Cardiovascular System Examination — OmpathStudy

Continued from $1. Topic 5: Percussion and Auscultation Objectives At the end of the lesson the learner will be able to: - 1) Percuss and palpate the preacordium in examination of the heart 2) Interpret the findings on physical examination PERCUSSION Is not routinely done because of the great accuracy of radiological examination. Has some valve if patient is too ill to move by showing the increased area of dullness due to pericardial effusion. It may demonstrate the basal dullness of right sternum in cases of aortic aneurysm. Is done when there is a possibility of cardiomegally and cardiac tamponade. AUSCULTATION 1.0 Introduction Is an important examination method. Use a suitable stethoscope with:- 1) A flat diaphragm - filters out low pitched sounds and helps identifying high pitched sounds e.g. murmur of aortic regurgitation. 2) A bell - that is used for auscultation of low-pitched sounds e.g. murmur of Mitral stenosis. 3) The ear-pieces should fit comfortably. 4) Tubing of about 25 cm long and thick enough to reduce external sounds Auscultation is used to confirm the rate and rhythm of the heart compared to the pulse. Will give information on the state of the myocardium/pericardium and the functioning of the heart valves. On auscultation, examine for:- 1) Heart sounds. 2) Heart rate and rhythm 3) Murmurs 4) Other added sounds like the pericardial rub 5) The different auscultatory areas are chosen due to variability of the heart sounds at these areas. Table: The Auscultatory/Landmark Area Surface marking/Landmark Mitral/Apex Apex beat 5th ICS midclavicular line 1st heart sound loudest Mitral murmurs and aortic regurgitation murmur 3rd & 4th heart sounds Tricuspid 4th ICS left of the sternum/left sternal edge Pulmonary 2nd ICS 1 cm to the left of the sternum Aortic 2nd ICS 1 cm to the right of the sternum Auscultation Areas Auscultate over the whole praecordium listening to: the apex, upper and lower left edge, upper right sternal edge and over the carotids and into the axial 3.0 The procedure of examination At each site: o Identify the 1st and 2nd heart sounds o Assess the character and intensity of the heart sounds. o Listen to the interval between heart and sounds for added sounds and murmurs. o Roll the patient onto the left side and listen at the apex using the bell lightly applied to the skin to detect the murmur of Mitral stenosis. o Sit the patient up, leaning forward and listen with the diaphragm for the murmur of aortic regurgitation and for the pericardial friction. o Note the features of any murmur heard. o If a murmur is present, palpate again for an accompanying thrill with the patient leaning forward and rolled onto the left side. 4.0 The Heart Sounds Auscultate for the heart sounds (1st and 2nd ) and note the following: 1) The rhythm 2) Character 3) Intensity 4) Splitting of the heart sounds The Rhythm In a normal rhythm the 1st and 2nd heart sounds are quite close together with internal following 2nd heart sound being relatively longer. The sequence is lub-dup-pause, lub-dub-pause. Intensity The intensity can be normal, exaggerated or diminished Exaggeration – the heart sounds become louder in conditions that increase the activity of the heart. 1) Nervousness 2) Exercise 3) Hyperthyroidism 4) Most obvious in the 1st heart sound Diminution is more due to extracardiac than to cardiac causes like:- emphysema and fluid/air in pleural/pericardial cavities Splitting of sounds In a normal heart the 1st and 2nd sounds are quite close but, the interval following the 2nd sounds is relatively long. THE FIRST HEART SOUND (1ST HS) Is due to the closure of mitral and tricuspid valves (mainly from the mitral element that is louder hence most easily heard) Best heard at the apex region Splitting ‘I-Lub’ -’Dup’ is due to asynchronous closure of Mitral and tricuspid valves (not pathological). Abnormalities of intensity of the 1st heart sounds include:- quiet heart sounds, loud heart sounds or variable heart sounds Quiet 1st HS 1) Low cardiac output e.g. pericardial effusion, air in pericardial cavity and mitral regurgitation 2) Poor left ventricular function 3) Low filling pressure 4) Emphysema 5) Pleural effusion 6) Air in the pleural cavity Loud 1st HS 1) Increased cardiac output 2) Large stroke volume 3) Mitral stenosis 4) Atrial fibrillation Variable 1st HS 1) Atrial fibrillation 2) Extra systoles 3) Complete heart block THE SECOND HEART SOUNDS (2ND HS) Due to the closure of pulmonary and aortic valves. Best heard using the diaphragm of the stethoscope at the upper sternum at the level of 2nd intercostal space. The aortic component is the loudest and is best heard at the aortic area and transmitted to the apex. The pulmonary component is best heard at the pulmonary area. Both may be heard (normal splitting) with the aortic component proceeding the pulmonary - ‘lub-d-dub’. Intensity of the components varies with age in that the aortic component dominates in the older age group as does the pulmonary in th