Cardiovascular Examination: The Complete Guide
EXAMINATION OF THE CARDIOVASCULAR SYSTEM
Before starting the examination ( and this is to be considered for any system and any subject ) , consider three things
1. Patient position
2. Patient exposure
3. Your position
1. Patient position
For examination of the cardiovascular system , he/ she should be supine or slightly propped up by about 30 degrees .
Only if very dyspnoeic he / she would prefer to be sitting upright due to orthopnoea
2. Patient exposure
The chest should be exposed upto the waist .
It is simple enough for a male patient but for female patient always ask the examiner or conductor for a screen for privacy . Boys in particular must also ask for a female attendant ; any nurse , student nurse or usually a female family member should help you this way .
3. Your position
After all is done and you are ready to face your examiner , wait on the right side of the bed , sir / madam shall come to the left side .
In case your are well and truly left handed , ask the examiner’s permission to wait on the left side and do everything from the left side .
Examination Proper
The cardiovascular system is examined under 4 headings
1. Examination of the PRECORDIUM
2. Examination of the PULSE
3. Examination of Blood Pressure ( B.P.)
4. Examination of the Neck Veins
1. Examination of the Precordium
The precordium is the part of the anterior chest wall which overlies the heart . We follow divide the examination of the Precordium into three parts :
1. Inspection
2. Palpation
3. Auscultation
Percussion was previously done to dileniate cardiac borders . Nowadays this is not done because there is a chance of dislodging a thrombus by heavy percussion and creating an embolus , which could be dangerous , even fatal .
Percussion has some value and shall be discussed later .
1.Inspection
We have two main targets we look for while inspecting the Precordium :
A. Shape of the Precordium
B. Any visible Impulse
A. Shape of the Precordium
There is no special normal shape , the anterior chest wall is symmetric from left to right . We look for this symmetry or abnormally for any precordial bulge .
There are two methods to look for a precordial bulge
1. Stand at the foot end of the bed and compare both sides of the anterior chest wall from that distance .
Look for any obvious or mild left sided bulge
2. Stand on the right side of the patient , either bend over or sit down and look tangentially across the anterior chest wall , looking for any left sided bulge .
Such a bulge would be found in cardiomegaly of childhood onset but we shall discuss possible findings in a separate texts . For now let’s focus on methods .
In your copy mention Precordium is of normal shape or left sided precordial bulge seen .
B. Any visible Impulse
Just stand on the right side of the bed and look for any visible Impulse .
Just mention visible Impulse present or absent over the precordium . The location of the impulse is a palpatory finding .
C. Any operative scars Possible ones include
a. A midline sternotomy scar
b. A submammary scar
c. A subclavicular scar for a permanent pacemaker
These are all common findings but post operative patients aren’t really part of your practical exam , so you might skip this point .
2. Palpation
Palpation is done area wise .
Post graduates are asked to palpate quite a lot of areas .. for you , for the time being let’s do at least the following ones . We may add to it later ..
A. The Apex Beat
B. The Base of the Heart
C. The Left Parasternal region ( The tricuspid area overlaps with this area)
D.The Epigastric area
A. Palpation of the Apical area
The apex beat is the LOWERMOST , OUTERMOST ,
MOST DEFINITE impulse over the precordium .
It normally is also the single palpable impulse and often the most forceful …but other abnormal impulses maybe more forceful .
The most forceful of multiple impulses is called the PMI or Point of Maximum Impulse ( Shall be discussed later )
We have two targets with the apex beat :
1. It’s LOCATION
2. It’s CHARACTER
1. Location of the apex beat
We all know that in adults , the normal apex beat is located in the left fifth intercostal space , half an inch inside the midclavicular line . ( Please note that this is different in children )
To find it , place the palm of your hand centering this normal location and concentrate on finding an impulse which fulfills the definition mentioned .
A normal apex is difficult to find without regular practice , a soft apex , more so . A powerful apex is often accompanied by multiple neighbouring impulses which cause confusion .
Try to find which matches the definition .
Use your palm …( the ulnar border of your hand is a smaller area and it shall take much a longer time .)
Then do the following steps …
a. Use the tip of a finger of the right hand and use it to localise the apex … Keep the finger there .
b. Use the other hand to find in sequence , the suprasternal notch , then the sternal angle of Louis , and then the second rib and hence the second intercostal space .
c. Count intercostal spaces until you locate the space with the apex in it .
d. Note the position of the apex in relation to the midclavicular line ie on the line or ‘x ‘ cm lateral or medial to it …
Thus you have located the apex .
If you cannot locate the apex repeat the steps in the left lateral position . The patient must be turned left lateral , about by 90 degrees .
