Physical Diagnosis- Cardiovascular

Extra heart sounds: systole

-ejection sounds are pathologic -occur early in systole, immediately after S1 -aortic and pulmonic valve opening or rapid distention of the proximal aorta or pulmonary artery at the onset of ejection -high pitched, sharp clicking quality

Heart murmur grading******

-grade 1- very faint, sometimes inaudible -grade 2- quiet, but heard immediately -grade 3- moderately loud -grade 4- loud with palpable thrill, NOT heard with stethoscope off chest -grade 5- very loud with thrill, heard with stethoscope partially off of chest -grade 6- very loud, thrill, heard with stethoscope completely off chest

Aortic stenosis murmur

-heard at 2nd and 3rd ICS -may radiate to carotid as bruit -usually right 2nd ICS and radiates to right carotid******

What do you feel for when palpating

-heaves, lifts, thrills, S1, S2, RV area -localized pulsations on finger pads, thrills on top of palm, heaves or lifts on bottom of palm

Measure JVP

-identify highest point of venous pulsation of the internal jugular -measure vertical distance above sternal angle -normal JVP is <4 cm above sternal angle**** (7-9cm) -elevated JVP (JVD) may mean volume overload or R heart failure -identifying highest point you see billowing/sail of JV and seeing how high above sternal angle that is

Carotid pulse inspection

-inspect carotid pulsations for amplitude and contour -patient supine with HOB elevated to 30º -inspect medial to the sternocleidomastoid muscles -medial to IJ -matches brachial pulse -carotid upstroke brisk without bruit

Cardiac Exam steps

-inspection (for heaves, point of maximum intensity (PMI) or apical impulse) -palpation (lifts and heaves (sustained impulses that rhythmically lift your fingers from an enlarged right/left ventricle), thrills (vibrations from aortic stenosis, use palm of hand), PMI, cardiac silhouette (R/L 2nd ICS, sternal border and left sternal border, and where 4 heart sounds are auscultated) -auscultation (heart sounds, murmurs)

Heart sounds R & L

-left heart, S1=mitral closure, S2= aortic closure -right heart, S1= tricuspid closure, S2= pulmonic closure -right side contracts slightly later than left, S1=M1T1; S2=A2P2 -lower pressure in right heart often don't hear those closures, but you can

Apical impulse

-location (usually 4th or 5th intercostal space, MCL or 7-9 cm lateral from midsternal line)- assess when supine, in LLD which displaces PMI to left -diameter (usually less than 2.5cm) -amplitude (usually small, brisk, tapping) -duration (listen, fell and estimate proportion)

Cardiac auscultation- squatting and valsalva maneuvers

-make different murmurs louder or softer -mitral valve prolapse (increase with decrease in BV aka valsalva-->chest pressure increased making harder for blood to return back to heart for left and ride side, decreased blood volume causes decreased murmur noise) -hypertrophic cardiomyopathy (standing valsalva or straining "bearing down" will increase murmur) -aortic stenosis (valsalva will increase intensity of murmur by increased venous return therefore increasing blood volume ejected, standing (strain) decrease it) (squat will increase flow or aortic stenosis b/c increasing volume across aortic valve, then either stand or bear down for strain phase which increases murmur/hypertrophy)

Adventitious heart sounds

-mixed cycle: not confined to one aspect of cardiac cycle --pericardial friction rub****: caused by pericarditis; inflammation of pericardial sac (pericarditis), best heard L 3rd ICS with pt leaning forward holding breath; scratchy, grating -patent ductus arteriosus: congenital opening between aorta and pulmonary arteries stays open; continuous murmur throughout systole and diastole, silent pause at end of diastole -venous hum: benign turbulent blood flow in jugular veins; heard above clavicles; better in seated position, goes away with lying down; harmless; can be mistaken for murmur

Mitral valve prolapse (MVP)

-most common mid-systolic click**** -heard mid to late systole -2-3% of the population have -ballooning of part of valve, common condition found in about 5% of population, usually no increase risk of heart disease -changes with squatting and standing due to venous return -with contraction of L ventricle (systole) the flailing leaflet

Heart murmurs

-murmurs are often longer duration than heart sounds -turbulent flow through valve causing a vibratory sound -can indicate disease (or benign) -heard best over respective auscultatory areas for the involved valve

Mitral stenosis

-opening snap heard early in diastole -usually caused by opening of stenotic mitral valve -loud, high pitched snapping sound

Heart murmurs continued

-quality (harsh (stenosis), blowing (regurgitation), rumbling, musical) -contour: pattern of sound intensity over time (crescendo= gets louder (mitral stenosis), decrescendo= gets softer (aortic regurgitation), crescendo-decrescendo (aortic stenosis/innocent flow murmurs), plateau= intensity constant (mitral regurg))

When are pulses palpable?

