physical exam part ii · 2018-11-11 · physical exam part ii kim a. eagle, md albion walter...
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Physical ExamPhysical ExamPart IIPart II
Kim A. Eagle, MDAlbion Walter Hewlett Professor
Director
Kim A. Eagle, MDKim A. Eagle, MDAlbion Walter Hewlett ProfessorAlbion Walter Hewlett Professor
DirectorDirector
University of MichiganUniversity of MichiganCardiovascular CenterCardiovascular Center
Physical Exam:Physical Exam:Part IIPart II
• Heart Sounds
• Heart Murmurs
HEART SOUNDSHEART SOUNDS
S1S1•• MITRAL + TRICUSPID CLOSURE (M1, T1)MITRAL + TRICUSPID CLOSURE (M1, T1)•• WIDE SPLITTING: RBBB, EBSTEINWIDE SPLITTING: RBBB, EBSTEIN’’SS
S2S2•• AORTIC + PULMONIC CLOSURE (A2, P2)AORTIC + PULMONIC CLOSURE (A2, P2)•• WIDE, PHYSIOLOGIC SPLITTING: RBBB, MRWIDE, PHYSIOLOGIC SPLITTING: RBBB, MR•• REVERSED (PARADOXICAL) SPLITTING: LBBB, REVERSED (PARADOXICAL) SPLITTING: LBBB,
RV PACING, SEVERE AS, HOCM, ISCHEMIARV PACING, SEVERE AS, HOCM, ISCHEMIA•• FIXED SPLITTING: ASDFIXED SPLITTING: ASD•• PULMONARY HTN: LOUD, SINGLE S2PULMONARY HTN: LOUD, SINGLE S2
S3 /S4 Gallop SoundsS3 /S4 Gallop Sounds
DIASTOLIC SOUNDSDIASTOLIC SOUNDS•• S3S3 ((““protoproto--diastolicdiastolic””))reliable indicator of LV reliable indicator of LV systolic dysfunction with systolic dysfunction with prognostic relevanceprognostic relevance
•• S4S4 ((““prepre--systolicsystolic””))associated with associated with ↑↑ LVEDPLVEDP
Drazner MH, et al. NEJM 2001;345:574
HEART SOUNDSHEART SOUNDS
Systolic ClicksSystolic Clicks•• EjectionEjection: Timing is co: Timing is co--incident withincident with
carotid upstrokecarotid upstrokeExamplesExamples: Ao/Pulm click (ES): Ao/Pulm click (ES)
•• NonNon--ejectionejection: Occurs after carotid up: Occurs after carotid up--strokestroke
ExampleExample: MVP: MVP
HEART SOUNDSHEART SOUNDS
Adventitious Diastolic SoundsAdventitious Diastolic Sounds•• Opening snap of mitral stenosisOpening snap of mitral stenosis
P2P2--OS interval inversely related to OS interval inversely related to LALA--LV pressure gradientLV pressure gradient
•• Pericardial knock Pericardial knock •• Tumor plop (myxoma)Tumor plop (myxoma)
HEART MURMURSHEART MURMURS
Systolic Heart MurmursSystolic Heart MurmursEarlyEarly: Acute MR, TR with normal PA: Acute MR, TR with normal PA
pressures pressures SettingsSettings:: Acute MI (Inf/Post > Ant)Acute MI (Inf/Post > Ant)
EndocarditisEndocarditisRuptured chordaeRuptured chordae
Acute vs. Chronic MRAcute vs. Chronic MR
HEART MURMURSHEART MURMURS
Systolic Heart MurmursSystolic Heart MurmursMidMid--systolic/Ejection: systolic/Ejection:
BenignBenignLeftLeft--sided: AS, HOCM, other sided: AS, HOCM, other RightRight--sided: PSsided: PS
LVOT OBSTRUCTIONLVOT OBSTRUCTION
FINDINGFINDING ASAS SASSAS DMSDMS HOCMHOCMPostPost--VPB PPVPB PP ↑↑ ↑↑ ↑↑ ↓↓ARAR ++ -- + + --S4S4 ++ -- -- ++Paradox S2Paradox S2 + + -- -- ++ECEC + + -- -- --LocationLocation 2RIS 1RIS 2RIS 4LIS2RIS 1RIS 2RIS 4LISCarotidCarotid ↓↓ R>L R>L ++ ↑↑
AS= aortic stenosis DMS= discrete, membranous ASSAS= supra-valvular AS HOCM= hypertrophic obstructive cardiomyopathyPP= pulse pressure VPB= ventricular premature beatEC= ejection click IS= interspace
HEART MURMURSHEART MURMURS
Caveats with Aortic StenosisCaveats with Aortic Stenosis•• Elderly: preserved carotidsElderly: preserved carotids•• Low output: Low output: ↓↓ intensityintensity•• Confusion with MR:Confusion with MR:
Gallarvardin effectGallarvardin effect↑↑ Intensity postIntensity post--VPBVPB
HEART MURMURSHEART MURMURS
Systolic Heart MurmursSystolic Heart Murmurs-- MidMid--late: late:
MVP (+/MVP (+/-- click)click)-- Differential radiation with leaflet prolapse Differential radiation with leaflet prolapse or flail:or flail:
posterior leaflet ante. radiationposterior leaflet ante. radiationanterior leafletanterior leaflet post. radiationpost. radiation
HEART MURMURSHEART MURMURS
Systolic Heart MurmursSystolic Heart MurmursHolosystolic/Plateau: Holosystolic/Plateau:
Chronic MRChronic MRChronic TRChronic TRVSDVSD
HEART MURMURSHEART MURMURS
DIASTOLIC MURMURSDIASTOLIC MURMURSEARLYEARLY
•• AR AR •• PR (GRAHAM STEELL)PR (GRAHAM STEELL)
MIDMID•• MS (ASSOCIATED FINDINGS)MS (ASSOCIATED FINDINGS)
•• TSTS•• FILLING COMPLEX (R or L) WITH LARGEFILLING COMPLEX (R or L) WITH LARGE
VOLUME LOAD DUE TO MR, TR, or ASDVOLUME LOAD DUE TO MR, TR, or ASD•• MYXOMAMYXOMA
HEART MURMURSHEART MURMURS
DIASTOLIC MURMURSDIASTOLIC MURMURSAortic Regurgitation (AR)Aortic Regurgitation (AR)
L > R sternal radiation with valve vs. root L > R sternal radiation with valve vs. root dis.dis.
