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“At Natural Medicine Seminars, we would like to continually encourage and challenge our students in becoming the best diagnosticians through advanced training.

Please enjoy this complimentary webinar.” Dr. Patrick Garrett

This is part one of a two part series. Part one – HeartPart two – Lungs

Advanced DiagnosticsAdvanced Diagnostics

IntroductionThe Cardiac Exam

–Normal Heart Sounds–Abnormal Heart Sounds

IntroductionThe Pulmonary Exam

–Normal Lung Sounds–Abnormal Lung Sounds

IntroductionIntroduction

Why bother listening to the heart?

Auscultation of the heart is an essential part of even a cursory cardiac exam. By listening to the heart you can gather information about the:

1) Rate of the heart2) Rhythm of the heart 3) Valvular function (e.g. stenosis, regurgitation,

insufficiency)

4) Anatomical defects (e.g. atrial septal defects -ASD, ventricular septal defect -VSD, ventricular hypertrophy)

The Cardiac ExamThe Cardiac Exam

Why bother listening to the heart?

Auscultation of the heart is an essential part of even a cursory cardiac exam. By listening to the heart you can gather information about the:

1) Rate of the heart2) Rhythm of the heart 3) Valvular function (e.g. stenosis, regurgitation,

insufficiency)

4) Anatomical defects (e.g. atrial septal defects -ASD, ventricular septal defect -VSD, ventricular hypertrophy)


Where to Listen and Why

#1 Start with the Tricuspid region located between the 3rd, 4th, 5th, and 6th intercostal spaces at the left sternal border (LLSB)



#2 Move to the Pulmonary region located between the 2nd and 3rd intercostal spaces at the left sternal border (LUSB)



#3 Then to the Mitral region is located near the apex of the heard between the 5th and 6th intercostal spaces in the midclavicular line



#4 End with the Aortic region located between the 2nd and 3rd intercostal spaces at the right sternal border (RUSB)

The Cardiac ExamThe Cardiac ExamFlow

Tricuspid, Pulmonary, Mitral (Bicuspid), Aortic

The Cardiac ExamThe Cardiac ExamHint:

Here is a mnemonic to help remember the different valve locations.

“A PeT Monkey”

Starting from the RUSB = A (Aortic Valve) LUSB = Pet (Pulmonic Valve)LLSB = PeT (Tricuspid Valve)Apex = Monkey (Mitral Valve) Don’t forget both of the carotids!

The Cardiac ExamThe Cardiac ExamHint:

Here is a mnemonic to help remember each of the atrial-ventricular valve locations.

“LAB RAT” Left AV valve = (Bicuspid)Right AV valve = (Tricuspid)


Additional Parts to the a complete cardiac examination

After the initial examination in the supine positions, several additional maneuvers should be accomplished in the thorough cardiac exam.


Additional Parts to the a complete cardiac

examination

First: Instruct the patient to turn onto their left side (left decubitus position) and listen with the bell of the stethoscope at the apex for mitral stenosis (This will be a low pitched diastolic murmur).


Additional Parts to the a complete cardiac

examination

Second: Instruct the patient to sit upright and re-examine the 4 valvular regions, again with the diaphragm of the stethoscope.


Maneuver

Rt Sided Lt Sided

TR / PS AS MRHypertrophic Cardiomyopathy

Change with Respiration

Inspiration Increased Decrease or no change

To decrease flow

Valsalva Maneuver Decrease Decrease Increase

Squat to Stand Decrease Variable Increase

To increase flow

Leg Elevation No Decrease No Decrease Decrease

Hand Grip Increase Increase Decrease

Stand to Squat Increase Variable Decrease

If a murmur is heard, further exam may be useful


Additional Parts to the a complete cardiac examination

Last: Instruct the patient to lean forward, exhale, and hold their breath. This Valsalva Manuever will increase the blood pressure and will help identify any underlying murmur.

Listen with the diaphragm between the second and third intercostal spaces at the right sternal (aortic) and left sternal (pulmonic) areas for aortic regurgitation.

The normal heart sounds are often described as sounding like “lub dub”.

Lub - The first heart sound is caused by vibrations arising from closure of both of the atrial-ventricular valves (mitral [bicuspid] and tricuspid). It coincides with the beginning of ventricular systole and so each first sound comes at the beginning of the pulse wave.

