21-Feb-23

REVISION OF ANATOMY OF THE HEART

SURFACE ANATOMY OF THE HEART

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HEART CHAMBERS, VALVES AND CIRCULATION:

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LAYERS OF HEART WALL:

SURFACES OF HEART :

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BORDERS OF THE HEART

CONDUCTION SYSTEM OF THE HEART:

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CRONARY ARTERIES

CARDIAC EXAMINATION
BY: DR Eman Abd El Halim

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A) History: AS IN CHEST EXAMINATION. FOR EXAMPLE:

PERSONAL:OCCUPATION (STRESS -> HTN )- HABITS:JUNCK FOOD-> HYPERCHOLESTEROL->
ATHEROSCLEROSIS-> CORONARIES -> IHD/MI
PAST: SURGERIES (OPEN HEART/CABG),DISEASES (HTN->HEART FAILURE ), MEDICATIONS (BETA BLOKERS-
>DECREASE HR)
PRESENT: ONSET: SUDDEN:MI/ANGINA
FAMILY: IHD/ HF
B) Assessment:
1- General examination
2- Local examination
1- General examination:
➢decubitus or position of the patient
➢Body built
➢Color
➢Mental state
➢Other problems
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➢ decubitus or position of the patient :

• A) squatting position : in case of patient’s with tetralogy of
fallot:

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☞ What is fallot of tetralogy & why squatting position??

- Tetralogy of fallot: It is cyanotic congenital heart disease. It is a case consists of 4 pathologies which are:

• Pulmonary stenosis: tightening in pulmonary valve.

• Right ventricular hypertrophy.

• Over ridding of aorta: means that aorta originate from both ventricles.

• Ventricular septal defect (VSD): appear in inter ventricular septum.

- And he is in squatting position because: • The main problem of this patient is cyanosis that occurs as the oxygenated blood and
deoxygenated blood are mixed so the blood pumped to the body is not fully oxygenated as normal.

• cyanosis decrease with squatting because this position creates pressure on the blood vessels delivering blood from lower limb to the
heart leading to decrease the amount of deoxygenated blood reaching the heart from inferior venacava so amount of mixed oxygenated &
deoxygenated blood also decreases leading to increase the amount of oxygen reaching cells so decreasing cyanosis.

Another explanation: squatting relive the associated dyspnea through increasing the pulmonary blood flow and consequently increases
arterial oxygen saturation By the following:

A- kinking the femoral arteries and thereby increasing the systemic vascular resistance and diminishing the shunt of blood from the right
ventricle to the left ventricle and aorta

B- compressing the splanchnic vessels thus increasing the systematic venous return. Squatting also helps trapping the markedly
oxygenated venous blood in the legs

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• Hemodynamics of squatting has two phases

• Immediately ( First 15 seconds) after squatting there is a sudden drop in venous return.
• Sustained squatting for 1-2 minutes result in steady increase in venous return, raised
systemic vascular resistance.

• Both these effects help the children with TOF. The initial trapping of highly desaturated
blood in the lower extremity gives a quick relief as soon as the child assumes this
posture. In the next 15 seconds or so the systemic vascular resistance increases and bring
the aortic after load sufficiently high to divert the blood into the pulmonary artery.
• The net effect of squatting is there is a transient or sustained (as long as child squats)
increase in pulmonary blood flow and this is made possible by the relative reduction of
right to left shunt as the aortic and systemic resistance is raised by this posture.
• Other explanations
• There is one more possible effect of squatting. By, compressing abdomen (Knee chest)
cause a mechanical push on the splanchnic blood pool into the aorta which has high o2
saturation. This is thought to provide immediate relief to brain hypoxia and avoid the
vicious respiratory/ hemodynamic cycle
• Apart from squat induced po2 raise there is a fall in the concentration of pco2 and raise
in blood Ph that pacify the sensitive respiratory centers,thereby bringing down the
tachypnea
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B) long sitting position :

• (the patient lying on 45 degree elevated head of the bed in left sided failure ): → (why) ?

• The main problem of this patient is orthopnea which is induced by supine lying position and relived with sitting.

• Orthopnea occurs in supine because:

- Diaphragm is elevated by elimination of gravity.

