Week 1 Clinical Skills CVS Examination PDF

Examination of the Cardiovascular System Part 1 General Examination, JVP Measurement and Examination of the Precordium From Talley and O’...

Examination of the Cardiovascular System Part 1 General Examination, JVP Measurement and Examination of the Precordium From Talley and O’Connor 6th/7th Edition Dr Dragan Mandić CVS Skills and Objectives Part 1 Introduction to the Cardiovascular Examination Skills Objectives 1. Become familiar with the relevant applied anatomy of the heart and major vessels, e.g. borders of heart and auscultation areas for the valves, great vessels within the thorax. Anatomy of the Precordium 1. Revise B.P. in relation to CVS disease. Understand the term General Examination ‘postural hypotension’ and be able to determine in a patient. (related to CVS) General Inspection 1. Revise and advance your understanding palpation of radial and carotid pulse in terms of rate, rhythm, volume and character. VS: BP, Pulse, Respiration, T° Practice radio- radial, radio-femoral delay and collapsing pulse; General Examination - CAJCOD learn their diagnostic significance. JVP measurement 1. Demonstrate the general examination in cardiac patients (inspection and CAJCOD relevant to CVS disease) 1. Perform the examination for assessment of the jugular venous pressure – JVP measurement and Abdominojugular Reflux.  Semi-fowler position Approach pt from the right. CVS examination General Rules X Introduce Yourself (name and role) Hi third year my name is Kaylee Tolmay Iam a & This will invare · me feeling & Obtain an informed consent medical student and today I need to examin your heart. listening to various areas Ask the pt. to undress, Semi Fowler position - angle of 30° to 45° on chest your Clean hands Adequately expose and cover the patient Approach the patient from their right side Precordium the portion of the body : over the heart and lower chest. CVS examination consists of: Ill/ Well? No/ Respiratory distress? Alert/ Confused? General Inspection Obesity, Cachexia, Dysmorphia(Congenital abnormalities ) Additional stuff - suppl. O2, tubes, ECG leads etc. Pulse: rate, rhythm, volume, character, delays Vital Signs Respiratory rate, blood pressure, temperature Hands CAJCOD Face Legs – oedema Jugular venous pressure Neck and JVP Abdominojugular reflux Inspection, Palpation Precordium Percussion, Auscultation Chest/back and abdomen Other Lower limbs CAJCOLD : cyanosis andemia (payors ; jaundice clubbing, bedema , & , , lymphadenopathy dehydration  General Inspection Comfortable? Ill or Well? MedRR ? - Tapido laboured · · use of intercostal muscles ? Respiratory distress - Yes or No ? respiration ? tripodding? · · Hasal flaring? Alert or Confused? Obesity, Cachexia Severe loss of weight & muscle & wasting There are Dysmorphia (congenital and acquired abnormalities causing CVS disease) some Marfan’s, Down, Turner syndrome etc. syndromes associated Cushing, hypothyroid, hyperthyroid etc. with Additional paraphernalia: specific Pillows support, raised head of the bed Supplemental O2, NG tube Cardida Monitoring, ECG leads, Defibrillator disease Peripheral IV access, central venous lines, IV medicines (inotropes, diuretics) Urinary catheters, Mobility aids etc. * Mitralvalve prolapse leaflets : of the Mitral value between the left heart chambers are floppy a backward (prolapse) like Dysmorphia example: Marfan’s Syndrome page a parachute into the Hearts LA durin contraction. M CVS abnormalities in Marfan’s Syndrome Mitral valve prolapse, Aortic root dilatation and Aortic regurgitation (AR) Dilatation/dissection of ↓ aorta Aortic dissection : condition inwhich fear occurs in the inner layer of the aorta, plod rushes into the fear causing the inner& middle to split/disect. layers  Vital signs: The art of reading a Pulse Rate - palpate radial artery take 15 or 30 sec if regular pulse; 1 min if irregular – atrial fibrillation Rhythm- palpate radial artery "premature beats" ~ Atrial Fibrillation (AF), AV Blocks, Extrasystoles,- > feels like y "Skipped beat" followed ↳ irregularly irreguar by a strong Deat. Volume - palpate carotid artery Good pulse? Weak pulse? Bounding pulse? Character - palpate carotid artery e.g. alternating pulse = severe LV dysfunction Radio/Radial pulse delay Aortic dissection, subclavian artery obstruction Radio/Femoral delay Aortic coarctation > "narrowing ofthe Morta" - ↳ a congenital heart defect that occurs when the portanarrows , making itdifficult for blood to flow through tro body. Volume = the strength of the expansion & contraction > - Pulse Volume Good pulses or Some people are normal. normal pulse volume Small pulse volume or