CVS Examination-Cardiac Examination-With Symptoms Analysis

Local Cardiac examination:

Inspection and Palpation.
Percussion .
Auscultation .

Inspection and Palpation

A- Shape of the precordium:
-Precordial bulge®denotes cardiac enlargement since childhood.
-Skeletal deformities :
Such As kyphosis ,scoliosis or pectus excavatum.
These may cause alteration of the position of the heart and great vessel which may predispose to heart failure.

Apex Beat:

Examine for :
1-Visible or not. (causes of invisible apex ? )
2-Site: (Apex beat is the outermost and lowermost palpable impulse on the chest wall. )
* Normally in the left 5th intercostal space ,just inside the Mid clavicular line (MCL) (9 cm from mid line ).

*Abnormalities in site :

-Outward displacement----®Right ventricular enlargement ,chest disease.
-Outward and downward ®Left ventricular enlargement,ventricular Aneurysm
-Displacement to Rt.-------®congenital Dextrocardia, chest disease

3-Extent :

Localized apex :Normal apical impulse do not exceed an an inch in diameter ( Lt. V. apex )

4- Character:

*Heaving sustained : ®Pressure overload ®causes: Aortic stenosis and hypertension.
*Hyperdynamic apex: causes (Volume overload ®aortic regurgitation, Mitral regurgitation, Tricuspid Regurgitation)
*Slapping apex ®Palpable S1 ®Mitral stenosis

5. Thrill

Murmurs may be so loud as to be palpable as thrill.
It is a palpable vibration of he chest wall similar to feeling back of a purring cat.
-It should be timed with apex beat, either systolic or diastolic.
-Diastolic thrill ®M.S.
-Systolic thrill ® M. R.
-It is most easily felt when the patient turns on to the left side.

Percussion

Surface anatomy of heart

Surface markings of heart borders;
A = 1.5 inch from midline on the
lower border of 2nd left costal cartilage.

B =1 inch from midline on the upper
border of the 3rd Rt. Costal cartilage.

C =3.5 inch from midline in the
left 5th intercostal space.

D =0.5 inch from midline on the
Right 6th costal cartilage .

How to percuss the heart ?

-Percussion of the right border of the heart .
-Percussion of the base of the heart .
-Percussion for dullness outside the apex .
-Percussion of the bare area of the heart

Percussion Of Heart:

1-Rt. Border:

First percuss the upper border of the liver in Right midclavicular line.
,then percuss one space above the upper border of the liver, from Right to Left.,parallel to sternum.
-Normally there is no dullness to the Right side of the sternum.

-Causes of dullness to the Rt. Of the sternum :
* Rt. Atrial enlargement.
* Pericardial effusion.
*Aneurysm of the ascending aorta

2. Percussion of Base Of The Heart (Upper border)

Percuss the 2nd Right And Left Intercostal spaces from MCL (mid clavicular line) to the sternum .
Normally both are resonant .

Causes of dullness in the Left 2nd space :
-Dilated pulmonary artery as in, pulm. HTN ,VSD ASD.
-Pericardial effusion.
-space occupying lesions in superior mediastinum.

Causes of dullness in the 2nd Right Intercostal Space:
-Dilatation of ascending aorta ,huge aneurysm in aortic arch.
-pericardial. Effusion and space occupying lesion in superior mediastinum.

3. Percussion of Left border:

Normally there is no dullness outside the apex .
Dullness outside apex = pericardial effusion .

Auscultation Of Heart:

Ascultatory Areas :
Mitral area
Pulmonary area.
First Aortic area .
Second Aortic area.
Tricuspid area

Comment on :

a- Heart sounds.
b-Additional sounds .
c- Murmurs .
d- Pericardial rub .(Pericarditis)

a) Heart Sounds:

First heart sound ( S1 ) is produced as a result of closure of A- V valve .
-Best heard at Mitral area,at the beginning of systole
-Accentuated S1 is heard in case of mitral stenosis.
.
-Weak S1 is heard incase of
1. mitral regurgitation.
2. calcified mitral valve.
3. Severe heart failure

-Variable S1 Is heard in case of atrial fibrillation.

Second heart sound (S2 ):
Produced by Closure of aortic &pulmonary valves
Best heard at base of the heart, at beginning of diastole .

Abnormalities :
On pulmonary area :
-Accentuated in pulmonary hypertension
On Aortic area :
-Accentuated A2 in found in Hypertension and Hyper dynamic states
-Weak A2 is found in aortic stenosis

B-Additional heart sounds

1-Gallop rhythm

It is hearing of 3 sounds (1st , 2nd ,and extra sound ) in the presence of tachycardia(like galloping horse)

2. Murmurs:

Murmurs are produced by excessive turbulence of blood flow within the circulation.

A- Systolic murmurs

1-Ejection systolic murmur
-It begins shortly after S1 and ends before S2 .
--Result from turbulent blood flow through sensed semilunar valves or ­blood flow through normal valve.
-Examples : Aortic stenosis ( Aortic area )
-Pulmonary stenosis, ASD .(pulmonary area )


2-Pansystolic murmur
Begin with S1
Extend throughout systol &
may spill over into early diastole
Examples: MR ,VSD .

B: Diastolic Murmur:

1-Early diastolic murmur
-It starts immediately after S2
-Soft blowing .
-loudest at its onset and dies away before end of diastole(Decrescendo)
-Best heard when patient lean forward and expiration.
-Result from leaking semilunar valves.
Causes : Aortic regurgitation and heard best at Second aortic area.


Pericardial Rub:
Scratching sound like friction between rough surfaces and has a superficial to and fro quality.
Best heard to the left of the lower sternum
It is accentuated when patient leans forward and by pressure with stethoscope.

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