Because this manoeuvre often caused the heart to rotate a but to the left , mention …Apex found in left lateral position .
If that fails repeat the procedure sitting up and leaning forward .
If that doesn’t work , advise MILD EXERCISE in your presence and then examine sitting up and leaning forward .
If that isn’t working try the right side for a dextrocardia or a heart pushed or pulled to the right .
If not palpable look for a logical explanation .
2. CHARACTER
Two main points are to be considered and at your level another point might be considered too
THE CHARACTER IS ALWAYS ASSESSED IN THE LEFT LATERAL POSITION ,NEVER SUPINE .
Points
A. Forceful or not forceful
B. Ill- sustained or Well – sustained
C. Left ventricular or Right ventricular
A. Forceful or Not forceful
Place your hand over the apex in the left lateral position and see if your finger tip ( usually we use the index finger ) is actually elevated or not … If it is elevated , the apex is forceful …if the apex just touched your finger and goes , it is not forceful .
B. Ill sustained or Well sustained
An ill sustained apex hits your finger and vanished fast
A well sustained apex remains in contact with your finger tip for a longer period Understanding this shall require practice .
Thus ,
TAPPING APEX is not forceful and ill sustained
HYPERDYNAMIC APEX is forceful and ill sustained
HEAVING APEX is forceful and well sustained .
C. Left ventricular or Right ventricular
When the left ventricle forms the apex , it WELL LOCALISED to a small circle usually less than 2.5 cm in diameter in an average adult .
When the right ventricle forms the apex , it is diffuse , ie , very difficult to localise to a small area or single intercostal space .
B. BASE OF THE HEART
The aortic area and the pulmonary area are together called the base of the heart .
They are respectively the left and right second intercostal spaces parasternally . ( Not the entire intercostal space )
Now the patient’s position must change .. He/she must …
1. SIT UP
2. LEAN FORWARD
3. HOLD HIS / HER BREATH AT THE END OF A FULL EXPIRATION
Sitting up and leaning forward brings the base of the heart closer to the anterior chest wall for better palpation .
Exhaling in full , deflated the lungs a bit and improves palpation .
You must help the patient to sit up and lean , placing your left hand on his/ her back between his / her scapulae usually .
Also encourage him / her to take a full inspiration just before exhaling … This will help him / her hold his / her breathe for a few seconds longer which you really need .
There are two methods henceforth :
1. Some teachers tell you to palpate both areas separately using your finger tips or part of the palm of your hand .
2. The other method is to place your entire right hand across the base and palpate both areas simultaneously .
Give the patient as much rest as he/ she needs between breathe holding .
C. LEFT PARASTERNAL REGION
The patient should be supine for this .
Holding his or her breath after a full expiration makes it easier for you .
The region to be examined is approximately the 3rd , 4 th and 5 th intercostal spaces on the left side but PARASTERNALLY ..ie just next to the sternum .
( Note that the second left space belongs to the base of the heart )
Use the ulnar border of your hand .
Alternatively , you may use the based of your fingers ie ..part of the palm over the metacarpal heads ..
Look for and mention the presence or absence of any Parasternal impulse .
D. Epigastric Pulsation
The patient must be supine
If the breath is held after a deep inspiration you get a better result .You may use you thumb in one method or alternatively three fingers as another method .
Press down in the Epigastric region , just below the sternum and feel for any possible impulse and mention
1. Present or Absent
2. Touching the finger tips in which case it is cardiac or the pulp of the fingers in which case it is abdominal .
3.AUSCULTATION
General Rules
1. Auscultation is always timed .
Always palpate the right carotid pulse with your left thumb while using your right hand to place the stethoscope on the patient’s chest .
Or vice versa if you are really left handed I guess …
S1 coincides with the carotid pulse / upstroke while S2 does not .
Simply going by Lub – Duo doesn’t work because in patients the quality of the sounds change for a variety of reasons ( to be discussed later under cardiovascular findings ) .
So remember to put your thumb on the carotid and keep it there while your stethoscope is on the patient’s chest .
2. Choice of stethoscope
Any company is fine as long as it works .
Littman is the best but rather expensive and unnecessary at this point in your life I feel . You should learn with a normal stethoscope before using a special instrument .
It can be a single tube …it’s not compulsory to have a double- tubed stethoscope anymore like it was for us .
3. Stethoscope : Diaphragm and Bell
Your stethoscope must however have both a diaphragm and a bell , not two diaphragms of different sizes , the smaller one being a paediatric diaphragm .
Some have a conical attachment which is actually a ‘fetoscope’ to be used to hear foetal heart sounds .This is acceptable however .
