CVS Assesment Lecture Notes

1. Muhammad Shahid
MSN, BSN, DPBCN, RN, BSc
Sr. lecturer IIN
Acknowledgement to Sir Hakim Shah
1

2. 1
• Review A&P of Heart
• Explain deferent cardio-dynamics
• Discuss cardiac cycle
2
• Demonstrate different techniques in cardiovascular assessment
• Perform complete history taking prioritizing risk factors
3
• Analyze health status of a cardiac patient and document
relevant data
• Apply collected data in developing a holistic care plan
2

3. • Heart (Pump)
• Neck Vessels
• Arteries
• Veins
• Capillaries
• Lymphatic Tissue
3

4. Functions of the
Cardiovascular System
To transport materials to and from cells:
• Oxygen and carbon dioxide
• Nutrients
• Hormones
• Immune system components
• Waste products
4

5. • Hollow, muscular organ
• 300 grams (size of a fist)
• 4 chambers
• Found in chest between lungs
• Surrounded by membrane called Pericardium
• Pericardial space is fluid-filled to nourish and protect the
heart.
5

6. • The heart is a complex
muscular pump that
maintains blood
pressure and flow
through the lungs and
the rest of the body.
• The heart pumps about
100,000 times and
moves 7200 liters (1900
gallons) of blood every
day.
6

7. Layers of Heart
• Pericardium
– Parietal
– Visceral (Epicardium)
• Epicardium
• Myocardium
• Endocardium
7

8. Pericardium
8

9. Cardiac Muscle
9

10. 10

11. Relation to Thoracic cavity
11

12. Circulation of Blood
12

13. Coronary Arteries
• Two coronary arteries originate from aorta
–Right coronary artery (RCA)
• Posterior descending artery (PDA)
–Left main (LM) coronary artery
• Left anterior descending (LAD)
• Left Circumflex (LCX)
13

14. 14

15. Blood supply to Heart Muscles
Right Coronary Artery (RCA)
• Supplies blood to:
– Right atrium
– portions of both ventricles
– cells of Sinoatrial (SA) and atrioventricular nodes
Left coronary artery
• Supplies blood to:
– left ventricle
– left atrium
– Interventricular septum
15

16. Atrioventricular Valves (AV-Valves)
• Connect right atrium to right ventricle and left
atrium to left ventricle
• Permit blood flow in 1 direction:
– atria to ventricles
• Between atria and ventricles
• Blood pressure closes valve cusps during
ventricular contraction
• Papillary muscles tense chordae tendineae:
– prevent valves from swinging into atria
16

17. AV-Valves
17

18. Conduction system
• Sinoatrial (SA) node
– Primary pacemaker of heart
– Intrinsic firing rate of 60-100 impulses/min
– Internodal pathways in atria conduct impulses
• Atrioventricular (AV) node
– Pathway for conducting impulses to ventricles
– Delays impulses to allow for emptying of atria –
atrial kick
– Intrinsic firing rate of 40-60 impulses/min
18

19. Cont…
• Bundle of His
– Travels down interventricular septum
– Divides into right bundle branch (RBB) and left
bundle branch (LBB)
– LBB divides further into an anterior and posterior
fascicle
– RBB and LBB terminate into Purkinje fibers
– Intrinsic firing rate of 20-40 impulses/min
19

20. 20

21. 21

22. Electrocardiogram (ECG or EKG)
22

23. Feature s of ECG
• P wave:
– atria depolarize
• QRS complex:
– ventricles depolarize
• T wave:
– ventricles repolarize
Time Interval
• P–R interval:
– from start of atrial
depolarization to start of
QRS complex
• Q–T interval:
– from ventricular
depolarization to
ventricular repolarization
23

24. Cardio-dynamics
Volumes
– EDV (Preload)
– ESV (After load)
– SV (70ml/beat)
– Ejection Fraction (55-70%)
–Cardiac Output
24

