Cardiovascular Assessment

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Cardiovascular Assessment

• Cardiac Portion of
• Complete Physical Assessment

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Prime SuspectThe Heart and the Vascular System

• Cardiovascular system
• Continuous, fluid-filled elastic circuit with a
  pump which connects all systems to each other
• communication / transportation of
• respiratory - oxygen and carbon dioxide
• endocrine - hormones, buffers and enzymes
• Gastrointestinal - nutrients, water, vitamins and
  minerals
• Consist of the heart and vascular system

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Cardiac Assessmentbegins at Introduction

• Beginning with Vital Signs
• Blood Pressure
• Heart Rate
• Temperature
• When confronted with multiple clients quick
  assessment can help prioritize and help in doing
  complete assessment.

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• Introduce yourself (LOC)
• assess that they know who, where, and why
• How do they feel
• Is it neurologic, endocrine problem, or could it
  be that they are not getting blood to brain
• Could be
• Low Blood pressure
• Low hemoglobin
• Vascular Problems
• Carotid disease

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Interview

• Chief Complaint
• Chest Pain
• may be identified as
• Indigestion
• burning
• discomfort
• tightness
• pressure in mid-chest
• left arm
• jaw pain

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• Description of chest Pain (PQRST)
• P - rovication - What provokes or makes worse
• Palliation - what relieves or does not
• Q-uality - what does it feel like
• R -egion - where is the pain and does it radiate
• S-everity - scale 0-10
• T-iming - continuous or intermittent.
  Relationship to other activities.

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• Dyspnea
• SOB
• Exertional
• Orthopnea - unable to lie flat
• Paroxysmal nocturnal
• wake up 2 hrs after sleep SOB, if accompanied
  by wheeze called - Cardiac asthma
• Cardiac cough - occurs at night in supine
  position, exertion, or turning to one side
• Headache
• Hypertension

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• Syncope
• Effort synocope - after heavy activity is started
  
• Aortic or subaortic stenosis.
• Stokes-Adams attack
• related to HB or rhythm disturbance
• Pacemaker syncope
• Malfunction or failure of artificial pacemaker
• Hypersensitive Carotid sinus syncope
• caused by pressure applied to carotid sinus body

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• Abdominal pain
• related to RVF (Right Ventricular Failure)
• Fatigue or weakness
• related to RVF
• Edema or weight gain
• related to RVF

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Korotkoffs Sounds

• Sounds heard during auscultation of blood
  pressure.
• Produced by vibratory motion of the arterial
  wall as the artery suddenly distends when
  compressed by a pneumatic BP cuff.
• Origin of sound may be within the blood passing
  through the vessel wall or within the wall itself.

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• 5 distinct Korotkoff sounds heard during
  auscultation of BP
• 1st - beat or tapping sound
• 2nd - murmur or swish sound
• 3rd - crisp tapping sound
• 4th - soft, muffled tone
• 5th - the last sound heard
• Systolic - The first beat or tapping heard
• Diastolic - The fourth sound heard

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Blood Pressure Measurement

• Materials needed
• Stethoscope
• Sphygmomanometer
• Alcohol sponge
• Choose cuff of appropriate size
• Too narrow may cause falsely high pressure
• Excessive wide a falsely low pressure

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• Patients arm should be extended at heart level.
• Artery above or below heart level, blood pressure
  may be elevated or decreased consecutively.
• Wrap deflated cuff snugly around upper arm
• Above antecubital area inner aspect of elbow.
• Center of bladder should rest directly over
  medial aspect of arm. (Most cuffs have an arrow
  for you to position over brachial artery at where
  you feel strongest pulse)

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• Place Bell of stethoscope on brachial artery at
  point of strongest pulse
• Locate brachial artery by palpation.
• Center the bell over the artery and hold it in
  place with one hand. The bell of the stethoscope
  transmits low pitched arterial blood sounds more
  effectively than the diaphragm.
• Pump air into cuff while auscultating the sound
  over brachial artery - until gauge registers
  160mm HG or at least 30 mm Hg above last audible
  sound.

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• Open valve and slowly deflate the cuff - 5 mm Hg
  / second. While releasing air - watch the column
  and auscultate the sound over the artery.
• When you hear the first beat or clear tapping
  note pressure on column. This is the SYSTOLIC
  pressure.
• Continue to release air gradually.
• Note the fourth Korotkoff sound (a soft, muffled
  tone) This is the DIASTOLIC pressure.
• Deflate the cuff quickly.

