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Archive:Precordial exam

2007-07-11T21:29:30Z

80.98.166.160: /* Other sounds */

==Inspection==
*from the foot of the bed
**chest wall deformity (pectus excavatum, carinatum)
**scars (thoracotomy, pacemaker)
**heaves (ventricular hypertrophy) and lifts
**visible apical beat
**impulses (under xiphoid – can mean RVH or Aorta).

==Palpation==
*using finger pads, palpate for apex impulse (PMI) - ''accurately measure MCL''
**location, size - one ICS
**amplitude - if increased, suggests volume/pressure overload
**duration - check in relation to carotid pulse (> 2/3 systole → sustained, LVH)
**if carotid is delayed = '''parvus et tardus''' → AV stenosis

*thrills - palpate at each of the 4 valve zones = grade 4 murmur
*heaves (with heel of hand)
**left sternal border → LVH
**PV → pulmonary hypertension
**AV → systemic hypertension
**inferior to xiphoid - RVH

==Auscultation==
*listen specifically for one sound at a time
*calibrate your timing to the radial pulse
*S1 > S2 in LLSB
*S2 > S1 in LUSB

===S1===
*louder → ↓ PR interval, ↑CO, ↑HR
*quieter → ↑ PR interval, MR, severe MS
*splitting → RBBB

===S2===
*splitting ↑ by continued inspiration (while patient not holding in breath)
*Loud S2 → hypertension (systemic or pulmonary circulation)
*Wide split S2 - RBBB, Pulmonary stenosis
*Fixed split S2 - ASD
*Paradoxical: LBBB, severe AS

===S3 (Ventricular Gallop)===
*lightly use bell at apex, best heard in LLD
*can be normal in young people and the pregnant
*noted in volume overload, increased transvalvular flow (TR, MR)

===S4 (Atrial Gallop)===
*lower pitched
*indicates stiff LV– LVH, post-MI

===Other sounds===
* '''Ejection click''' - between S1 and S2
* '''Carotid bruit'''
* '''Pericardial friction'''

===Murmurs===
Describe a murmur in its ''timing'', ''shape'', ''intensity'' and ''radiation''

{| border="1" cellpadding="2" cellspacing="0"
|-
|Type
|Character
|Best Heard
|Radiation
|-
|Aortic stenosis
|systolic, crescendo-decrescendo
|AV, lean forward
↓with Valsalva
|carotids, clavical
|-
|Aortic regurg
|early diastolic
decrescendo
|L2-4 ICS
Lean foward
|Apex
|-
|Mitrial Stenosis
|Mid diastolic rumble
|Apex, LLD
|No radiation
|-
|Mitrial Regurge
|pansystolic
|apex
|L axilla
|-
|VSD
|pansystolic, harsh
|L sternal border
|-
|PDA
|continuous
|aortic valve
|L clavical
|}

====Intensity====

1/6 = quieter than S1 
2/6 = same as S1 
3/6 = louder than S1 with no thrill 
4/6 = thrill present 
5/6 = heard with edge of scope in contact with skin 
6/6 = heard with scope off of the chest 

==Special tests==

*↑ blood flow to heart (leg raise, squatting)
**↑ AS, ↓HoCM, ↓MR
*↓ blood flow to heart (Valsalva)
**↓ AS, ↑ MR, ↑HoCM

==Other OSCE modules==
{{OSCE2}}
[[Category:Medicine]][[Category:OSCE]]

Archive:Precordial exam

2007-07-11T21:27:59Z

80.98.166.160: /* Inspection */

==Inspection==
*from the foot of the bed
**chest wall deformity (pectus excavatum, carinatum)
**scars (thoracotomy, pacemaker)
**heaves (ventricular hypertrophy) and lifts
**visible apical beat
**impulses (under xiphoid – can mean RVH or Aorta).

==Palpation==
*using finger pads, palpate for apex impulse (PMI) - ''accurately measure MCL''
**location, size - one ICS
**amplitude - if increased, suggests volume/pressure overload
**duration - check in relation to carotid pulse (> 2/3 systole → sustained, LVH)
**if carotid is delayed = '''parvus et tardus''' → AV stenosis

*thrills - palpate at each of the 4 valve zones = grade 4 murmur
*heaves (with heel of hand)
**left sternal border → LVH
**PV → pulmonary hypertension
**AV → systemic hypertension
**inferior to xiphoid - RVH

==Auscultation==
*listen specifically for one sound at a time
*calibrate your timing to the radial pulse
*S1 > S2 in LLSB
*S2 > S1 in LUSB

===S1===
*louder → ↓ PR interval, ↑CO, ↑HR
*quieter → ↑ PR interval, MR, severe MS
*splitting → RBBB

===S2===
*splitting ↑ by continued inspiration (while patient not holding in breath)
*Loud S2 → hypertension (systemic or pulmonary circulation)
*Wide split S2 - RBBB, Pulmonary stenosis
*Fixed split S2 - ASD
*Paradoxical: LBBB, severe AS

===S3 (Ventricular Gallop)===
*lightly use bell at apex, best heard in LLD
*can be normal in young people and the pregnant
*noted in volume overload, increased transvalvular flow (TR, MR)

===S4 (Atrial Gallop)===
*lower pitched
*indicates stiff LV– LVH, post-MI

===Other sounds===
'''Ejection click''' - between S1 and S2
'''Carotid bruit'''
'''Pericardial friction'''

===Murmurs===
Describe a murmur in its ''timing'', ''shape'', ''intensity'' and ''radiation''

{| border="1" cellpadding="2" cellspacing="0"
|-
|Type
|Character
|Best Heard
|Radiation
|-
|Aortic stenosis
|systolic, crescendo-decrescendo
|AV, lean forward
↓with Valsalva
|carotids, clavical
|-
|Aortic regurg
|early diastolic
decrescendo
|L2-4 ICS
Lean foward
|Apex
|-
|Mitrial Stenosis
|Mid diastolic rumble
|Apex, LLD
|No radiation
|-
|Mitrial Regurge
|pansystolic
|apex
|L axilla
|-
|VSD
|pansystolic, harsh
|L sternal border
|-
|PDA
|continuous
|aortic valve
|L clavical
|}

====Intensity====

1/6 = quieter than S1 
2/6 = same as S1 
3/6 = louder than S1 with no thrill 
4/6 = thrill present 
5/6 = heard with edge of scope in contact with skin 
6/6 = heard with scope off of the chest 

==Special tests==

*↑ blood flow to heart (leg raise, squatting)
**↑ AS, ↓HoCM, ↓MR
*↓ blood flow to heart (Valsalva)
**↓ AS, ↑ MR, ↑HoCM

==Other OSCE modules==
{{OSCE2}}
[[Category:Medicine]][[Category:OSCE]]