25. Cardiac out-put
• Volume of blood ejected per minute
• Averages between 4-8L/min
Stroke volume
Amount of blood ejected from the heart during one
contraction. Average SV 70ml/beat
• CO = Stroke volume X heart rate
=70 ml X 60 beats/min
=4,200 ml/min
25

26. Cardiac out-put
26

27. Cardiac Cycle
• The period between the start of 1 heartbeat and
the beginning of the next
• Includes both contraction and relaxation
2 Phases of the Cardiac Cycle within any 1 chamber,
so total 8 phases
1. Systole (contraction) Atrial systole+ Ventricle Systole
2. Diastole (relaxation) Atrial Diastole+ Ventricle diastole
• In any chamber blood pressure rises during systole
and falls during diastole
• Blood flows from high to low pressure:
– Controlled by timing of contractions
– Directed by one-way valves
27

28. 8 Phases of Cardiac Cycle
1. Atrial systole:
– Atrial contraction begins
– Right and left AV valves are open
2. Atria eject blood into ventricles:
– Filling ventricles
3. Atrial systole ends:
– AV valves close
– Ventricles contain maximum volume-End-
Diastolic Volume (EDV)
28

29. Cont…
4. Ventricular systole:
– Isovolemic ventricular contraction
– Pressure in ventricles rises
– AV valves shut
5. Ventricular ejection:
– Semilunar valves open
– Blood flows into pulmonary and aortic trunks
Stroke volume (SV) = 60% of end-diastolic volume
6.Ventricular pressure falls:
– Semilunar valves close
– Ventricles contain End-Systolic Volume (ESV), about
40% of end-diastolic volume
29

30. Cont…
7.Ventricular diastole:
– Ventricular pressure is higher than atrial pressure
– All heart valves are closed
– Ventricles relax (isovolumetric relaxation)
8. Atrial pressure is higher than ventricular
pressure:
– AV valves open
– Passive atrial filling
– Passive ventricular filling
– Cardiac cycle ends
30

31. 3 Factors that Affect ESV
1.Preload:
• Ventricular stretching during diastole. Directly
proportional to EDV
• Affects ability of muscle cells to produce
tension
2. Contractility:
– Force produced during contraction, at a given
preload
3. Afterload:
– Tension the ventricle produces to open the
semilunar valve and eject blood. Directly
proportionate to ESV, SVR
31

32. EDV, Preload, and Stroke Volume
• At rest:
– EDV is low
– myocardium stretches less
– stroke volume is low
• With exercise:
– EDV increases
– myocardium stretches more
– stroke volume increases
32

33. Ejection Fraction
• A measure of the function of the left ventricle, also
called left ventricular ejection fraction (LVEF). The
ejection fraction is the percentage of blood ejected
from the left ventricle with each heart beat. An LVEF
of 50% indicates that the left ventricle ejects half its
volume each time it contracts. A normal ejection
fraction is 50% or higher. A reduced ejection fraction
indicates that cardiomyopathy is present.
33

34. Example:
• A healthy heart with a total blood volume of 100 mL
that pumps 60 mL to the aorta has an ejection
fraction of 60%.
• A heart with an enlarged left ventricle that has a
total blood volume of 140 mL and pumps the same
amount (60 mL) to the aorta has an ejection fraction
of 43%.
34

35. Cardiac Cycle
35

36. 36

37. Cardiac Cycle and Heart Rate
• At 75 beats per minute:
– cardiac cycle lasts about 800 msecs
• When heart rate increases:
– all phases of cardiac cycle shorten, particularly
diastole
37

38. Control of Heart Rate
• Autonomic
Innervation
• Hormones
38

39. Areas of Heart on Chest
 Precordium - area on chest overlying the heart
Heart lies behind and just left of sternum
(usually)
A small portion of right atrium extends to right of
sternum
Upper portion of heart (atria) is called the base
and points posteriorly
Lower portion of heart (ventricles) is the apex
and points anteriorly apex of left ventricle
touches chest wall near 5th ICS at MCL
 PMI: where apex of left ventricle touches anterior
chest wall near LMCL at 4th to 5th ICS; Usually felt
just below left nipple
39