vasoconstriction, hypovolemia, shock, MI, heart week pulses failure, AS, MS, PE, Aortic coarctation, etc. Large pulse volume or anaemia, fever, pregnancy, exercise, bounding pulses thyrotoxicosis, liver cirrhosis, etc. Pulse Character Normal pulse Normal character as a rapid rise in pressure followed by slower character reduction in pressure. Palpable in aortic stenosis (AS) due to the outflow obstruction. Anacrotic pulse Pulse is weak and rises slowly - “Pulsus parvus et tardus”. The time taken to reach the peak is prolonged and the entire wave is flattened and of small amplitude. Dicrotic pulse Result of mixed AS and AR as well as hypertrophic cardio- (bisferiens pulse) myopathy causing double pulse (exaggerated dicrotic notch). Collapsing pulse Palpable in aortic regurgitation (AR). Characterised by a large character upstroke followed by a rapid fall in pressure. See CVS skill video. Alternans pulse Characterised by a pulse with alternating strong and weak beats. It is a sign of LV failure (indicates poor prognosis). Pulse Paradoxus Excessive and palpable fall of pulse volume during inspiration. Occurs in cardiac tamponade, constrictive pericarditis and severe asthma. Also auscultated - SBP drops during inspiration. Performed to Radio- Radial and Radio- Femoral Pulse Delay determine whether there is a subclavian Palpate both radial pulses artery simultaneously. stenosis or Radio- pulses occurring at different aortic Radial pulse times – one side delayed. dissection delay which will Causes : Subclavian artery delay the stenosis or Aortic dissection. pulse to one side Palpate both radial and Performed femoral pulse to simultaneously determine Radio- Normally femoral pulse whether comes 5 msec. before the there is an Femoral radial pulse. obstruction or coarction pulse delay Causes : If radial pulse felt ↑ of the aorta before femoral pulse - indicates obstruction or coarctation of aorta. Blood Pressure related to CVS Hypertension: a BP = or > to 140/90 mm Hg Hypotension: a blood pressure of < 90/60 mmHg Narrow pulse pressure: < 25 mmHg of difference Systolic between the SBP and DBP. Causes: aortic Diastolic stenosis, congestive heart failure and cardiac Blood tamponade. Pressure Wide pulse pressure: > 100 mmHg of difference between SBP and DBP. Cause: aortic (SBP/DBP) regurgitation and aortic dissection. Difference between arms: > 20 mmHg difference in blood pressure between each arm is abnormal and may suggest aortic dissection. Exaggerated reduction in BP when patient stands up. Postural Causes: Hypovolemia, Diabetic neuropathy, Stenotic hypotension Valvular disease (AS, MS), Drugs (antihypertensive, diuretics), Addison disease, Elderly etc.  Postural hypotension, also known as orthostatic hypotension, is a condition where a person's blood pressure drops significantly when they move from a lying or sitting position to a standing position. This sudden drop in blood pressure can cause symptoms such as dizziness, lightheadedness, blurred vision, or even fainting. Postural Hypotension (Orthostatic Hypotension) Technique of BP measurement: 3 min 1. Patient’s blood pressure is measured first in the supine position (sitting if necessary) 2. Patient stands up immediately. 3. 3 min later BP measurement is repeated while patient is still in the standing position. Postural Hypotension is 4. Next, calculate the differences confirmed when the difference is: SBP supine – SBP standing >15mmHg for the systolic BP and DBP supine – DBP standing >10 mmHg for the diastolic BP I.e. the patient cannot compensate for the change in BP that occurs upon assuming a Symptoms of postural hypotension: standing position dizziness, blurred vision, syncope confusion, headache, nausea palpitations, fatigue, Examination Hands Peripheral Cyanosis, Pallor – indicates poor systemic perfusion Cap refill (>2 sec), cold and sweaty hands – indicates poor syst. perfusion Clubbing – infective endocarditis, congenital cyanotic heart disease Splinter haemorrhages - infective endocarditis Osler’s nodes (tender) - infective endocarditis Janeway lesions (non-tender) - infective endocarditis Xanthomata - hyperlipidemia Turgor - dehydration  Hands and Nails Exam Clubbing 1. Look from the top for distal 2. Look from the side for finger nail fold/nail angle changes phalanxes swelling 3. Palpate nail fold for the sponginess 4. If still not sure, do the Schamroth’s sign Clubbing is an increase in the soft tissue of the distal part of the fingers or toes. Clubbing In heart disease: Any disease featuring chronic hypoxia Congenital cyanotic heart disease Tetralogy of Fallot (most common cause) Infective endocarditis Atrial myxoma (benign tumour)  *A good radial pulse volume will also tell you about the absence or presence of poor peripheral perfusion 1. Peripheral Cyanosis – perfusion problem? 