2 Session 2_HeartExam2

8/10/2019 2 Session 2_HeartExam2

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Session 2: Heart Exam

In addition to above noted materials on page 1: also study physiologic concepts

related to interpretation of the heart exam, including the Khan Academy video links

listed under Cardiac hysiology! and the "eart #ounds Collection! links listed on

the Assignments page posted on e$ake%

&"I'(# )*+ '- &* .I#&'to are belo/% specially focus on the heart sounds%

0eet the heart! source: KhanAcademy.org, by Rishi Desai) 10mins

.ub -ub! source: KhanAcademy.org, by Rishi Desai 9mins

"eart #ounds Collection: "eart #ounds Collection source: YouTube.com, byDr. Prodigious2:3 'ormal 4irst and #econd "eart #ounds!

3 roduction and Components of the 4irst #ound!3 #econd "eart #ound!3 4ourth "eart #ound, #5!3 &hird "eart #ound, #6!3 0urmurs!3 #ystolic 0urmurs!3 -iastolic 0urmurs!3 ericardial 4riction 7ub!

holosystolicmurmur3307%mp6

#6%mp6

#5%mp6

Cardiac xam:

Information type Examples$hat constitutes a normal physicalexam fnding

$here anatomically2structures are normally

locaed, including hel!"ule#ernal landmar$s

$hat a normal structure

looks like visualappearance2, feels likepalpation2, or sounds likeauscultation, percussion2

In healthy patients, the point of maximal impulse0I2 should be located in the left mid3clavicularline 8thintercostal space and smaller than a 9uarter%

In most adults, the right atrium sits 8 cm to ; cmbelo/ the sternal angle%

+nder infant video: $hen observing for cyanosis atrue pink tongue like a stra/berry is normal!
https://www.khanacademy.org/science/healthcare-and-medicine/the-heart/heart-introduction/v/meet-the-hearthttps://www.khanacademy.org/science/healthcare-and-medicine/the-heart/heart-introduction/v/lub-dubhttp://www.youtube.com/watch?v=hFFepTYcYdQ&list=PLz27Rlp3y6Xt5VhIYamPYDooNDXG1Boxbhttp://www.youtube.com/watch?v=WvrIcA7JHfs&list=PLz27Rlp3y6Xt5VhIYamPYDooNDXG1Boxbhttp://www.youtube.com/watch?v=ks21Lsym1r8&list=PLz27Rlp3y6Xt5VhIYamPYDooNDXG1Boxbhttp://www.youtube.com/watch?v=n_mIZeLjnrQ&list=PLz27Rlp3y6Xt5VhIYamPYDooNDXG1Boxbhttp://www.youtube.com/watch?v=hMrfSm8VD-4&list=PLz27Rlp3y6Xt5VhIYamPYDooNDXG1Boxbhttp://www.youtube.com/watch?v=tGcAidBJCdM&list=PLz27Rlp3y6Xt5VhIYamPYDooNDXG1Boxbhttp://www.youtube.com/watch?v=NfI43oUl7l0&list=PLz27Rlp3y6Xt5VhIYamPYDooNDXG1Boxbhttp://www.youtube.com/watch?v=MBbJU5IVd1A&list=PLz27Rlp3y6Xt5VhIYamPYDooNDXG1Boxbhttp://www.youtube.com/watch?v=fI4XXFRotNE&list=PLz27Rlp3y6Xt5VhIYamPYDooNDXG1Boxbhttp://ewake.wakehealth.edu/MD/files/Class2017/holosystolicmurmur--MR.mp3http://ewake.wakehealth.edu/MD/files/Class2017/S3.mp3http://ewake.wakehealth.edu/MD/files/Class2017/S4.mp3https://www.khanacademy.org/science/healthcare-and-medicine/the-heart/heart-introduction/v/meet-the-hearthttps://www.khanacademy.org/science/healthcare-and-medicine/the-heart/heart-introduction/v/lub-dubhttp://www.youtube.com/watch?v=hFFepTYcYdQ&list=PLz27Rlp3y6Xt5VhIYamPYDooNDXG1Boxbhttp://www.youtube.com/watch?v=WvrIcA7JHfs&list=PLz27Rlp3y6Xt5VhIYamPYDooNDXG1Boxbhttp://www.youtube.com/watch?v=ks21Lsym1r8&list=PLz27Rlp3y6Xt5VhIYamPYDooNDXG1Boxbhttp://www.youtube.com/watch?v=n_mIZeLjnrQ&list=PLz27Rlp3y6Xt5VhIYamPYDooNDXG1Boxbhttp://www.youtube.com/watch?v=hMrfSm8VD-4&list=PLz27Rlp3y6Xt5VhIYamPYDooNDXG1Boxbhttp://www.youtube.com/watch?v=tGcAidBJCdM&list=PLz27Rlp3y6Xt5VhIYamPYDooNDXG1Boxbhttp://www.youtube.com/watch?v=NfI43oUl7l0&list=PLz27Rlp3y6Xt5VhIYamPYDooNDXG1Boxbhttp://www.youtube.com/watch?v=MBbJU5IVd1A&list=PLz27Rlp3y6Xt5VhIYamPYDooNDXG1Boxbhttp://www.youtube.com/watch?v=fI4XXFRotNE&list=PLz27Rlp3y6Xt5VhIYamPYDooNDXG1Boxbhttp://ewake.wakehealth.edu/MD/files/Class2017/holosystolicmurmur--MR.mp3http://ewake.wakehealth.edu/MD/files/Class2017/S3.mp3http://ewake.wakehealth.edu/MD/files/Class2017/S4.mp3