40. Normal heart Sounds
 Heart sounds can be auscultated anywhere over
precordium, but are heard best at defined listening
points (auscultory landmarks)
 S1 (lub) - produced by closure of mitral and tricuspid
valves (A-V valves)
Signifies beginning of systole
Best heard over apical area (left, midclavicular, 5th
ICS-Tricuspid & Mitral)
Valve closure is almost simultaneous, so only one
sound is heard
40

41. Cont..
 S2 (dub) - produced by closure of aortic and
pulmonic valves (semilunar valves)
Valve closure may be less simultaneous, so
sometimes hear physiological splitting of S2 (split
S2)
Best heard over base area (Aortic & Pulmonic)
41

42. Abnormal Heart sounds
Murmur
• Turbulent sound made as blood flows across a
stiff valve, leaks across an incompetent valve; or
leaks through a septal defect. Caused by:
– Narrowed or stenosed valve
– Incompetent or regurgitant valve
– Atrial or ventricular septal defect
– Increased metabolic states
• Classified based on timing in cardiac cycle
– Systolic
– Diastolic 42

43. Cont…
• Quality of murmur – blowing, rumbling or
whistling
• Loudness or intensity is graded
• Grade I/VI
• Grade II/VI
• Grade III/VI
• Grade IV - Thrill
• Grade V - Thrill, M with stethoscope
• Grade VI - Thrill, M without stethoscope
 A thrill indicates diseased valve or obstructed vessel
Most murmurs are d/t valve disease; some are from
septal defects
43

44. Physiology of Hear sounds
 Systole - contraction of the ventricles; Normally
silent interval that begins with S1 and ends with S2
 Diastole - period when ventricles are relaxed;
Normally silent period that starts with S2 and ends
with S1
S3 – ventricular gallop; fainter sound, right
after S2; heard best with pt on L side (lub dub
eeh or Ken-tuck-y)
– S3 is normal in children and young adults, but is
abnormal in older adults and may indicate heart
failure
– Heard in early diastole right after S2
– Characteristic of LV failure 44

45. 45

46. Cont…
S4 – Atrial gallop; heard right before S1 (ta
lub dub or Ten-ne-see
Heard in late diastole right before S1
Heard during atrial contraction as atria force blood
into resistant ventricles
Characteristic of HTN, heart failure, pulmonary
disease
Lift or heave: overly forceful ventricular contraction that can
be felt on precordium with palm. Heave are due to heart
failure.
46

47. S3 and S4
47

48. S2 splitting
48

49. 49

50. S1 spitting
50

51. 51

52. Snap & Click
• Abnormal valve sounds
– Snap – stenosis of mitral valve
– Click – stenosis of aortic valve
52

53. Pericardial Friction Rub
• Produced by inflammation
of pericardial sac
• Heard during systole and
diastole
• Best heard with diaphragm
with client sitting up and
leaning forward
53

54. Cardiac Land Marks
 Aortic area - 2nd ICS, RSB
 Pulmonic area - 2nd ICS, LSB
 Erb’s point – midway b/w pulmonic & tricuspid
 Tricuspid area - 5th ICS, LSB
 Mitral area - 5th ICS, 1 cm medial to midclavicular
line- LMCL ( PMI, apex)
Always Phone Early To Mother
54

55. 55

56. 56

57. Cardiac land Marks
57

58. Areas to hear sounds of valves
58

59. • Blood vessels are divided into a pulmonary circuit and
systemic circuit.
• Artery - vessel that carries blood away from the heart. Usually
oxygenated
• Vein - vessel that carries blood towards the heart. Usually
deoxygenated.
• Capillary - a small blood vessel that allow diffusion of gases,
nutrients and wastes between plasma and interstitial fluid
59