- There is increase in venous return that increase load on heart so increases the problem.

- Inefficient contraction of respiratory muscles

c) Prayers position:
• leaning forward in pericarditis

• This position increase intra abdominal pressure to increase intra thoracic pressure to relatively decrease venous return to
the heart so that to decrease the pressure on the heart wall ( pericardium) to decrease pain sensation.

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➢ Body built
• A – Thin (cachetic ): As in advanced left side heart failure because of the
low cardiac output causing low oxygenation of body tissue and so low
nutrition.

• B - Obese: As in right side heart failure because the right side cannot meet
the increased or even normal venous return leading to general venous stasis
leading to generalized edema which give the patient the obese appearance.
Also obesity suggesting coronary artery disease

• C - Inversed pyramid: As in cases of coaortcation of aorta.

• N.B – Coaortcation of aorta means narrowing of the descending aorta.
• - In general body built is the balance between ages, sex, weight, height.
• D- Marfan's syndrome: patient with lean body built, thin face, long spidery
fingers seen in atrial septal defect

• E-physical development ( infantilism due to sever cardiac diseases starting

in childhood)

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➢ Color: ( pallor- cyanosis- jaundice- malar flushes)

• Malar flushes : a mauve ( reddish blue) discoloration in the butterfly distribution of nose &
checks is characterized observed in cases of tight mitral stenosis
• Pale color: -Appears in face; indicates Rheumatic fever. ALSO Pallor MAY BE due to anemia or
vasoconstriction caused by aortic valve disease or heart failure
• Jaundice: - Yellowish discoloration of skin and mucus membrane due to increase amount of
bilirubin >3 mg. Site: Sclera of eye.
• Cyanosis:
• - Bluish discoloration of skin and mucous membrane due to increased amount of reduced
hemoglobin more than 5 gm. %. also denotes chronic poor oxygen delivery to the peripheral
tissues of the hands and feet
• - Normally reduced hemoglobin = 2%.

• - And oxygenated hemoglobin = 98%.

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Central (GAS EXCHANGE PROBLEM) Peripheral (LOW COP)

Common in cases of • fallot of tetralogy .Atrioventricular shunt. • Atherosclerosis in periphery

.coronary artery disease. in congenital heart • in advanced heart failure due to
disease, corpulmonale , and advanced heart vasoconstriction and low cardiac output
failure
Sites .libs, nose, hands, ears, lower limb. .mouth, . Lips, nose, hands, ears, lower limb only
inner libs, tongue. (Why?)
Increase with .Exercise. .Heat. .anything increases the heart .Cold. .Rest. .anything decrease heart rate
rate.
Decrease with .Rest only. .Exercise. .Heat. .Increase heart rate

Differential cyanosis:
- Is the bluish coloration of the lower but not the upper extremity and the head. This is seen in patients with a patent ductus
arteriosus (PDA).
- Patients with a large ductus develop progressive pulmonary vascular disease, and pressure overload of the right ventricle
occurs.
- As soon as pulmonary pressure exceeds aortic pressure, shunt reversal (right-to-left shunt) occurs.
- The upper extremity remains pink because the brachiocephalic trunk, left common carotid trunk and the left subclavian trunk is
given off proximal to the PDA.
N.B: - Patent duct’s arteriosus is a persistent connection between descending aorta and pulmonary artery, it is normally opened in
fetus for nourishment but closed after birth in 4 -6 hours & some sources say it closed after 3 weeks from birth.

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➢ Mental status
A) Mood: -anxiety. -Depression following myocardial infarction
B) Level of coordination: -cooperative. -Uncooperative.
C) level of consciousness:
• Alert ‫واعى تمام‬
• Confused ‫مرتبك‬
• Automatic‫واعى بس سرحان شوية‬
• Stupor ‫مدروخ بس مش قوى‬
• Delirious‫مدروخ‬
• Semi- comatose ‫بيدخل في غيبوبة ويفوق‬
• Comatose ‫غيبوبة‬

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➢ Other problems

• 2-puffy eye lids: indicates heart failure

• 3-Rheumatic chorea: Involuntary jerky purposeless “pseudo-purpose “movement with emotional liability.

• 4-venous pulsation: Differentiate between arterial & venous pulsation?