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$hat constitutes an abnormalphysical exam fnding

%i&e limisbeyond /hich a

structure is enlarged

Abnormal locaionsofstructures

Abnormal appearances,

textures, or soundsassociated /ith examinationof a structure

+nder infant video: $hen observing for cyanosis adeeper red tongue like a raspberry is cyanotic!

levated ?ugular venous distension is de@nedas ndinterspace at right sternal borderulmonic area 3 ndinterspace at left sternal border


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&ricuspid area > 5thand 8thintercostals space at leftsternal border0itralApexF0I2 area > 8th intercostal spcemidclavicular line

Assess the !eart ratenormal, slo/,

or fast for age2 and r!yt!mregularvs% irregular2%

Assess cardiac sounds "S#$ S2%through auscultation near each ofthe 5 valves, noting any extra orabnormal sounds murmurs$ ru&s$S' or S( gallops2%

Assess murmursfor the follo/ingcharacteristics:o Intensity "grade I IV%o )iming systolic *s+ diastolic$

and earlyFmidFlate timing /ithinthat phase2

o S!ape intensity over time, e%g%,

crescendo, decrescendo, etc%2o ,ocation of maximal intensity

o -adiation

hysical characteristics of the

structure or appearance of body partsbased on normal, expecteddevelopmental progression over timei%e%, age3related changesFfeatures2

nFa

-iEerences in the normal physicalexam @ndings in children compared toadults if mentioned in the assignedstudy materials2

Denign murmurs are common inchildren%

o #tills murmur: systolic,

vibratoryo =enous hum school age2:

continuous

0I often not palpable in young

infants%

In young children the 0I is often one

interspace higher than in adults so,interspace 5%

#6 and #5 can be heard in normal,

healthy children usu% pathologic in


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adults2

Children often have sinus arrhythmiacorrelating /ith breathing cycle:o Increased heart rate /ith

inspiration

o -ecreased heart rate /ithexpiration

I./0 from Po1er Point and lecture notes pro*ided:

.ub dub! of normal #1, #:

o S# "lu&3%: tricuspid G mitral valves shut at beginning of systole

o S2 "du&3%: aortic G pulmonic valves shut at beginning of diastole

P!ysiologic split S2: delayed pulmonic valve closure during

inspiration /ixed split S2:

pathologic

0urmurs

/eatures of 4enign "innocent3% *s+ Pat!ologic murmurs

/eature:

,i5ely &enign murmur$ ifall of t!e follo1ing are

true:,i5ely pat!ologic murmur$ if any of

t!e follo1ing are present:"istoryFsymptoms

atient is completelyasymptomatic

atient is symptomatic, e%g%, diHcultybreathing, orthopnea, dyspnea /ithexertion, diy, etc%

0urmurfeatures

#ystolic murmur#oft J grade II2

-iastolic murmur=ery loud murmur, incl% associated /ith a

thrill grade I=2xtra heartsounds

'o other extra heart soundsincl% #6, #5, clicks, orrubs2

#6, #5, clicks, or rubs present# has a @xed split i%e%, every beat2

features 'ormal other than thepresence of a murmur

Abnormally strong or /eak pulses"yperactive precordiumF0Inlarged liver andFor spleen
http://www.blaufuss.org/tutorial/index1.htmlhttp://www.blaufuss.org/tutorial/index1.html


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dema

.abFradiology features

'ormal chest x3ray'ormal electrocardiogram

C(2

Abnormal cardiac silhouette on CL7Abnormalities on C( suggesting

chamber enlargement

6rade PE /indings

I very faint, heard only after listener has tuned in!

II9uiet, but heard immediately after placing the stethoscope on

the chest

III moderately loud

I= loud, /ith thrill

=very loud, /ith thrillM may be heard /hen stethoscope is

partly oE the chest

=Ivery loud, /ith thrillM may be heard /hen stethoscope entirely

oE the chest

Pericardial /riction -u&s: high fre9uencyM leathery,! s9ueaky,!heard best /ith diaphragm, at ..#D, /ith pt leaning for/ard or supineMhas both systolic and diastolic components


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7ecall Aar&ment 0! 3 A& 0


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xact angle of the patient isnNt crucially important, since the


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4)ES

=ascular structures of neck:

Carotid artery lays deep to #C0

Internal ?ugular vein lies beneath #C0 ad?acent to carotid artery, itNs not normally

visible

xternal ?ugular vein runs at an angle along #C0 to/ard clavicle and can be

observed easily

Child

.ung diseases causes increased /ork of breathing%

Cardiac diseases often cause peaceful tachypnea%

#1F# are normally crisp in children

.isten for intensity of A and to detect splitting of #, aortic is normally

louder than pulmonic

#6 Dest heard at lo/er left border rapid ventricular @lling% .o/ pitched early

diastolic sound%

#5 not often heard in children, lo/ fre9 late diastolic before @rst heart sound%


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0ost common benign murmur in preschool and school aged children is called

Stills Murmur> (rade I 3 II F =I musical vibratory early and mid3systolic murmur

/ith multiple overtones located over mid or lo/er left sternal border but also

fre9uently heard over carotid arteries%

Compression of carotid arteries often causes precordial murmur to disappear%

Venous !um: Also found in preschool and school aged children% ItNs a soft

hollo/ continous sound, louder in diastole heard belo/ right clavicle% It can be

completely eliminated by maneuvers that aEect venous return such as lying supine,

changing head position or performing ?ugular venous compression% It has same

9uality as breath sounds and is thus fre9uently overlooked%

Infant

alpate peripheral pulses

4eel for femoral pulse >this lays in midline belo/ inguinal crease bet/een iliaccrest and symphysis pubis% &his helps to rule out coarctation of aorta%

alpate dorsalis pedis and posterior tibial pulses, brachial pulse antecubital

fossa2 and radial as /ell%

lace hand on chest to feel for thrills, rare for infants%

Infants commonly have premature atrial or ventricular beats that sound like

skipped beats% &hese usually go a/ay /hen infant cries and heart rate

increases%

-etecting the split beat of #, detecting this eliminates many serious

congenital heart defects%

#6 are commonly heard in infants% #5 are rare in ne/borns%

7ecall infants breathe rapidly% .isten for heart murmurs in axilla and also the

back to help identify pulmonic murmus%

2 Session 2_HeartExam2

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