Dub - The second heart sound is softer, shorter and of higher frequency and is caused by closure of the semi-lunar valves (aortic and pulmonary). It coincides with the end of ventricular systole and so occurs at the end of each pulse wave.

Clinical Pearl: Because of their relationship to the pulse wave it is useful to listen to the heart sounds while feeling the pulse.

Normal Heart SoundsNormal Heart Sounds

Abnormal SoundsAbnormal Sounds

The presence of a murmur indicates either increased or turbulent blood flow.

Turbulent flow may arise because of abnormal flow across a valve or as a result of an abnormal communication between the chambers of the heart / great vessels.


When are murmurs considered “normal”?

Increased flow across a normal valve may occur in high output states, such as pregnancy, severe anemia, or associated with a significant pyrexia.

In the event that you hear a murmur, your description and documentation should include these 4 properties of an “abnormal” heart sound:

1) LOCATION 2) TIMING 3) GRADE 4) QUALITY


LOCATION - Knowing the location of the murmur will help determine the most likely etiology, diagnostic testing, and follow up. Note any radiation of the sound. (i.e. Aortic will radiate into the carotids)

*Location of maximal intensity (i.e. …between the 2nd and 3rd intercostal spaces at the right sternal border [2-3 ICS / URSB] with radiation into right carotid)


Radiation


Location of Maximal Intensity

Radiation Typical for

2nd right intercostal space Right carotid artery Aortic stenosis

5th or 6th left intercostal space

Left anterior axillary line, left axilla

Mitral regurgitation (including mitral regurgitation due to mitral valve prolapse)

Left axilla Lower left sternal border

LRSB, Epigastrium, 5th ICS mid left thorax Tricuspid regurgitation

5th left intercostal space mid- left thorax

Lower left sternal border

Hypertrophic cardiomyopathy

TIMING – Knowing the timing of the heart sound will narrow down the most likely cause.

*Note which part of the diastolic systolic phase the sound occurs. (i.e. early diastolic, pan systolic, etc)



Determining the timing

Early Systolic – The murmur will over shadow the lub. This will sound like : Murmur-Dub

Mid Systolic – The murmur will occur after the lub and prior to the dub. This will sound like : Lub -MurmurDub

Late Systolic – The murmur will over shadow the dub. This will sound like : Dub-Murmur

HoloSystolic – The murmur will over shadow both of the lub and the dub. This will sound like : Murmur-Murmur


Murmur Timing and other Descriptions

Description Possible Diagnosis

Systolic ejection murmur Normal, pulmonic, or aortic stenosis

Early diastolic murmur Aortic regurgitation

Ejection Sound Aortic valve disease

Pansystolic murmur Tricuspid or mitral regurgitation

Late diastolic murmur Tricuspid or mitral stenosis

Systolic click with late systolic murmur Mitral valve prolapse

Opening snap with diastolic rumble murmur Mitral stenosis

S3Normal in children and occurs in heart

failure

S4 Physiological and in various diseases

GRADING – Every murmur should be graded according to its intensity. This will differentiate a light murmur from a harsh murmur.



Murmur Grades

Grade Volume Thrill

1 Sound is very faint, only heard in ideal circumstances No

2 Sound is loud enough to be generally heard No

3 Sound is louder then grade 2 but no thrill No

4 Sound is louder then grade 3 with a thrill Yes

5 Sound is heard with stethoscope partially off chest Yes

6 Sound is heard with stethoscope entirely off chest Yes

Thrills – Typically a murmur that is loud enough to be graded a 4, 5, or 6 will be associated with a palpable thrill.

To check for a thrill, place the palm of your right left hand across the base of the heart. You should be able to feel the vibration transfer through the chest wall.


QUALITY – The quality and pitch of the heart sound.

*This may include terms such as harsh, musical, rumble, blowing. Use the modifier – High, Medium, Low and note any changes in body position or with respiration.



Quality

If there is a musical “honk” or “coo”, it is usually due to an Aortic Stenosis.

If the murmur creates a “harsh” sound it is also usually due to an Aortic Stenosis.

Clinical ExamplesClinical Examples

If the sound is normal, document the rate and rhythm and the absence of an audible murmur.

If the sound is abnormal, document rate, rhythm, location of murmur, timing, grade, and quality. If the sound radiates, make sure to note where.