2. Palm pallor – anaemia or perfusion problem? 3. Palpate for sweaty cold palms; 4. Immediately check Capillary refill Possible causes of all 4 signs: overactivity of the sympathetic nervous system, hypovolaemia, poor cardiac output, acute coronary syndrome, shock etc. fat-reddish non-tender sis Look for: Osler’s nodes (tender) Janeway lesions (non-tender) S v tender nodules under one skin Osler's nodes Janeway lesions painful, red, raised lesions found on the hands and are non-tender, small erythematous or haemorrhagic feet. macular or nodular lesions on the palms or soles only a associated with a number of conditions, including few millimeters in diameter infective endocarditis, pathognomonic of infective endocarditis. caused by immune complex deposition. caused by septic emboli which deposit bacteria, forming microabscesses.  D look for on the nuilked ~ assigns of infective Splinter Haemorrhages endocarditis Splinter Haemorrhages are tiny blood clots that run vertically under the nails Causes: infective endocarditis (IE), vasculitis, scleroderma, systemic lupus erythematosus, rheumatoid arthritis, psoriatic nails, antiphospholipid syndrome, haematological malignancy, and trauma Peripheral Cyanosis nails Pallor nails Tar Stains s a sign of heavy smoking ↓ this has possible cardiovascular consequences.  ~ suggests the possibility of the At having early ischaemic heart Xanthomata - Hyperlipidaemia disease Xanthomas are well circumscribed lesions in the connective tissue of the skin, tendons or fasciae that predominantly consist of foam cells. Typically form over the joints: hands, feet, knees and elbows. Palmar xanthomata and tuberoeruptive xanthomata (over knees and elbows) occur in type III hyperlipidaemia. Tendon xanthomas are associated with type II hyperlipidaemia. Risk factor for ischaemic heart disease (IHD). A xanthelasma is a sharply demarcated yellowish collection of cholesterol underneath the skin, usually on or around the eyelids. Strictly, a xanthelasma is a distinct condition, only being called a xanthoma when becoming larger and nodular, assuming tumorous proportions. Still, it is often classified simply as a subtype of xanthoma. Face exam Eyes Anaemia + Jaundice - may suggest mitral Arcus cornealis / senilis stenosis. Xanthelasma > Cheeks redness (mitral facies) Mouth Lips – peripheral cyanosis Tongue – central cyanosis Frenulum – anaemia Bad teeth – site for bacteraemia, IE! High arch palate (Marphan’s)  Eye signs in Hyperlipidaemia Xanthelasma is a sharply demarcated yellowish deposit of cholesterol underneath the skin of the lids. Larger deposits elsewhere on the body called Xanthoma. V skin lipid nodules can be found on the Corneal arcus (arcus senilis) is a condition where cholesterol forms deposits in T face. cornea. It is visible as a grey ring around the outer part of the cornea. pathoghomonic VO in young Cholesterol people forms deposits incorred Mitral facies Mitral facies refers to a distinctive facial appearance associated with mitral stenosis. Patient present with rosy cheeks, whilst the rest of the face has a bluish tinge due to cyanosis. https://wellcomecollection.org/works/vhzpqha4 Jaundice Caused by passive congestion of the liver or acute ischaemic hepatitis in the right sided cardiac failure, Pallor Caused by poor perfusion or anaemia. Look at the frenulum – if pale then it means look anaemia (not a perfusion problem). frenulum to distinguised at the perfusion problem from anderia  & Peripheral and Central Cyanosis peripheral afanosis II poor perfusion generally “Blue lips” is the sign of “Blue tongue” is the only visible peripheral cyanosis. sign of central cyanosis. NB. Cyanosis is caused by an increase in the deoxygenated haemoglobin level to above 5 g/dL. Below that level we can’t see cyanosis even though the patient is hypoxic. Anaemic patients might not have visible cyanosis because of the overall lack of f haemoglobin which decreases deoxygenated haemoglobin to below 5 g/dL. wontbe visibile in hypoxic pts that are also severely andemic High arched palate in Marfan’s syndrome Dental caries and periodontitis Frequent cause of infective endocarditis (IE).  