propedevtika engleski etc

8/18/2019 propedevtika engleski etc

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The thyroid gland

Palpation: The thyroid can be examined while you stand in front of or behind the patient.

Exam from behind the patient is described below:

1. Stand behind the patient and place the middle three fingers of either hand along the

mid-line of the neck !ust below the chin. "ently walk them down until you reach the

top of the thyroid cartilage the first firm structure with which you come into contact.

#se gentle pressure otherwise this can be uncomfortable. $ake sure that you tell your

patients what you%re doing so they know you%re not trying to choke them& The cartilage

has a small notch in its top and is approximately 1.'-( cm in length. )s you cannot

actually see the area that you%re examining it may be helpful to practice in front of a

mirror. *ou can also try to identify and feel the structures from the front while looking

at the area in +uestion before performing the exam from behind.

(. ,alk down the thyroid cartilage with your fingers until you come to the horiontalgrooe which separates it from the cricoid cartilage /the first tracheal ring0. *ou

should be able to feel a small indentation /it barely accepts the tip of your finger0

between these ( structures directly in the mid-line. This is the crico-thyroid

membrane the site for emergent tracheal access in the eent of upper airway

obstruction.

. 2ontinue walking down until you reach the next well defined tracheal ring. 3ow slide

the three fingers of both hands to either side of the rings. The thyroid gland extends

from this point downwards for approximately (- cm along each side. The two main

lobes are connected by a small isthmus that reaches across mid-line and is almost

neer palpable. )pply ery gentle pressure when you palpate as the normal thyroid

tissue is not ery prominent and easily compressible. 4f you%re unsure or wish

confirmation hae the patient drink water as you palpate. The gland should slide

beneath your fingers while it moes upward along with the cartilagenous rings. 4t

takes a ery soft experienced touch in order to actually feel this structure so don%t be

disappointed if you can%t identify anything.

5. Pay attention to seeral things as you try to identify the thyroid: 4f enlarged /and this is a

sub!ectie sense that you will deelop after many exams0 is it symmetrically so6 #nilateral

s. bilateral6 )re there discrete nodules within either lobe6 4f the gland feels firm is it

attached to the ad!acent structures /i.e. fixed to underlying tissue.. consistent with malignancy0or freely mobile /i.e. moes up and down with swallowing06 4f there is concern re:

malignancy a careful lymph node exam /described aboe0 is important as this is the most

common site of spread.

The Thyroid Exam

Prior to palpation look at the thyroid region. 4f the gland is +uite enlarged you may actually notice it

protruding underneath the skin. To find the thyroid gland first locate the thyroid cartilage /a.k.a the

)dams )pple0 which is a mid-line bulge towards the top of the anterior surface of the neck. 4t%s

particularly prominent in thin males sits atop the tracheal rings and can be seen best when the patient

tilts their head backwards. 7eiation to one side or the other is usually associated with intra-thoracic pathology. 8or example air trapped in one pleural space /known as a pneumothorax0 can generate


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enough pressure so that it collapses the lung on that side causing mediastinal structures along with

the trachea to be pushed towards the opposite chest. This deiation may be isible on inspection and

can be accentuated by gently placing your finger in the top of the thyroid cartilage and noting its

position relatie to the midline. The thyroid gland lies approximately (- cm below the thyroid

cartilage on either side of the tracheal rings which may or may not be apparent on isual inspection.

4f you%re unsure gie the patient a glass of water and hae them swallow as you watch this region.Thyroid tissue along with all of the ad!acent structures will moe up and down with swallowing. The

normal thyroid is not isible so it%s not worth going through this swallowing exercise if you don%t see

anything on gross inspection.

Lymph Nodes: The ma!or lymph node groups are located along the anterior and posterior

aspects of the neck and on the underside of the !aw. 4f the nodes are +uite big you may be

able to see them bulging under the skin particularly if the enlargement is asymmetric /i.e. it

will be more obious if one side is larger then the other0. To palpate use the pads of all four

fingertips as these are the most sensitie parts of your hands. Examine both sides of the head

simultaneously walking your fingers down the area in +uestion while applying steady gentle pressure. The ma!or groups of lymph nodes as well as the structures that they drain are listed

below. The description of drainage pathways are rough approximations as there is fre+uently a

fair amount of ariability and oerlap. 3odes are generally examined in the following order:

Palpating Anterior Cervical Lymph

Nodes 1. )nterior 2erical /both superficial and deep0:

3odes that lie both on top of and beneath the

sternocleidomastoid muscles /S2$0 on either

side of the neck from the angle of the !aw to

the top of the claicle. This muscle allows the

head to turn to the right and left. The rightS2$ turns the head to the left and ice ersa.

