Physical Exam Of The Cardio- Vascular System James G. Laws D.O. MACOI An Important Part Of The Physical Exam Of The Cardio-Vascular System That Is Commonly Overlooked Is? 1. Palpation Of The PMI Which Can Bring Out Findings Causing You 20% To Suspect Mitral Stenosis. 2. Auscultation Of Left Sternal Border Which Can Help In The 20% Diagnosis Of Tricuspid Regurgitation. 3. Auscultation Of The Neck Which Can Suggest Either Aortic 20% Stenosis Or Carotid Stenosis. 4. Comparison Of Both Radial Pulses Which Can Suggest 20% Ascending Aortic Aneurysm. 5. Checking For The Hepato-jugular Reflux Which Can Bring 20% Out Signs Of Mitral Regurgitation. 10 Countdown Always Begin Exam On Right Side Of The Patient Always Expose The Chest For The Best This Allows You To Results Reach Across The Patient To The PMI This Allows The Stethoscope Tubing To Be Straight And Does Not Loop Down Making Contact With Best Exam Done Patient Or Bed With The Patient Covering At 40-60 Degree Head Up Position Remember The Shorter The Tubing The Less Distance The Sound Has To Travel Always Begin Exam With Palpation Then Go To Auscultation First Check Second Palpate The PMI Both The Carotids And The Femorals Third Palpate The Aorta Fourth Compare Both Radials Note How Close Carotids Are to Apex Beat = Both The Skin of Neck PMI And The Aorta Note Relationship Between Nipple Line And PMI If The LV Is GUESS WHERE Enlarged What Happens You Should Place To The PMI??? Duhhh Your Hand To Begin Palpation Of The Chest? Down And To The Left CORRECT !!!! And If The Heart Is Also Dilated It Will Be Moved Down As Well Guess What This Will You Guessed Right If You Do To The Said It Moved It To The PMI LEFT Where Will The PMI Be On A Patient With This Thick Dilated Heart!!! Yep Down And To The Left Why Does This Happen??? Leak 3 Liters/Min. 5 Liters/Min. Same Thing Can Happen To Ao. ValveThe LV Will Now Have To The LV Will Pump 8 liters/Min. Pump The Normal How Does The Cardiac Output LV Respond To Plus The Leak This Volume The LV Will OnceOverload Again Dilate And Again A Volume What Will Happen A Large Heart Overload To The PMI A Vol. Over Load LV AI Or MR LV With A Pressure Normal Size LV Overload Such As BP120/80 HBP Or AS 210/? What Will This Do To The PMI? Severe Pulmonic Stenosis Note The STERNUM Marked Correct !!!! Thickening Of If You Said It Will Right Ventricular Move Myocardium MEDIALLY And RV Enlargement Is Up And Medial Near The Sternum Sooooo Acute MI Would Be In LV Enlargement Is Normal Position. Down And Left (Not Enough Time For Change To Take Place) Palpation Of Carotid Pulse Is Often Overlooked During Physical Exam Aortic Stenosis Slow Upstroke Bounding Pulse Prolonged Waterhammer Pulse Pulse Wide Pulse Pressure Corrigan’s Pulse Caused By The Large Volume Of Blood Being Ejected Through The AV i.e. The Normal Forward Flow Plus The Regurgitant Volume Eliciting The Hepatojugular Reflux (A Sign Of Right Heart Failure Usually Following Left Heart Failure) Patient Must Be Relaxed Breathing Normally If Face Turns Red Trunk Elevated 30 Patient Is Holding Degrees Their Breath Or Doing A Valsalva Firm Sustained Pressure Either Of Which Results In Error On Abdomen While Observing Jugular Pulse This Causes Venous With Right Heart Failure Pressure To Or Constrictive Rise And Gives A False Pericarditis The Jugular Positive Pulse Level Rises Start Your Exam From The Patient’s Right So Your Stethoscope Tubing Auscultation Of The Neck Will Be In A Straight Line In My Experience Is To The Area You Are Commonly Overlooked Use ReverseListening Z To i.e.. Less Noise To AuscultateBanging All On The Patient Valve AreasAnd Less Resistance To Air Flow Right Aortic Left Pulmonic Tricuspid ‘Neath The Sternum The Mitral Gets The Apex Beat Here’s HowAnd I Was Taught AuscultationThat’s The When Way IWe Was Learn A Student ‘Em After Palpation Comes Auscultation Right Carotid Arises From The Must Re- Brachio- Emphasize Cephalic Relationship Trunk Between Carotids And Aorta QUESTION? Left Carotid Arises Which Carotid Might Directly From The Transmit An Aorta Aortic Murmur The LOUDEST? AV Duhhhhhh One Of The Most Commonly Missed Note They Have Parts Of The Physical Auscultated From Base Exam Is Auscultation To Angle Of Jaw Of The Neck Carotid Bruits Are High Pitched And I Feel Best Heard With The Diaphragm But As Long As You Auscultate The Carotids I Don’t Care What Side Of The Stethoscope You Use So ThisAortic One Stenosis Part Of IsThe Transmitted To The Physical Exam Allows EvaluationCarotids As Both Well For Usually AS AndHarsh Carotid And StenosisRumbling Anterior Surface Pulmonic Valve Aortic Valve With This Anatomy In Mind Why Is It Logical To Listen To The Areas Just Described nd Right 2nd Intercostal Left 2 Intercostal Space Equals Aortic Space Equals Pulmonic Listening Post Listening Post AI Heard Along Left Sternal Border Remember The Aorta And The Pulmonary