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• Problem and Possible Cause for
• False-high reading
• Cuff too small - (bladder must be approximately
  20 wider than the circumference o f arm).
• Cuff wrapped too loosely, reducing effectiveness
  (tighten cuff)
• Slow cuff deflation, causing venous congestion in
  arm ( Never deflate the cuff more slowly than 2
  mm Hg/ heartbeat)
• Tilted mercury column (Read pressure column
  vertically)
• Poorly timed measurement -after eating,
  ambulated, appeared anxious, or flexed arm
  muscles.

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• False-low reading
• Incorrect position of arm (make sure the arm is
  level with patients heart)
• Mercury column below eye level (Read the mercury
  column at eye level)
• Failure to notice auscultatory gap (sound fades
  out for 10 - 15 mm Hg, then returns (estimate
  systolic pressure by palpation before actually
  measuring it)
• Inaudible low-volume sound (Chart as the palpated
  systolic pressure)

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Heart Rate

• Gently press your index, middle, and ring finger
  on the radial artery, inside the patients wrist.
• Count the beats for 60 seconds, or for 30 seconds
  and multiply by 2. (60 second count more
  efficient.)
• Assess rhythm and volume by noting the pattern
  and strength. If you detect an irregular beat,
  repeat the count. IRREGULARITIES ARE IMPORTANT
  SIGNS

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Skin and Appendages

• Color
• The range of expected skin color varies from dark
  brown to light tan with pink or yellow overtones.
• Pallor may be indicator of
• anemia
• SNS
• Sympathomimetics
• Dopamine

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• Cyanosis (Peripheral vs. Central Cyanosis)
• Peripheral (cold) cyanosis
• Fingertips
• Toes
• Associated with peripheral hypoperfusion or
  vasoconstriction

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Cyanosis (Central)

• Central (warm) cyanosis
• Seen on lips, tongue, mucous membranes
  associated with deoxygenated hemoglobin note in
  dark-skinned persons - appear as ashen color
• May be late sign of hypoxemia in anemic clients
• May be early sign of hypoxemia in Chronic
  Bronchitis (Blue Bloaters)
• Blue because of chronic hypoxemia
• Bloaters because of Chronic Right Ventricular
  failure

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• Moisture
• Diaphoretic
• Dryness
• Temperature
• Cold skin may be related to hypoperfusion
• Turgor
• Decrease in skin turgor (tenting) related to
  interstitial dehydration
• Edema
• Indicates increase in interstitial fluid

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Edema

• Note location
• Facial
• allergies -anaphylaxis
• Steroids
• exogenous
• prednisone
• endogenous - Cushings syndrome
• Renal disease - Nephrotic syndrome
• Dependent RVF

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• Degree of Pitting
• Grade 1 - 0 to 1/4 in.
• Grade 2 -1 /4 to 1/2 in
• Grade 3 - 1/2 to 1 in.
• Grade 4 - gt 1 in.

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Lesions

• Arterial disease
• may cause ulcers at the toes or points of trauma
• Venous disease
• may cause ulcers at sides of ankles

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Arterial Disease

• Excruciating pain in acute occlusions
• Intermittent claudication in chronic occlusions
• Pulses are diminished or absent
• Color is pale
• Temperature cool or cold
• Edema is absent
• Skin changes
• Thin, shiny, atrophic skin
• Loss of hair
• thickened toenails
• Ulcerations
• At toes or points of trauma

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Venous Disease

• Crampy pain
• Homans sign in thrombophlebitis
• Normal pulses (may be difficult to palpate due to
  severe edema)
• Normal to ruddy color
• Warm to touch
• Edema - may be severe
• Skin Changes
• Brown pigmentation at ankles
• Ulcerations
• At sides of ankles

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Fingertips and nail-beds

• Color
• bluish nail-beds with peripheral disease
• Capillary refill lt3 sec
• gt3 - hypoperfusion
• Clubbing
• Loss of normal angle between base of nail and
  skin
• indicates chronic hypoxia

