CARDIAC EXAMINATION MINI-QUIZ 1. Sitting bolt upright, your dyspneic (short of breath) patient has visible jugular venous pulsations to the angle of his jaw, which is 12 cm above his sternal angle. What is his right atrial pressure? Why might he be short of breath? 2. Which point on the jugular venous pulse occurs near the beginning of diastole? a. The A wave b. The C wave c. The x descent d. The V wave e. The y descent 3. Systole starts: a. At S1 b. At S2 c. At the highest point of the jugular venous pulse d. At the lowest point of the jugular venous pulse 4. S1 is loudest at the: a. Right upper sternal border b. Left upper sternal border c. Left lower sternal border d. Apex 5. S2: 6. S4: a. Is loudest at the apex b. May be normally split in both inspiration and expiration c. Splits audibly at the left lower sternal border d. Consists of aortic followed in inspiration by pulmonic closure a. Usually comes shortly after S3 b. Is not unusual in healthy young athletes c. Often is caused by reduced ventricular elasticity d. Is intermittent in atrial fibrillation, when the atria don t contract 7. Your patient has a loud murmur at the left lower sternal border. Your hand on her parasternal area feels no vibration. This murmur is: a. I/VI b. II/VI c. III/VI d. IV/VI 8. Innocent murmurs: a. Often occur at the right sternal border b. Occasionally occur in diastole c. Are accompanied by inspiratory splitting of S2 d. May be accompanied by a palpable thrill 9. Which finding makes aortic stenosis least likely? a. Delayed rise of upstroke of carotid pulse b. Late peaking intensity of murmur c. Quiet S2 d. Failure of murmur to radiate to the right carotid
INTRODUCTION TO PHYSICAL EXAMINATION OF THE HEART Objectives: By the end of this session, you will be able to: 1. Recognize the elements and significance of the jugular venous pulse. 2. Understand and hear S1 and S2. 3. Know the physiology and sound of S3 and S4. 4. Identify systole and diastole by palpation and listening 5. Be able to describe heart murmurs. 5. Hear and understand the mechanism of three common systolic murmurs. 1. JUGULAR VENOUS PULSE (JVP): What: Visible pressure changes in the right atrium. ACxVy A: Atria contract; blood flows back briefly into the vena cava C: Closure of tricuspid valve stops forward flow of blood x: Downslope as atria begin to fill V: Volume of atria increases with filling, increasing pressure in vena cava y: Downslope as tricuspid valve opens and ventricles begin to fill Where: near (superficial JV) and under (deep JV) the sternocleidomastoid muscle How: patient at 30 to 45 degrees; measure cm. above sternal angle (angle of Louis). Sternal angle is 5 cm above right atrium; height of JVP above sternal angle plus 5 equals right atrial pressure. Normal RA pressure: 5-10 cm H20. Why: 1. Diagnose heart failure or fluid overload. Either will elevate RA pressure and thus raise JVP. Abdominojugular reflux (also called hepatojugular reflux - HJR): pressure on epigastrium briefly increases JVP. Accentuated in right heart failure. 2. Diagnose complete heart block or AV dissociation: atria and ventricles beat independently, RA often contracts against closed tricuspid valve, causing cannon A waves. 2. PALPATION 1. Location of heart: Right ventricle: anterior Left ventricle: left heart border/apex/posterior Right atrium: right heart border Left atrium: posterior
2. PMI - Point of Maximum Impulse What: palpable contraction of left ventricle (LV) during systole Location: around 5 th intercostal space in midclavicular line; lower and more medial in slender patients or patients with emphysema Size: one interspace; approximately dime-size Duration: brief (longer is sustained ) Intensity: not strong (if intense, a lift or heave ) Not always palpable: about 75% of people have palpable PMI 3.Palpation of parasternal area and base: Lifts: in parasternal area (left sternal border) may mean right ventricular hypertrophy (thickening) Thrills: palpable heart murmur (murmurs are graded I/VI to VI/VI; thrill = IV/VI) 3. AUSCULTATION: (listening) How: Use both bell (low pitched sounds such as S3 and S4 gallops) and diaphragm (high pitched sounds, including S1, S2 and most murmurs). LIGHT touch with bell. Where: at least four locations (valve areas): Aortic or RSB: right 2nd intercostal space (just under and right of angle of Louis) Pulmonic or LUSB: left second intercostal space, just left of sternum Tricuspid or LLSB: left fourth intercostal space Mitral or Apex: 5 th intercostal space in midclavicular line Optional: left 3 rd intercostal space Location notes: 1. Valves are not always noisiest in their assigned areas 2. Loud murmurs may be in several areas and difficult to localize 3. Named area is direction of flow, not location of valve What: What makes noises in the heart? Valves closing: Atrioventricular (S1) and semilunar (S2) valves Blood striking left ventricle: S3 and S4 (these are audible thus only at apex=lv) Increased flow across normal valves Turbulence through abnormal valve
