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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 ...
Useful in :
 Cardiac causes – Cardiomegaly, pericardial
effusion, pulmonary artery
dilatation, dilated
cardiomyopathy, et...
Useful in :
 Respiratory causes : Pleural effusion,
hydropnemothorax,
collapse, fibrosis.
* To find the cause of displace...
Auscultation
Auscultatory areas
1. Mitral area – 5th left ICS in mid-clavicular line
(corresponds to apex beat)
2. Tricuspid area – 4th left ICS just late...
4. Pulmonary area – 2nd left ICS close to
sternum
5. Gibson’s area – 2nd left ICS away from
sternum
* The murmur of patent...
Other areas of Auscultation
 Carotids
 Supraclavicular region
 Infraclavicular region
 Axillary region
 Back – inters...
Check for
 Heart sounds
 Heart murmurs
 Gallops
 Opening snap
 Ejection click
 Pericardial knocks
 Pericardial rub
...
Heart sounds
The heart sounds are audible vibrations of
variable intensity, frequency and quality
generated by beating of ...
First heart sound (S1)
 Produced by closure of AV valves
 Best audible at apex
 Indicates the beginning of ventricular ...
Factors that affect intensity of
S1
 Position of AV valve cusps at the onset of
ventricular systole
 Heart rate
 Pliabi...
Soft S1
 Mitral regurgitation
 Tricuspid regurgitation
 Ventricular dysfunction
 Calcified, stenosed mitral valve
 Ca...
Loud S1
 Mitral stenosis
 Tricuspid stenosis
 Atrial septal defect
 Mechanical prosthetic valve
 High output states
...
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
...
Splitting of S1
 Components – M1 and T1
 Appreciated when
 Causes
• Early closure of mitral valve
• Delayed closure of ...
Reverse splitting of S1
 Delayed mitral component
 Tricuspid component is heard earlier than
mitral component
 Causes
•...
Second heart sound(S2)
 Produced by closure of pulmonary and aortic
valve
 Indicates the beginning of diastole
 Normal ...
Abnormalities of aortic
component
 Intensity – Accentuated or diminished
 Timing – Early or late
Accentuated diminished
...
Abnormalities of pulmonic
component
 Intensity – Accentuated or diminished or
absent
 Timing – Delayed
Pulmonary arteria...
Abnormalities in splitting of S2
 Wide splitting of S2 splitting during expiration
 If interval increases during inspira...
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 ...
 Delay in A2 results in closely split, single or
paradoxically split S2.
 In paradoxically split S2, the split is wide i...
A single second sound
 Either A2 or P2 or a combination of both
 The decision whether it is aortic or pulmonary
or a com...
Third heart sound (S3)
 Protodiastolic sound or ventricular gallop,
produced by intial passive filling of ventricles
 He...
Fourth heart sound (S4)
 Presystolic gallop/atrial gallop, produced by
rapid emptying of atrium into a non-compliant
vent...
Added sounds
 Gallop rhythm
 Opening snap
 Ejection click
1. Triple rhythm
2. Quadruple rhythm
3. Summation gallop
Murmurs
 Turbulence caused by increased flow through
normal/stenosed valve or a normal flow
through a stenosed valve/orif...
Site
 Note the site of maximum intensity of murmur
 VSD – Murmur best heard in left 3rd and 4th
ICS
 Pulmonary ejection...
Timing
 Timing of the murmur in relation to ventricular
activity noted
 Appreciated by palpating the carotid artery
whil...
Systolic murmurs
 Heard during systole
1. Regurtitant systolic murmurs
• Start immediately after 1st heart sound and may
...
2. Ejection systolic murmur
• Due to the blood flow in pulmonary or aortic
outflow tracts
• There is gap b/n first heart s...
Diastolic murmurs
 Heard in diastolic phase of cardiac cycle
 Three mechanisms
 According to timing
a) Semilunar valve ...
Early diastolic mumur
 Decresendo murmur starts immediately after
second heart sound
 Causes :
• Aortic regurgitation
• ...
Mid diastolic murmur
 Starts after the second heart sound
 Clear gap present between second sound and murmur
 Occcurs d...
Continuous murmurs
 Starts in systole and continue into diastole
 Causes :
• PDA
• Venous hum
• Rupture of sinus of vals...
Intensity
 Grading
Grading Character
Grade 1 Very soft (heard in quiet room)
Grade 2 Soft, but easily audible
Grade 3 Mod...
 A cresendo murmur increases in intensity
(MS, PDA)
 A decresendo murmur decreases in intensity
(AR)
 Venous hum has no...
Pitch
 High pitched or Low pitched
 See if the murmur is best heard with the bell or
diaphragm of the stethoscope
Low pi...
Character or Quality
 Soft/harsh/blowing/rough/vibratory or humming
 Rough when obstruction to blood flow (AS,
PS)
 Blo...
Conduction or Transmission
Conducted murmur Transmitted murmur
Same intensity Decreased intensity
Same duration Decreased ...
Variation of murmur with various
Manoeuvres
 Respiration : There is accentuation of right
side murmurs during inspiration...
Description of murmurs
Condition Murmur Description
Mitral regurgitation Pansystolic High pitched, soft blowing pansystoli...
Innocent murmurs
 Functional or benign murmurs
 Occur in the absence of abnormality
 Accentuated during periods of febr...
Common innocent murmurs
 Still’s murmur
 Venous hum
• Low pitched vibratory or musical murmur heard in mid systole
• Sof...
Dynamic auscultation
 Manoeuvres include :
• Inspiration
• Expiration
• Valsalva manoeuvre
• Muller manoeuvre
• Squatting...
Valsalva manoeuvre
 This is an attempted forced expiration in
closed glottis when mouth and the nose are
closed
 Signifi...
Percussion and Auscultation of CARDIOVASCULAR system.
Percussion and Auscultation of CARDIOVASCULAR system.
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Percussion and Auscultation of CARDIOVASCULAR system.

