best heard in left 3rd and 4th ICS

Pulmonary ejection systolic murmur – left 2nd ICS

Timing

Timing of the murmur in relation to ventricular activity noted

Appreciated by palpating the carotid artery while auscultating the precordium

1.Systolic2.Diastolic3.Continuous

Systolic murmurs

Heard during systole

1. Regurtitant systolic murmurs

• Start immediately after 1st heart sound and may continue to 2nd sound• Usually pansystolic or holosystolic• Intensity is uniform throughout• Causes : VSD Tricuspid regurgitation Mitral regurtitation

1. Regurtitant systolic murmur2. Ejection systolic murmur

2. Ejection systolic murmur

• Due to the blood flow in pulmonary or aortic outflow tracts• There is gap b/n first heart sound and murmur• Intensity of murmur follows a diamond shaped configuration with midsystolic peak• Causes : Pulmonary stenosis Aortic stenosis Pulmonary hypertension Tetrology of fallot

Diastolic murmurs

Heard in diastolic phase of cardiac cycle Three mechanisms

According to timing

a) Semilunar valve regurgitationb) Atrioventricular valve stenosisc) Increased blood flow through AV valve

1. Early diastolic2. Mid diastolic3. Presystolic

Early diastolic mumur

Decresendo murmur starts immediately after second heart sound

Causes :• Aortic regurgitation• Pulmonary regurgitation

Mid diastolic murmur

Starts after the second heart sound Clear gap present between second sound and

murmur Occcurs due to functional or anatomic stenosis of

AV valves Causes :

Due to MITRAL valve

Due to TRICUSPID valve

• Mitral stenosis• Mitral regurgitation• VSD• PDA

• Tricuspid stenosis• Tricuspid regurgitation• ASD

* Presystolic murmur occurs in mitral and tricuspid stenosis

Continuous murmurs

Starts in systole and continue into diastole

Causes : • PDA• Venous hum• Rupture of sinus of valsalva• Arteriovenous shunts• Pulmonary A-V fistula• Coronary A-V fistula• VSD with AR• MR with AR• AS with AR

• Due to combination of systolic and diastolic murmur• Known as to and fro murmur

Intensity

Grading Grading Character

Grade 1 Very soft (heard in quiet room)

Grade 2 Soft, but easily audible

Grade 3 Moderate – no thrill

Grade 4 Loud with thrill present

Grade 5 Very loud with thrill and murmur heard with stethoscope barely placed on chest wall

Grade 6 Loud and audible with a stethoscope just off the chest wall

A cresendo murmur increases in intensity (MS, PDA)

A decresendo murmur decreases in intensity (AR)

Venous hum has no change

Pitch

High pitched or Low pitched See if the murmur is best heard with the

bell or diaphragm of the stethoscope

Low pitchedHigh pitched

Character or Quality

Soft/harsh/blowing/rough/vibratory or humming

Rough when obstruction to blood flow (AS, PS)

Blowing in case of incompetent valves (MR)

Conduction or Transmission

Conducted murmur Transmitted murmur

Same intensity Decreased intensity

Same duration Decreased duration

Generally, murmurs from aortic and mitral valve may be conducted to other parts of precordium

Functional or flow murmurs are heard over wide area of the precordium

* ESM of AS is loudest in the aortic area and will be radiated to the axilla and the apex* Pansystolic murmur of MR is best heard in the mitral area and may be conducted to axilla or back

Variation of murmur with various Manoeuvres

Respiration : There is accentuation of right side murmurs during inspiration and left sided murmurs during expiration

Posture : Venous hum murmur varies with posture

Certain manoeuvres :

Description of murmurs

Condition Murmur Description

Mitral regurgitation

Pansystolic High pitched, soft blowing pansystolic murmur of grade __ best heard with the diaphragm of the stethoscope, conducted/transmitted to axilla and back with the patient lying in left lateral position with breath held in expiration

Ventricular septal defect

Pansystolic High pitched, soft blowing pansystolic murmur of grade 4 best heard with the diaphragm of the stethoscope in the left 3rd and 4th ICS in parasternal region

Patent ductus arteriosus

Continuous Grade 4 continuous murmur best heard with the diaphragm of the stethoscope in the left 2nd ICS

Innocent murmurs

Functional or benign murmurs Occur in the absence of abnormality Accentuated during periods of febrile illness or

other high – output states Features :

• Asymptomatic• Normal cardiac silhouette on chest X-ray• Normal ECG• Usually systolic, may be continuous• < grade 3/6 with no radiation or transmission• No cyanosis• Normal pulses and heart sounds

* They are usually present in children

Common innocent murmurs

Still’s murmur

Venous hum

• Low pitched vibratory or musical murmur heard in mid systole• Soft quality, short in duration• Best heard in left lower sternal border and apex, no radiation• Grade 2 – 3/6, common after 3 years of age and rare in infancy• No cardiac abnormalities present

• Continuous murmur• Best heard with bell in right supraclavicular region with head turned to oppoite side in sitting posture• Disappears on lying down

Dynamic auscultation

Manoeuvres include :

• Inspiration• Expiration• Valsalva manoeuvre• Muller manoeuvre• Squatting to standing• Standing to squatting• Passive leg exercise• Isometric hand grip• Transient arterial occlusion• Administration of amyl nitrate• Leaning forwards • Chin turned upwards

Valsalva manoeuvre

This is an attempted forced expiration in closed glottis when mouth and the nose are closed

Significance : • Increases heart rate, BP and then decreases the heart rate in that order. This sequence will be absent in CCF• Ejection systolic murmur in PS will be increased and that of AS will be decreased• Murmur of mitral valve prolapse becomes longer and louder• HOCM – systolic murmur becomes louder