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====Pulse==== | ====Pulse==== | ||
[[Image:Circulatory System | [[Image:Circulatory System.svg|thumb|right|400px|'''Figure 1.''' Body locations for examining the pulse.]] | ||
The peripheral pulsations should be assed by both palpitation of the pulse and auscultation for bruits. Pulse abnormalities and bruits increase the likelihood of peripheral arterial disease. Pulsations should be assessed and documented in several arteries in the body in order to get an idea of the state of peripheral vasculature. Easily and fast palpable pulses in healthy individuals include the brachial, radial, and ulnar arteries of the upper extremities and the femoral, popliteal, dorsalis pedis, and posterior tibial arteries of the lower extremities. Minor or absent pulsations suggest a severe stenotic lesion proximal of the palpation site. To asses the cardiac (dys)function through the pulse generally an artery close to the heart should be selected, such as the carotid. Bounding high-amplitude carotid pulses suggest an increase in stroke volume and should be accompanied by a wide pulse pressure on the blood pressure measurement. A weak carotid pulse suggests a reduced stroke volume. [Figure 1] | The peripheral pulsations should be assed by both palpitation of the pulse and auscultation for bruits. Pulse abnormalities and bruits increase the likelihood of peripheral arterial disease. Pulsations should be assessed and documented in several arteries in the body in order to get an idea of the state of peripheral vasculature. Easily and fast palpable pulses in healthy individuals include the brachial, radial, and ulnar arteries of the upper extremities and the femoral, popliteal, dorsalis pedis, and posterior tibial arteries of the lower extremities. Minor or absent pulsations suggest a severe stenotic lesion proximal of the palpation site. To asses the cardiac (dys)function through the pulse generally an artery close to the heart should be selected, such as the carotid. Bounding high-amplitude carotid pulses suggest an increase in stroke volume and should be accompanied by a wide pulse pressure on the blood pressure measurement. A weak carotid pulse suggests a reduced stroke volume. [Figure 1] | ||
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Additionally, the characteristics of the right internal jugular pulse should be assessed, because they can be reveal clinical signs of right-heart function and rhythm disturbances. The distinctive waves of the jugular vein are summarized in Table 7 and visualized in Figure 2. | Additionally, the characteristics of the right internal jugular pulse should be assessed, because they can be reveal clinical signs of right-heart function and rhythm disturbances. The distinctive waves of the jugular vein are summarized in Table 7 and visualized in Figure 2. | ||
[[Image:Jugular Venous Pulse. | [[Image:Jugular Venous Pulse.svg|right|thumb|300px|'''Figure 2.''' Jugular venous pulse waveform.]] | ||
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===Cardiac Auscultation=== | ===Cardiac Auscultation=== | ||
[[Image:Gray1216 modern locations.svg | [[Image:Gray1216 modern locations.svg|thumb|right|400px|'''Figure 3.''' Locations for cardiac auscultation]] | ||
The acceleration and deceleration of blood and the subsequent vibration of the cardiac structures during the phases of the cardiac cycle are causing heart sounds. In healthy adults, there are two normal heart sounds often described as a lub and a dub (or dup), that occur in sequence with each heart beat. These are the first heart sound (S1) and second heart sound (S2), produced by the closing of the atroventricular valves and semilunar valves respectively. In addition to these normal sounds, a variety of other sounds may be present including heart murmurs, adventitious sounds, and gallop rhythms S3 and S4.To hear cardiac sounds, use a stethoscope with a bell and a tight diaphragm. The bell is best used to hear low-frequency sounds which are associated with ventricular filling. The diaphragm is best used to appreciate the medium-frequency sounds that are associated with valve opening and closing. Cardiac murmurs are caused due to turbulent blood flow and are usually high-to-medium frequency. In most cases the diaphragm is best used to hear cardiac murmurs. An important exception to this is the low-frequency atrioventricular valve inflow murmurs, such as that produced by mitral stenosis, which are best heard with the bell. Murmurs may be physiological or pathological. Abnormal murmurs can be caused by stenosis restricting the opening of a heart valve, resulting in turbulence as blood flows through it. Abnormal murmurs may also occur with valvular insufficiency (or regurgitation), which allows backflow of blood when the incompetent valve closes with only partial effectiveness. | The acceleration and deceleration of blood and the subsequent vibration of the cardiac structures during the phases of the cardiac cycle are causing heart sounds. In healthy adults, there are two normal heart sounds often described as a lub and a dub (or dup), that occur in sequence with