MURMURS

MURMURS

Grading of intensity of murmurs:

Grade I - So faint and heard only with special effort

Grade II - Soft but readily detected

Grade III - Prominent but not loud

Grade IV - Loud usually with palpable thrill

Grade V - Very loud with thrill

Grade VI - Heard without stethoscope on the chest wall

Classification of Murmurs: (Systolic, Diastolic and Continuous)

1.Systolic Murmur(SM)

a) Mid Systolic Ejection Murmur:

b) Pansystolic à MI, TI, VSD

c) Late Systolic à MVP, PS, HOCM.

2. Diastolic Murmurs

a) Early Diastolic:

à AI

à PI

à Graham Steell’s Murmur

b) Mid Diastolic:

à MS

à TS

à Carey Coomb’s Murmur

à Austin Flint’s Murmur

à Flow Murmurs

c) Late Diastolic:

à MS

à TS

à Lt and Rt Atrial Myxona

3. Continuous Murmurs

à PDA

à Surgically Produced shunts in TOF

à Coarctation Aorta

à Venous Hum

à Mammary Souffle

PALPATATION

1. APEX BEAT:

• Patient should be examined in the supine, sitting, and left lateral decubitus position.

• Normal apex beat is palpable as brief outward impulse

(intersection of left mid clavicular line and 5th ICS)

• Apex beat > 2cm indicate LV enlargement.

• Double apical impulse caused by LVH and forceful LA contraction.

2. LEFT PARASTERNAL LIFT

• Best appreciated by the distal palm or with the finger tip.

• Palpable anterior systolic movement sustained up to S2

indicate RVH.

• Giant presystolic lift seen in HCM.

3. ABDOMEN

• Abdominal aorta (aneurysm)

• Liver (hepatomegaly, pulsatile liver)

• Ascitis

4. Diastolic shock

• Palpable S2

5. Thrill

• Palpable murmur

• Definite evidence of presence of organic ht ds.

JVP

JVP

• The Normal JVP consist of 3 +ve pulse waves (a,c and v) and 2 –ve pulse wave (x and y)

Normal JVP

A -- Atrial systole à Coincide with 4th H.S.

X -- Atrial relaxation

C -- Bulging of TV into RA during V systole à begins at the end of 1st H.S.

V -- filling of RA while TV is closed

Y -- Decline in RA pressure when TV opensà corresponds with 3rd H.S.

• X´ descent: systolic

• Y descent: diastolic

A wave

a) Absent in AF

b) Diminished in:- i)Tachycardia

ii) Increased PR Interval

c) Large a waves:- i) TS

ii) PS

iii) Pulm. HTN

d) Canon a waves à Complete ht block.

Elevated JVP

a) RVF

b) Cardiac tamponade

c) TS

d) SVC obst.

e) Hyperkinetic Circulatory state

f) Increased bld. Vol.

PALPATION

Inspection

Precordium

Ant. Aspect of Chest which ovelies the ht.

N precordium has a smooth contour, slightly convex.

Bulging:

• Enlarged ht

• Pericardial effusion

• Mediastinal tumor

• Pleural effusion

Flattened:

• Fibrosis of lung

• Old Pleural / Pericardial effusion

• Congenital deformity

APEX PULSE

• Lower most and outer most part of cardiac impulse seen.

• N it is in the 5th left ICS just inside midclavicular line.

PULSATIONS

• Lt parasternal à RVH , aneurysm of aorta

• Epigastric à RVH , liver pulsation.

• II ICS à dilated pulm. Artery , aneurysm aorta

• Suprasternal à AR , Coarctation of aorta , Hyper kinetic state

• Rt side of chest à dextrocardia

Dilated Veins Over The Chest Wall

• Intrathoracic obst.

• SVC and IVC obst.

• Rt sided ht failure.

CYANOSIS

Cyanosis

• Is not apparent till Hb <>

• In CHD cyanosis is observed if R to L shunt is > 25% of CO and not improved by 100% of O2

• Good examination of tongue, lips, earlobes, fingers, toes is recommended

Four Type of Cyanosis