Etiology of Pediatric Etiology of Pediatric MurmursMurmurs

30% Innocent Murmur20% Ventricular Septal Defect, VSD11% Aortic Stenosis AS /AI9% Mitral Valve Prolapse MVP/Mitral

Regurgitation MR7% Sub Aortic Stenosis (HOCM)7% Pulmonary Stenosis, PS5% Tetralogy of Fallot, ToF9% other

Finley et al. Assessing children's heart sounds at a distance with digital recordings Pediatrics. 2006 Dec;118(6):2322-5.

Normal Heart SoundNormal Heart Sound

Click on the speaker to hear the heart sound

Note the Lub Dub sound

Now go to the next page and listen to the most common abnormal sounds you will

hear in adults.

Mitral RegurgitationMitral RegurgitationClick on the speaker to hear the heart sound

Mitral StenosisMitral Stenosis

Aortic RegurgitationAortic Regurgitation

Aortic StenosisAortic Stenosis

Pulmonary StenosisPulmonary Stenosis

Tricuspid RegurgitationTricuspid Regurgitation

VSDVSD

PericarditisPericarditis

Mid-Systole ClickMid-Systole Click

Opening SnapOpening Snap

Tumor PlopTumor Plop

Third Heart SoundThird Heart Sound

Fourth Heart SoundFourth Heart Sound

Physiological SplitPhysiological Split

Wide SplitWide Split

Normal Heart Sounds S1

S1 - The first heart tone, or S1, forms the "lub" of "lub-dub" and is composed of components Mitral and Tricuspid valves. It is caused by the sudden block of reverse blood flow due to closure of the atrioventricular valves at the beginning of ventricular contraction, or systole. When the pressure in the ventricles rises above the pressure in the atria, venous blood flow entering the ventricles is pushed back toward the atria, catching the valve leaflets, closing the inlet valves and preventing regurgitation of blood from the ventricles back into the atria. The S1 sound results from reverberation within the blood associated with the sudden block of flow reversal by the valves.

Normal Heart Sounds S2

S2 - The second heart tone, or S2, forms the "dub" of "lub-dub" and is composed of components Aortic and Pulmonic valves. It is caused by the sudden block of reversing blood flow due to closure of the aortic valve and pulmonary valve at the end of ventricular systole, i.e beginning of ventricular diastole. As the left ventricle empties, its pressure falls below the pressure in the aorta, aortic blood flow quickly reverses back toward the left ventricle, catching the aortic valve leaflets and is stopped by aortic (outlet) valve closure. Similarly, as the pressure in the right ventricle falls below the pressure in the pulmonary artery, the pulmonary (outlet) valve closes. The S2 sound results from reverberation within the blood associated with the sudden block of flow reversal.

Mitral Regurgitation

• Mitral regurgitation (MR), also known as mitral insufficiency or mitral incompetence, is a valvular heart disease which consists of abnormal leaking of blood through the mitral valve, from the left ventricle into the left atrium of the heart

Mitral Stenosis

• Mitral Stenosis is a valvular heart disease characterized by the narrowing of the orifice of the mitral valve of the heart.

• With mitral stenosis, the valve does not open completely, and to transport the same amount of blood the left atrium needs a higher pressure than normal to overcome the increased gradient.

Aortic Regurgitation

• Aortic regurgitation (AR), also known as aortic insufficiency or aortic incompetence, is a valvular heart disease which consists of abnormal leaking of blood through the aortic valve, from the aorta into the right ventricle of the heart

Aortic Stenosis

• Aortic Stenosis is a valvular heart disease characterized by the narrowing of the orifice of the aortic semilunar valve of the heart.

• With Aortic stenosis, the valve does not open completely, and to transport the same amount of blood the right ventricle needs a higher pressure than normal to overcome the increased gradient.

• This will eventually lead to right ventricular hypertrophy.

Pulmonary Stenosis

• Pulmonary Stenosis is a valvular heart disease characterized by the narrowing of the orifice of the pulmonic semilunar valve of the heart.

• With pulmonary stenosis, the valve does not open completely, and to transport the same amount of blood the left ventricle needs a higher pressure than normal to overcome the increased gradient.

• This will eventually lead to left ventricular hypertrophy.

Tricuspid Regurgitation

• Tricuspid regurgitation (TR), also known as tricuspid insufficiency or tricuspid incompetence, is a valvular heart disease which consists of abnormal leaking of blood through the tricuspid valve, from the right ventricle into the right atrium of the heart

VSD

• A ventricular septal defect (VSD) is a defect in the ventricular septum, the wall dividing the left and right ventricles of the heart.