Arterial pulsation Venous pulsation

-Carotid pulsation. -jugular pulsation. (heart or liver)

-Medial or anterior to Sternocleidomastoid (SCM) -lateral or posterior to SCM

-Better felt than seen. -Better seen than felt

-synchronous to heart beats. -Before or after heart beats

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• 5-clubbing fingers: -Hypertrophy of connective tissue of nail-bed.

-Normally there is angle of 160; in clubbing hand this angle disappears and this indicates chronic poor oxygen
perfusion to the distal tissues of the hand and feet.

-Causes: Congenital heart disease. -In lower limbs is due to pulmonary hypertension or PDA. Blue clubbing:
associated with cyanotic congenital heart disease. Pale clubbing: in infective endocarditis

-TEST AND GRADES AS IN CHEST EXAMINATION

6- lower extremities ( cardiac edema in right heart failure). Test for pitting and non pitting edema

7- neck : ( vigorous pulsations, nodding of the head in aortic regurge)

8- fever ( rheumatic fever, infective endocarditis)

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• Vital signs :

• Palpate radial and carotid pulse

• Rate ( 60-90 b/min), Rhythm, Character/ contour, Volume/ amplitude, Radio- femoral delay

• Palpate all peripheral pulses : Carotid, temporal, brachial , radials, femoral so, popliteal, dorsalis pedis, posterior tibials

• Palpating pulse gives a good idea about the character of the pulse

• The pulse changes its character as it moves peripherally The peripheral pulse give a good idea of the distal circulation, the
rate and rhythm

• Pulse deficit: When the heart rate is fast as in atrial fibrillation, all cardiac impulses may not be transmitted to the
periphery. Hence the heart rate will be more than the pulse rate

• Blood pressure: Measure blood pressure in both arms- supine In patients with orthostatic symptoms- measure blood
pressure 5 min after standing a drop of at least 20 mmhg is expected if the test is positive

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Local examination: (Inspection, Palpation, Percussion&

Auscultation )
I- Inspection:
A. Previous operation
B. Skeletal deformities
C. Suprasternal pulsation
D. Pericardial area
E. Parasternal area
F. Apex beat
G. Dilated veins of chest wall
H. Epigastric area

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A) Previous operation: scars of previous operation like:

• Median sternotomy: heart (e.g; open heart surgery or chest surgery)

• Lat throcotomy: valve operation ( mitral valve replacement or chest surgery ( e.g; lobectomty)

• Supraclavicular : permanent Pacemaker

• Midaxillary line: pcd(pacer-cardioverter-defibirlator)

B) Skeletal deformities: -scoliosis. -kyphosis. -Kyphoscoliosis. , barrel chest, pectus excavatum (

funnel chest)-> shift heart laterally and so apex pulsation

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C) Suprasternal pulsation: (NECK pulsation):

- Physiologically supra sternal notch pulsation: normal in tension &stress ,anxiety, exercises or fever

- Pathologically: carotid pulsation: due to aortic regurge.

-Pathologically: jugular vein pulsation: CHF

D ) Pericardial area: (pericardial bulge, mediastinal position)

• Pericardial area: Is the area of chest over laying the heart. Normally this site equal bilaterally.
• Observe shape of the pericardium.
• If there is pericardial bulge-> denotes a large heart due to cardiac disease since childhood ( infancy) ( congenital
heart disease or rheumatic heart disease ), Rt ventricle enlargement or mediastinal tumor, pericardial effusion
• How?! Stand at pt's head or foot and observe sternal border from 2nd to 6th rib to
mid clavicular line

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E) Parasternal area: when you see pulsations by eyes

a- lt parasternal (3rd, 4th, 5th intercostal space(ICS) pulsations: ( right ventricular enlargement due to pulmonary
hypertension (HTN)), ( huge left atrium which displace rigt ventricle),

( pulmonary stenosis

b- Rt parasternal pulsation :( Right atrium enlargement)

c- aortic area pulsations ( Rt 2nd ICS) : due to systematic HTN, SYSTOLIC (AS), diastolic (AR), Rt atrial
enlargement, internal mammary artery in thin lactating female, aortic aneurysm

d- pulmonary area pulsation ( lt 2nd ICS) : due to pulmonary HTN , pulmonary A. dilatation , aortic aneurysm,
aneurysm dilatation of lt atrium

F) Apex beat: sometimes visible and usually palpable .