During systole

Heart sounds: splitting

-splitting refers to the separation of heart sounds into 2 components (R/L) -S1 and S2 can be split, but the splitting of S2 is more important clinically -physiologic splitting: separation of S1 or S2 into separate sounds accentuated by inspiration, disappears with expiration (w/ inspiration, increased capacity in pulmonary vascular bed with expanding lung, prolongs ejection from right ventricle, delays closure of pulmonic valve) -R heart normally moves slower than left, and lag is accentuated by increased intrathoracic pressure (deep inspiration) b/c this causes increased R heart venous return therefore more blood to eject from pulmonic valve -physiologic splitting is normal however there can be abnormals-->primarily is the split fixed regardless of expiration or inspiration? suggests severe right ventricular failure or some sort of heart disease

Cardiac exam positions

-start patient position at 30 degrees head elevation with you on right side -other positions will be left lateral decubitus (LLD) (for PMI and S3/S4 by bringing the ventricular apex closer to the chest wall), sitting up and leaning forward (will bring ventricular outflow tract closer to chest, improving detection of aortic regurg and pericardial friction rubs), and valsalva

Cardiac auscultation

-start with pt supine HOB at 30 degrees -listen to entire precordium (right 2nd ICS, left 2,3,4,5th ICS, apex) -use both diaphragm and bell (diaphragm for higher pitched sounds, bell for lower pitched sounds, press lightly, apex with bell for S3, S4, mitral stenosis) -press firmly with diaphragm, diaphragm better for high pitched S1, S2 and murmurs of aortic/mitral regurg

Most likely valve to get endocarditis for IVDU?

-tricuspid (rt AV)

Innocent murmurs

-turbulent flow across valve due to strong ventricular ejection of blood -common in children (50-80% with only 1% pathologic), young adults -no evidence of CVD -no physiological or structural abnormalities -prominent in fever, anemia, pregnancy-->due to vibration of pulmonary tree, flow across semilunar valves

Cardiac auscultation- left lateral decubitus

-use bell -brings LV closer to chest wall -accentuates S3, S4, and mitral stenosis

Cardiac auscultation-sitting up, leaning forward

-use diaphragm -accentuates aortic regurgitation

S4

-usually not heard -problem with ventricular compliance usually aortic stenosis -occurs just before S1 when the atria contracts and blood strikes a stiff LV -sounds like Tennessee

Amplitude

-usually small and feels brisk and tapping -some young people have increased amplitude or hyperkinetic impulse, especially when excited or after exercise with normal duration -increased amplitude may reflect hyperthyroidism, severe anemia, pressure overload of LV, volume overload of LV

Systole

-ventricular contraction-->when LV pressure exceeds aortic pressure, aortic valve opens -aortic and pulmonic valves open while mitral and tricuspid valves close -blood ejected out from heart into aorta -begins after S1 -aortic valve closure= S2

Diastole

-ventricular relaxation -begins with S2 -as pressure rises in LA, mitral valve OPENS (not normally audible) -period of rapid ventricular filling followed by atrial contraction (usually not audible, if audible, think about problems with ventricular compliance) -rapid ventricular filling= S3 -atrial contraction= S4

Apical impulse abnormalities

-with pregnancy, PMI moves upward -lateral displacement makes low ejection fraction 5-10 x more likely -diameter >3 cm suggests L ventricular enlargement--usually only one interspace of the ribs/chest wall -sustained high amplitude impulse suggests LVH--should last first 2/3 of systole or less but not continue to S2 -high amplitude or hyperkinetic suggests hyperthyroidism, severe anemia, volume overload, HTN with CHF -duration helps identify LVH--lasts 2/3 of systole but not past second heart sound (sustained duration increases likelihood of LVH) -stronger heave elsewhere after finding suggests aortic aneurysm or R side heart enlargement

Where does the base of the heart lie?

-2nd ICS (sternal angle) -superior aspect of heart -defines the junction between the pulmonic artery and the right ventricle, close to sternum

Where does the apical impulse lie?

-5th ICS or just medial to midclavicular line -if have R ventricular hypertrophy from something like COPD, PMI (point of maximal impulse) may be more medial over the epigastrium/xiphoid, not always palpable

Where does the apex of the heart lie?

-5th ICS, 7-9 cm from midsternal line -inferior aspect of heart

CV Exam

-Assess jugular venous pressure (JVP) -Assess carotid pulse -Examine the heart (inspection, palpation, auscultation) -Peripheral vascular exam

Inspections of JVP

-EJ is often easily visible, not necessarily sign of disease -IJ not normally visible, looking for signs of distention that indicate disease (increased right heart pressure)

What two sounds do you hear when listening to heart and what are they?