4 .AUSCULTATION PROPER
We shall auscultate the various areas of the heart in sequence using both diaphragm and bell as necessary .
We shall always use the diaphragm first and the bell if necessary .
The diaphragm is to be applied with heavy pressure ( also do this for respiratory system auscultation ) .It enhances the sound you want to hear .
The bell however is to be placed with as light pressure as is possible ..let’s say optimum pressure ie just enough to occlude the margins and block out airflow and ambient sound …not more .
Otherwise , the skin below the bell is stretched and behaves just like a diaphragm .
The diaphragm is used for high – pitched sounds ( most sounds you hear are high – pitched ) The bell is for low pitched sounds ( S3 , S4 , murmur of Mitral Stenosis ) .
So keeping our thumb on the carotid we shall auscultate the following areas :
1. Mitral area ( also referred to as the apex )
2. Base of the Heart ( meaning the aortic and pulmonary areas )
3. The tricuspid area
4. The neoaortic area ( when necessary ie ..only for pts of Aortic Regurgitation where the murmur is best heard )
5. Any other part of the Precordium if an abnormal sound is detected .
The areas
1. Mitral area : wherever the apex is …
2. Aortic area : the right
2nd intercostal space just parasternally .
3. Pulmonary area : the left 2nd intercostal space just parasternally .
4. Tricuspid area : the left lower parasternal area ie 4th and 5 th intercostal spaces parasternally on the left .
5 . Neoaortic area :
The left 3rd intercostal space , just parasternally .
AREAWISE AUSCULTATION
Remember that we shall auscultate every area ie areawise but describe our findings soundwise eg
S1, S2 , S3 , S4 , Snaps and Clicks , Murmurs , others
1. Auscultation of the mitral area
a. First palpate to find the exact location …
b. Place thumb over right carotid
c. Place diaphragm over apex exactly while patient is supine
d. Turn him/ her left lateral and continue to auscultate with diaphragm and timing with carotid . e. Apply bell now and continue in left lateral posture while timing …this is to look for low pitched sound which are better heard with the bell ( only better heard with the bell after you have had tons of practice and can place the bell pin – pointedly over the right spot , otherwise the diaphragm is much easier to use )
You are specially looking for murmur of MS here or an S3 with the bell . ( Or an S4 ) .
2 . Auscultation of the Tricuspid area
a. Patient remains supine throughout .
b. No need to localise ..you know where it is ..
c. Place diaphragm over the tricuspid area and listen while timing with the carotid . d. Switch to bell looking for any low pitched sound ( specially S3 or S4 )
3. Auscultation of the base of the heart
The patient’s position is sitting up
leaning forward
And holding his / her breath at the end of a full expiration ..
( Refer to palpation of the base of the heart for details …it’s exactly the same ) However , then you
a. Place your thumb over the carotid
b. Place your diaphragm over the aortic area firmly
c. Listen in the correct posture .
d. Repeat the procedure for the pulmonary area
4. Auscultation of the neoaortic area
Repeat the procedure followed for the aortic area but over the correct place ie the neoaortic area ..just below the aortic area .
AUSCULTATION of MURMURS :
a. If you find a murmur , time it with the carotid with extra care …if the two coincide the murmur is systolic , if not the murmur is diastolic ..
TIMING is the single most important finding to diagnose a murmur , apart from area best heard .
b. Area where a murmur is best heard , done by a labourious and meticulous process called INCHING
Any murmur , unless very soft can heard widely over the Precordium , so it seems to be coming from all over the place .
Careful auscultation ( and thus requires hours of practice plus knowing the relevant theory ) shall reveal that the murmur is loudest over a particular part of the Precordium … often corresponding to one of the 5 areas mentioned above ( not always though ) .That place is the area of origin of the murmur ( the place where it is best heard ) .
This plus timing should seal your diagnosis .
Inching therefore is the art of following a murmur across a patient’s chest until you find your desired location .
The fact that a murmur originating from one location can heard , albeit more softly at others parts of the Precordium is called CONDUCTION of the murmur ( such a phenomenon is obvious if a sound is sufficiently loud ) .
A murmur is due to abnormal and turbulent blood flow … sometimes the intensity of the sound remains the same ALONG A PARTICULAR DIRECTION for a short distance … this is called SELECTIVE PROPAGATION / RADIATION .
This can also be found by the process of inching ( which is simply following a murmur around to its most likely source ) .