Sounds: lub-dub = S1-S2 S1: Mitral and tricuspid (atrioventricular or AV) valves closing Loudest at apex Usually single S2: Aortic and pulmonic valves (semilunar) closing Loudest at base (top of heart is base) Usually splits with inspiration; this is audible only in pulmonic area Combines sounds of closing Aortic (A2) and Pulmonic (P2) valves Aortic is louder; can distinguish Pulmonic (P2) at LUSB - its area Pulmonic closes later than aortic in inspiration - thus split then Abnormal conduction can cause fixed split (never closes) or paradoxic split (expiratory split, closes with inspiration) Rhythm: should be regular, but often normal sinus arrhythmia: slower in expiration A few sounds that are often abnormal (but may be heard in healthy people): S3 and S4: sounds of blood striking the left ventricle (thus heard at the apex). Both occur in diastole. S3: Rapid ventricular filling just after aortic valve closes and mitral valve opens, i.e. just after S2 ; low pitched (hear with bell) May be a sign of a flaccid ventricle, e.g. congestive heart failure May be heard in healthy athletic young people Sound: Sloshing-in or It s-floppy S4: Atrial contraction fills ventricle rapidly just before mitral valve closes, i.e. just before S1 ; low pitched (hear with bell) Heard if left ventricle is stiff: from high blood pressure, heart attack, etc. Sound: a-stiff-wall
HEART MURMURS Murmurs: What they are: Turbulence caused by -- increased flow across normal valves: pregnancy, innocent murmur -- turbulent flow through abnormal valves: tight valve (stenosis) or leaky valve (regurgitation or insufficiency) Murmurs: How to describe them Timing: Systolic: Between S1 and S2 If unsure: check carotid pulse and/or palpate PMI. Both of these occur during systole. Most common murmurs occur in systole Can be early systolic, late systolic or holosystolic (all of systole) Diastolic: After S2 Intensity (Loudness): I/VI: Need quiet room and trained ear to hear II/VI: Audible to anyone who listens attentively III/VI: Loud, but not palpable IV/VI: Like III, but with a palpable thrill V/VI: Audible with stethoscope placed perpendicular to chest wall VI/VI: Audible without a stethoscope 3. Quality: Shape of murmur: Diamond-shaped (can hear S1 and S2) typical of stenosis (narrowing) or flow murmurs; Constant intensity (may blur S1 and S2) typical of valvular regurgitation (leak) Can be musical (often innocent), blowing (regurgitant or innocent), harsh (stenosis) 4. Location (see above)
A FEW COMMON MURMURS: SYSTOLIC: Innocent (flow) murmur: II/VI or softer, blowing, diamond-shaped, at pulmonic area Listen for S2: if fixed split, think atrial septal defect Mitral insufficiency/ regurgitation (leaky valve) Holosystolic, blowing, constant intensity Loudest at apex; often radiates to axilla Aortic stenosis: Diamond-shaped; somewhat harsher quality Usually loudest at aortic area (though sometimes in tricuspid area) If worse, may have S4, too Evidence-based lesson: Does this patient have aortic stenosis? Best to rule in aortic stenosis: Delayed rate of rise of carotid pulse Mid to late peak in intensity of murmur Quieter S2 Best to rule in aortic stenosis: Failure of murmur to radiate to right carotid artery JAMA 1997; 277: 564-71 RUB: Mitral valve prolapse: Classically preceded by one or more clicks in midsystole Murmur (if present) follows is late systolic Heard at apex Common in slender young women usually benign DIASTOLIC Aortic insufficiency/regurgitation: Blowing Loudest in aortic or tricuspid areas Louder if patient squats or clenches hands (this increases systemic vascular resistance, increasing regurgitation) Leathery, squeaky sound made by pericardial friction Often has 3 components heard in systole and diastole Sometimes louder with position change (e.g. sitting up)