60. Cont…
• Systemic vessels
– Transport blood through the body part from left
ventricle and back to right atrium
• Pulmonary vessels
– Transport blood from right ventricle through lungs
and back to left atrium
• Blood vessels and heart are regulated to ensure
blood pressure is high enough for blood flow to meet
metabolic needs of tissues
60

61. Blood Flow
61

62. • Coronary Artery Disease
• Hypertension
• Rheumatic Heart Disease
• Bacterial Endocarditis
• Congenital Heart Disease
62

63. Risk Factors (Noncorrectable)
• Family Hx (BP, stroke, CVD, MI-death <50, DM,
hyperlipids)
• PMH (DM, CAD, CHF, CHD, Rheumatoid Fever,
CRF arrhrythmia, CV surg, blood disorders,
aneurysms, emboli, hypo-hyper thyroid)
• Age, Sex (Male)
• Personality type
63

64. Risk Factors (Correctable)
• Cigarette Smoking
• Essential HTN
• Hyperlipidemia (Reduced HDL-cholesterol)
• Nutrition/diet - obesity/body fat -
Anaerobic exercise
• Environmental, stress, emotional, physical
demands
• Menopause - estrogen replacement
• Drug use - alcohol, cocaine, Rx, OTC
64

65. Blood Pressure (Adults) NIH, 6th
Report, 1997
• Optimal Systolic <120 & Diastolic <80
• Normal Systolic <130 & Diastolic <85
• High-Normal
Systolic 130-139 or
Diastolic 85-89
65

66. Blood Pressure
• Right Arm - 5-10 mmHg higher than Left
• Leg - 15-20 mmHg higher than arm
• Pulse Pressure -
• Orthostatic hypotension - systolic > of 20
mmHg.
66

67. Hypertension (Adults) NIH, 6th Report,
1997
• Stage I
• Systolic 140-159 or Diastolic 90-99
• Stage II
• Systolic 160-179 or Diastolic 100-109
• Stage III
• Systolic >180 or Diastolic >110
67

68. Hypertension (Children)
• Normal = < 90th %ile: Systolic & /Diastolic
• High Normal = 90-95th %ile
• Hypertension = > 95th %ile
68

69. Cholesterol
• Acceptable <170 mg/dl -(Child) <200 (Adult)
• Borderline 170-199 mg/dl - (Child) 200-239
(Adult)
• High >-200 mg/dl - (Child) >240 (Adult)
69

70. HDL-Cholesterol
• 25% of total
• “Protective”
• Low: Genetic, smoking, obesity, sedentary,
hypertriglyceridemia, anabolic steroids,
progestational agents, some beta-blocking
agents
70

71. LDL-Cholesterol
• 70% of total
• Atherogenic
• Acceptable LDL <110 mg/dl
• Borderline LDL 110-120 mg/dl
• High LDL >-130
• Morbid >200mg/dl
71

72. Cholesterol - Children
• Universal screening not recommended
• Family History of cholesterol above 240,
premature CVD
• Lifestyle risk factors
72

73. Sinus Arrhythmia
• Physiologic splitting of S2
• Increase with inspiration
• Decrease with expiration
73

74. Jugular Venous Pressure
• Reflects pressures in right side of heart
• Assess internal jugular pressure (not palpable)
• Pulsations best visible with client @ 45 degree
angle
(45-60)
• Measure highest level of pulsations from
sternal angle
• Pressures > 3-4 cm above sternal angle =
elevated
74

75. Peripheral Vascular History
• Pain
• Skin temperature & color
• Edema
• Ulceration
• Emboli
• Stroke
• Dizziness
75

76. Peripheral Vascular Assessment
• General
• Arterial Pulse
• Bruits: Carotid, abdominal
• Lymphatics
• Homan’s sign for DVT
76