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• Splinter hemorrhages
• Red to black linear streaks running from base to
  tip of nail
• bacterial endocarditis
• Oslers nodes
• Painful red subcutaneous nodules on fingertips
• indicate embolization of bacterial endocarditis

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• Peripheral Pulses
• Carotid - palpate only lower half and never
  palpate both carotids simultaneously
• Brachial
• Radial and Ulnar
• Femoral
• Popliteal
• Posterior tibialis
• Dorsalis Pedis

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• Pulse contour
• Pulsus Magnus
• readily palpable - not easily obliterated
• Characteristic of
• Hypertension
• Aortic Insufficiency
• Pulsus Parvus
• Pulse difficult to feel, easily obliterated
• small weak pulse
• Characteristic of
• Aortic and/or mitral Stenosis
• Cardiac Tamponade
• Constrictive Pericarditis

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• Pulsus Alternans
• Pulses have large amplitude beats followed by
  pulses of small amplitude
• Every other beat weaker than the preceding one
• Characteristic of Left Ventricular Failure
• Pulsus Paradoxus
• Exaggeration of normal response to inspiration
• Normal decrease in BP during inspiration is 10
  mmHg or less
• BP drop more than 10 mmHg during inspiration
• Characteristic in
• Pericardial effusion
• Cardiac tamponade
• Advanced HF
• Severe Lung disease

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• Pulsus Bisferiens
• Two pulses palpated during systole with second
  slightly weaker than the first
• Characteristic of
• Hypertrophic Cardiomyopathy
• Aortic stenosis or regurgitation
• Water-hammer (Corrigans) pulse
• Increased pulse pressure with a rapid upstroke
  and downstroke and shortened peak
• Characteristic of Aortic Regurgitation

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Head and Neck

• Head
• Head bobbing up and down with heartbeat
• Called de Mussets sign
• Indicates aortic aneurysm or regurgitation
• Eyes
• Exophthalmos - abnormal protrusion of the eye
• Usually due to hyperthyroidism
• May be seen in advanced HF with Pulmonary
  hypertension

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• Ears
• Diagonal bilateral earlobe creases (McCartys
  sign)
• May indicate coronary artery disease if seen in
  individuals lt 45 years of age.

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Neck

• Neck vein distention of greater than 2 cm above
  the sternal angle is indicative of any of the
  following
• Right Ventricular Failure
• Hypervolemia
• Tension Pneumothorax
• Cardiac Tamponade

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• To Evaluate
• Place patient at 45 degree angle
• Identify sternal angle
• raised notch that is created where the manubrium
  and the body of the sternum join - (Angle of
  Lewis)
• Measure height of neck distention above level of
  sternal angle

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Estimate Central Venous Pressure

• Add 5 cm to height of neck vein distention
• Normal CVP is 3 to 8 cm
• Evaluate hepatojugular or abdominojugular reflux
• Apply pressure over right upper quadrant
• Evaluate increase in neck vein distention
• Increase gt 3 cm
• Hepatojugular reflux and Right ventricular failure

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Landmarks

• Anatomic
• Clavicle
• Sternum
• Ribs
• Intercostal spaces
• Angle of Louis
• Xiphoid process
• Costal margin and angle

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Imaginary Landmarks

• Mid-sternal line (MSL)
• Mid-clavicular Line (MCL)
• Anterior Axillary Line (AAL)
• Midaxillary Line (MAL)
• Posterior Axillary line (PAL)
• Scapular Line (SL)
• Midspinal line

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Location of Heart

• Between the sternum and spinal column
• Lies between second intercostal space and Fifth
  intercostal space (5 ICS)
• Apex normally at fifth LICS and MCL

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PrecordiumInspect and Palpate

• Point Of Maximum Impulse (PMI)
• Frequently visible and usually palpable
• Location
• Fifth LICS and MCL
• Lateral displacement
• Left ventricular dilation (aortic or mitral
  insufficiency)
• Upward displacement (pregnancy, ascites)
• Right to left mediastinal shift
• Tension Pneumothorax
• Left ventricular hypertrophy or failure

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• Medial Displacement
• Downward displacement of the diaphragm
• COPD
• Left to right mediastinal shift
• Left Pleural Effusion
• Tension Pneumothorax
• Intensity
• normally light tap
• HF may increase (cause heave)

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• Size of PMI
• 1 - 2 cm
• Heave
• Lifting of chest wall (indicative of failure)
• Left ventricular heave felt at or near the apex
• Right ventricular heave (or lift) felt at or near
  the sternum

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• Thrill
• Palpable vibration associated with a murmur or
  bruit
• Felt where the murmur is heard the loudest or a
  location of a bruit.
• Murmur - a periodic sound of short duration
  intracardiac in origin.
• Bruit - a sound or murmur heard, extracardiac.

