THE PHYSICAL EXAMINATION IN CARDIOLOGY AND INNOCENT MURMURS

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THE PHYSICAL EXAMINATION IN CARDIOLOGY AND
INNOCENT MURMURS

• Jeff Boris, Lt Col, USAF, MC
• Pediatric Cardiologist

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Cardiac physical examination can be amongst the
most diagnostic if done correctly and carefully

• Knowledge of cardiac physiology and auscultation
  techniques/maneuvers can often determine a
  diagnosis, or help to form a strong differential
  diagnosis

3
Physical examination--

• Evaluating signs throughout the body for evidence
  of hemodynamic sufficiency or insufficiency
• More difficult to assess in infants and children
• Exam findings should be often easier to hear in
  cooperative younger children and in adolescents
  than in adults

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GENERAL EXAMINATION GUIDELINES
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The patient

• Should have their shirt(s) off, or wear an
  examination gown
• Females nine years old and older should wear a
  gown with the opening in the front
• Should be calm and quiet

6
The stethoscope

• Should be your own!!!
• Should have a separate bell and diaphragm
• Bell allows in all sounds
• Diaphragm lets in middle and high frequency
  sounds, attenuates low pitched sounds

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The stethoscope (cont.)

• Bell should be used relatively lightly (avoid
  diaphragm effect)
• Diaphragm should be small enough to fit on the
  chest of the patient
• Should have tubing which is short (16-18 inches)
• Should have earpieces that are comfortable and
  snug

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The environment

• Should be quiet (patient, family, clinic
  attendants, exam room, surrounding areas)
• May briefly disconnect ventilator or occlude
  suction devices
• Brief bilateral occlusion of infants nares (warn
  the parents first)
• Should be well lit

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INSPECTION

• Chest observation gives clues to cardiopulmonary
  disease
• Can be insensitive

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INSPECTION (cont.)

• Asymmetry can indicate RVE
• Increased A-P chest diameter indicates chronic
  air trapping/hyperinflation
• Pectus deformities--usually no significant
  cardiopulmonary consequences
• Kyphoscoliosis--can have cardiopulmonary effect

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INSPECTION (cont.)

• Polands anomaly (unilateral absence of
  pectoralis major/minor)
• Harrisons grooves seen in the lower chest
• Pulsations/rocking seen with large shunts, MR, or
  AI

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Apical Impulse

• Visualization to assess ventricular
  size/thickness
• Normally distinct and located at 4ICS at/inside
  the midclavicular line

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Apical Impulse (abnormal)

• Hyperdynamic impulse in normal location think
  increased cardiac output or LVH
• Hyperdynamic and downward/leftwardly displaced
  think LVE
• Indistinct impulse associated with RVH
• Precordial heave is seen with RVE

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PALPATION

• Sometimes overlooked and not always helpful
• Use the most sensitive portion of the hand
• Lay the heel of R hand at left sternal border
  with fingertips pointing to left axilla

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RV impulse

• Felt at the LSB--usually slight
• RVH (without RVE)--parasternal tap (sharply
  localized, quickly rising)
• RVE (with or without RVH)--parasternal lift
  (diffuse, gradually rising)

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LV/apical impulse (PMI)

• Found w/ the fingertips with the patient upright
• Note interspace location, relation to the
  midclavicular/anterior axillary line, amplitude
  compared to RV impulse

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LV/apical impulse (abnormal)

• Strong impulse is due to increased cardiac output
  or LVH
• Downward/leftward displacement--LVE (with or
  without LVH)

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Thrills

• Palpation of a loud murmur
• Found in the precordial, suprasternal, or carotid
  artery area
• If low intensity murmur, probably just a
  pulsation and NOT a thrill

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PERCUSSION

• Usually not performed for cardiac borders, but
  for lung fields
• Should be done in the upright position (even
  infants can be held upright....)

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AUSCULTATION the bread and butter of the
business
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Where to listen

• Apex/5LICS (mitral area)
• Left lower sternal border/4LICS (tricuspid and
  secondary aortic area)
• Right middle sternal border/2RICS (aortic area)
• Left middle sternal border/2LICS (pulmonary area)

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Where to listen (cont.)