77. HOPI
• Chest pain
• Irregularities of rhythm
• Dyspnea
• Syncope
• Fatigue
• Dependent Edema
• Hemoptysis
• Cyanosis 77

78. Cont…
Medical history
• Co-morbid
• Hospitalization
• Drugs
• Infections
Family History
• DM, CAD, HTN, Cancer, CHD, CVA, DVT,
• Genogram
78

79. Cont…
Social History
• Role/relationship
• Stress
• Anxiety/depression
• Conflicts
• Job related health hazards
History of smoking, alcohol, substance abuse
Activity and exercises
79

80. History of cardiac symptoms
• Chest pain
• Anxiety
• Dyspnea
• Diaphoresis
• Syncope/near syncope episodes
• Nausea
• Edema lymphadenopathy,
• Fatigue, pallor, palpitations,
• Leg ulcerations (atrophy, hair loss), diabetic
neuropathy (esp. without sweat), claudication
80

81. Differential Chest Pain
• Cardiac
• Vascular
• Pulmonary
• Gastrointestinal
• Neural
• Musculoskeletal
• Emotional
81

82. Angina
82

83. Chest Pain Attributes
• P - provocative-palliative factors
• Q - quality
• R - region
• S - severity
• T - Timing
83

84. Cont…
• P - Exertion sustained before pain (lag),
• P - Emotion, eating, cold
• P - Subsides with rest, Nitroglycerine
• Q - Deep, pressure, squeeze, heavy, strangle,
• Q - Tight, Levine’s sign
84

85. Cont…
• R - Substernal/retrosternal
• R - Mild to severe intensity, can radiate
• R - Jaw, arms, neck, back: Diffuse
• R - Location stereotyped for individual
• R - Variations indicate change, unstable angina
• S - Mild to severe
85

86. Cont…
• T - Episodic, “seizes”
• T - Duration is short: 2-3 minutes
• T - (<1 >10 minutes)
86

87. Chest pain in Acute MI
• Steady, deep pain
• Lasts 20 minutes or longer
• May not be relieved by nitroglycerine
• Feeling chest contriction, crushing
• Nausea, vomiting diaphoresis
• May occur at rest, with exertion or stress
87

88. Chest pain in Pericarditis
• Deep constant or pleuritic pain
• Pericardial friction, may be related to resp.
• Increases with cough
• Sharp, stabbing
• Fever or recent infection
• Shallow breathing, sitting up, leaning forward
relieves
88

89. Pulmonary Chest pain
• Onset gradual or sudden (hours to days)
• Fever, infection, cough (sputum, blood)
• Pain over lung fields
• Mild - severe, sharp ache
• Air hunger, dyspnea, restlessness
• Splinting, moist air, rest, heat, sitting up may
relieve
89

90. Respiratory Movement Pain
• Pleurisy, overuse, trauma
• Sharp, burning, stabbing, shooting, deep
• Crushing or tearing sensations
90

91. Musculoskeletal: Chest Wall
• Tenderness to palpation of chest wall
• Chest wall maneuvers may precipitate pain
• Examples:
– Rib Fracture, arthritis, muscle spasm or myositis,
– costochondritis, slipping cartilage
91

92. Gastrointestinal
• Gradual of sudden onset
• Esophagitis & gastritis may occur after eating,
leaning over
• Pain may be burning, retrosternal, epigastric or
radiate
• Mild to severe
• Intermittent or continuous
• Food, antacid, standing, belching may relieve
• Emotional stress, caffeine, spices, heavy meals,
• Cold liquids, alcohol, exercise, smoking may
aggravate
92

93. Palpitations: Arrhythmias
• Cardiac
• Thyrotoxicosis
• Hyypoglycemia
• Fever
• Anemia
• Anxiety
• May not indicate serious disease
• Other factors: caffeine, tobacco, drugs
93