The only tragedy here is that the terms conduction and radiation are often interchanged casually ..and this causes much confusion . Shall clarify this later after checking various books .
c. DYNAMIC AUSCULTATION
This is a process by which certain procedures , manoeuvres can change the characteristics of murmurs and thus aid in diagnosis . I am posting a small note on this …shall discuss this later . Also features of individual murmurs pore bolbo after finishing this .
Please note that good auscultation takes good time .. lots of practice …
Also for a particular patient you often have to concentrate for a good few seconds to minutes before you can actually hear sounds .
It takes time to tune in to the sounds
Initially , all sounds are heard together as a confused mess .
So you must
a. Take time to auscultate ..lots of time
b. Try to find S1 and S2 ( provided both are present ) timing shall tell you which is which .. Then you shall know whether you are listening to the systole or the diastole ..
c. Always focus on one sound at a time .
d. After much hearing , try to hear everything in sequence to put together the total pattern or cadence of the sound .
e. Remember your theory while auscultating
f. Try to correlate the auscultatory findings with the palpatory findings …ie Learn to THINK AND SEE SIMULTANEOUSLY .
EXAMINATION OF THE CARDIOVASCULAR SYSTEM
NECK VEINS
Examination of the Neck Veins gives us a clue to the presence of heart failure or at least if venous congestion is present or not .
A . Choice of blood vessel
We choose the Internal Jugular Vein on the right side .
The External Jugular Vein is much easier to see but :
1. It is not directly in line with the heart like the internal vein is ..( so the Internal vein behaves somewhat like a manometer to estimate the pressure in the right atrium ie the central venous pressure )
2. The external jugular vein passes through several layers of deep cervical fascia and so is often kinked and provides a less accurate estimation .
So we choose the Internal Jugular Vein and on the right side where it is directly in line with the Superior Vena Cava .
B. Locating the Vein
The vein is not as superficial as the external which can be seen with ease .
The engorgement of this vein rather its actual shape can be made out in the space between the two heads of the sternocleidomastoid on the right side above the right sided clavicle .
C . Patient’s position to see the engorged neck vein .
1. He / She must be reclining on the bed propped up at 45 degrees with a backrest . Different angulations may be used – ( explained below ) .
2. The patient’s head should be tilted very slightly to the RIGHT SIDE , to loosen the skin over the base of the neck .
3. The patient’s head may be flexed slightly with a small pillow if necessary . 4. The patient should breathe normally .
We thus look for any obvious engorgement .
D. Differentiating from the Carotid Pulse
It is actually possible to confuse the carotid pulse with the Internal Jugular Vein . So to differentiate , note that …
a. The carotid pulse is usually better felt than seen , the Internal Jugular Vein is better seen than felt .
b. The Carotid Pulse is a single impulse while the Internal Jugular Venous impulse is sinuous ( wavy ) .
c. The Carotid Pulse does not show alterations with the phases of respiration while the Internal Jugular Venous Pulse usually becomes smaller during inspiration and more prominent during expiration .
d. The internal jugular venous impulse can be obliterated by firm pressure at the root of the neck while it is not possible to obliterate the carotid pulse .
Plus there are other points mentioned across various books .
E. Choice of angulation
Why 45 degrees and why not?
Veins are capacitance vessels … normally they are proximally engorged and peripherally partially collapsed . The height /level of engorgement of the internal jugular vein ( remember that this is just about in line with the right atrium ) depends on the amount of engorgement of the heart and circulation itself ..
And this height of engorgement follows Torricelli’s Principle that The height of the venous column remains the same irrespective of the position / degree of tilt of the person) vein .
It has been seen that at an inclination of 45 degrees , the upper level of venous engorgement of the Internal Jugular Vein is just NOT VISIBLE behind the clavicle .
So it follows that if the vein were engorged and visible at 45 degrees , there is obvious venous congestion ( probably due to heart failure ).
However , in keeping with Torricelli’s Principle , if the degree of engorgement is very high , the upper level of engorgement can rise even upto and behind the mastoid process thus becoming very difficult to
see and difficult to measure clinically .
In such a case , making the patient inclined steeper , say at 60 degrees or even making him / her sit upright would reveal the upper level of venous engorgement making it easier to assess clinically .
Thus we may choose between 45 degrees and sitting upright as the situation demands .
Now we shall try to examine the neck vein and answer the following questions :
1 Is the vein engorged or not ?
2. If engorged , is it pulsatile or not pulsatile ?
If non- pulsatile we search for an appropriate and usually non- cardiac cause
3. If engorged and pulsatile , we now measure the level of venous engorgement and thus get an clinical estimate of the central venous pressure in cm of water .
4. We try to identify the individual wave forms namely , a , x , v and y and also look for any abnormality which could suggest a diagnosis .