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Important points one should note while taking Cardiovascular case..
By MANOJ KUMAR, Rangaraya Medical College

Published in: Health & Medicine
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Percussion and Auscultation of CARDIOVASCULAR system.

  1. 1. CARDIOVASCULAR EXAMINATION  INSPECTION  PALPATION  PERCUSSION  AUSCULTATION - Manoz marwin
  2. 2. PERCUSSION
  3. 3.  It is done to see the enlargement of the dullness of the cardiac region  Left border APEX  Right border RIGHT STERNAL MARGIN
  4. 4. 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.
  5. 5. 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.
  6. 6. Auscultation
  7. 7. Auscultatory areas
  8. 8. 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
  9. 9. 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
  10. 10. Other areas of Auscultation  Carotids  Supraclavicular region  Infraclavicular region  Axillary region  Back – interscapular and infrascapular regions, bruits in the back
  11. 11. Check for  Heart sounds  Heart murmurs  Gallops  Opening snap  Ejection click  Pericardial knocks  Pericardial rub  Diastolic knock  Prosthetic valve sounds
  12. 12. 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
  13. 13. 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.
  14. 14. 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.
  15. 15. 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
  16. 16. Loud S1  Mitral stenosis  Tricuspid stenosis  Atrial septal defect  Mechanical prosthetic valve  High output states  Short PR interval, tachycardia  Atrial myxoma  In normal children
  17. 17. Varying intensity of S1  Atrial fibrillation  Complete heart block  Extra systoles
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. Wide variable splitting of S2  Pulmonic stenosis due to delay in P2  Mitral regurgitation  VSD due to early A2
  26. 26. 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
  27. 27.  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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. Added sounds  Gallop rhythm  Opening snap  Ejection click 1. Triple rhythm 2. Quadruple rhythm 3. Summation gallop
  32. 32. 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
  33. 33. 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
  34. 34. Timing  Timing of the murmur in relation to ventricular activity noted  Appreciated by palpating the carotid artery while auscultating the precordium 1.Systolic 2.Diastolic 3.Continuous
  35. 35. 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 murmur 2. Ejection systolic murmur
  36. 36. 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
  37. 37. Diastolic murmurs  Heard in diastolic phase of cardiac cycle  Three mechanisms  According to timing a) Semilunar valve regurgitation b) Atrioventricular valve stenosis c) Increased blood flow through AV valve 1. Early diastolic 2. Mid diastolic 3. Presystolic
  38. 38. Early diastolic mumur  Decresendo murmur starts immediately after second heart sound  Causes : • Aortic regurgitation • Pulmonary regurgitation
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42.  A cresendo murmur increases in intensity (MS, PDA)  A decresendo murmur decreases in intensity (AR)  Venous hum has no change
  43. 43. Pitch  High pitched or Low pitched  See if the murmur is best heard with the bell or diaphragm of the stethoscope Low pitched High pitched
  44. 44. 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)
  45. 45. 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
  46. 46. 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 :
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. 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
  51. 51. 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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