They can be easily identified by asking the

patient to turn their head into your hand while

you proide resistance. 7rainage: The

internal structures of the throat as well as part

of the posterior pharynx tonsils and thyroid

gland.

(. Posterior 2erical: Extend in a line posterior to the S2$s but in front of the trapeius

from the leel of the mastoid bone to the claicle. 7rainage: The skin on the back of the head. )lso fre+uently enlarged during upper respiratory infections /e.g.

mononucleosis0.

. Tonsillar: 9ocated !ust below the angle of the mandible. 7rainage: The tonsilar and

posterior pharyngeal regions.

5. Sub-$andibular: )long the underside of the !aw on either side. 7rainage: The

structures in the floor of the mouth.

'. Sub-$ental: ust below the chin. 7rainage: The teeth and intra-oral caity.


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;. Supra-claicular: 4n the hollow aboe the claicle !ust lateral to where it !oins the

sternum. 7rainage: Part of the throacic caity abdomen.

) number of other lymph node groups exist. tonsilar region of otherwise

healthy indiiduals. This likely represents se+uelae of past pharyngitis or dental infections.

$alignancies may also inole the lymph nodes either primarily /e.g. lymphoma0 or as a site

of metastasis. 4n either case these nodes are generally:

• 8irm non-tender matted /i.e. stuck to each other0 fixed /i.e. not freely mobile but

rather stuck down to underlying tissue0 and increase in sie oer time.

The location of the lymph node may help to determine the site of malignancy. 7iffuse

bilateral inolement suggests a systemic malignancy /e.g. lymphoma0 while those limited toa specific anatomic region are more likely associated with a local problem. Enlargement of


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nodes located only on the right side of the neck in the anterior cerical chain for example

would be consistent with a s+uamous cell carcinoma fre+uently associated with an intra-oral

primary cancer.

T?@)A

Palpation: Palpation plays a relatiely minor role in the examination of the normal chest as

the structure of interest /the lung0 is coered by the ribs and therefore not palpable. Specific

situations where it may be helpful include:

1. )ccentuating normal chest excursion: Place your hands on the patient%s back with

thumbs pointed towards the spine. @emember to first rub your hands together so thatthey are not too cold prior to touching the patient. *our hands should lift

symmetrically outward when the patient takes a deep breath. Processes that lead to

asymmetric lung expansion as might occur when anything fills the pleural space /e.g.

air or fluid0 may then be detected as the hand on the affected side will moe outward

to a lesser degree. There has to be a lot of plerual disease before this asymmetry can be

identified on exam.


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(. Tactile 8remitus: 3ormal lung transmits a palpable ibratory sensation to the chest

wall. This is referred to as fremitus and can be detected by placing the ulnar aspects of

both hands firmly against either side of the chest while the patient says the words

B3inety-3ine.B This maneuer is repeated until the entire posterior thorax is coered.

The bony aspects of the hands are used as they are particularly sensitie for detecting

these ibrations.

Assessing Fremitus

Pathologic conditions will alter fremitus. 4n particular:

). 9ung consolidation: 2onsolidation occurs when the normally air filled lung

parenchyma becomes engorged with fluid or tissue most commonly in the

setting of pneumonia. 4f a large enough segment of parenchyma is inoled it

can alter the transmission of air and sound. 4n the presence of consolidation

fremitus becomes more pronounced.

C. Pleural fluid: 8luid known as a pleural effusion can collect in the potential

space that exists between the lung and the chest wall displacing the lung

upwards. 8remitus oer an effusion will be decreased.

Percussion: This techni+ue makes use of the fact that striking a surface which coers an air-

filled structure /e.g. normal lung0 will produce a resonant note while repeating the same

maneuer oer a fluid or tissue filled caity generates a relatiely dull sound. 4f the normal

air-filled tissue has been displaced by fluid /e.g. pleural effusion0 or infiltrated with white

cells and bacteria /e.g. pneumonia0 percussion will generate a deadened tone. )lternatiely

processes that lead to chronic /e.g. emphysema0 or acute /e.g. pneumothorax0 air trapping inthe lung or pleural space respectiely will produce hyper-resonant /i.e. more drum-like0

notes on percussion. 4nitially you will find that this skill is a bit awkward to perform. )llow

your hand to swing freely at the wrist hammering your finger onto the target at the bottom of

the down stroke. ) stiff wrist forces you to push your finger into the target which will not

elicit the correct sound. 4n addition it takes a while to deelop an ear for what is resonant and

what is not. ) few things to remember:


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1. 4f you%re percussing with your right hand stand a bit to the left side of the patient%s

back.