5. We perform what is called an abdominal jugular reflux if necessary .
1. Engorged or not ? As mentioned above
2. Pulsatile or not ?
Just inspect closely , use a torch if you need to and look for waves ..
If seen it is pulsatile and engorged due to some cardiac cause …if not the engorgement is probably due to some local obstruction, often at the level of the Superior Vena Cava ( read Superior Vena Caval Syndrome ) .
3. Measure the central venous pressure
a. Place a 15 cm ruler from your school days ( preferably transparent )
horizontal to the ground and held carefully at the same level as the uppermost level of the engorgement of the neck vein .
Now take a second similar ruler and place it vertically , the 0 cm mark being at the Sternal angle of Louie
Note where the first horizontal ruler intersects with the second vertical ruler . The mark in cm is noted … This the level of engorgement above the sternal angle .
Traditional teaching says that for an average adult , the centre of the right atrium is 5 cm below the sternal angle .
So 5 cm plus your measurement gives you the central venous pressure in cm of water .
4. Identification of waves
Keep the patient in an optimum position when the waves are all visible .
Now take a torch and shine it TANGENTIALLY across the root of the neck so that the venous waves cast a long dancing shadow .
This shadow reveals individual waves more clearly ( it is very difficult to do but you must at least all the theory of how to do it and all possible abnormal findings )
Now , place your right hand over the left carotid ( remember your left hand is holding a torch steadily while you are staring at his / her neck intentedly )
You will note positive and negative waves …
Remember that a wave is presystolic in timing while v is systolic .
So positive wave that matches with the carotid is v , the other positive wave is a … The negative wave before v is x and after v comes y wave …
PLEASE READ ALL THE THEORY OF ABNORMAL NECK VEIN WAVES .
5. Searching for an Abdomino Jugular reflux .
This is not necessary if the vein is well engorged .
However ,if it is not engorged and you are suspecting imminent heart failure …it shall be revealed by this test .
The idea is to squeeze blood from the Splanchnic Circulation into the systemic circulation . Normally this never poses a problem but in case of imminent heart failure it can be quite obvious and an early warning sign of fluid overload .
Steps :
a. We put the patient reclined at 45 degrees as discussed above
b. We spread our fingers and apply firm and sustained pressure over the umbilical region for exactly 15 seconds .
Previously a Hepatojugular reflux was done , doing the same process , but over the liver . This has been found to be painful because the congested liver is often tender due to stretching of the Glisson’s capsule by hepatic congestion .
So now we do the Abdomino Jugular Reflux instead .
At 10 seconds of pressure we inspect the neck vein …
It should have risen to at least 3 cm above the sternal angle and should remain so until we release pressure .
Thus a positive test reveal imminent heart failure while a negative test is normal .
Shall finish cardiovascular examination tomorrow I hope ..
EXAMINATION OF THE CARDIOVASCULAR SYSTEM EXAMINATION OF THE PULSE
We examine the following points
1. Rate
2. Rhythm
3. Volume
4. Any special character
5. Condition of the Arterial wall 6. Radio-radial delay
7. Radio- femoral delay
8. Equally palpable in all 4 limbs
click here ( pulse )to learn about pulse
INTERPRETATION OF FINDINGS : CARDIOVASCULAR SYSTEM ON INSPECTION
1. Precordial Bulge
A precordial bulge can be caused by cardiomegaly but only in really significant cases of cardiomegaly which are of childhood onset .
The adult rib cage is far less pliable and is not known to bulge outwards when the heart enlarges .
So if you see an obvious precordial bulge , your first thought should be CONGENITAL HEART DISEASE .
Even Rheumatic heart disease may present with a precordial bulge if it has an earlier onset ( usual age is 5-15 years for onset ).
Other causes of heart disease are far less likely .
Also note that you are essentially comparing both halves of the anterior chest wall .
Various pulmonary causes of an assymetric chest eg
Pleural effusion , pneumothorax , lung fibrosis or lung collapse are far more common than Congenital Heart Disease in adults ..
You shouldn’t confuse .
Respiratory examination : Things you need to know
2. Any visible Impulse
Normally , even in a very thin person , the only normal visible impulse should be the apex beat ( though technically you cannot confirm that it is the apex until you palpate it ) .
Any other impulse if visible is most likely to be abnormal .
Visible impulses seen over the precordium indicate a volume overloaded state , whatever the cause .
Eg ..
Any cause of eccentric cardiomegaly ( increased preload ) due to various heart diseases eg MR , AR , ASD , VSD , PDA
Situations where a normal heart is volume overloaded eg Pregnancy , Severe Anaemia ,
ON PALPATION 1. Apex beat
a. Location of the apex beat . Normally , it is
In the left , 5th intercostal space .