• Left and right infraclavicular areas
• Left anterior axillary line
• R and L axillae
• R and L interscapular areas of back (for
  pulmonary/aortic collaterals)

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Where to Listen (Other sites)

• Lungs
• Cranium (temples/orbits/fontanelle)
• Liver
• Neck (carotid area)
• Abdomen
• Lumbar/abdominal region over renal area
• Mouth/trachea with respiration
• Femoral artery

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How to listen

• Have a system, e.g. method of inching
• Listen systematically S1, S2, systolic sounds,
  systolic murmurs, diastolic sounds, diastolic
  murmurs

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Normal heart sounds
LUB
DUP
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S1

• May be due to acceleration/deceleration phenomena
  in the LV near the A-V valves
• Best heard at the apex and LLSB
• Often sounds single unless slow heart rate

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S1 (cont.)

• If split heard better at the apex, may actually
  be S4 or ejection click
• Tends to be more low-pitched and long as compared
  to S2
• Differentiate S1 from S2 by palpating carotid
  pulse
• S1 comes before and S2 comes after carotid
  upstroke

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Decreased S1

• Slowed ventricular ejection rate/volume
• Mitral insufficiency
• Increased chest wall thickness
• Pericardial effusion
• Hypothyroidism

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Decreased S1 (cont.)

• Cardiomyopathy
• LBBB
• Shock
• Aortic insufficiency
• First degree AV block

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Other Abnormal S1 (cont.)

• Increased S1
• Increased cardiac output
• Increased A-V valve flow velocity (acquired
  mitral stenosis, but not congenital MS)
• Wide splitting of S1
• RBBB (at tricuspid area)
• PVCs
• VT

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S2

• From closure vibrations of aortic and pulmonary
  valves
• Often ignored, but it can tell much
• Divided into A2 and P2 (aortic and pulmonary
  closure sounds)
• Best heard at LMSB/2LICS
• Higher pitched than S1--better heard with
  diaphragm

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S2 splitting (normal)

• Normally split due to different impedance of
  systemic and pulmonary vascular beds
• Audible split with gt 20 msec difference
• Split in 2/3 of newborns by 16 hrs. of age, 80
  by 48 hours
• Harder to discern in heart rates gt 100 bpm

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S2 splitting (normal, cont.)

• Respiratory variation causes ? splitting on
  inspiration ? pulmonary vascular resistance
• When supine, slight splitting can occur in
  expiration
• When upright, S2 usually becomes single with
  expiration

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S2 splitting (abnormal)

• Persistent expiratory splitting
• ASD
• RBBB
• Mild valvar PS
• Idiopathic dilation of the PA
• WPW

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S2 splitting (abnormal, cont.)

• Widely fixed splitting
• ASD
• RBBB

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S2 splitting (abnormal, cont.)

• Wide /mobile splitting
• Mild PS
• RVOTO
• Large VSD or PDA
• Idiopathic PA dilation
• Severe MR
• RBBB
• PVCs

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S2 splitting (abnormal, cont.)

• Reversed splitting
• LBBB
• WPW
• Paced beats
• PVCs
• AS
• PDA
• LV failure

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Single S2

• Single S2 occurs with greater impedance to
  pulmonary flow, P2 closer to A2
• Single and loud (A2) TGA, extreme ToF, truncus
  arteriosus
• Single and loud (P2) pulmonary HTN!!
• Single and soft typical ToF
• Loud (not single) A2 CoA or AI

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Extra heart sounds
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S3 (gallop)

• Usually physiologic
• Low pitched sound, occurs with rapid filling of
  ventricles in early diastole
• Due to sudden intrinsic limitation of
  longitudinal expansion of ventricular wall
• Makes Ken-tuck-y rhythm on auscultation

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S3 (cont.)