(. )sk the patient to cross their hands in front of their chest grasping the opposite

shoulder with each hand. This will help to pull the scapulae laterally away from the

percussion field.

. ,ork down the BalleyB that exists between the scapula and ertebral column which

should help you aoid percussing oer bone.

5. Try to focus on striking the distal inter-phalangeal !oint /i.e. the last !oint0 of your left

middle finger with the tip of the right middle finger. The impact should be crisp so you

may want to cut your nails to keep blood-letting to a minimum&

'. The last ( phalanges of your left middle finger should rest firmly on the patient%s back.Try to keep the remainder of your fingers from touching the patient or rest only the

tips on them if this is otherwise too awkward in order to minimie any dampening of

the perucssion notes.

;. ,hen percussing any one spot ( or sharp taps should suffice though feel free to do

more if you%d like. Then moe your hand down seeral inter-spaces and repeat the

maneuer. 4n general percussion in ' or so different locations should coer one hemi-

thorax. )fter you hae percussed the left chest moe yours hands across and repeat

the same procedure on the right side. 4f you detect any abnormality on one side it%s a

good idea to slide your hands across to the other for comparison. 4n this way one

thorax seres as a control for the other. 4n general percussion is limited to the posterior lung fields.


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. BSpeed percussionB may help to accentuate the difference between dull and resonant

areas. 7uring this techni+ue the examiner moes their left /i.e. the non-percussing0

hand at a constant rate down the patient%s back tapping on it continuously as it

progresses towards the bottom of the thorax. This tends to make the point of inflection

/i.e. change from resonant to dull0 more pronounced.

Practice percussion& Try finding your own stomach bubble which should be around the left

costal margin. 3ote that due to the location of the heart tapping oer your left chest will

produce a different sound then when performed oer your right. Percuss your walls /if they%re

sheet rock0 and try to locate the studs. Tap on tupperware filled with arious amounts of

water. This not only helps you deelop a sense of the different tones that may be produced but

also allows you to practice the techni+ue.

Auscultation: Prior to listening oer any one area of the chest remind yourself which lobe of

the lung is heard best in that region: lower lobes occupy the bottom >5 of the posterior fieldsF

right middle lobe heard in right axillaF lingula in left axillaF upper lobes in the anterior chest

and at the top 1>5 of the posterior fields. This can be +uite helpful in trying to pin down thelocation of pathologic processes that may be restricted by anatomic boundaries /e.g.

pneumonia0. $any disease processes /e.g. pulmonary edema bronchoconstriction0 are

diffuse producing abnormal findings in multiple fields.

Put on your stethoscope so that the ear pieces are directed away from you. )d!ust the head

of the scope so that the diaphragm is engaged. 4f you%re not sure scratch lightly on the

diaphragm which should produce a noise. 4f not twist the head and try again. "ently rub the

head of the stethoscope on your shirt so that it is not too cold prior to placing it on the

patient%s skin.

The upper aspect of the posterior fields /i.e. towards the top of the patient%s back0 are

examined first. 9isten oer one spot and then moe the stethoscope to the same position on

the opposite side and repeat. This again makes use of one lung as a source of comparison for

the other. The entire posterior chest can be coered by listening in roughly 5 places on each

side. ?f course if you hear something abnormal you%ll need to listen in more places.

The lingula and right middle lobes can be examined while you are still standing behind the

patient.

Then moe around to the front and listen to the anterior fields in the same fashion. This is

generally done while the patient is still sitting upright. )sking female patients to lie down will

allow their breasts to fall away laterally which may make this part of the examination easier.

) few additional things worth noting.

)sk the patient to take slow deep breaths through their mouths while you are performing your

exam. This forces the patient to moe greater olumes of air with each breath increasing the duration

intensity and thus detectability of any abnormal breath sounds that might be present.

Sometimes it%s helpful to hae the patient cough a few times prior to beginning auscultation. This

clears airway secretions and opens small atelectatic /i.e. collapsed0 areas at the lung bases.