Acute AR : soft, early diastolic murmurAcute AR : soft, early diastolic murmurChronic AR: classic high pitched, Chronic AR: classic high pitched,
decrescendodecrescendo
Pulmonic Regurgitation (PR)Pulmonic Regurgitation (PR)With severe PA HTN (loud P2, Graham With severe PA HTN (loud P2, Graham
Steell)Steell)After repair of TOF: low pitched, softAfter repair of TOF: low pitched, soft
HEART MURMURSHEART MURMURS
CONTINUOUS MURMURSCONTINUOUS MURMURS•• PDAPDA•• Ruptured Sinus of Valsalva aneurysmRuptured Sinus of Valsalva aneurysm•• AV fistula (Coronary, other)AV fistula (Coronary, other)•• Cervical venous hum, mammary souffleCervical venous hum, mammary souffle
QUESTIONQUESTION
For which of the following combination of findings For which of the following combination of findings would CT assessment of the ascending aorta be would CT assessment of the ascending aorta be indicated ?indicated ?
A.A. MidMid--systolic click at the apex with a midsystolic click at the apex with a mid--late grade late grade 2 systolic murmur.2 systolic murmur.
B.B. Late systolic click at the lower left sternal borderLate systolic click at the lower left sternal borderC.C. Early systolic click at the lower left sternal border Early systolic click at the lower left sternal border
with a grade 1 diastolic murmur along the left with a grade 1 diastolic murmur along the left sternal border.sternal border.
D.D. Early systolic click at the 2Early systolic click at the 2ndnd LICS with a grade 2 LICS with a grade 2 midmid--sytolic murmur. Click becomes softer on sytolic murmur. Click becomes softer on inspiration.inspiration.
Dynamic AuscultationDynamic Auscultation
RespirationRespiration↑↑ RR--sided murmurssided murmurs↓↓ LL--sided murmurssided murmurs
ExampleExample: TR (Carvalho: TR (Carvalho’’s sign)s sign)ExceptionException: pulmonic valve click: pulmonic valve click
Dynamic AuscultationDynamic Auscultation
Valsalva ManueverValsalva Manuever↓↓ venous return, venous return, ↓↓ preload, preload, ↑↑ afterloadafterload
ExamplesExamplesHOCM: HOCM: ↑↑ obstruction, obstruction, ↑↑ murmurmurmur
AS: AS: ↓↓ preload, preload, ↓↓ murmurmurmurMVP: MVP: ↓↓ preload, preload, ↑↑ murmurmurmur
Dynamic AuscultationDynamic Auscultation
Standing/SquattingStanding/SquattingStanding: rapid Standing: rapid ↓↓ preload/afterloadpreload/afterloadSquatting: rapid Squatting: rapid ↑↑ preload/afterloadpreload/afterload
ExampleExampleHOCM: HOCM: standstand: : ↑↑ murmurmurmur
squatsquat: : ↓↓ murmurmurmur
Dynamic AuscultationDynamic Auscultation
Standing/SquattingStanding/SquattingStanding: rapid Standing: rapid ↓↓ preload/afterloadpreload/afterloadSquatting: rapid Squatting: rapid ↑↑ preload/afterloadpreload/afterload
ExampleExampleMVP: MVP: standstand: click/murmur closer: click/murmur closer
to S1, to S1, ↑↑ murmurmurmursquatsquat: click/murmur away : click/murmur away from S1, from S1, ↓↓ murmurmurmur
Dynamic AuscultationDynamic AuscultationMVPMVP
Dynamic AuscultationDynamic Auscultation
Hand Grip/4 Extremity BP CuffHand Grip/4 Extremity BP Cuff↑↑ afterloadafterload
ExamplesExamplesMR: MR: ↑↑ murmurmurmurVSD: VSD: ↑↑ murmurmurmur
QUESTION QUESTION
Which of the following murmurs decreases Which of the following murmurs decreases in intensity during the Valsalva maneuver?in intensity during the Valsalva maneuver?
A. Chronic mitral regurgitationA. Chronic mitral regurgitationB. Aortic stenosisB. Aortic stenosisC. HOCMC. HOCMD. MVPD. MVP