How?! Stand on the right side of patient > if cant see it go to left side of patient and squat

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G) Dilated veins of chest wall: ( due to Superior Vena Cava or Inferior Vena Cava OBSTRUCTION)

H) Epigastric area: if there is pulsation there is :

- IF IN the left side ( finger tips in palpation ) : A problem in right ventricle. Rt ventricular hypertrophy

-If in: midline ( Palm in palpation ): A Problem in abdominal aorta, anemia.

-IF IN the right side ( thumb in palpation ): A Problem in liver ( portal vien or vena cava), tricuspid regurge

• How?! Ask pt to stop breathing & observe any pulsation between xyphstenal junction & umblicus ( inspect then
palpate )

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PALPATION:
1. APEX beat
2. Suprasternal area
3. Epigastric pulsation
4. THRILLS
5. Jugular Venous Pressure (JVP)
6. HEPATOJAGULAR REFLEX (HJR)
7. Tracheal position

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1. APEX beat (PMI( point of maximum impulse):

Def: the Lower most and outermost point of cardiac impulse. Contraction of left ventricle during systole. It is
sometimes visible and usually palpable in 75% of subjects. Normally: dime sized, tapping, brief and not strong

Location: Normally located at left 5th intercostal space (ICS) midcalavicular line( 3:5 inches/ 8:10 cm from mid
sternal line
How?! > Procedure:
Patient supine, P.T. stand on patient 's Rt side and observe the apex pulsation. If
can see it locate it by palpation
If can't see stand on lt squat: if pulsating palpate by 2 fingers but if not clear and
can't be palpated in a supine position ; stand on patient 's Rt side and put your
hand on 4,5,6th ICS and ask patient to turn lying him left side and palpate it (left
lateral position)
Patient: lying supine turning slightly to the left side (left lateral position) .
- Therapist: with your hand under the patient axilla moving medially till I fell the pulse.
- Advantage of this position:
1- Apex beat more superficial. 2- Palpate the beat if diffused.
3- Pressure on heart between my hand & surface under him will increase load on heart so more obvious pulse.
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Causes of invisible and impalpable apex beat:

➢ Obesity

➢ Thick muscular chest

➢ Apex behind ribs( felt in lateral position)

➢ Weak contraction

➢ Chest causes ( emphysema, pneumothorax, pleural

effusion)

➢ Cardiac causes ( pericardial effusion, dextrocardia)

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Causes of shifting of apex:

1- causes outside heart:

➢ Chest and abdomen disease which may push , pull the heart

➢ Fibrosis and collapse-> pull the heart toward lesion

➢ Pleural effusion and pneumothorax -> push heart away from lesion

➢ Deformity of chest ( kyphoscoliosis, funnel chest)

➢ Mediastinal lesion ( tumor, aortic aneurysm) displace apex downward

➢ Abdominal distension ( pregnancy, ascites) displace apex upward and to left

2- Causes from heart:

➢ Cardiac enlargement (left ventricle hypertrophy( LVH): shift downward and out) ( Right ventricle hypertrophy
(RVH): outward shift)

➢ Dextrocardia ( shift to Right)

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• Upward displaced: fibrosis of apex of lung, COLLAPSE OF UPPER LOBE OF LEFT LUNG, ascitis,
pregnancy, spleenomegally, paralysis of lt part of diaphragm , ABDOMINAL TUMORS

• Downward displacement: chest causes ( COPD, emphysema ,chest wall deformities), cardiac causes( lt ventricle
enlargement) , mediastinal tumor, aortic aneurysm, thin subject with long chest

• Inward (Rt)displacement: chest causes ( Rt side lung fibrosis or collapse , lt side pleural effusion or
pneumothorax ), cardiac causes(dextrocardia)

• Outward displacement ( TO LEFT ): chest causes ( chest wall deformity, lt side lung fibrosis or collapse , Rt side
pleural effusion or pneumothorax ), cardiac causes (Rt ventricle enlargement , LEFT VENTRICLE
ENLARGEMENT )

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Size: Intensity:

• Normally: dime sized, <3cm • Normally : isn't strong

• Abnormally: increase in ventricular hypertrophy • Abnormally: lift = heavy intense in ventricular hypertrophy or
stenosis
Localization:
Force:
• localized: LVH.
• Forcible: left ventricular enlargement
• Diffuse: Right ventricular enlargement(RVE) /dilatation
• Forcible and sustained: stenosis (Aortic Stenosis )
Character:
• Forcible and no sustained: Aortic regurge
• Normally: tapping
• Weak: RVE
• Abnormally:
Duration:
- hyperdynamic-> regurge
• Normally: brief
-heavy or forceful: ventricular hypertrophy
• Abnormally: longer ( sustained) sign of heart failure

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2- Suprasternal area: normally pulsating by palpation.

3- Epigastric area:

-Patient: long sitting.

Therapist hand: vertical on Epigastric area between xyphstenal junction & umblicus .

- Ask pt to stop breathing

▪ Pulse in midline under palm of hand: aortic pulsation. A Problem in abdominal aorta, anemia.

▪ Pulse to the right ( thumb) : liver pulsation > A Problem in liver ( portal vien or vena cava), tricuspid regurge

▪ Pulse to the left & up (finger tips ): Right ventricle pulsation > A problem in right ventricle. Rt ventricular
hypertrophy

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• 4- Thrills:

• Def : it is palpable murmur ( murmur is audible vibrations) In the pericardium ( palpable murmur) from hrt and bl.
V.

• All thrills must be combined with murmur but not all murmurs combined with thrills ( in 4,5,6th grade of murmur)

• Sites of thrills:( where murmurs are loudest)

➢ At apex: from Mitral valve ( Mitral Regurge , Mitral Stenosis) or referred from Aortic Valve ( Aortic Stenosis)

➢ At base of heart ( Pulmonary artery & aorta)

➢ Parasternal thrills

➢ At Rt side of neck

➢ At aortic area: (Aortic Stenosis, Aortic Regurge)

• Time of thrill if: systolic with carotid pulse ( LVE or Mitral Regurge or Aortic Stenosis)

Diastolic no carotid pulse (Mitral Stenosis or Aortic Regurge)

• How?!by finger tips or ulnar surface( better feeling vibration)

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4- Jugular Venous Pressure (JVP):

• The JVP has waveforms which correspond to physic pressure changes in the right atrium

• Head of bed : 45’ angle,

• Patient: long sitting, patient’s head rotated to left ,examine both Sides, find external Jugular
vein and Internal Jugular vein,

• Identify highest point of pulsation in RT Internal Jugular vein ,

• Extend long rectangular object & put a ruler on angle, measure distance ( normally: 3cm if
increased more than 3:4 this means increased pressure as in Rt side heart failure , Tricuspid
Stenosis, Superior Vena Cava obstruction

• N.B: The CVP IS MEASURED as the vertical distance to the sternal angle +5 cmH2O ( the
sternal angle is 5 cm away from the center of the right atrium)

5- Hepatojagular reflex (HJR):

• Apply gentle pressure ( 30:40 mm Hg) over Rt upper quadrant or middle abdomen for at least
10 sec up to 1 minute & observe Jugular vein. - If internal jugular vein in the neck become
congested and pulsated then it is a liver or heart problem (How to differentiate if it is a heart
or liver problem ?)

• Repeat JVP if more than 3 or > = 4 : so it indicate + HJR.

• normally JVP decrease due to increased venous return but may rise for 10 sec then decrease

• - If distance is less than 7cm so it is a hepatic problem if equal or more than 7 cm then the
problem is a cardiac problem from the right side.

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Percussion
• Confirm normal position of the heart, liver & stomach. Also assess heart size but it is not very
helpful
• Notes: we do heavy percussion in assessing heart except bare area while in lung assessment we do light percussion

- Either:

• resonance = Air or

• Dullness = blood / fluid.