4f the patient cannot sit up /e.g. in cases of neurologic disease post-operatie states etc.0

auscultation can be performed while the patient is lying on their side. "et help if the patient is unable


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to moe on their own. 4n cases where een this cannot be accomplished a minimal examination can be

performed by listening laterally>posteriorly as the patient remains supine.

@e+uesting that the patient exhale forcibly will occasionally help to accentuate abnormal breath

sounds /in particular wheeing0 that might not be heard when they are breathing at normal flow rates.

,hat can you expect to hear6 ) few basic sounds to listen for:

) healthy indiidual breathing through their mouth at normal tidal olumes produces a soft

inspiratory sound as air rushes into the lungs with little noise produced on expiration. These are

referred to as essicular breath sounds.

,heees are whistling-type noises produced during expiration /and sometimes inspiration0 when air

is forced through airways narrowed by bronchoconstriction secretions and>or associated mucosal

edema. )s this most commonly occurs in association with diffuse processes that affect all lobes of the

lung /e.g. asthma and emphysema0 it is fre+uently audible in all fields. 4n cases of significant

bronchoconstriction the expiratory phase of respiration /relatie to inspiration0 becomes noticeably prolonged. 2linicians refer to this as a decrease in the 4 to E ratio. The greater the obstruction the

longer expiration is relatie to inspiration. ?ccasionally focal wheeing can occur when airway

narrowing if restricted to a single anatomic area as might occur with an obstructing tumor or

bronchoconstriction induced by pneumonia. ,heeing heard only on inspiration is referred to as

stridor and is associated with mechanical obstruction at the leel of the trachea>upper airway. This may

be best appreciated by placing your stethescope directly on top of the trachea.

@ales /a.k.a. crackles0 are scratchy sounds that occur in association with processes that cause fluid

to accumulate within the aleolar and interstitial spaces. The sound is similar to that produced by

rubbing strands of hair together close to your ear. Pulmonary edema is probably the most common

cause at least in the older adult population and results in symmetric findings. This tends to occur firstin the most dependent portions of the lower lobes and extend from the bases towards the apices as

disease progresses. Pneumonia on the other hand can result in discrete areas of aleolar filling and

therefore produce crackles restricted to a specific region of the lung. Gery distinct diffuse dry-

sounding crackles similar to the noise produced when separating pieces of elcro are caused by

pulmonary fibrosis a relatiely uncommon condition.

7ense consolidation of the lung parenchyma as can occur with pneumonia results in the

transmission of large airway noises /i.e. those normally heard on auscultation oer the trachea...

known as tubular or bronchial breath sounds0 to the periphery. 4n this setting the consolidated lung

acts as a terrific conducting medium transferring central sounds directly to the edges. 4t%s ery similar

to the noise produced when breathing through a snorkel. 8urthermore if you direct the patient to say

the letter %eee% it is detected during auscultation oer the inoled lobe as a nasal-sounding %aaa%. These

%eee% to %aaa% changes are referred to as egophony. The first time you detect it you%ll think that the

patient is actually saying %aaa%... hae them repeat it seeral times to assure yourself that they are really

following your directions&

Secretions that form>collect in larger airways as might occur with bronchitis or other mucous

creating process can produce a gurgling-type noise similar to the sound produced when you suck the

last bits of a milk shake through a straw. These noises are referred to as ronchi.

)uscultation oer a pleural effusion will produce a ery muffled sound. 4f howeer you listencarefully to the region on top of the effusion you may hear sounds suggestie of consolidation


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originating from lung which is compressed by the fluid pushing up from below. )symmetric effusions

are probably easier to detect as they will produce different findings on examination of either side of

the chest.

)uscultation of patients with seere stable emphysema will produce ery little sound. These

patients suffer from significant lung destruction and air trapping resulting in their breathing at smalltidal olumes that generate almost no noise. ,heeing occurs when there is a superimposed acute

inflammatory process /see aboe0.

$ost of the aboe techni+ues are complimentary. 7ullness detected on percussion for example may

represent either lung consolidation or a pleural effusion. )uscultation oer the same region should help

to distinguish between these possibilities as consolidation generates bronchial breath sounds while an

effusion is associated with a relatie absence of sound. Similarly fremitus will be increased oer

consolidation and decreased oer an effusion. )s such it may be necessary to repeat certain aspects of

the exam using one finding to confirm the significance of another. 8ew findings are pathognomonic.