Artery Cross Each Other Most Common Differentiation Between Murmurs Physicians Will Need To Make Is Between AS And MR Commonly These Patients Will Have PVC’s And These Can Be Used To Differentiate Between These Two Murmurs Beat After PVC Beat Before PVC Sinus Beat Sinus Beat PVC Sinus Beat Beat After Beat PVC Before PVC PULSUS ALTERNANS (A Sign Of Heart Failure) When Taking B.P. Very Common In Cath Lab To Have Lower The CuffYou Pressure Can Take To High Low Alternation Of LV Systolic Level WhereAdvantage Korotkoff OfSounds This Pressure In A Heart Failure Case FirstIn AHeard Office Setting Less Forceful Alternate Beat Does Not Pass This Systolic Pressure Take Pulse At Wrist HR Will Be Half That Detected By Aulscultation Of Heart How To Auscultate For Gallop Sounds Raising The Legs Will Increase Return To Heart And Can Bring Out Both Gallops Or Murmurs You Do Need To Listen To The Heart However You Can Also Exercise The Patient By Having Them Hop Up And On One Leg Or Do Sit ups Aortic Insufficiency Is Difficult To Hear Best Heard With Patient Sitting Up Leaning Forward In Full Exhalation All This Brings Heart Closer To Chest Wall Use The Diaphragm In The 3rd Or 4th Left Intercostal Space Another Position That Brings Heart Closer To Chest Wall Also Have Patient Exhale Then Examine During Exhalation Remember For AI Listen In 3rd Or 4th Intercostal Space Just Left Of Sternum Use The Diaphragm The Murmur Of Mitral Stenosis Is Also Very Difficult To Hear Listen For This Murmur With The Bell Have Patient In Left Lateral Decubitus Position. Place Yourself On Their Right Side As Shown Start Auscultation Halfway Between The PMI And The Xiphoid Process Exercise Such As Sit-ups In Bed Can Bring Out This Murmur IHSS Or Obstructive Cardiomyopathy Note The Obstruction Soooo What Happens Outflow Tract Is Much To The Murmur Obstruction Worse During Valsalva? Thickness Of Septum Is Fixed During Valsalva The LV Gets Smaller i.e. Less Volume A Very Soft Systolic Murmur Could Be Heard At 4LSB No Pressure Gradient Aortic Pressure LV Pressure Same Patient Pressures Measured During Valsalva Sooooo What Would Have Happened To The Loudness Of The Murmur??? Gradient During Valsalva Aortic Pressure LV Pressure An Important Part Of The Physical Exam Of The Cardio-Vascular System That Is Commonly Overlooked Is? 20% 1. Palpation Of The PMI Which Can Bring Out Findings Causing You To Suspect Mitral Stenosis. 20% 2. Auscultation Of Left Sternal Border Which Can Help In The Diagnosis Of Tricuspid Regurgitation. 3. Auscultation Of The Neck Which Can Suggest Either Aortic 20% Stenosis Or Carotid Stenosis. 4. Comparison Of Both Radial Pulses Which Can Suggest 20% Ascending Aortic Aneurysm. 5. Checking For The Hepato-jugular Reflux Which Can Bring 20% Out Signs Of Mitral Regurgitation. 10 Countdown An Important Part Of The Physical ExamOf The Cardio- Vascular System That IsCommonly Overlooked Is? Palpation Of The PMI Which Can Bring Out Findings 20% Causing You To Suspect Mitral Stenosis. 20% Auscultation Of Left Sternal Border Which Can Help In The 20% Diagnosis Of Tricuspid Regurgitation. 20% Auscultation Of The Neck Which Can Suggest Either Aortic 20% Stenosis Or Carotid Stenosis. 20% Comparison Of Both Radial Pulses Which Can Suggest 20% Ascending Aortic Aneurysm. 20% Checking For The Hepato-jugular Reflux Which Can Bring 20% Out Signs Of Mitral Regurgitation. 20% First Slide Second Slide The End Any Questions? Valsalva Results In Post PVC Smaller LV Beat Cavity Greater But Contractility Septal Causes Thickness Increased Remains The Gradient Same Therefore More Obstructive And Murmur Increases Important Bedside Tool To Differentiate AORTIC STENOSIS From MITRAL REGURGITATION Remember !!! Aortic Insufficiency Causes Bounding Carotids And Wide Pulse Pressure One Of The Most Frequently Overlooked Portions Of The Physical Exam Of The HEART Is Palpation And Auscultation Of The Carotids Remember Larger The LV Less Obstructive The Septum Smaller The LV More Obstructive Note Thickening And Redundantancy Of The Mitral Valve Including Had Holter While Driving A Motorcycle Down Leaflets Cordae And A Ohio Highway At Over 100 Miles Per Hour Papillary Muscle Showed Him To Be Going In And Out Of VT Increased Blood Volume Causes The Mitral Leaflets And Cordal Structures To Reach The Point Where They Suddenly Stop Later In Systole Therefore The Mid Systolic Click Occurs Later During Systole Decreased Blood Volume Allows The Mitral Valve Apparatus To Reach The Point Where It Suddenly Stops At An Earlier Time During Systole Therefore The Mid Systolic Click Occurs Earlier In Systole Control Click Is Mid Systolic Standing Reduces Volume Return To Heart Mitral Structures Reach Their End Sooner Click Earlier Squat Increases Volume Return Mitral Structures Reach Their End Later Click Later Hypokinetic Pulse ( Small, Weak) 1.Related To Decreased Rate Of Rise Of L.V.