Examination of Chest and Abdominal

As aIready mentioned earlier, any overt deformity of the chest, for example kyphosis,scoliosis, pectus exacavatum and pectus carcinatu~n are to be noted as any one these lnay displace the apex beat producing apparent cardiomegaly. Even pectus excavatum can cause functional systolic murmur at lefi sternal border due to pressure from without.

A large descending thoracic aneurysm can produce a thrusting pulsation in lefi. sternal border called Thoracic jerk.Percussion of 2nd intercostals space is very imporiant as obIiteration of resonance always indicate enlargement of large arteries either pulmonary, aorta or sometimes both. An aneurysm of ascending can produce pulsation in right 1st and 2nd interspace.

Excessive pulsation of intercostal arteries in back can be seen and felt especially on stooping forward while standing in case of severe coarctation of Aorta with large collateral vessels.Examinatio~l of Abdomen

The contour of abdomen is to be recorded. Normally tlie abdomen is scaphoid in sharp in a young adult. In case of fullness and bulge presence of ascites is to be ruled by pel*ci~ssion (shifting dullness). Any organomegaly is to be noted, especially for enlargement of liver and spleen. A soft mildly enlarged liver is better demonstrated by light percussion as it may be missed during palpation. Unless the spleen enlarges more than double its size spleenic tip may not be palpable. Hence, in case of suspected enlargement obliteration of spleenic resonance beyond mid axillary line is expected.Kidneys are better palpated by applying pressure by one hand at renal angle and palpating kidney by other hand on nnteriority abdominal wall. Between both hands an enlarged kidney or a renal mass can be felt well and c?n pl~shed backward and forward showing its ballotability. The detection of an enlarged kidney in case of hypertension can be important and poycystic disease of kidney must be ruled out.

In case of aneurysnl a pulsatile mass in the midline of abdomen can be often palpated.When two fingers are placed by tlie side of st~ch Inass a systolic expansile movement is well demonstrated.In elderly patient a saprapubic nlass d ~ I1 r on percussion is caused by enlarged and overdistended bladde~-due to cnlarged prostrate or bladder neck obstruction.Pullnonary hypertension can be secondary to ~msuspected cirrhosis of liver.

Relevant other Examination

Examination ofteelll for any infection is a 111ust especially in valvular heart disease as this can be a potent source of infection.Thyroid gland deserves special mention as occult toxicity may present as recurrent palpitation and/or supracventricular tachycardia. One of tlie remote causes of persistent congestive 1iear-t failure nlay be occi~lt tliyrotoxicosis.

Examination of lower limb for evidence of venous tliro~~~bosis for suspected pullnonay embolis~n or chronic pulmonary hypertension slio~~ld not be overlooked.

Peripheral signs of infective endoca~riitis like Oslar nodes, splinter Iiaemorrhage to be loolced for.

Erythema nodosum over tlie tibia1 shin will point to active rheumatic fever. In arthralgia tlie joint movement may be painfill loi~t will lack tlie sign of inflammation,like rise of temperature and redness. Rlieu~natic nodules are fixed to fascia and cannot be moved underneath the skin and is usually found over subcutaneous bony parts like occiput, subcutaneous radial, bone, libial shin, scapular border and around wrist and knee joints.

Dynamic Auscultation

It involves detelnlining the effects on heart sounds and murmurs of va-ious physiological and pharmacological manoeuvres, which alter the circulatory dynamics.

The manoeuvres commonly employed are:

1) Respiration

2) Valsalva manoeuvre

3) Postural changes.

Pren~ature ventricular contractions.

Iso~~letric exercise.

Phar~nacologic agents, e.g., amyl nitrite.

1)Respiration
a) S,: Splitting of S, is audible during inspil-ation.

b) Diastolic Sourrds arrd Ejectiorz Sourrds: Inspiration augments RVS, and RVS, \vhereas LVS, and LVS, are diminislled. The only right-sided event to diminish during inspiration is the pulmonary ejection click in patients with pulmonary stenosis. Respiration doesn't affect the intensity of aortic ejection sounds, except in Tetralogy of Fallot with pulmonary atresia.

c) Murrnurs: Murmurs originating from right side of the heart are accentuated during inspiration. In patients with MVP, the n~idsystolic click and the systolic murmur occur earlier in systole and may get accentuated during inspiration as reduction in the LV cavity iimcreases the redundancy of the mitral valve and hence increases the prolapse.

2) Valsalva Rlanocuvre

This consists of deep inspiration followed by forced inhalation against a closed glottis for 10-20 seconds. It can be performed by placing examiners hand over patients abdoinen and asking llinl to apply as much force as possible.The normal response consists of four phases:

Phase I: Transient rise in systemic BP as straining commence.

Phase 11: Reduced venous return and systolic BP with reflex tachycardia.

Phase 111: Abrupt, transient reduction in syslenlic BP as straining ceases.

Phase IV: Overshoot of systelnic BP and reflex bradycardia.

Phase V: A,-P, interval narrows.

S, and S, arc attenuated.

Murmurs of AS and PS and of MR and TR diminish (as stroke volume and systemic BP falls).MVP click and systolic murnlur begins early (as LV volunle is reduced).
 

HOCM illurmur conles early in systole.

Phase VI: S, split widens.

Murmurs on right side are accentuated. (As venous return increases).This manoeuver shouldn't be performed in patients with IHD because of the acconlpanying fall in coronary blood flow.

3)Muller Manoeuver
In this manoeuver, patient forcibly inspires while the nose is held closed and mouth firmly sealed for 10 seconds.It exaggerates the inspiratory efforts and hence augments the right side murmurs and filling sounds.

