Percussion and Auscultation of CARDIOVASCULAR system.

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

1. CARDIOVASCULAR EXAMINATION INSPECTION PALPATION PERCUSSION AUSCULTATION - Manoz marwin

2. PERCUSSION

3. It is done to see the enlargement of the dullness of the cardiac region Left border APEX Right border RIGHT STERNAL MARGIN

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. 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. Auscultation

7. Auscultatory areas

8. Mitral area – 5 th left ICS in mid- clavicular line (corresponds to apex beat) Tricuspid area – 4 th left ICS just lateral to the lower end of the sternum Aortic area First aortic area – 2 nd right ICS close to sternum Second aortic area or ERB’S area – 3 rd left ICS close to sternum * The early diastolic murmur of AR and pansystolic murmur of VSD are best heard at ERB’S AREA

9. Pulmonary area – 2 nd left ICS close to sternum Gibson’s area – 2 nd left ICS away from sternum * The murmur of patent ductus arteriosus is best heard at gibson’s area

10. Other areas of Auscultation Carotids Supraclavicular region Infraclavicular region Axillary region Back – interscapular and infrascapular regions, bruits in the back

11. Check for Heart sounds Heart murmurs Gallops Opening snap Ejection click Pericardial knocks Pericardial rub Diastolic knock Prosthetic valve sounds

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 S 1 S 2 S 3 S 4

13. First heart sound (S 1 ) 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. Factors that affect intensity of S 1 Position of AV valve cusps at the onset of ventricular systole Heart rate Pliability of the valve cusps * S 1 may be normal, soft, loud or variable intensity.

15. Soft S 1 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. Loud S 1 Mitral stenosis Tricuspid stenosis Atrial septal defect Mechanical prosthetic valve High output states Short PR interval, tachycardia Atrial myxoma In normal children

17. Varying intensity of S 1 Atrial fibrillation Complete heart block Extra systoles

18. Canon sound(bruit de canon) Loud S 1 heard intermittently in complete heart block and in interference, dissociation when the ventricles contract shortly after atria. Associated with short PR interval

19. Splitting of S 1 Components – M 1 and T 1 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. Reverse splitting of S 1 Delayed mitral component Tricuspid component is heard earlier than mitral component Causes Right ventricular pacing Ectopic beats Idioventricular rhythm of right ventricle

21. Second heart sound(S 2 ) Produced by closure of pulmonary and aortic valve Indicates the beginning of diastole Normal splitting Two components – A 2 and P 2 A 2 louder than P 2 Appreciable during inspiration

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. 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. Abnormalities in splitting of S 2 Wide splitting of S 2 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 A 2 Late P 2 A 2 – P 2 interval ≥ 0.03 sec during expiration

25. Wide variable splitting of S 2 Pulmonic stenosis due to delay in P 2 Mitral regurgitation VSD due to early A 2

26. Wide and fixed splitting of S 2 ASD Right bundle branch block Total anomalous pulmonary venous connection * In these conditions, splitting is due to delay in P 2

27. Delay in A 2 results in closely split, single or paradoxically split S 2 . In paradoxically split S 2 , the split is wide in expiration, but narrows during inspiration

28. A single second sound Either A 2 or P 2 or a combination of both The decision whether it is aortic or pulmonary or a combination is based on clinical profile Tetrology of fallot  A 2 VSD with pulmonary hypertension  Combination * Interpretation of single second sound is not dependant on auscultation alone

29. Third heart sound (S 3 ) 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. Fourth heart sound (S 4 ) 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. Added sounds Gallop rhythm Opening snap Ejection click Triple rhythm Quadruple rhythm Summation gallop

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. Site Note the site of maximum intensity of murmur VSD – Murmur best heard in left 3 rd and 4 th ICS Pulmonary ejection systolic murmur – left 2 nd ICS

34. Timing Timing of the murmur in relation to ventricular activity noted Appreciated by palpating the carotid artery while auscultating the precordium Systolic Diastolic Continuous

35. Systolic murmurs Heard during systole Regurtitant systolic murmurs Start immediately after 1 st heart sound and may continue to 2 nd sound Usually pansystolic or holosystolic Intensity is uniform throughout Causes : VSD Tricuspid regurgitation Mitral regurtitation Regurtitant systolic murmur Ejection systolic murmur

36. 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. Diastolic murmurs Heard in diastolic phase of cardiac cycle Three mechanisms According to timing Semilunar valve regurgitation Atrioventricular valve stenosis Increased blood flow through AV valve Early diastolic Mid diastolic Presystolic

38. Early diastolic mumur Decresendo murmur starts immediately after second heart sound Causes : Aortic regurgitation Pulmonary regurgitation

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. 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. 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. A cresendo murmur increases in intensity (MS , PDA ) A decresendo murmur decreases in intensity (AR) Venous hum has no change

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. 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. 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. 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. 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 3 rd and 4 th ICS in parasternal region Patent ductus arteriosus Continuous Grade 4 continuous murmur best heard with the diaphragm of the stethoscope in the left 2 nd ICS

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. 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. 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. 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