94. Dyspnea
• Cardiac: Left ventricular failure, mitral stenosis.
• Paroxsysmal nocturnal dyspnea (PND)
• Orthopnea
• Dyspnea with exertion
• Trepopnea - > better while lying on side
• Pulmonary
• Emotional
• High-altitude
• Anemia
94

95. Syncope
• Fainting, dizziness, blackout
• Cardiac
• Metabolic
• Psychiatric
• Neurologic
• Orthostatic hypertension
• Vasovagal -vasodepresson
• Micturation - visceral reflex
• Cough - chronic lung disease
• Carotid sinus - sensitivity (pressure)
95

96. Fatigue (most common)
• Decreased cardiac output
• CHF
• Mitral valvular disease
• Anxiety & depression
• Anemia or chronic diseases
96

97. Dependent Edema
• CHF
• Worse as day progresses
• SOB
Grading
• +1 = 2mm
• +2 = 4mm
• +3 = 6 mm
• +4 = 8 mm
97

98. Hemoptysis
• Differentiate:
– Hemoptysis
– Hematomesis
cyanosis
• Lower extremities (differential: R - L SHUNT:
PDA
98

99. 99

100. Skin
• Cyanosis
• Tuberous xanthomata
• Erythema marginatum: Rheumatic fever
• Cold, clammy - low output states
• Widespread vasodilatation - high output
states
• Pallor - anemia
100

101. Nails
• Splinter hemorrhages (endocarditis)
• Clubbing (cyanotic CHD, chronic pulm
infections, cirrhosis)
101

102. Face & Eyes
• Hypercholesterolemia (Xanthelasma, arcus
senilis)
• Lens displacement (Marfan’s )
• Hypertelorism (CHD)
102

103. Mouth & Neck
• Petichiae
• High arched palate (CHD)
• Webbing (Turner’s)
103

104. Extremities & Lesions
• Rheumatic nodules
• Osler’s nodes (small, tender, transient nodules in the pads of
fingers and toes and the palms and soles indicate infective endocarditis).
• Xanthoma tuberosum
• Varicose veins
• Leg ulcerations (ischemic vs stasis)
• Ear creasing before age 60
• Arachnodactyly (Spider fingers). (Marfan’s,
CHD)
104

105. Abdominal & Vascular
• Ascities
• Abdominal bruits
• Systemic venous congestion - enlargement,
tenderness.
• Hepatojugular reflux (manual compression
test)
• Jugular Venous Distention
105

106. • Pulses
• Temperature
• Bruits
• Lymph nodes
• Lymphangitis
• Edema, Lymphedema
106

107. Cont…
 Assess for peripheral edema, document location and
grade
 Assess capillary refill time (blanch test, capillary fill
time (CFT) - should be <3 seconds
 Assess peripheral perfusion (blood flow) - color,
temperature, edema, hair pattern, skin changes,
phlebitis, CFT
 Homan’s sign – pain in calf with passive dorsiflexion
of foot
107

108.  Scale for measuring peripheral pulse volume
+0 = absent or not discernible
+1 = thready, weak, difficult to feel
+2 = normal, detected readily, obliterated by
strong pressure
+3 = bounding, difficult to obliterate
 Reasons for using specific pulse points: radial,
temporal, carotid, apical, brachial, femoral,
popliteal, posterior tibial, pedal; know where each
pulse is located
108

109. Central Vessels
Usually assessed during examination of neck
Carotid arteries provide oxygenation to the
head and neck, and are the only source of
oxygen for the brain
Carotid pulses correlate well with central aortic
blood pressure, so when BP is so low that
peripheral pulses are weak or not palpable,
carotid arteries are still be palpable
Palpate, auscultate - if bruit heard, palpate for
thrill
109

110. Cont…
• The murmur of aortic stenosis may radiate to
the carotid arteries (especially the right).
• The term bruit is French for “noise” or
“sound.” It refers to an extra or "adventitial"
sound of arterial or venous origin caused by a
pathological narrowing of the blood vessel.
• A carotid artery bruit in an older adult is
associated with atherosclerotic vascular
disease and an increased incidence of both
cardiovascular and cerebrovascular events.
110