4)Postural Cliarlgcs

a) On sudden assumption of supine position from standing 011 sittiiigpositioli or suddcn passive eleva~ion of both Icgs: Venous rcturn irlcrcascs that increases tlie RV stroke volu~iic for several cardiac cycles imniediately and later on the LV stroke volume increases and consequently S, split widens. RS, and RS,, systolic niurnlurs of PS, TR and VSD arc aug~i~ented inlmcdiately. Later on LVS, LVS,- niurniur of AS, MR and VSD are accentuated; due to increased LV ehd diastolic volulne the click dnd systolic lnurniur of MVP and HOCM are diminished.

b) Rapid standing or sitting up from supine position lias opposite effect.

c) With assunlption of left lateral dccubitus tliere is accentuation S,, LVS, and LVS,, OS, murnlur associatcd with MS and MR, ~uidsystolic click and late systolic murmur of MVP.

5)Isonietric Excrcisc

Can be carried out by doing handgrip excrcise wllicll is sustaiiied over 20-30 second. It results in transiellt increase in SVR, BP, Heart rate, Cardiac output and LV filling pressure.LVS, and LVS, are accentuated.

Systolic nu-nlur of AS is diminislled with reduction in gradient across the valve.Murmur gf AR, MR and VSD is accentuated. Systolic niumiur of HOCM diminished and systolic ciick and niuiniur of MVP are delayed (as LV volu~iie increases).

This should be avoided in patient with niyocardial ischaeniia and ventricular arrhythmia.

6)Pharmacologic Agents

a) A111yl Nitrite

It produces vasodilatation whicli initially results in niarked fall in BP and in the next 30-60 seconds there is reflex tachycardia followed by an increase in cardiac output.

An ampoule of amyl nitrite is taken in gauze and crushed near the supine patients nose and the patient is asked to inhale over 10-15 seconds.Major auscultatory changes occur in the 1st 30 secorzds aJer iitlzalatioil:S, is augmented, A, is diminished, and pathological S , is augmentcd.A,-OS interval shortens.Murn~urs of MR, VSD and AR are reduced.Systolic mcrmurs AS, PS, HOCM and TR are accentuated.Diastolic murnlurs of MS, TS and PR are accentuated.PDA nlurnlur and of AV fistula are reduced.


If amyl nitrite is not available, the test can be done using isosorbide dinitratc.b) Phenylephine and Meihoxamine They have opposing effects to amyl nitrite as they increase the systemic BP.phenylephine due to its shorter duration of action is preferred.Both cause reflex bradycardia and reduced contractility and cardiac output. Both are given intravenously, with elevation of BP lasting for 3-5 minutes with methoxainine.These agents should not be used in patients with systemic hypertension or those in CHF.

Pericardial Rub

Generation of sound: The sound is generated due to rubbing of visceral and parietal pericardial surfaces against each other. In case rub is suspected but not heard in supine position, the following technique can be used. Apply the stethoscope firmly to precordium while thc patient rests on elbows and knees (as the opposition of two layers of pericardiuln is better).Characteristic: Superficial, scratchy, leathery sound component. In sinus rhythms,the typical rub is three phased (one systolic and two diastolic).

• Mid systolic
• Diastolic
• Pre systolic

The rnid systolic phase is most consistent followed by the presystolic phase(disappears in atrial fibrillation).

Most likely causes o F pericardial friction rules are Rheumatic, Pericarditis,tuberculosis, Pericarditis.Immediately post open heart surgery

MI

Uremia.

It can often be heard posteriorly over the back.

Continuous Murmurs

These murmurs are continuous throughout systole and diastole. It is due to continuous blood flow in the same direction in both systole and diastole unlike a to and fro murmur in which blood flows in one direction in systole and in opposite direction in diastole.

Coetinuous

Characteristic: High pitch continuous "Machinery ' lnurnlur best heard in the second left intercostal space with radiation to chest, neck and back. It typically begins after S1, gradually increases in intensity, peaks at or immediately after S2 and gradually fades to a variable duration in diastole depending oil pulmonary arlery pressure; the higher the pressure lesser the duration of nwrnlur in diastole.There are some additional clicking sounds in late systole and in early diastole,called Eddy sounds are veiy characteristic of a continuous murmur caused by 

PDA Murmur

If the next loudest sound is not heard in the first left interspace but heard in the third left interspace the diagnosis of PDA should not be entertained and the other causes of continuous murmur such as coronaiy artery cai~leral fistula into RA/RV or Ruptured Sinus of Valsalva should be kept in mind.

ti)Venous Hum

Characteristic: Col~tinuous sound with diastolic component often a h~glicr pitched and louder than the systolic, best heard just above the clavicle, lllore likely on the right side (right Jugular vein larger than the left). It is best heard with the bell of the stethoscope with the patient sitting up with his or her feet on the bed and his head turned away maximally with raised chin. It disappears on con~pressing jugular vein. It is most common type of noimal continuous murmur and often heard in healthy children.

iii) Arteriovenous Continuous Murmur

These can be coilgenital as in coronaly astev !istula entering RA/RV/PA, sinus of valsalva to right side of heart cominunication and ALCAPA or it can be acquired as in surgically created AV fistulas.

iv) Arterial Continuous Murmurs

These originate in constricted arteries as in carotid or femoral artery obsti-uction (Mumurs are louder in systole, often only systolic) or in non-constricted arteries as in patients with large systemic lo pulmonary arterial collaterals in TOF with pulmonary atresia. Mammary soufflk is an innocent murmur heard durtrllb late pregnancy and puerperiunl. It is typically louder in systole.