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Auscultation

• Stethoscope
• snug fitting earplugs
• Tubing
• two tubings preferable for high frequency sounds
• Not longer than 12 to 15 inches

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• Chest Piece
• Diaphragm - held firmly against skin
• Used for high pitched sounds
• S1, S2 and splits, pericaridal friction rubs,
  most murmurs
• Bell- held tightly enough against skin to create
  seal
• Used for low pitched sounds S3, S4

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• Auscultation Areas
• Aortic - 2nd RICS at Right sternal border
• Pulmonic - 2nd LICS at Left sternal border
• Erbs Point - 3rd LICS at Left sternal border
• Tricuspid - 5th LICS at Left sternal border
• Mitral - 5th LICS at mid-clavicular line

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• Auscultation should be performed in each of the
  five cardiac areas
• use of the diaphragm first, then the bell of the
  stethoscope. Using firm pressure with the
  diaphragm and light pressure with the bell
• Assess the overall rate and rhythm of the heart
  -noting the area being accessed.
• Breathing normally, then holding breath listen
  for S1 while palpating the carotid pulse. S1
  coincides with the rise of the carotid pulse.
  (Systole)
• Note the intensity, any variations, the effect of
  respiration and any splitting of S1

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Basic Heart Sounds

• There are four basic heart sounds S1, S2, S3 and
  S4. S1 and S2 are the most distinct heart
  sounds.
• S3 and S4 may or may not be present their
  absence is not an unusual finding, but their
  presence does not necessarily indicate a
  pathologic condition.

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Rules to consider

• Left sided heart events precede right side
  (mitral component precedes tricuspid of S1,
  Aortic event precedes pulmonic of S2)
• Left sided heart events are normally loudest
  during expiration, and right sided events are
  normally loudest during inspiration.

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• S1 is the result of the closure of the AV valves
• indicate the beginning of systole and is best
  heard toward the apex where it is usually louder
  than S2
• S2 is the result of closure of the semi-lunar
  valves and indicates the end of systole
• indicates the end of systole and is best heard in
  the aortic and pulmonic areas.

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Heart sounds according to Cardiac Area

• Aortic area
• Loudness - S1lt S2
• Duration - S1 gt S2
• Pulmonic area
• Loudness - S1 lt S2
• Duration - S1 gt S2
• Erbs Point
• Loudness - S1 lt S2
• Duration - S1 gt S2

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• Mitral area
• Loudness - S1 gt S2
• Duration - S1 gt S2
• Tricuspid Area
• Loudness - S1 gt S2
• Duration - S1 gt S2

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Splitting of S1 and S2

• S1
• usually is not heard because the sound o the
  tricuspid valve closing is too faint to hear.
• Heard best when audible in the tricuspid area
• S2
• Expected due to the higher pressures and
  depolarization occurs earlier on the left side of
  the heart.
• Ejection times on the right are longer and
  pulmonic valve closes a bit later than the aortic
  valve.

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S1 and S2 Split

• S1 is the result of closure of the AV valves -
  indicating the beginning of systole. Mitral and
  Tricuspid valves.
• Heard best at tricuspid area on inspiration.

• Although there is some asynchrony between closure
  of the mitral and tricuspid valves - usually
  heard as one sound.
• Narrowly split may be normal

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• A split S1 is more abnormal than normal and is
  associated with any one of the following
• RBBB
• Left ventricular (epicardial) pacemaker
• Left ventricular ectopy

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• Split S2
• Both Aortic and Pulmonic components can be heard
• Inspiratory only is normal
• Called physiologic split of S2
• Split ONLY during inspiration
• Caused by intra-thoracic changes in pressure
  increased venous return to right and decreased
  venous return to left

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Expiratory Split of S2

• Increased splitting during inspiration (split on
  expiration but split more on inspiration)
• RBBB (Right Bundle Branch Block)
• Left ventricular ectopy
• Severe mitral regurgitation
• Ventricular septal defect