• Best heard with patient supine or in left lateral
  decubitus
• Increased by exercise, abdominal pressure, or
  lifting legs
• LV S3 heard at apex and RV S3 heard at LLSB

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S3 (abnormal)

• Seen with Kawasakis disease--disappears after
  treatment
• If prolonged/high pitched/louder
• can be a diastolic flow rumble indicating
  increased flow volume from atrium to ventricle

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S4 (gallop)

• Nearly always pathologic
• Can be normal in elderly or athletes
• Low pitched sound in late diastole
• Due to elevated LVEDP (poor compliance) causing
  vibrations in stiff ventricular myocardium as it
  fills
• Makes Ten-nes-see rhythm

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S4 (cont.)

• Better heard at the apex or LLSB in the supine or
  left lateral decubitus position
• Occurs separate from S3 or as summation gallop
  (single intense diastolic sound) with S3

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S4 Associations

• CHF!!!
• HCM
• severe systemic HTN
• pulmonary HTN
• Ebsteins anomaly
• myocarditis

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S4 Associations (cont.)

• Tricuspid atresia
• CHB
• TAPVR
• CoA
• AS w/ severe LV disease
• Kawasakis disease

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Click

• Usually pathologic
• Snappy, high pitched sound usually in early
  systole
• Due to vibrations in the artery distal to a
  stenotic valve

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Can be associated with

• Valvar aortic stenosis or pulmonary stenosis
• Truncus arteriosus
• Pulmonary atresia/VSD
• Bicuspid aortic valve
• Mitral valve prolapse (mid-systolic click)
• Ebsteins anomaly (can have multiple clicks)

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Does NOT occur w/ supravalvar or subvalvar AS, or
calcific valvar AS.
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Whoop (sometimes called a honk)

• Loud, variable intensity, musical sound heard at
  the apex in late systole
• Classically associated w/ MVP and MR
• Seen w/ VSDs closing w/ an aneurysm, subAS,
  rarely TR
• Some whoops evolve to become systolic murmurs

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Friction rub

• Creaking sound heard with pericardial
  inflammation
• Classically has 3 components can have fewer than
  3 components
• Changes with position, louder with inspiration

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Murmur

• Sounds made by turbulence in the heart or blood
  stream
• Can be benign (innocent, flow, functional) or
  pathologic
• Murmurs are the leading cause for referral for
  further evaluation
• Dont let murmurs distract you from the rest of
  the exam!!

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Cardiac exam and murmur general descriptors

• Various combinations used for all normal and
  abnormal heart sounds

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General descriptors

• Heart sound splitting
• Grade/intensity
• Phase
• Shape
• Pitch

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General descriptors (cont.)

• Timing within the phase
• Duration within the phase
• Character/quality
• Location of maximum intensity on the precordium
• Radiation of murmur

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MANEUVERS
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Routine positions--

• Supine and standing or sitting examinations
  should be performed on all patients

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Other physical maneuvers
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Squatting

• Increases afterload/systemic vascular resistance,
  initially increased venous return, increased
  stroke volume, decreased HR
• Reduces the murmur of AS w/ HCM
• Increases the murmur of MR

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Sudden standing

• Decreased afterload, decreased venous return and
  stroke volume, increased heart rate, increased
  SVR)
• Accentuates the murmur and S4 of subAS, MVP, and
  HOCM

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Left lateral decubitus positioning or leaning
forward in an upright
position

• Apex of the heart falls toward the chest wall
• Brings out mitral valve and aortic valve murmurs

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Some maneuvers for innocent murmurs (more later)

• Jugular vein compression/turning the head can
  abolish venous hum
• Lying the patient perfectly flat is the most
  reliable method of quieting the hum.
• Compression of the subclavian artery or shoulder
  extension can abolish supraclavicular bruit

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Other maneuvers

• Transient arterial occlusion
• Breath-holding in end-expiration in the upright
  position or leaning forward
• Deep breath inspiration in upright position
• Lower extremity elevation (passive) while lying
  down
• Exercise (running in place)

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Other maneuvers (cont.)