Half an inch inside the midclavicular line .
If the apex is DOWN and OUT …ie in the left 6 th intercostal space and on or outside the midclavicular line , then it indicates .. volume overload of the left ventricle / left ventricular hypertrophy due to volume overload / eccentric left ventricular hypertrophy ( all mean the same …just different expressions )
If the apex is OUT but not down ( ie still in the 5 th intercostal space ) then it indicates right ventricular hypertrophy / right ventricular volume overload causing eccentric hypertrophy .
NOTE that an apex beat can be shifted by a ‘PULL’ or a ‘PUSH ‘ from a LUNG pathology .. eg. Pleural effusion and pneumothorax push the heart and therefore the apex beat away while lung fibrosis and lung collapse pull it the heart and apex towards themselves .
b . Character of the apex beat
We had mentioned three possible characters of the apex beat during examination :
1. Normal or TAPPING which is not forceful and ill – sustained .
2. HYPERDYNAMIC
which is forceful and ill sustained b
3. HEAVING
which is forceful and well – sustained
Normal or tapping apex is found in the normal heart and also in mitral stenosis
Hyperdynamic apex is found in MR , TR , ASD , VSD , PDA
that is in any patient with a volume overload heart ie increased pre load .
This is also called eccentric hypertrophy where the affected chamber of the heart gets larger than normal but the wall becomes thinner gradually .
Heaving apex beat is found in patients with a pressure overload which causes a CONCENTRIC HYPERTROPHY , ie the chamber size remains the same or decreases while the walk thickness increases .
It is due to an increased afterload and is often due to AS , long standing systemic hypertension .
3. Left ventricular apex Vs Right ventricular apex
A left ventricular apex is WELL LOCALISED , usually to a circle of diameter less than 2.5 cm ( a bigger diameter is another feature of left ventricular hypertrophy )
A right ventricular apex is DIFFUSE , ie difficult to localise with certainty . 2. Palpable P2 .
This is also called DIASTOLIC SHOCK .
It is an impulse palpable in the pulmonary area found only during diastole . It is an indicator of pulmonary hypertension .
3. Other palpable heart sounds
Shall be discussed separately .
4. Right parasternal impulse .
If present it indicates right ventricular hypertrophy either due to pressure or volume overload . It can be graded into three levels of severity .
1. Grade 1 : IMPULSE
It is palpable but does not elevate the palpating hand .
Grade 2 : LIFT
It is palpable and elevates the palpating hand but can be compressed .
Grade 3 : HEAVE
It is palpable , elevates the palpating hand and cannot be compressed .
5. Epigastric impulse
If it predominantly touched the tips of your fingers of the palpating hand , it is due to a right ventricular hypertrophy .
This finding is particularly useful in lung patients where right ventricular hypertrophy exists due to chronic parenchymal lung disease but a parasternal impulse is not found due to the overinflated lung .
If it touches the pulp of your palpating fingers primarily it is due to the abdominal aorta , perhaps an abdominal aorta aneurysm or maybe a pulsatile liver .
6. Thrills
These are palpable components of a murmur .
They are found at the area of production of the murmur and do not radiate like the murmur does .
They must be timed with the carotid impulse .
If diastolic , the murmur is diastolic and if systolic , then systolic . We shall discuss auscultatory findings tomorrow ..
INTERPRETATION OF FINDINGS : CARDIOVASCULAR SYSTEM AUSCULTATION
We shall discuss the following findings : S1 S2 S3 S4
Opening Snap Ejection click
Various Murmurs , chiefly
MS – Mitral Stenosis
MR – Mitral Regurgitation/ Incompetence AS – Aortic Stenosis
AR – Aortic Regurgitation / Incompetence MURMURS:
A. What is a Murmur ?
A murmur is an abnormal heart sound produced to abnormal and turbulent flow of blood through the heart .
It may be produced by abnormal flow through a normal valve , normal flow through an abnormal valve or by flow through an abnormal orifice in the heart .
B. How to describe a murmur : We consider the following points :
a. Timing
Systolic or Diastolic
b. Low – pitched or high pitched
c. Area best heard
d. Configuration
Crescendo , Decrescendo , Crescendo- Decrescendo ,or Plateau 😊😊
e . Best heard with diaphragm or bell f. Position best heard
g.Any radiation present or not
h. Other info
Thus ,
MITRAL STENOSIS
The murmur of Mitral Stenosis is a Low pitched
Mid-diastolic , Rumbling murmur , best heard with the bell of the stethoscope , at the apex of the heart , in the left lateral position ,at the end of expiration , accentuated by mild exercise , has no radiation being localised to the apex and has a presystolic accentuation .
