heart examination

Aortic, Pulmonary, Erb’s, Tricuspid, Mitral

what is the order of listening to heart areas?

aortic area (1)

in what area would you hear ejection clicks, carotid/subclavian artery abnormalities, and aortic stenosis?

pulmonary area (2)

in what area would you hear patent ductus arteriosus, pulmonary stenosis/regurgitation, and pulmonary ejection sounds

right atrial area (3-5 ICS just below aortic area)

in what area would you hear tricuspid regurgitation?

left ventricular area (ICS 2-5 in line with right aortic area)

in what area would you hear mitral or aortic stenosis/regurgitation, and L vent S3, S4?

Right ventricular area (2-5 ICS over sternum)

in what area would you hear tricuspid stenosis or regurgitation, ventricular septal defect

Left atrial area (2-4 ICS)

in what area would mitral valve regurgitation be heard?

a sound from turbulent bloodflow

what is a murmur?

Grade 1/6: barely audible (quiet room, sharp ears)

Grade 3/6: easily heard
Grade 4/6: easily heard with palpable thrill (vibration)

Grade 6/6: audible without stethoscope directly on chest wall

describe the Intensity grading of systolic murmurs

Grade 1/4: barely audible (quiet room, sharp ears)
Grade 2/4: faint, but immediately audible
Grade 3/4: easily heard
Grade 4/4: very loud

describe the Intensity grading of diastolic murmurs

large pressure gradients

what does a murmur pitch of 700 Hz indicate?

greater flow rates

what does a murmur pitch of 1 Hz indicate?

how the intensity changes (crescendo, decrescendo)

what does shape describe?

area of transmission due to direction of turbulent flow

what is radiation of a heart sound?

alter loading on heart to change intensity of murmur

what is the purpose of manuevers

• Increases venous return to heart – accentuates aortic/pulmonary stenosis
• Elevates Total Peripheral Resistance – increases murmur of mitral/tricuspid regurgitation

what should squatting result in?

specifically accentuates murmur of Mitral Valve Prolapse

what would the maneuver of standing help for?

• Increases heart rate and TPR (how much resistance blood faces as it moves through body)
• Accentuates back flow murmurs (aortic/mitral regurgitation, septal defect)
• Diminishes forward flow murmurs (aortic stenosis)

what is the result of the isometric hand grip maneuver?

• P2 component of S2 delayed from increased flow
• Murmurs increased intensity are right-sided

what is the result of the deep breathing maneuver?

• Reduces venous return
• Diminishes most systolic murmurs
• After release, right sided murmurs return faster than left

what is the result of the Valsalva maneuver? (forced exhalation against closed glottis)

aortic stenosis

after S1, high-frequency, heard best in aortic area, but also widely; radiates toward neck

pulmonic stenosis

also after S1, may have click and proceed beyond S2; does not radiate as widely, but may transmit to neck or left shoulder

regurgitation of blood across incompetent mitral/tricuspid valve or VSD (ventricular septal defect; a hole between R and L vents)

what is pansystolic?

Mitral Valve Prolapse bowing of abnormal leaflets into L atrium

what is heard by a late systolic murmur?

regurgitant flow through aortic or pulmonic valve

• - decrescendo only

what is the early diastolic murmur?

turbulent flow across stenotic mitral/tricuspid valve, or increased flow over normal valve (L/c)

• - decrescendo then crescendo

what is the mid-late diastolic murmur?

Patent ductus arteriosus

communication btw aorta and pulmonary trunk. Blood flows
from aorta to pulmonary (w/ persistent pressure gradient during systole & diastole)

To and Fro murmur

what murmur does this describe: both aortic stenosis and regurgitation. Discrete systolic & diastolic components

Apical impulse assessment (feeling left ventricle contraction to aorta)

most lateral point of systolic outward motion felt on chest wall

Subxiphoid palpation

what does this describe:

• Hand over epigastrium with
fingertips pointing toward head
• Patient should hold deep
inspiration
• Abdominal aortic pulsations strike
palm of hand
• Very specific for right ventricular
impulse
• Impulse indicates right ventricular
pressure/volume overload

thrills

Murmurs exceeding grade IV out of VI transmit vibrations to chest wall

Distal metacarpals useful to detect thrills, fingertips for localization

how are thrills felt?