• Isometric handgrips
• Valsalva (straining) maneuver--forced expiration
  against a closed glottis after full inspiration
  for at least 10 seconds
• Chemical maneuvers--rarely, if ever, performed
  today due to better imaging techniques

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THE REST OF THE BODY--dont forget it!!
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Vital signs

• Temperature
• Respiratory rate
• Heart rate
• Blood pressure
• Oxygen saturations
• Weight and height

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Lungs

• Pulmonary congestion probably nonexistent in
  infants (more manifest by tachypnea or
  retractions)
• Cardiac asthma fine crackles heard in older
  children associated w/ CHF (coarse crackles
  indicate a pneumonia)

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Lungs (cont.)

• Possible signs of increased pulmonary blood flow
• Tachypnea
• Dyspnea
• Retractions
• Flaring
• Grunting
• Panting

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Edema

• Caused by systemic venous congestion
• Seen more in older children and adults (little
  evidence of this in infants)
• More often seen in renal- or liver-induced
  hypoproteinemia (esp. if marked)

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Edema (cont.)

• Locations
• Periorbital
• Scrotal
• Pre-sacral
• Hand/foot area
• Nonpitting pedal/hand edema or lymphedema in a
  newborn think Turners or Noonans syndrome

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Liver

• Measure at midclavicular line where it crosses
  the 9th costal cartilage
• Can be right-sided (situs solitus), left-sided
  (situs inversus), or midline (situs
  ambiguous--measured subxiphoid)

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Liver (cont.)

• Measurements
• 2-3 cm below the RCM in the infant
• 2 cm below the RCM from 1-3 years of age
• 1 cm below the RCM from 4-5 years of age
• Use warm, gentle hands

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Liver--abnormal

• Hepatomegaly caused by systemic venous congestion
• Right-sided CHF liver enlarges, becomes firm,
  loses distinct edge
• Pulsatile liver tricuspid regurgitation or
  other cause of elevated R sided pressures
• Hard liver may be more serious than large, soft
  liver

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Spleen

• Normally felt in newborns under the LCM
• Significant enlargement can indicate TORCH
  infection with an associated cardiac lesion
• Isolated splenomegaly is usually not seen w/ CHF

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Infective endocarditis

• Splenomegaly
• New/changing murmur
• Fever
• Positive blood cultures
• Neurologic changes
• Peripheral signs of embolic phenomena

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Ascites

• Severe right or right AND left sided CHF--from
  Fontan anastomosis, dilated cardiomyopathy

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Nutrition/muscle mass

• Wasting (systemic, bitemporal)--from poor
  nutrition/high metabolic demand (CHF)

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Skin

• Sweating and pallor (diaphoresis) --associated
  with increased adrenergic tone

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Cyanosis of the mucus membranes

• Central--from gt 3g reduced Hb in the arterial
  blood due to cardiac or pulmonary shunting
• Acrocyanosis--from low cardiac output
• Differential cyanosis

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Arterial Pulses

• Assess for rate, rhythm, volume, character
• Evaluate radial, brachial, femoral, pedal
  (dorsalis pedis or posterior tibialis) pulses
• Also palmar and plantar pulses in newborns
• Congenital absence of dorsalis pedis in 10 of
  population
• Simultaneous evaluation of both radial pulses and
  R radial plus a femoral pulse

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Rate

• Bradycardic (conditioning, heart block, digoxin
  toxicity)
• Normal
• Tachycardic (CHF, excitement, fever, anemia,
  arrhythmia)

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Rhythm

• Regular
• Irregular (can be sinus arrhythmia with
  respiratory variation or PAC/PVCs)
• Regularly irregular
• Irregularly irregular (arrhythmia)

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Volume

• Bounding/water hammer (pulse pressure gt30 mmHg in
  infant, gt50 mmHg in child)
• Full
• Normal
• Thready
• low output states shock, severe CHF, large VSD
  or PDA
• L sided obstruction AS, aortic atresia, HLHS
• Absent

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Character

• Normal
• Alternans
• Bisferiens
• Paradoxus

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Clubbing

• Thickening of tissues at the base of the nails
• Due to capillary engorgement associated with
  chronic hypoxemia and polycythemia.
• Seen in cyanotic congenital heart disease and
  pulmonary disease
• Can reverse after improvement of hypoxemia, can
  disappear with anemia

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OTHER SYSTEMS
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Facial features of certain syndromes, chromosomal
anomalies, and associations important to
recognize

• Anomalies of the eyes and lens, nose, ears,
  mandible/maxilla, tongue, dentition and gingiva,
  asymmetry of the facial musculature, etc.