• This allows oxygenated from the left ventricle to mix with de-oxygenated blood from the right ventricle.

Pericarditis

• Pericarditis is an inflammation of the pericardium (the fibrous sac surrounding the heart).

• Chest pain, radiating to the back and relieved by sitting up forward and worsened by lying down, is the classical presentation.

• Other symptoms of pericarditis may include dry cough, fever, fatigue, and anxiety. Pericarditis can be misdiagnosed as myocardial infarction (heart attack), and vice versa.

Mid-Systolic Click

• Mid-systolic clicks are due to blood flow through the semilunar valves.

• They occur at the start of blood ejection — which starts after S1 — and ends with the cessation of the blood flow — which is before S2. Therefore, the onset of a midsystolic ejection murmur is separated from S1 by the isovolumic contraction phase; the cessation of the murmur and the S2 interval is the aortic or pulmonary hangout time. The resultant configuration of this murmur is a crescendo-decrescendo murmur.

• Causes of midsystolic ejection murmurs include outflow obstruction, increased flow through normal semilunar valves, dilation of aortic root or pulmonary trunk, or structural changes in the semilunar valves without obstruction.

Opening Snap

• The Opening Snap in addition to a typical murmur indicates the murmur is due to mitral stenosis and not a flow rumble across a non-stenotic valve.

• The timing of the Opening Snap has been suggested as a gauge of the severity of the stenosis.

Third Heart Sound (S3)

Rarely, there may be a third heart sound also called a protodiastolic gallop, ventricular gallop, or informally the "Kentucky" gallop as an onomatopoeic reference to the rhythm and stress of S1, S2, and S3 together (S1=ken; S2=tuc; S3=ky).

It occurs at the beginning of diastole after S2 and is lower in pitch than S1 or S2 as it is not of valvular origin.

The third heart sound is benign in youth and some trained athletes, but if it re-emerges later in life it may signal cardiac problems like a failing left ventricle as in dilated congestive heart failure (CHF).

S3 is thought to be caused by the oscillation of blood back and forth between the walls of the ventricles initiated by inrushing blood from the atria.

The reason the third heart sound does not occur until the middle third of diastole is probably because during the early part of diastole, the ventricles are not filled sufficiently to create enough tension for reverberation. It may also be a result of tensing of the chordae tendineae during rapid filling and expansion of the ventricle.

Tumor Plop

A third heart sound can also be simulated by a myxoma of the left atrium. This type of third heart sound is often referred to as a "tumor plop".

The "tumor plop" is caused by the gelatinous tumor, which is attached by a stalk to the atrial septum, plunging into the ventricle and pushing the blood ahead of it like a syringe plunger.

Fourth Heart Sound (S4)

The rare fourth heart sound is sometimes audible in healthy children and again in trained athletes, but when audible in an adult is called a presystolic gallop or atrial gallop.

This gallop is produced by the sound of blood being forced into a stiff / hypertrophic ventricle.

It is a sign of a pathologic state, usually a failing left ventricle.

The sound occurs just after atrial contraction ("atrial kick") at the end of diastole and immediately before S1, producing a rhythm sometimes referred to as the “Tennessee” gallop where S4 represents the "tenn-" syllable. The combined presence of S3 and S4 is a quadruple gallop. At rapid heart rates, S3 and S4 may merge to produce a summation gallop.

Physiological SplitDuring inspiration, the increased negative intrathorasic pressure which allows lung

expansion also induces both increased blood return from the body into the right ventricle and simultaneous reduced blood volume return from the lungs into the left ventricle. Because of the increased blood volume in the right atrium, the pulmonary valve stays open longer during ventricular systole whereas the aortic valve closes slightly earlier due to slightly reduced left ventricular volume.

Thus the Pulmonary Valve component of S2 is delayed relative to the Aortic valve component. This delay in P2 versus A2 is heard as a slight broadening or even "splitting" of the second heart sound, though usually only in the pulmonic area of the chest because the P2 is soft and not heard in other areas.

During expiration, the less negative (than during inspiration) intrathoracic pressure no longer increases blood return to the right ventricle versus the left ventricle, the right ventricle volume in no longer increased, the pulmonary valve closes earlier, Pulmonic valve occurs earlier and overlaps Aortic valve.