MITRAL REGURGITATION
The murmur of Mitral Regurgitation is a High- pitched , pan systolic murmur , blowing , murmur , plateau in configuration ,best heard with the diaphragm of the stethoscope ,at the apex of the heart , in the left lateral position ,at the end of expiration ,is accentuated by mild exercise , and commonly radiates to the axilla but sometimes to the base of the heart .
AORTIC STENOSIS
The murmur of aortic stenosis is a high pitched , harsh mid- systolic / ejection systolic murmur , diamond shaped or crescendo – decrescendo in configuration , best heard with the diaphragm of the stethoscope at the aortic area , the patient sitting up , leaning forward and holding his/ her breath at the end of a full expiration , is accentuated by mild exercise and radiates into the carotid artery .
AORTIC REGURGITATION
The murmur of aortic regurgitation is a high – pitched , soft , blowing murmur , decrescendo in configuration , best heard with the diaphragm of the stethoscope ,at the neo- aortic area , the patient sitting up , leaning forward and holding his/ her breath at the end of a full expiration ,is accentuated by hand grip and radiates downward along the left Parasternal margin .
Thes
INTERPRETATION OF FINDINGS CARDIOVASCULAR SYSTEM AUSCULTATION
S1
This is produced by closure of the atrioventricular valves ( eg mitral and tricuspid but chiefly mitral ) at the beginning of ventricular systole .
So S1 marks the end of diastole and the beginning of systole .
In other words , any abnormal sound eg a murmur is systolic if it occurs just after S1 ( but before S2 .
Similarly , any sound which occurs just before S1 is systolic ( actually late systolic ) .
Note that normal sounds S1 and S2 are valve closure sounds ( sounds produced due to valve opening are always abnormal eg Opening Snap and Ejection Click ) .
So always start auscultation by looking for S1 …it helps you to time other sounds ( the also S2 ) .
It coincides with the carotid pulse .
This is best heard at the apex in the same manner as we auscultate the apex . ( Refer to methods of auscultation )
So with reference to S1 :
a. Look for S1 ..if present it helps you as mentioned above . b. If heard note it’s intensity ie is it LOUD or SOFT .
c. Loud S1
There are several causes :
1. The first cause is any cause of tachycardia provided the heart is not in failure .
This is a broad term including many many causes , both physiological and pathological :
Physiological :
Exercise / Any heavy physical exertion
Anxiety
Pathological
All non physiological causes of a hyperdynamic circulation
Eg.
Severe pallor Thyrotoxicosis Fever
Hypovolemia ( all causes of shock but not cardiogenic shock in this case )
2. Mitral stenosis
This cause really matters in your exam …but it is not the most common cause among abnormal causes in general
3. Short P-R interval
( Shall explain this later )
d.Soft S1
1. The first cause is always heart failure due to any disease .. if the left ventricle does not generate pressure , the valves shall close softly ( please read your cardiac cycle again , very thoroughly ) .
2. Long P- R interval
3. Non cardiac causes which interfere with auscultation eg .
a. Thick muscular chest wall
b. Obesity
c. Pericardial or Pleural Effusion d. Emphysema
All of these causes are simple physical barriers to auscultation .
A big cause for you is lack of practice and experience , so be careful
Also , it could be a sign of a very weak heart due to cardiogenic shock … please look for other signs of heart failure , a low BP , cold clammy extremities before you draw a final conclusion .
S2
This is caused by closure of the semilunar valves at the end of ventricular systole .
Any abnormal sound heard just before it is systolic in timing , Any abnormal sound heard just after is diastolic .
This sound is best heard at the base of the heart . However , the choice of position maybe different .
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Note that S1 had two components M1 and T1 , of which M1 is normally much louder and therefore we auscultate the apex to examine S1 ( because M1 is produced at the apex ) .
S2 has two parts as well A2 and P2 produced at the aortic and pulmonary areas respectively by semilunar valve closure .
A2 is much louder than P2 but both are clinically very important .
A2 is normally heard across the entire precordium .
What you all call S1 S2 or LUB – DUPP on casual auscultation is actually S1 A2 . P2 is normally very soft and heard only at the pulmonary area .
So , to auscultate S2 ( both components ) you must auscultate the pulmonary area .
Also , the phenomenon of physiological splitting is such that a normal P2 is only audible at the height of inspiration when it is adequately separated from A2 . During expiration it is so close to A2 and normally so soft it is inaudible .