Oedema Classification - Causes of Oedema Pitting Oedema (Mnemonic- CHILD): Non-pitting Oedema Cardiac failure Myxoedema: Hypoalbuminemia Generalized (Hypothyroidism) Insufficiency (venous), Idiopathic Pretibial (Grave’s disease) Liver disease Lymphedema: Drugs (Vasodilators) Angioneurotic oedema Classification - Site and distribution Bilateral pedal oedema - systemic: Unilateral pedal oedema - local: CCF DVT anaemia cellulitis chronic kidney disease compartment syndrome chronic liver disease filariasis a sign of right ventricular > - failure Cardiac Pitting Oedema Pitting results from pressure applied over oedematous subcutaneous tissue, resulting in a depressed area caused by the displacement of interstitial fluid. Press gently with your thumb for at least 10 seconds on each extremity over the dorsum of the foot and or behind the medial malleolus. Proceed up the shin to above the knee to measure severity of oedema. Sacral oedema: Inspect and palpate the sacrum for evidence of pitting oedema in bed ridden patients. Severity of Bilateral Pedal Pitting Oedema: 1+ (mild): Both feet and ankles 2+ (moderate): Both feet and legs - below knees 3+ (severe): Generalized, including both feet, legs - below and above knees, arms and face, usually with ascites.  reliable sign of a right ventricular failure ~ Jugular Venous Pressure (JVP) ↳measured usingthe internal jugular vein rather than the external Anatomy: juguar rein Internal jugular vein Rises between two heads, proceeds under then emerges medial to the sternomastoid muscle. The IJV not seen, but its pulsations are seen up to the jaw. top of the pulsating column indicates JVP. External jugular vein is not used! tortuous course in the thoracic cavity subject to compression not accurate. Internal jugular vein (IJV) acts as a pressure gauge JVP is a direct transmission of the RA pressure to the IJV. JVP is read as the height of the blood column in cm H2O. N.B. Patient positioning greatly affects the measurements of JVP. Patient must be positioned head/torso up 45% ideally!  This makes IV pulsation readily vision & JVP Measurement Technique 1. Position the patient in a semi- recumbent position (at 45°). 2. Ask the patient to turn their head slightly to the left. 3. Measure the vertical distance between the sternal angle and the top of the IJV pulsations using 2 rulers. 4. Add 5 cm to that value = JVP (JVP reflects right atrial pressure which is 5 cm below the sternal angle). Distinguishing Jugular vs. Carotid pulsations. JVP is visible but not palpable JVP has complex wave form (a, c, v waves) – double waveform pulsation of JVP vs. one impulse of carotid artery. JVP decreases on inspiration Mus itWeAs a JVP fills from above if compressed Abdominojugular reflux causes increase in JVP The normal mean JVP is 6 - 8 cm H2O. Deviations from normal range reflect either: 1. hypovolemia (i.e., mean venous pressure ≤ 5 cm H2O) or, 2. High JVP - see next slide (mean venous pressure ≥ 9 cm H2O). Clinical Methods:. 3rd edition. H Kenneth Walker, MD, W Dallas Hall, MD, and J Willis Hurst, MD.  Abnormally high JVP Value Causes: 1. Venous hypertension - due to fluid overload. 2. Impaired filling of RV / RV failure due to: Left-sided heart (LV) failure - causes right ventricular (RV) failure. Pulmonary hypertension - COPD or interstitial lung disease. Tricuspid regurgitation (TR) and tricuspid stenosis (TS) RV infarct - causes RV failure. Constrictive pericarditis, Pericardial effusion: Back’s triad: distended neck veins, hypotension, muffled heart sounds. Causes: idiopathic, tuberculosis and rheumatoid arthritis. 3. Superior Vena Cava (SVC) obstruction positive Pemberton's sign Causes: lung and mediastinal tumors, large retrosternal goiter, aortic aneurysm. ~is porderline put ~ done when JVP elevation we still RV failure Abdominojugular Reflux Suspect This test is done when JVP elevation is borderline between 8-9 cm (RV failure, TR). Press over upper part of abdomen for 15 secs (mind the tenderness from the enlarged liver) Abdominal compression leads to increased flow of blood to right atrium (RA). Failing RA/RV will not be able to handle this extra blood - and results in a sustained raise in JVP level > 1 cm as a consequence. In normal hearts there is temporary raise of 1 cm followed by fall of JVP back to normal. In isolated LV failure hepatojugular reflux is negative.  Thank you These slides are packed with information specifically intended for distance learning. Please proceed to the Part 2 Examination of the Cardiovascular System Part 2 Examination of the Precordium From Talley and O’Connor 6th/7th Edition Dr Dragan Mandić  CVS Skills and Objectives Part 2 Examination of the Precordium Skills Objectives 1. Learn and practice skills related to the physical Praecordium examination of the CVS including inspection, palpation, Inspection, percussion and auscultation. Palpation, Percussion 1. Learn to palpate the apex beat for location, size and Auscultation heart sounds: character; as well as palpation of parasternal heave, normal S1 & S2 palpable P2 and thrills related to CVS pathologies. additional S3 & S4 Auscultation 1. Use the stethoscope correctly to carry out an Murmurs auscultatory assessment of a normal heart and have a Pericardial rub clear understanding of the normal heart sounds 1 and 2, their intensity and splitting. Learn to recognize additional sounds 3 and 4 and their significance. 