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S3

• Ventricular gallop
• Occurs early in diastole
• Caused by rapid rush of blood into a dilated
  ventricle.
• Heard best with bell
• Associated primarily with Heart Failure

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• Associated with
• Fluid overload
• Cardiomyopathy
• Ventricular septal defect
• Mitral or tricuspid regurgitation
• __S1____S2__S3

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S4

• Atrial Gallop
• Dull, low pitched occurring late in diastole
  before S1..
• Caused by atrial contraction and propulsion of
  blood into a non-compliant ventricle
• Heard best with bell

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• Associated with
• Myocardial ischemia or infarction
• Hypertension
• Ventricular ectopy
• AV blocks
• Severe aortic or pulmonic stenosis.
• __S4__S1___S2__

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Extra Heart Sounds

• Summation gallop
• All four heart sounds plus tachycardia
• Merging of S3 and S4 causing a louder
  mid-diastolic sound
• Pericardial friction rub
• scratchy sound - usually triphasic systolic,
  early and late diastolic
• Caused by pericardial inflammation
• after MI or CABG

• Snaps
• Opening snap
• Short, high-pitched early diastole
• Caused by
• Opening of stenotic AV valve
• Increased flow
• closing snap
• Really a loud S1
• Caused by closure of AV valve

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Murmurs

• Caused by turbulence
• Increased flow through a normal valve
• Forward flow through a stenotic valve
• Backward flow through a regurgitant valve
  (insufficient or incompetent)
• Flow through a AV fistula or septal defect
• Flow into a dilated chamber or a portion of a
  vessel

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• Description
• Timing
• Systolic
• Holosystolic AV regurgitation or VSD
• Midsystolic (Ejection) - Semilunar stenosis
• Late - papillary muscle dysfunction Hypertrophic
  cardiomyopathy (IHSS) Idiopathic hypertrophic
  subaortic stenosis.
• Location
• Place murmur is loudest
• Radiation
• Direction murmur radiates
• Intensity
• Levine scale

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• Levine scale
• Grade I/VI barely audible
• Grade II/VI clearly audible, but quiet
• Grade III/VI Moderately loud w/o a thrill
• Grade IV/VI Loud, w/ or w/o
• Grade VI/V Loud, thrill present, audible
  w/stethoscope partially off chest
• Grade VI/VI- loud, w/thrill, stethoscope off
  chest

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• Timing
• Synchronize S1 and S2 with Carotid pulse
• Listen for murmur
• Lub - murmur - dub is systolic murmur
• Lub - dub - murmur - is a diastolic murmur

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• Diastolic murmurs
• produced with a stenotic Mitral / Tricuspid
  valve
• Produced with a incompetent Aortic/Pulmonic valve

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• Systolic murmurs
• produced by a stenotic Aortic or Pulmonic valve
• Produced by incompetent Mitral / Tricuspid valve

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• Pitch
• High pitched (heard w/ diaphragm)
• Mitral / Tricuspid regurgitation
• Aortic / Pulmonic stenosis or regurgitation
• Low Pitched (heard best w/bell
• Mitral and Tricuspid stenosis
• Quality
• soft, harsh, blowing, musical, rumbling, or rough

• Vascular Sound bruit
• Turbulent sound
• may be heard over
• Carotid
• Aorta
• Renal
• Iliac
• Femoral
• Associated with plaque or aneurysm

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• Common Murmurs
• Holosystolic
• Mitral area
• toward L axilla
• Blowing, harsh
• Mitral regurgitation
• Tricuspid
• Along right sternal border
• Blowing, harsh
• Tricuspid Regurgitation
• 3-4 ICS at lower sternal border
• Harsh
• Ventricular septal rupture or defect

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• Midsystolic
• Aortic area
• Toward right side of neck
• Harsh
• Aortic Stenosis
• Pulmonic
• Toward Left side of neck
• Harsh
• Pulmonic Stenosis

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• Early diastolic
• Aortic or Erbs point
• Blowing
• Aortic Regurgitation
• Pulmonic
• Blowing
• Pulmonic Regurgitation
• Mid to late diastolic
• Mitral area
• Rumbling
• Mitral Stenosis
• Tricuspid
• Rumbling
• Tricuspid Stenosis1