Plus to increase the separation more we ask the patient to lie down ( supine ) when searching for a normal P2 . This is in contrast to the usual process of sitting up , leaning forward used for the base of the heart . The supine position increases venous return thus delaying the pulmonary valve closure even more .. making it easier to hear ..the patient must hold his / her breath after a deep inspiration .
Try to hear your own P2 ..a very soft sound heard just after A2 … It is really difficult . Thus for auscultation of S2 ,
a. We auscultate the pulmonary area in the usual process used for the base of the heart , looking for A2 .
b. We then make the patient supine , ask him / her to take a deep breath and look for a P2 at the height of inspiration .
c. We note the splitting between A2 and P2 . Possible findings and Interpretations here :
a. A2 is loud …
This is possible when the closing pressure is high ( note cardiac cycle again ) eg a high pressure in the aorta .
So the obvious cause is SYSTEMIC HYPERTENSION .
b. A2 is soft or inaudible
1. Either the closing pressure is low …
Low pressure in the aorta ..eg SHOCK or HEART FAILURE ..in which case all heart sounds shall be soft
2. The valves do not appose properly during closure …so valvular aortic incompetence
c. P2 is loud
The obvious cause is PULMONARY HYPERTENSION …
This is commonly caused by :
1. long standing Chronic parenchymal lung diseases like COPD , asthma , ILD 2. Various heart diseases of a certain duration
eg .Valvular heart disease , specially mitral valve disease Certain Congenital Heart Diseases
d. P2 is soft
Low closing pressure seen in pulmonary stenosis when a lesser amount of blood enters the pulmonary artery and hence the lungs .
When the valve cusps do not appose well as in Pulmonary Regurgitation.
e. Splitting of S2
This can be wide or narrow Wide can occur due to
a. A delayed P2 as seen in any condition where there is increased blood flow to the right heart eg .
ASD .
b. An early A2 seen in MR , VSD
Narrow is when the P2 happens early because of increased closing pressure … The classic cause is PULMONARY HYPERTENSION ..causes mentioned just above .
Also splitting can be wide and fixed as in ASD …
Among other books , please refer to GHAI’s Paediatrics for a nice easy cardiac discussion .
S3
This is a flow sound not related directly to valve opening or closing .
It is produced in the first rapid filling phase of the ventricular diastolic when an abnormally large amount of blood suddenly drops into the left ventricle , in the first part of diastole .
It can be physiological
a. Young people who are fit eg Athletes
b. Pregnancy
c. Any person below 40 years of age who has no other symptoms or signs . However , if found exclude any possible heart disease before calling it physiological .
Pathologically ,it is found in volume overload states , eg Heart failure
Severe Anaemia
Thyrotoxicosis
But specially in Mitral Regurgitation .
It is a low pitched sound , best heard with the bell …so use diaphragm first , then check with the bell .
Also check both mitral and tricuspid areas separately using the appropriate methods …because when the left ventricle fails the S3 is left ventricular and best heard at the apex …if right ventricular it is best heard at the base .
However , most of you shall get LV S 3 s …focus more on that .
S4
This is produced by the second rapid filling phase of the ventricle eg by atrial contraction / systole .
In other words , it can never be present during atrial fibrillation when there is no net effective atrial contraction.
This is always pathological .
It is found where the ventricle is stiff ie unable to relax adequately to allow filling during diastole .
The most common cause is IHD .
other causes include
Aortic stenosis
Long standing systemic hypertension
Opening Snap
This is an opening sound produced at the mitral valve during mitral stenosis .
It is produced due to sudden , forceful opening of the mitral valve during early diastole .
It indicates a pliable eg flexible valve therefore earlier disease .
Note the mnemonic
OKT3
eg
Opening Snap
Pericardial Knock ( in pericardial effusion pts ) Tumour plop ( in left atrial myxoma patients ) S3
These are four possible abnormal sounds heard just after S3 .. read the theory …but you must find the opening Snap or the S3 if really audible ..
The other two are really rare .
Just note that to hear S3 , focus on S2 and look for an abnormal sound nearby , just after A2 To hear S4 , focus on S1 and look for an abnormal sound just before S1
Ejection click
This is produced during valvular aortic stenosis .
Just after S1 the aortic valve opens suddenly under force … It indicates a pliable valve .
However in Rheumatic AS , the fibrosis usually doesn’t allow a click .. similarly in atherosclerotic AS the damage reduced pliability ..
So an Ejection Click ,if heard , usually indicates AS in the background of an bicuspid aortic valve when the valve remains pliable until much later …
So don’t expect one in most of your patients .
Thank you! for reading