1. Learn to classify murmurs and their association with valvular heart diseases: AS, AR, MS, MR. Precordium - Inspection Scars Median sternotomy CABG Valve replacement Lateral thoracotomy Infraclavicular scar Infraclavicular (pacemaker) Median Sternotomy and Lt thoracotomy scars Apex beat – visible pulsations Barrell chest Pectus excavatum Pacemaker box Chest drain Pectus excavatum, Barrell chest, apex beat displaced cannot feel the apex beat  Precordium - Palpation 1. Apex beat (AB) A. Site (displaced) B. Size (localized/ diffuse) C. Character Heaving Dynamic Tapping Double 2. Parasternal heave 3. Palpable P2 pulmonary hypertension 4. Thrills (palpable murmurs) Systolic Diastolic In order to find our palpation points we have to have a reference point for where to start counting the rib and intercostal spaces. This reference point is the sternal angle which is at the level of the second rib and sometimes at the level of the second intercostal space. Angle of Louis or Sternal Angle The angle of Louis is at the level and used to localize the 2 nd rib or sometimes the 2nd ICS. is a reference point from where to start counting ribs or ICSs below. First find the sternal notch, then walk your finger down the manubrium a few centimetres until you feel a distinct bony ridge. This is the sternal angle.  Apex beat Site MCL Apex beat: 5th intercostal space just medial to MCL onthe L ↓ mid clavicular line First find the sternal angle and then the second rib on the left,then count until the 5th intercostal space. Located the midclavicular line. The apex beat is located just medially to Apex the midclavicular line in the 5th intercostal space. beat displaced latera a -defineitas undi s ped , 1a. Apex Beat: Displacement Start at a lateral position and move medially in order to avoid missing a displaced beat. Displaces laterally concentric ventricular enlargement (NB. Displacement not allays present) Displaces inferolaterally in eccentric ventricular enlargement NB. If you are unable to feel the apex beat turn the patient to the left lateral position - to bring the heart closer to the chest wall. Displacement can also be the result of chest deformity, pleural and pulmonary disease.  1b. Apex Beat: Size Palpate with fingertips. Localised Area of impulse < than R5 coin size. Diffuse Area of impulse > than R5 coin. Can be felt in two or more ICSs. 1c. Apex Beat: Character Pressure loaded: Forceful, heaving (sustained) impulse due to concentric Left ventricular hypertrophy. Volume overloaded: Forceful, hyperdynamic, impulse felt over larger area due to eccentric, dilated left ventricular hypertrophy. Tapping apex beat: Non-forceful, palpable first heart sound (S1) in mitral stenosis (MS) Double impulse: Two impulses felt with each systole hypertrophic cardiomyopathy (HOCM)  Analysis of an Apex Beat Is the Apex Beat Forceful? No Yes Is S1 palpable (flicking at your finger)? Is it heaving (lifting your finger? No Yes No Yes Normal Tapping Hyperdynamic Heaving Apex Apex Apex Apex Undisplaced, 5th Undisplaced, 5th Volume loaded Pressure loaded. ICS just medial to ICS just medial to MCL. MCL Displaced laterally Undisplaced, or and inferiorly. slightly displaced Well localised. Well localised. Diffuse apex beat, apex. Non-tapping (S1 Tapping beat in not palpable Mitral Stenosis. Dilated LV, eccentric localised apex. hypertrophy. Concentric LV hypertrophy. a of ~ sign Right rentric a a 2. Palpation for parasternal heave Place heel of right hand just lateral to the left parasternal border (PSB) area between 2nd to 4th ICS (intercostal space). Enlarged right ventricle (RV) pushes anteriorly chest wall. Heel of your hand lifts with chest wall with each systole.  3. Feeling for Palpable P2 1 loud 2nd Palpation with the Rt index and/or middle finger over the pulmonary area in heart left 2nd intercostal (ICS) may reveal the palpable tap of pulmonary valve m sound closure (palpable P2) in cases of pulmonary hypertension. mum due to keymonam value 4. Palpation for thrills A thrill is a palpable vibration caused by turbulent blood flow through a heart valve or a ventricular septal defect. Essentially a palpable murmur. They are also used for grading of the intensity of a murmur. Yanke Usually felt in the base and apex of the heart. heard with a Stethoscope. Palpating thrills at the apex of the heart Palpating thrills at the base of the heart coming from Mitral and Tricuspid valves coming from Aortic and Pulmonic valves  Adom Percussion done in examination a o Not very useful and we do not examine it in OSCE. Percuss the precordium to determine the position of the left heart border if apex beat not palpable. So it's done at the same level laterally from the level of apex beat and proceed medially. AUSCULTATION OF THE HEART 1. 