111. Measuring JVP
• Position the patient’s bed so that you can see
the top of the internal and/or external jugular
vein. Begin with the head of the bed at 30°,
and adjust it up and down as necessary. An
oblique light source (a penlight shone across
the neck) may help you identify the veins.
• The right atrium sits 5 cm below the sternal
angle (Angle of Luis).
111

112. Cont…
• Measure the vertical distance from the top of
the venous pulsations in the internal jugular
vein, or the blood column in the external
jugular vein, to the sternal angle. Add this
distance to 5 cm. This is the jugular venous
pressure.
112

113. 113

114. Hepatojugular Reflux
• If you suspect that central venous pressure is
elevated, check the abdominojugular test
(also called hepatojugular reflux). Place firm
pressure on the patient’s midabdomen for 10
seconds. Locate the neck veins, and observe
them as you release the pressure. If JVP falls
by more than 4 cm with release of pressure,
the test is positive.
The normal JVP is up to 10 cm of H2O.
114

115. The cardiac exam occurs after the chest and breast exams, with
the patient positioned supine and the examiner on the right.
You will also examine the patient in:
• Partial left lateral decubitus position (rolled over 45° to the
left side)
– PMI felt best
– Mitral stenosis murmur heard best
– S3 and S4 heard best
• Sitting up, leaning forward, with breath briefly held
– Aortic regurgitation murmur heard best
– Cardiac rub heard best
115

116. • Inspect and then palpate the precordium for
the point of maximal impulse (PMI), noting its
position and diameter. If you cannot feel the
PMI in the supine position, ask the patient to
roll to the partial left lateral decubitus
position, and palpate again.
• Inspect and then palpate the precordium for
abnormal, sustained outward movement,
called a lift or heave. If a patient has a
murmur, palpate for thrills.
116

117. Cont…
• Gently palpate each carotid artery separately
and assess the strength of the pulse and the
briskness of the carotid artery upstroke.
• The normal PMI (which is palpable in only 30%
of normal adults) is < 2 cm in diameter in the
supine patient, and < 4 cm in the partial left
lateral decubitus position.
117

118. Heave or Lift
• A heave or lift is a sustained, systolic outward
movement of the precordium, associated with
heart failure.
• A right ventricular heave or lift is best palpated at the left
sternal border
• A left ventricular heave or lift is best palpated at the
cardiac apex
Thrill
• A thrill is a vibration (like a cat purring) felt
when a cardiac murmur is grade IV-VI / VI.
118

119. • Listen at four basic locations using the diaphragm and bell of
the stethoscope firmly applied to bare skin in a completely
quiet room:
Position:
• Sitting, leaning forward, supine & left lateral decubitus
position
Area
• Cardiac apex (mitral valve area)
• Tricuspid area (left lower sternal border [LLSB])
• Pulmonic area (left 2nd ICS)
• Aortic area (right 2nd ICS)
119

120. Purpose of Cardiac Auscultation
To find out:
• Abnormalities in Rate & Rhythm
• Abnormalities in S1 & S2 (Gallops-S3,S4)
• Ejection Clicks & Murmurs
• Variations in S2 Splitting
• Pericardial Friction Rubs
120

121. Technique of Auscultation
• At each location, listen first to S1 and S2,
observing amplitude and splitting. Then, for
several cardiac cycles, pay attention only to
systole, listening for murmurs and extra
sounds. Then do the same for diastole. If
you hear a murmur or extra sound, “inch”
your stethoscope across the precordium,
noting where it is loudest and where it
radiates.
121

122. Cont…
• Use the bell of the stethoscope lightly applied
to bare skin to listen at the cardiac apex for
S3, S4, and the murmur of mitral stenosis
(Mitral Area). If you suspect but don’t hear
any of these, roll the patient to the partial left
lateral decubitus position and listen again.
122