It is physiological to hear a "splitting" of the second heart tone in younger people, during inspiration and in the "pulmonary area", i.e. the 2nd ICS (intercostal space) at the left edge of the sternum. During expiration the interval between the two components normally shortens and the S2 sounds become merged.

Wide Split

A bundle branch block will produce continuous splitting but the degree of splitting will still vary with respiration.

If splitting does not vary with inspiration, it is termed a "fixed split S2" and is usually due to an atrial septal defect (ASD) or ventricular septal defect (VSD). The ASD or VSD creates a left to right shunt that increases the blood flow to the right side of the heart, thereby causing the pulmonic valve to close later than the aortic valve independent of inspiration/expiration.

Reverse splitting indicates pathology. Aortic stenosis, hypertrophic cardiomyopathy, left bundle branch block, and a ventricular pacemaker could all cause a reverse splitting of the second heart sound.

Diagnosing Murmurs

Accuracy in Diagnosis of Systolic Murmurs Maneuvers

• This study looks at the sensitivity, specificity and predictive value of physical exam maneuvers that historically have been used in diagnosing systolic murmurs.

• Two cardiologist independently examined 50 patients age 6 to 85 years of age ( mean age 45) with a systolic murmur I / VI or greater. The cardiologists were separated from the patients by a partition. An independent examiner instructed the patients in the maneuvers and supervised the implementation of them.Sapira, JD. The art and science of bedside diagnosis. (Urban & Schwarzenberg, Baltimore-Munich) 1990.

Results for Systolic MurmurManeuvers--result in

increased murmur

Murmur Sens(%) Spec(%) LR+ LR-

Inspiration Right-sided 100 88 8.3 0

Valsalva HCM 65 96 16.25 0.36

Squat to stand HCM 95 84 5.9 0.06

Handgrip

Mitral regurgita

tion, VSD 68 92 8.5 0.35

Transient arterial occlusion

Mitral regurgita

tion, VSD 78 100 -

Maneuvers--result in decreased murmur

Murmur Sens(%)Spec(%

)LR+ LR-

stand to squat HCM 95 84 5.9 0.06

Leg elevation HCM 85 91 10.63 0.16

Handgrip HCM 85 75 3.4 0.2

Wiggers Diagram Summary

Phase EKGHeart

soundsAortic valve

Mitral valve

A Atrial systole P S4* closed open

B Ventricular systole - Isovolumetric/isovolumic contraction QRS S1 ("lub") closed closed

C1 Ventricular systole - Ejection 1 - open closed

C2 Ventricular systole - Ejection 2 T open closed

D Ventricular diastole - Isovolumetric/isovolumic relaxation - S2 ("dub") closed closed

E1 Ventricular diastole - Ventricular filling 1 - S3* closed open

E2 Ventricular diastole - Ventricular filling 2 - closed open

Cardiac References

• "The Cardiovascular System." Bates, B. A Guide to Physical Examination and History Taking. 9h Ed. 2005.

• Aronow, WS, and I Kronzon. Correlation of prevalence and severity of valvular aortic stenosis determined by continuous-wave Doppler echocardiography with physical signs of aortic stenosis in patients 62 to 100 years with aortic systolic ejection murmurs. Am J Cardiol 1987. 60(4):399-401.

• Badgett RG, CR Lucey, CD Mulrow, DL Simel, D Rennie. Can the clinical examination diagnose left sided heart failure in adults? JAMA 1997; 277:1712-1718.

• "Choudhry NK, Etchells EE. Does This Patient Have Aortic Regurgitation? JAMA. 1999; 281:2231. • Etchells E, C Bell, K Robb, DL Simel, and D Rennie. Does this patient have an abnormal systolic

murmur? JAMA 1997; 277:654-571. • Fye, WB. Disorders of the heartbeat: A historical overview from antiquity to the mid-20th century. Am

J Cardiol 1993; 72:1055-1070. • Gaeschke, R, GH Guyatt, DL Sackett for the Evidence-Based Medicine Working Group. Users'

guides to the medical literature. VI. How to use an article about a diagnostic test. A: Are the results of the study valid? JAMA 1994. 271:389-91.

• McGee S. Evidence based physical diagnosis. WB Saunders Co. 2001. • McMichael, J. History of atrial fibrillation 1628-1819: Harvey - de Senac - Laennec. Br Heart J 1982;

48:193-197. • Sapira, JD. The art and science of bedside diagnosis. (Urban & Schwarzenberg, Baltimore-Munich)

1990.

The End

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