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CNS

• Developmental delay
• Seizures
• Certain personality traits associated with these
  findings (usually not in isolation)

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Extremities

• Abnormal palmar creases
• Polydactyly
• Arachnodactyly
• Thumb/radial anomalies
• Phocomelia
• Pseudohypertrophy
• Nail anomalies

90
GI tract

• T-E fistula
• Omphalocele
• Imperforate anus
• Diaphragmatic hernia
• Esophageal or duodenal atresia

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GU tract

• Renal anomalies
• Bladder anomalies
• Gonadal dysgenesis
• External genitalia anomalies
• Nephrocalcinosis

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Skeleton

• Scoliosis
• Sternal anomalies
• Tall or short stature
• Hypermobility of the joints
• Fused/hemi/absent/butterfly vertebrae
• Caudal regression

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Skin

• Poor wound healing
• Increased elasticity
• Lentigines/nevi
• Hemangiomata
• Petechiae
• Fragility/bruisability
• Cafe au lait spots

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Endocrine anomalies

• Hypercalcemia
• Hypocalcemia
• Hyper or hypothyroidism
• Hypogonadism
• Renal tubular acidosis

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INNOCENT MURMURS
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INNOCENT MURMURS

• Also known as flow, benign, normal,
  nonpathologic, functional, inorganic, or
  physiologic
• Occur in up to 77 of neonates, 66 of children,
  and can be increased to up to 90 with exercise
  or using phonocardiography

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General Rules of Innocent Murmurs

• Grade I-III intensity
• No thrills associated at any area of precordium
• Only minimal transmission
• Not harsh
• Brief duration (usually early to mid-systole)

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More General Rules of Innocent Murmurs

• Never solely diastolic
• Never loudest at the RUSB/R base
• No clicks
• Normal S2

99
Occur at areas of mismatch of normal blood flow
volumes with decreasing vessel caliber size

• e.g. LVOT, RVOT, branch PAs, etc.
• Better heard in children due to their thinner
  chest walls with greater proximity of stethoscope
  to vessel

100
Having more than one innocent murmur in a patient
is normal, too!
101
Vibratory Systolic Murmur (Stills Murmur)

• Most common innocent murmur of childhood
• Needs maneuvers ? normal ECG to differentiate
  from subAS, HOCM, VSD

102
Stills Murmur (Characteristics)

• Locationmax at LLSB
• Radiationmay radiate to LMSB, apex, and R-L base
  (hockey-stick distribution), although may not
  completely radiate
• Timingmid-systole
• Intensitygrade I-II
• Pitchmid to low

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Stills Murmur (Characteristics, cont.)

• Charactervibratory, groaning, musical, buzzing,
  squeaking, guitar-string twanging, cooing
  dove
• Variationloudest supine, after exercise, with
  fever, anemia, or excitement Disappears or
  localizes to LLSB when upright

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Stills Murmur (Characteristics, cont.)

• Age rangeuncommon in infancy, commonly age 2 to
  6 years, rare in teens
• Etiologyunknown, may be associated with LV
  ejection
• Similar murmur seen with LV false tendons (but
  does not tend to diminish as much when upright)

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Innocent Pulmonary Systolic Murmur

• Need to differentiate from ASD, PS, subAS, VSD,
  and true/organic PPS

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Innocent Pulmonary Systolic Murmur
(Characteristics)

• LocationLUSB
• Radiationpossible to hear at LMSB
• Timingearly to mid-systole with peak in
  mid-systole

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Innocent Pulmonary Systolic Murmur
(Characteristics, cont.)