They hae their greatest meaning when used together to paint the most informatie picture.

G7

Think anatomically. The right 4 runs between the two heads /sternal and claicular0 of the

sternocleidomastoid muscle /S2$0 and up in front of the ear. This muscle can be identified by asking

the patient to turn their head to the left and into your hand while you proide resistance to the

moement. The two heads form the sides of a small triangle with the claicle making up the bottom

edge. *ou should be able to feel a shallow defect formed by the borders of these landmarks. 3ote you

are trying to identify impulses originating from the 4 and transmitted to the oerlying skin in this area.

*ou can%t actually see the 4. The External ugular /E0 runs in an obli+ue direction across thesternocleidomastoid and in contrast to the 4 can usually be directly isualied. 4f the E is not readily

apparent hae the patient look to the left and alsala. This usually makes it +uite obious. E

distention is not always a reliable indicator of eleated 2GP as ales designed to preent the

retrograde flow of blood can exist within this essel causing it to appear engorged een when 2GP is

normal. 4t also makes seeral turns prior to connecting with the central enous system and is thus not

in a direct line with the right atrium.

)#S2#9T)T4?3

1. Cecome comfortable with your stethescope. There are multiple brands on the market

each of which incorporates its own ersion of a bell /low pitched sounds0 and

diaphragm /higher pitched sounds0. Some hae the diaphragm and bell on opposite

sides of the head piece. ?thers hae the bell and diaprhragm built into a single side

with the bell engaged by applying light pressure and the diaphragm engaged by

pushing more firmly. )dult pediatric and newborn sies also exist. )nd some

combine adult and pediatric scopes into a single unit. Take the time to read the

instructions for your particular model so that you are familiar with how to use it

correctly. Seeral sample stethescopes are pictured below. 4t%s worth mentioning that

almost any commercially aailable scope will do the !ob. The most important BpartB is

what sits betwen the ear pieces&


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(. Engage the diaphragm of your stethescope and place it firmly oer the (nd right

intercostal space the region of the aortic ale. Then moe it to the other side of the

sternum and listen in the (nd left intercostal space the location of the pulmonic ale.

$oe down along the sternum and listen oer the left 5th intercostal space the region

of the tricuspid ale. )nd finally position the diaphragm oer the 5th intercostal

space left midclaicular line to examine the mitral area. These locations are roughapproximations and are generally determined by isual estimation. 4n each area listen

specifically for S1 and then S(. S1 will be loudest oer the left 5th intercostal space

/mitral>tricuspid ale areas0 and S( along the (nd @ and 9 intercostal spaces

/aortic>pulomonic ale regions0. 3ote that the time between S1 and S( is shorter then

that between S( and S1. This should help you to decide which sound is produced by

the closure of the mitral>tricuspid and which by the aortic>pulmonic ales and

therefore when systole and diastole occur. 2ompare the relatie intensities of S1 and

S( in these different areas.

Auscultation of the Heart

. 4n younger patients you should also be able to detect physiologic splitting of S(. That

is S( is made up of ( components aortic /)(0 and pulmonic /P(0 ale closure. ?n

inspiration enous return to the heart is augmented and pulmonic ale closure is

delayed allowing you to hear first )( and then P(. ?n expiration the two sounds

occur closer together and are detected as a single S(. )sk the patient to take a deep

breath and hold it giing you a bit more time to identify this phenomenon. The two

components of S1 /mitral and tricuspid ale closure0 occur so close together that

splitting is not appreciated.


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5. *ou may find it helpful to tap out S1 and S( with your fingers as you listen

accentuating the location of systole and diastole and lending a isual component to

this exercise. ,hile most clinicians begin asucultation in the aortic area and then moe

across the precordium it may actually make more sense to begin laterally /i.e. in the

mitral area0 and then progress towards the right and up as this follows the direction of blood flow. Try both ways and see which feels more comfortable.