each heart beat. These are the first heart sound (S1) and second heart sound (S2), produced by the closing of the atroventricular valves and semilunar valves respectively. In addition to these normal sounds, a variety of other sounds may be present including heart murmurs, adventitious sounds, and gallop rhythms S3 and S4.To hear cardiac sounds, use a stethoscope with a bell and a tight diaphragm. The bell is best used to hear low-frequency sounds which are associated with ventricular filling. The diaphragm is best used to appreciate the medium-frequency sounds that are associated with valve opening and closing. Cardiac murmurs are caused due to turbulent blood flow and are usually high-to-medium frequency. In most cases the diaphragm is best used to hear cardiac murmurs. An important exception to this is the low-frequency atrioventricular valve inflow murmurs, such as that produced by mitral stenosis, which are best heard with the bell. Murmurs may be physiological or pathological. Abnormal murmurs can be caused by stenosis restricting the opening of a heart valve, resulting in turbulence as blood flows through it. Abnormal murmurs may also occur with valvular insufficiency (or regurgitation), which allows backflow of blood when the incompetent valve closes with only partial effectiveness. | ||
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[[Image:P1. | [[Image:P1.svg|thumb|right|400px|'''Figure 4.''' Murmur sound shapes.]] | ||
*Timing in the cardiac cycle – Murmurs could be heard early, mid or late in systole, throughout systole (holosystolic), early, mid or late in diastole or continuous. See below for more detail. | *Timing in the cardiac cycle – Murmurs could be heard early, mid or late in systole, throughout systole (holosystolic), early, mid or late in diastole or continuous. See below for more detail. | ||
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**Lateral decubitis – In this manoeuvre the patient rolls partly onto the left side and the apex should be auscultated. By bringing the left ventricle closer tot the chest, left-sided murmurs an generally louder. | **Lateral decubitis – In this manoeuvre the patient rolls partly onto the left side and the apex should be auscultated. By bringing the left ventricle closer tot the chest, left-sided murmurs an generally louder. | ||
**Vasalva manoeuvre – During this manoeuvre the patient bears down and expires against a closed glottis (hold the breathe and strain hard for 10 seconds). A increasing intrathoracic pressure and markedly reducing venous return to the heart will be caused by this manoeuvre. Almost all cardiac murmurs decrease in intensity, however during strain the murmur of hypertrophic obstructive cardiomyopathy may become louder because and the murmur associated with mitral regurgitation from mitral valve prolapse may become longer and louder because of the earlier occurrence of prolapse during systole. After release of the strain the murmur will decrease and most other murmurs will increase in intensity. | **Vasalva manoeuvre – During this manoeuvre the patient bears down and expires against a closed glottis (hold the breathe and strain hard for 10 seconds). A increasing intrathoracic pressure and markedly reducing venous return to the heart will be caused by this manoeuvre. Almost all cardiac murmurs decrease in intensity, however during strain the murmur of hypertrophic obstructive cardiomyopathy may become louder because and the murmur associated with mitral regurgitation from mitral valve prolapse may become longer and louder because of the earlier occurrence of prolapse during systole. After release of the strain the murmur will decrease and most other murmurs will increase in intensity. | ||
**Isometric hand grip – The patient has to relax his body while squeezing both fists. The manoeuvre increases arterial and left ventricular pressure, thus increasing afterload and flow gradient for mitral regurgitation, ventricular septal defect, and aortic regurgitation; the murmurs should then increase in intensity. The manoeuvre is in particular useful in distinguishing the increasing murmur of mitral regurgitation from a similar or lowering pitch aortic stenosis. | **Isometric hand grip – The patient has to relax his body while squeezing both fists. The manoeuvre increases arterial and left ventricular pressure, thus increasing afterload and flow gradient for mitral regurgitation, ventricular septal defect, and aortic regurgitation; the murmurs should then increase in intensity. The manoeuvre is in particular useful in distinguishing the increasing murmur of mitral regurgitation from a similar or lowering pitch aortic stenosis. | ||
====Murmurs categorized by time in cardiac cycle==== | ====Murmurs categorized by time in cardiac cycle==== | ||
[[Image: | [[Image:Phonocardiograms from normal and abnormal heart sounds.svg|thumb|right|500px|'''Figure 5.''' Representation of the sound waves of murmurs associated with heart disease.]] | ||
A schematic scheme of the heart sounds and heart murmurs are shown in Figure 5. | A schematic scheme of the heart sounds and heart murmurs are shown in Figure 5. | ||