percussion and auscultation of cardiovascular system
DESCRIPTION
Important points one should note while taking Cardiovascular case.. By MANOJ KUMAR, Rangaraya Medical CollegeTRANSCRIPT
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CARDIOVASCULAR EXAMINATION
INSPECTION PALPATION PERCUSSION AUSCULTATION
- Manoz marwin
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PERCUSSION
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It is done to see the enlargement of the dullness of the cardiac region
Left border APEX Right border RIGHT STERNAL
MARGIN
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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.
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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.
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Auscultation
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Auscultatory areas
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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
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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
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Other areas of Auscultation
Carotids Supraclavicular region Infraclavicular region Axillary region Back – interscapular and infrascapular
regions, bruits in the back
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Check for
Heart sounds Heart murmurs Gallops Opening snap Ejection click Pericardial knocks Pericardial rub Diastolic knock Prosthetic valve sounds
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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
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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.
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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.
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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
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Loud S1
Mitral stenosis Tricuspid stenosis Atrial septal defect Mechanical prosthetic valve High output states Short PR interval, tachycardia Atrial myxoma In normal children
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Varying intensity of S1
Atrial fibrillation Complete heart block Extra systoles
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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
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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
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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
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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
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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
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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
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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
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Wide variable splitting of S2
Pulmonic stenosis due to delay in P2
Mitral regurgitation VSD
due to early A2
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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
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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
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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
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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
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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
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Added sounds
Gallop rhythm
Opening snap Ejection click
1. Triple rhythm2. Quadruple rhythm3. Summation gallop
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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
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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
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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
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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
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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
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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
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Early diastolic mumur
Decresendo murmur starts immediately after second heart sound
Causes :• Aortic regurgitation• Pulmonary regurgitation
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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
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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
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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
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A cresendo murmur increases in intensity (MS, PDA)
A decresendo murmur decreases in intensity (AR)
Venous hum has no change
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Pitch
High pitched or Low pitched See if the murmur is best heard with the
bell or diaphragm of the stethoscope
Low pitchedHigh pitched
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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)
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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
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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 :
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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
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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
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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
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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
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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
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