'. 9isten for extra heart sounds /a.k.a. gallops0. ,hile present in normal sub!ects up to

the ages of (H-H they represent pathology in older patients. )n S is most commonly

associated with left entricular failure and is caused by blood from the left atrium

slamming into an already oerfilled entricle during early diastolic filling. The S5 is a

sound created by blood trying to enter a stiff non-compliant left entricle during atrial

contraction. 4t%s most fre+uently associated with left entricular hypertrophy that is the

result of long standing hypertension. Either sound can be detected by gently laying the

bell of the stethoscope oer the apex of the left entricle /roughly at the 5th intercostal

space mid-claicular line0 and listening for low pitched Bextra soundsB that either follow S( /i.e. an S0 or precede S1 /i.e. an S50. These sounds are +uite soft so it may

take a while before you%re able to detect them. Positioning the patient on their left side

while you listen may improe the yield of this exam. The presence of both an S and

S5 simultaneously is referred to as a summation gallop.

Listening for Extra Heart Sounds


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;. $urmurs: These are sounds that occur during systole or diastole as a result of

turbulent blood flow. and fall into ( broad groups:

1. 9eaking backwards across a ale that is supposed to be closed. These are

referred to as regurgitant or insufficiency murmurs /e.g. mitral regurgitation

aortic insufficiency0.

(. 8low disturbance across a ale that will not open fully>normally. These ales

suffer from arying degrees of stenosis /e.g. aortic stenosis0.


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4t%s worth mentioning that sometimes Bflow murmursB can occur resulting from high

output across structurally normal ales. 4n addition some ales with insignificant

degrees of pathology /e.g. aortic sclerosis - where the ale leaflets are slightly

calcified yet function normally0 generate murmurs. 7istinguishing which murmurs are

clinically releant takes thought and practice. 4e added a description of some helpful

features below.

Traditionally students are taught that auscultation is performed oer the 5 areas of the

precordium that roughly correspond to the BlocationB of the 5 ales of the heart /i.e.

aortic ale area I%s the (nd @ight 4ntercostal Space pulmonic ale area I%s the (nd

942S tricuspid ale area I%s 5th 942S and mitral ale area I%s 5th 942S in the

midclaicular line0. This leads to some misperceptions. Gales are not strictly located

in these areas nor are the sounds created by alular pathology restricted to those

spaces. So while it might be ?= to listen in only 5 places when conducting the

normal exam it is actually +uite helpful to listen in many more when any abnormal

sounds are detected. 4f you hear a murmur ask yourself:

1. 7oes it occur during systole or diastole6

(. ,hat is the +uality of the sound /i.e. does it get louder and then softerF does it

maintain the same intensity throughoutF does it start loud and become soft06 4t

sometimes helps to draw a pictoral representation of the sound.

. ,hat is the +uantity of the sound6 The rating system for murmurs is as

follows:

1>;... 2an only be heard with careful listening

(>;... @eadily audible as soon as the stethescope is applied to the chest

>;... 9ouder then (>;

5>;... )s loud as >; but accompanied by a thrill

'>;... )udible een when only the edge of the stethescope touches the

chest

;>;.. )udible to the naked ear$ost murmurs are between 1>; and >;. 9ouder generally /but not

always0 indicates greater pathology.

5. ,hat is the relationship of the murmur to S1 and S( /i.e. when does it start and

stop06

'. ,hat happens when you march your stethescope from the (nd @42S /the aortic

area0 out towards the axilla /the mitral area06 ,here is it loudest and in what

directions does it radiate6 Cy moing in small increments /i.e. listening in or

1H places along the chest wall0 you will be more likely to detect changes in the

character of a particular murmur and thus hae a better chance of determining

which ale is affected and by what type of lesion.


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b. )uscultation oer the carotid arteries /see under aortic stenosis for additional

information0: 4n the absence of murmurs suggestie of aortic alular disease you can

listen for carotid bruits /sounds created by turbulent flow within the blood essel0 at

this point in the exam. Place the diaphragm gently oer each carotid and listen for a

soft high pitched BshshingB sound. 4t%s helpful if the patient can hold their breath as

you listen so that you are not distracted by transmitted tracheal sounds. The meaningof a bruit remains somewhat controersial. 4 was taught that bruits represented

turbulent flow associated with intrinsic atherosclerotic disease... and that the

disappearance of a bruit which was preiously present was a sign that the lesion was

progressing /i.e. further encroachment on the lumen of the essel0.


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. )re better heard when the patient sits up and exhales.

5. )re heard in the carotid arteries and oer the right claicle. @adiation to the

claicle can be appreciated by simply resting the diaphragm on the right

claicle. To assess for transmission to the carotids hae the patient hold their

breath while you listen oer each artery using the diaphragm of your stethescope. 2arotid bruits can be confused with the radiating murmur of aortic

stenosis. 4n general carotid bruits are softer. )lso murmurs associated with

aortic pathology should be audible in both carotids and get louder as you moe

down the essel towards the chest. 4n settings where carotid pathology

coexists with aortic stenosis a loud transmitted murmur associated with a

alular lesion may oerwhelm any sound caused by intrinsic carotid disease

masking it completely.