-FIRST noise (S1)= mitral valve CLOSING -SECOND noise (S2)= aortic valve closing -in between these noises, aortic valve is open and LV Is pushing out blood -similar events happening on R side, but less likely to hear given lower pressure than L side -at base, S1<S2 -at apex, S1>S2

Jugular venous pressure

-JVP reflects R atrial pressure equals central venous pressure and R ventricular end-diastolic pressure (ie heart failure/fluid overload) -position patient supine with head raised to 30º, tilted slightly away from side you are inspecting -use tangential lighting to identify landmarks -looking at internal jugular vein -identify amplitude (looking for absent or prominent waves-->absent in a fib, prominent in resistance with R atrial contraction) and timing of venous pulsations (two waves of pulsations, a wave just precedes S1 (atrial kick) and V wave with S2 (venous filling before tricuspid opens), lateral to SCM -if pt is dehydrated, may need to lower the bed to see venous pulsations -if pt has fluid overload (meaning obvious LE edema/abdominal ascites) need to elevate the head of the bed to see the JVP

Most anterior cardiac surface

-R ventricle; thin wall, under low pressure -L ventricle lies behind R ventricle except for apex -left heart sounds more prominent

Where are S1 and S2 loudest?

-S1 loudest at apex (mitral valve closing, "lub") -S2 loudest at base (aortic valve closing, "dub")

Ventricular gallop

-S3 -physiological or pathological -heard early in diastole during rapid ventricular filling and can be physiologic in children but usually pathologic in pts over 40 -kentucky

Atrial gallop

-S4 -heard late in diastole, just before S1 -dull low pitched sound, heard best with bell -can be physiologic in athletes and some older individuals but more often pathologic -audible atrial contraction against non-compliant L ventricle -duh to ventricular hypertrophy causing decreased compliance following atrial contraction -tennesee

What do systole and diastole occur between?

-Systole (between S1 and S2, which is shorter than diastole) -Diastole (between S2 and S1)

Pathologic murmurs

-arise from structural abnormalities in valves -stenosis (hardening or narrowing of valve, impedes blood flow through valve) -regurgitation (failure of valve to close completely, allows backflow of blood)

Carotid pulse exam continued

-auscultate FIRST for bruits because if theres plaque could potentially break off -have pt hold breath -use diaphragm (or bell for bruit; arterial bruits tend to be higher frequency) of stethoscope to listen for bruit (rumbling sound of turbulent blood flow through artery, can be from arterial stenosis, tortuous carotid artery, aortic stenosis) -palpate for amplitude, rate, contour, thrills (palpable purr or vibration)

Venous hum

-benign turbulent blood flow in jugular veins; heard above clavicles; better in seated position, goes away with lying down; harmless; can be mistaken for murmur

S3

-called a gallop -occurs after S2 early in diastole when stiff ventricle is filling -happens right after aortic valve closes -common in kids and young adults -if problem in >40 YO patients, think poor ventricular compliance (contractility or systolic heart failure with volume overload) -sounds like kentucky -in elderly, sign of CHF

Jugular venous pressure pulsations

-carotid pulsations look/feel like single strong palpable impulse -IJV venous pulses look like billowing sails with gentler wave forms usually 2 per heart beat (collapsible, press on RUQ to accentuate hepato-jugular reflux is JVD is suspected) -JV Distension indicates increased pressure in right heart (usually due to heart failure)

Pericardial friction rub

-caused by pericarditis*** (inflammation of pericardial sac) -best heard L 3rd ICS with pt leaning forward holding breath -scratchy, grating

Patent ductus arteriosus

-congenital opening between aorta and pulmonary arteries stays open; continuous murmur throughout systole and diastole, silent pause at end of diastole

What to look for in heart murmur

-description: location, intensity, timing (systole/diastole), pitch, quality (crescendo/decrescendo), radiation (can you hear in carotid?)

Diastolic murmur

-early diastolic -mid-diastolic -late diastolic -ALWAYS pathologic

Systolic murmur

-early systolic (ejection) -midsystolic -late systolic -holosystolic (usually regurgitation) -may be innocent or pathologic -can have normal heart valve but related to abnormal flow

Cardiac auscultation areas

1- aortic 2- pulmonic 3 & 4- tricuspid 5- PMI, mitral region S2 louder at 1, S1 louder at 5

Which sounds should you identify first?

S1 and S2, then figure out what else you hear

Blood flow through heart and lungs

Vena cavas-->RA-->RV-->pulmonary trunk-->pulmonary aa-->lungs-->pulmonary vv-->LA-->LV--> aorta

If you're having trouble locating S1 and S2 where you should try to find them?

carotid pulses; feel at same time as listening, S1 just before upstroke, S2 follows