2. It is practically used for everything else but the area of the mitral valve. 1. The diaphragm filters out low pitched sounds and intensifies high pitched sounds such as normal heart sounds. 2. The bell is a resonating chamber and therefore amplifies low pitched sounds like mitral stenosis diastolic murmur. Exam Options When Auscultating Female Patients Female patients helps with auscultation As you proceed keep the area you are not and protects her dignity by covering and auscultating covered. lifting her left breast. so you can access the mitral area for auscultation Auscultating Female Patients  Precordium Auscultation areas Midclavicular line - #endICS 2nd ICS Aortic area Pulmonary & & area Left barasternally right A parasternally Tricuspid area 4th ICS Left parasternally X5th Mitral area ICS Apex beat & midclavicular line. It is recommended to start listening at the inlet of the left ventricle, then Areas and Order of Auscultation continue outlet of the left ventricle, then inlet to the right ventricle and outlet to the right ventricle. 1. Start over Mitral area - 5th ICS Lt 2. Inch towards Aortic area - 2nd ICS Rt 3. Move down Rt SB Tricuspid area - 4th ICS Lt Anatomical vs. auscultatory valvular areas 4. Finish at Pulmonary area 2nd ICS Lt NB. Order: “Start at the left ventricular inlet and finish at the right ventricular outlet!”  Now we focus on what we're hearing. Process of Auscultation at each auscultatory area : Then we focus on finding physiological second sound splitting over the pulmonary area and then we 1. Concentrate on the 1st and 2nd Heart Sound (S1 and S2). report it as splitting of Listen and report on their intensity and splitting at each the second sound on inspiration. auscultatory area. 2. Listen and report on the physiological P2 splitting on inspiration over the pulmonary area - 2nd ICS left. 3. Listen and report on extra heart sounds S3 and S4 4. Any additional sounds such as snaps, clicks. 5. If murmur heard – classify (according to the following slide) 6. Pericardial rub – listen for and report In healthy adults, there are always two normal heart sounds - S1 and S2 (1st and 2nd HS) First heart sound S1 Associated with the closure of the AV valves - Mitral and Tricuspid. It lasts longer and have lower frequency (pitch). Sounds like “Lub”. Best heard at the apex. Loud S1 (and palpable) – Mitral Stenosis Second heart sound S2 Associated with the closure of the Aortic and Pulmonary (Pulmonic) valves. It has a higher frequency (pitch). Sounds like “Dub”. Best heard at the base of the heart (pulmonary area - 2nd ICS left). And then they can split Two Components of S2 - Aortic Closure A2 and Pulmonic Closure P2. apart and be heard during respiration. Loud P2 (and palpable) – Pulmonary Hypertension So there is a physiological Production and Components of the Second Sound (S2). splitting of second sound of a pulmonary area on inspiration. Pulmonary component of the 2nd sound splitting (P2) Spliting of P2 sounds like “Dr”. Sing it: “Lub –Dub” - “Lub –Dub” - “Lub –Dr” - “Lub –Dr” - “Lub –Dub” etc. Normal in expiration Splitting in inspiration  Other Heart Sounds S3 - 3rd heart sound S4 - 4th heart sound Summation gallop S1-4 - all 4 sounds present Opening snap - Mitral Stenosis Mid-systolic click - Mitral prolapse Pericardial knock - pericarditis Metallic click - prosthetic valve Purspadstudumoverload of thenicatefor a > S3 and S4 sounds/ gallop cardiac failure S3 - Protodiastolic gallop or ventricular gallop. Sounds like "lub-dub-ta“or “slosh-ing- in”. S3 corresponds to rapid ventricular filling during early diastole. Clinical Significance: can be S3 indicates volume overload or congestive cardiac failure (CCF). Associated dilated cardiomyopathy with dilated ventricles contribute to the sound. - normal in adults Benign in youth and some trained athletes but in adults over 40 always considered below cours abnormal. esp S4 - Presystolic gallop or atrial gallop. Sounds like "ta-lub-dub“ or “a-stiff-wall”. athletes Produced by the sound of blood being forced into a stiff/hypertrophic ventricle ("atrial kick"). sign Clinical significance: Seen in patients with stiff left ventricles, resulting