'. 2arotid upstrokes refer to the +uantity and timing of blood flow into the

carotids from the left entricle. They can be affected by aortic stenosis and

must be assessed wheneer you hear a murmur that could be consistent with)S. This is done by placing your fingers on the carotid artery as described

aboe while you simultaneously listen oer the chest. There should be no delay

between the onset of the murmur which marks the beginning of systole and

when you feel the pulsation in the carotid. 4n the setting of critical /i.e. ery

seere0 aortic stenosis small amounts of blood will be e!ected into the carotid

and there will be a lag between when you hear the murmur and feel the

impulse. This is referred to as diminished and delayed upstrokes /a.k.a. parus

et tardus0 as opposed to the full and prompt inflow which occurs in the

absence of disease. $ild or moderate stenosis does not alter the character of

carotid in-flow.

;. Sub-)ortic stenosis is a relatiely rare condition where the obstruction of flow

from the left entricle into the aorta is caused by an in-growth of septal tissue

in the region below the aortic ale known as the aortic outflow tract. 4t causes

a crescendo-decrescendo murmur that sounds !ust like aortic stenosis. )s

opposed to )S howeer the murmur is louder along the left lower sternal

border and out towards the apex. This makes anatomic sense as the obstruction

is located near this region. 4t also does not radiate loudly to the carotids as the

point of obstruction is further from these essels in comparison with the aortic

ale. *ou may also be able to palpate a bisferiens pulse in the carotid artery

/see under aortic insufficiency0. 8urthermore the murmur will get softer if theentricle is filled with more blood as filling pushes the abnormal septum away

from the opposite wall decreasing the amount of obstruction. 2onersely it

gets louder if filling is decreased. This phenomenon can actually be detected

on physical exam and is a useful way of distinguishing between )S and sub-

aortic obstruction. )sk the patient to alsala while you listen. This decreases

enous return and makes the murmur louder /and will hae the opposite effect

on a murmur of )S0. Then again while listening s+uat down with the patient.

This maneuer increases enous return causing the murmur to become softer.

Standing will cause the opposite to occur. *ou need to listen for (H seconds or

so after each change in position to really appreciate any difference. Cecause

the degree of obstruction can ary with entricular filling sub-aortic stenosis is


16/19

referred to as a dynamic outflow tract obstruction. 4n aortic stenosis the degree

of obstruction that exists at any gien point in time is fixed.

!urmurs of !itral &egurgitation $!&%:

D. Sound the same throughout systole.

. "enerally do not hae the harsh +uality associated with aortic stenosis. 4n fact

they sound a bit like the BshshingB noise produced when you pucker your lips

and blow through clenched teeth.

J. "et louder as you moe your stethescope towards the axilla.

1H. ,ill get een louder if you roll the patient onto their left side while keeping

your stethescope oer the mitral area of the chest wall and listening as they

moe. This maneuer brings the chamber receiing the regurgitant olume the

left atrium closer to your stethescope accentuating the murmur.

11. "et louder if afterload is suddenly increased which can be accomplished by

haing the patient close their hands tightly. $@ is also affected by the olume

of blood returning to the heart. S+uatting increases enous return causing a

louder sound. Standing decreases enous return thereby diminishing the

intensity of the murmur.

Sometimes murmurs of aortic stenosis and mitral regurgitation co-exist which can be

difficult to sort out on exam. $oing your stethescope back and forth between the

mitral and aortic areas will allow for direct comparison which may help you decide if more then one type of lesion is present or if the +uality of the murmur is the same in

both locations changing only in intensity /i.e. consistent with a one ale problem0.

'# (iastolic !urmurs: Tend to be softer and therefore much more difficult to hear

then those occurring during systole. This makes physiologic sense as diastolic

murmurs are not generated by high pressure entricular contractions. 4n adults they

may represent either aortic regurgitation or mitral stenosis neither of which is too

common. ,hile systolic murmurs are often obious you will probably not be able to

detect diastolic murmurs on your own until you hae had them pointed out by a more

experienced examiner.