123. Characteristics of Murmur
Describe five characteristics of any murmur:
• Grade on a I to VI scale
• Timing - systolic or diastolic
• Quality of the sound (e.g., harsh or blowing)
• Location where it is loudest
• Radiation – listen across the precordium and
in the carotids
123

124. Diastole and systole
124

125. 125

126. Grading of Murmur
• I—don’t hear it immediately; very faint
• II—heard fairly easily as soon as you start
auscultating the chest
• III—seems loud
• IV—has a thrill (i.e., you can feel it when you
palpate the precordium)
• V—thrill present & heard with only the edge of
the stethoscope touching the chest wall
• VI—thrill present & heard with the stethoscope
just above the precordium, not touching
126

127. Cont….
Usual characteristics of common systolic murmurs:
• Mitral regurgitation: any grade, holosystolic,
blowing, loudest at apex, sometimes radiating to
axilla.
• Aortic stenosis: any grade, diamond shaped,
harsh, loudest at right upper sternal border,
often radiating to carotids
• Flow or innocent murmur: Grade I or II/VI, early
or midsystolic, loudest at left sternal border, no
associated symptoms or abnormal exam findings
127

128. Cont…
• Diastolic murmurs are less common than
systolic murmurs, and are always abnormal.
The most common diastolic murmurs are
aortic insufficiency and mitral stenosis.
128

129. Innocent Murmur
• Systolic (except for venous hum)
• Common - Children, teenage & high output
conditions
• Grade III or less
• Altered by position
• Absence of cardiac enlargement
129

130. Ejection click
• Ejection clicks are high-pitched sounds that occur at the moment
of maximal opening of the aortic or pulmonary valves. They are
heard just after the first heart sound. The sounds occur in the
presence of a dilated aorta or pulmonary artery or in the
presence of a bicuspid or flexible stenotic aortic or pulmonary
valve. Ejection clicks may also be called ejection sounds.
• The diastolic correlate of the ejection click is the opening
snap, which occurs at maximal opening of a flexibly stenotic
mitral or tricuspid valve.
130

131. Technique to listen E-Clicks
• Because of their high frequency, clicks are best heard with
the diaphragm of the stethoscope.
• Aortic and pulmonary clicks are most prominent at Aortic
and Pulmonic area.
• Mitral and tricuspid clicks are loudest along the Mitral and
tricuspic area.
• The first step in identifying a click is to distinguish it from
normal heart sounds and determine its timing in the cardiac
cycle. This is best accomplished by simultaneously
auscultating the heart and palpating the carotid artery pulse
to clearly identify the first (S1) and second (S2) heart sounds.
131

132. Cont…
• Systolic clicks may be further characterized by their
location in systole, that is, early, mid, or late systolic
clicks.
• Once the timing of the click is ascertained, its
response to respiration, postural change, Valsalva
maneuver (Inspiration, squantting, passive leg
raising), or various pharmacologic agents, such as
amyl nitrite or phenylephrine, should be evaluated.
132

133. “Innocent” Murmurs
• Normal EKG or chest X-ray
• Short, Systolic, Soft
• If in doubt – echo, physiologic splitting of S2
133

134. Children - Common Organic Murmurs
• ASD
• VSD
• PDA
• Pulmonic Stenosis
• Aortic Stenosis
• Coarctation of Aorta
134

135. References
• B ickley.L.S (2011) Bates’ guide to physical examination and history
taking (10th ed).Philadelphia: J.B.Lippincott
• Marcus, G. M., J. Cohen, et al. (2007). "The utility of gestures in
patients with chest discomfort." Am J Med 120(1): 83-89.
• World Wide Web Page, Martini, F. H. Fluid and Transport [online]
August2, 2008 [cited 2011 January 19]. Available from: URL:
http://library.med.utah.edu/kw/pharm/
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