from conditions such as hypertension, aortic stenosis, ischemic cardiomyopathy or ischaemic event (angina, MI) and hypertrophic cardiomyopathy. Stiff or thick myocardium  Heart Murmurs Murmurs are heart sounds that are produced as a result of turbulent blood flow that is sufficient to produce audible noise. - Two clinically significant types: pathological and innocent murmurs NB. Palpate the right carotid artery with your thumb during auscultation for heart murmurs in order to identify systolic or diastolic timing of the murmur. T in order to find Systolic Murmurs: onetimas ing pansystolic - MR ejection systolic – AS Diastolic Murmurs: early diastolic - AR mid-diastolic - MS Continuous Murmurs: heard throughout systole and diastole - PDA Classification of the murmurs 1. Timing refers to whether the murmur is a systolic or diastolic murmur. 2. Shape refers to the intensity over time; murmurs can be crescendo (presystolic accentuation murmur of MS), decrescendo (AR) or crescendo- decrescendo (ejection murmur of AS). 3. Location refers to where the heart murmur is usually auscultated best; e.g. over aortic valve Rt 2nd ICS, apex 5th ICS MCL, Lt sternal border 4th ICS etc. 4. Radiation refers to where the sound of the murmur radiates. The general rule of thumb is that the sound radiates in the direction of the blood flow; e.g. toward the neck in AS or apex of the heart in AR etc. 5. Intensity refers to the loudness of the murmur, and is graded on a scale from 0-6/6. MS murmur is soft and therefore graded on scale 0-4/4. 6. Pitch can be low or high and is determined by whether it can be auscultated best with the bell or diaphragm respectively. 7. Quality refers to unusual characteristics of a murmur, such as blowing - MR; blowing and harsh – VSD; rumbling – MS; or musical – AR (Austin- Flint).  aka - "loudness" Grading Intensity of the murmurs Grade 1/6 - Very faint, heard only by an experienced practitioner in a silent room; may not be heard in all positions. Grade 2/6 - Quiet, but heard immediately after placing the stethoscope on the chest. Grade 3/6 - Loud, no thrill. Grade 4/6 - Loud, with palpable thrill (i.e., a tremor or vibration felt on palpation) Grade 5/6 - Very loud, with thrill. May be heard when stethoscope is partly off the chest. Grade 6/6 - Very loud, with thrill. May be heard with stethoscope entirely off the chest.  -making it easiera Dynamic Manoeuvres are the interventions that change intensity and nature of a murmur: making it louder and easier to distinguish from the other murmurs. There are many manoeuvres but we will teach only two at this stage. 1. Positioning of the patient in the left lateral position will increase the intensity of murmur of mitral stenosis. (causes louder MS diastolic murmur). Use the bell of your stethoscope. Listen over the apex. ↳earpt C 2. Leaning forward and holding breath in expiration Intensifies murmur of aortic regurgitation (causes louder AR diastolic murmur). forward brings the past Listen with diaphragm on Rt 2nd ICS (or on the left lower sternal border 3rd ICS) and them ask to hold their The murmur radiates toward the apex. ofthe breath in heart gases to the stetha expiration scope Untreated valvular lesions will have signs and symptoms of congestive cardiac failure (CCF). Overload signs and symptoms: Dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea. S3 (3rd heart sound) heard due to volume overload. Pulmonary oedema (LV failure): crackles and wheezes basally or throughout the lung fields (more severe); - pulmonary congestion: fine basal inspiratory crackles. Leg, liver oedema, ascites (RV failure). Low cardiac output state signs and symptoms: Confusion, syncope, Peripheral cyanosis, weak pulses, tachycardia, hypotension, shock. Myocardial ischaemia with aortic stenosis Palpitation, chest pain. 4th heart sound (S4) might be heard due to ischaemic, hypertrophic and stiff LV wall. Next 4 slides looks at the most preregant valvular disorders Aortic Stenosis -AS In AS, there is narrowing of the aortic valve creating loud systolic murmur (after 1st heart sound which correlate with carotid pulse). History of dyspnoea, chest pain, syncope (symptoms of severe AS). Signs of heart failure on general and precordium exam. Carotid pulse is weak and late. Palpation: Apex Beat (AB): Displaced, localised, forceful & heaving (sustained); Precordial thrill at the base of the heart. One may hear the s4 – LV concentric hypertrophy/ stiff wall. Auscultation - Murmur: Systolic ejection murmur (crescendo-decrescendo). Heard loudest at the right sternal border, at the 2nd ICS. Radiates to the neck or carotid arteries bilaterally. Louder during expiration. Aortic