Aortic &egurgitation $A&%) a#*#a# Aortic nsufficiency $A%:


17/19

1(. 4s best heard along the left para-sternal border as this is the direction of the

regurgitant flow.

1. Cecomes softer towards the end of diastole /a.k.a. decrescendo0.

15. 2an be accentuated by haing the patient sit up lean forward and exhale while

you listen.

1'. ?ccasionally accompanies aortic stenosis so listen carefully for regurgitation

in patients with )S.

1;. ,ill cause the carotid upstrokes to feel extraordinarily full as significant

regurgitation increases entricular pre-load resulting in e!ection of an

augmented stroke olume. )4 can also produce a double peaked pulsation inthe carotids known as a bisferiens pulse which is +uite difficult to appreciate.

8eeling your own carotid impulse at the same time that you%re palpating the

patient%s may accentuate this finding. 4n cases of co-existent )S and )4 a

bisferiens pulse suggests that the )4 is the dominant problem. 4t may also be

present with sub-aortic stenosis /see aboe0 helping to distinguish it from )S.

!itral Stenosis $!S%:

1D.


18/19

there any maneuers which affect its intensity6 @emember that these sounds are

created by mechanical eents in the heart. )s you listen remind yourself what is

happening to produce each of them. Cy linking auscultatory findings with physiology

you can build a case in your mind for a particular lesion.

A fe, final comments a-out auscultation:

1. Pulmonic ale murmurs are rare in the adult population and een when

present are difficult to hear due to the relatiely low pressures generated by

the right side of the heart.

(. Tricuspid regurgitation /T@0 is relatiely common most fre+uently associated

with eleated left sided pressures which are then transmitted to the right side of

the heart /though a number of other processes can cause T@ as well0. 4n this

setting both mitral and tricuspid regurgitation often co-exist. The murmur of

$@ is generally louder then that of T@ again due to the higher pressures on

the left side of the heart. 4t can therefore be difficult to sort out if there is co-existent T@ when $@ is present. Try to listen along both the low left and right

sternal borders /areas where the tricuspid ale is best assessed0 and compare

this to the mitral area. $oe your stethoscope slowly across the precordium

and note if there is any change in the character>intensity of the murmur. T@

murmurs are also accentuated by inhalation which increases enous return and

therefore flow across the ale.

. Patients with 2?P7 /emphysema0 often hae ery soft heart sounds. )ir

trapping and subse+uent lung hyperinflation results in a posterior-inferior

rotation of the heart away from the chest wall and causes the interposition of

lung between the chest wall and heart. 4n this setting heart sounds can be

accentuated by haing the patient lean forward and fully exhale prior to

listening. 8urthermore in any patient with particularly BnoisyB breath sounds

it may be helpful to ask them to hold their breath /if they%re able0 while you

examine the heart.

5. @ubs: These are uncommon sounds produced when the parietal and isceral

pericardium become inflamed generating a creaky-scratchy noise as they rub

together. The classic rub is actually made up of three sounds associated with

atrial contraction entricular contraction and entricular filling. 4n reality its

rare to hear all components /more commonly ( are apparent0. They can beaccentuated by listening when the patient sits up leans forward and exhales

bringing the two layers in closer communication. 4 feel compelled to mention

this finding only because a common short hand for reporting the results of the

cardiac exam comments on the absence of Bgallops murmurs or rubsB

implying /incorrectly0 that rubs are a fre+uent finding.

'. 4f a patient has an abnormal heart sound due to a structural defect that has been

+uantified by echocardiography make sure that you compare your findings to

those identified during the study. This is a great way of learning&

;. 7on%t get frustrated& )uscultation is a difficult skill to BmasterB and we are allcontinually refining our techni+ues. Take your time. $ake sure the room is


19/19

+uiet. Ce patient. )sk for help fre+uently. @ead about particular murmurs and

their pathophysiology when you encounter them. ) number of the more subtle

findings /e.g. an S or S50 can be ery difficult to identify when the patient is

tachycardic a not uncommon scenario as this is one of the compensatory

mechanisms for dealing with the dysfunction that has generated these findings

in the first place. @e-examination after the patient has made clinicalimproement may be more reealing.

4n general many of the aboe techni+ues are not used when examining eery patient. 4f the

exam is normal it would be neither efficient nor reealing to put a patient through all of these

maneuers. The goal is to hae a Bbag of skillsB at your disposal that you can reach into and

employ to better define abnormalities when they present themseles.

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