• Intensitygrade I-III
• Pitchmid to high-pitched
• Charactersoft, blowing, somewhat grating,
  diamond-shaped

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Innocent Pulmonary Systolic Murmur
(Characteristics, cont.)

• Variationlouder when supine, fever, exercise,
  anemia
• Age rangemost commonly age 8-14 years, but early
  childhood to young adults
• Etiologynormal ejection vibrations into MPA

109
Physiologic Peripheral Pulmonic Stenosis (PPS)

• Need to differentiate from valvar PS, ASD,
  true/organic PPS, and ToF

110
Physiologic PPS (Characteristics)

• LocationLUSB
• RadiationLMSB, bilateral axillae, mid-back,
  approximately same intensity over entire
  precordium
• Timingearly to mid-systole

111
Physiologic PPS (Characteristics, cont.)

• Intensitygrade I-II
• Pitchhigh-pitched
• Characterblowing, not harsh, diamond-shaped
• Variationnone

112
Physiologic PPS (Characteristics, cont.)

• Age rangenewborns, especially premies. May last
  3 6 months but not longer (requires further
  eval if persistent)
• Etiologysmall relative size of branch PA
  bifurcation to MPA at birth with acute angle ?
  turbulence and relative obstruction

113
Supraclavicular or Brachiocephalic Systolic
Murmur (Carotid Bruit)

• Need to differentiate from supravalvar or valvar
  AS, CoA, bicuspid AoV
• Bruit is French for noise

114
Carotid Bruit (Characteristics)

• Locationsuprasternal notch, supraclavicular
  areas
• Radiationcarotids, below clavicles
• Timingearly to mid-systole

115
Carotid Bruit (Characteristics, cont.)

• Intensitygrade I-III, ?IV (may have a faint
  localized thrill)
• Pitchmid-pitched
• Charactermay be slightly harsh

116
Carotid Bruit (Characteristics, cont.)

• Variationdecreased intensity with hyperextension
  of shoulders louder with anxiety, anemia, or
  trained athletes w/ resting bradycardia
• Age rangechildren and young adults
• Etiologyunknown, ? turbulence at takeoff of
  carotid or brachiocephalic vessels

117
Venous Hum

• Most common continuous innocent murmur, and
  probably the second most common innocent murmur
• Need to differentiate from AS/AI, AVM, anomalous
  left coronary artery arising from the PA, or PDA
  if L-sided

118
Venous Hum (Characteristics)

• Locationanterior neck to mid-infraclavicular
  area, R side gt L side
• Radiationmay go to LMSB
• Timingcontinuous with diastolic accentuation
• Intensitygrade I-III
• Pitchmid to low

119
Venous Hum (Characteristics, cont.)

• Charactersoft, whispering, roaring, or blowing,
  distant-sounding
• Variationdisappears when supine, with head turn
  AWAY from the side listened to, with gentle
  manual compression of jugular venous return w/
  fingers, or w/ Valsalva

120
Venous Hum (Characteristics, cont.)

• Age range
• pre-school through grade school age (very common)
• adol. to young adults (rarely heard, can be seen
  w/ increased blood flow states e.g. anemia,
  pregnancy, thyrotoxicosis)
• Etiologyturbulence in jugular and subclavian
  venous return meeting in SVC

121
Mammary Souffle

• Occurs in certain circumstances of breast
  development/activity and disappear otherwise
• Differentiate from PDA, AVM, or AS/AI
• Souffle is French for breath

122
Mammary Souffle (Characteristics)

• Locationheard over/just above breasts in late
  pregnancy or in lactating women
• Radiationnone
• Timingmay be systolic only, systole with
  diastolic spill-over, or continuous with late
  systolic accentuation (most common)

123
Mammary Souffle (Characteristics, cont.)

• Intensitygrade I-III
• Pitchmid to high
• Characterblowing or breath-like
• Variationobliterated by increased stethoscope
  pressure or compressing the tissue on both sides
  of the stethoscope

124
Mammary Souffle (Characteristics, cont.)

• Age rangerare (hopefully!) in pediatric
  population
• Etiologyincreased blood flow to the relatively
  smaller mammary blood vessels