Regurgitation - AR In AR, the aortic valves doesn’t close which is essential during diastole. Therefore in AR blood flows back into the left ventricle causing diastolic murmurs (after the S2). Signs and symptoms of CCF on general and precordium exam. Palpation: Large-volume, 'collapsing' pulse on carotid and radial arteries. The apex beat is typically forceful, diffuse, displaced inferolaterally (laterally and down to 7th ICS) and hyperdynamic. S3 heart sound (S3 gallop) heard due to volume overload of LV. Auscultation - Murmur: Early diastolic murmur (decrescendo). Best heard at aortic area (right 2nd ICS) when the patient is seated and leans forward with breath held in expiration. The murmur radiate toward the apex. Usually soft and seldom causes thrill.  Mitral Stenosis -MS In MS there is a narrowing of the mitral valve increase resistance of blood flow to the Lt ventricle. Left ventricle is underloaded and small in size. Signs and symptoms of decompensated congestive cardiac failure (CCF). Palpation: Palpable S1. The S1 is loud and felt as “undisplaced tapping apex beat”. Thrill is rarely palpable at the apex. Diastolic murmur of MS is very soft. Palpable P2 : pulmonic component of the 2nd sound will become loud and is felt as palpable P2 → pulmonary congestion. Parasternal heave is also felt → enlarged RV. Auscultation: (sounds like “foot-ta-ta-rue”, for the learning purposes only!) 1. First, presystolic accentuation murmur starts just before S1. It merges and stops with S1 (sounds like “foot”). 2. Then 2nd heart sound (S2) is heard (1st “ta”). 3. An opening snap (OS), which is an additional sound which may be heard after the S 2. OS correlates to the forceful opening of the thickened, non-pliable mitral valve leaflets. Sign of severity of MS. (2 nd “ta”) 4. Followed by a mid-diastolic rumbling murmur. (“rue”) Best heard at the apical region (5th ICS MCL) - not radiating. The murmur is low pitched and best heard with the bell of the stethoscope. Accentuated in left lateral decubitus position (rolling the patient towards left). Mitral Regurgitation - MR In MR the valves are unable to close which is essential during systole blood flows back to the left atrium causing a systolic murmur. Signs and symptoms of decompensated congestive heart failure (CCF). Palpation: In advanced cases apex beat is hyperdynamic, diffuse and displaced laterally and inferiorly, suggesting eccentric hypertrophy of LV. Apical thrill. Parasternal heave (enlarged RV). Palpable P2 may be present. Auscultation - Murmur: Blowing pansystolic murmur (plateau). Radiates toward the left axilla. Heard best at the apex (5th ICS MCL).  Examples of other heart murmurs Machinery murmur of Patent Ductus Arteriosus (PDA) In PDA blood flows from the aorta to the pulmonary artery murmur during systole and diastole. Pericardial friction rub (PFR): Patients with pericarditis, an inflammation of the sac surrounding the heart (pericardium), may have an audible pericardial friction rub. This is a characteristic scratching, high-pitched sound emanating from inflamed pericardial surfaces rubbing against each other It is the loudest in systole, but can often be heard at the beginning and at the end of diastole. Louder on sitting up and expiration. It changes from hour to hour. NB. Please listen to all the sounds provided in this lecture. They will be used in your OSCE! (except the last two – PDA and PFR). At the end, do not forget! Back exam Abdomen exam Inspection: Examine for: scars, deformities, lumps Hepatomegaly Pulsatile liver – Tricuspid Palpation regurgitation (TR) Sacral oedema Splenomegaly – IE, CCF Auscultation: Ascites - CCF Breath sounds: Aortic aneurism – high BP, Increased at the bases (BB) Femoral arteries with basal crackles and Palpation and Auscultation for signs of peripheral vascular wheezes (pulmonary oedema disease due to LV failure) Absent on one or both bases - BB – standspercuss forbreathing’ for ‘bronchial pleural effusion.  Further assessments and investigations Peripheral vascular examination: to identify peripheral vascular disease, which is common in patients with central CVS pathology. Record a 12-lead ECG: to look for evidence of arrhythmias, myocardial ischaemia/infarct, ventricular enlargement etc. Urine Dipstick: to identify proteinuria or haematuria which can be associated with hypertension. Bedside capillary blood glucose: to look for evidence of underlying diabetes mellitus, a significant risk factor for cardiovascular disease. Perform fundoscopy: if there were concerns about hypertension (HT), fundoscopy performed to look for hypertensive retinopathy and papilloedema (malignant HT). Thank You