A. Pulmonary area
B. Aortic area
C. Bare area of the heart
D. Lower third of sternum
E. Liver
F. Spleen

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Area Location Normally Abnormally

A) Pulmonary area
B) Aortic area:
C) Bare area of heart: - Area
of heart not covered by lung
tissue.
D) Rt border of heart:
E) waist of the heart:
Lower third of sternum:
: - Left 2nd intercostal space
beside loise angle.
-Right 2nd intercostal space.
- Present in 4th to 6th
intercostal spaces 1 inch to
the left (between
midclavicular & parasternal
lines).
Rt 4th ICS sternal border.
lt 3rd ICS,
Lower third of sternum
resonance. if dullness = enlargement of atrium
or ventricle.
resonance if dullness = enlargement of atrium
or ventricle.
Dullness (by light If reasonance ( emphysema, COPD,
percussion). PNEUMOTHORAX, dextrocardia).
If increased dullness (RVE, LVE,
pericardial effusion)
dullness If to Rt may be due to (
enlargement of Rt atrium,
pericardial effusion, dextrocardia, lt
pneumothorax or pleural effusion)
normally 1/2 dullness If dullness increased ( obliteration
of normal apex. of waist of the heart by; e.g lt
atrium dilatation)
Resonance (direct If dullness = Right ventricular
percussion) enlargement.
pericardial effusion,

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Area Location Normally Abnormally

Liver: (upper border ) Rt 5th ICS MC line to 7th ICS dullness -As in chest exam.
MA line. -N.B: Severe pain in
hepatomegaly cannot tolerate
percussion.

Spleen Lt 9MCL,10MAL,11MSL ICS dullness As in chest exam.

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Auscultation
• A) heart sounds
• B) murmurs
• C) pericardial rub

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Systole diastole

A) heart sounds :
• 1ST HEART sound
• 2nd HEART sound
• 3rd HEART sound
• 4th HEART sound
• N.B:
• Splinting
• Gallop
• Surface anatomy of valves and areaes of auscultation
• Problems in valves
• N.B: cardiac cycle takes 0.8 sec. (systole = 0.3, diastole=0.5).
• use both sides of stethoscope:
➢ ( diaphragmatic: high pitched , S1& S2 , most murmur) ,
➢bell ( low , S3-S4, few murmur (MS) ,
• use light touch as pressure turn it to diaphragm

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HEART SOUND Pitch Time Cause Heard Heard by

SOUNDS at

FIRST LUP High Beginning of systole Closure of M&T valves Apex Diaphragm of
stesocope

SECOND DUP High Beginning of diastole Closure of P&A valves Pulmon Diaphragm of
ary stesocope
area

THIRD ‫كنتاكى‬ Low Directly after 2nd heart - VENTRICULAR gallop Apex Bell (Better
VENTRICUL sound ( in diastole ) - Volume overload palpated
AR gallop than
auscultated
)
FOURTH Atrial gallop Low Before first heart sound - Old age (physiological) Apex Bell
( end of diastole/ - Strong Atrial contr. To
presystolic ) pump bl. To stiff ventricles
- Atrial gallop
- Pressure overload

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• N.B:

1. Splitting:

- Occurs because normally aortic valve close before pulmonary valve as left ventricle is
stronger than right ventricle.

- Some times this time increase than normal because:

• Physiologically: in deep inspiration venous return increase so right ventricle take more time
to push it causing late closure.

• Pathologically: pulmonary stenosis

• - There is a reversed splitting if pulmonary valve closes before aortic as in:

➢ aortic stenosis,

➢hypertrophic cardiomyopathy.

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• 2. Gallop:
- Extra heart sound with tachycardia.
- Either :
➢ 3rd or 4th +tachycardia or
➢ 3rd +4th +tachycardia. ‫صوت حصان‬
- Due to large volume of blood passing through the valve.
- Physiologically: Athlete, Pregnancy.
- Pathologically: Heart failure.

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• 3. Surface anatomy of valves:

- Pulmonary valve: left 3rd sternocostal cartilage (junction).

- Aortic valve: left 3rd intercostal space.

- Mitral valve: left 4th sternocostal junction.

- Tricuspid valve: left 4th intercostal space.

- N.B: valves are not loudest in their assigned areas

- Auscultation areas:

☞ These valves heard at:

- Pulmonary: left 2nd intercostal space “pulmonary area “.

- Aortic: Right 2nd intercostal space “Aortic area”.

- Mitral: left 5th intercostal space midclavicular line “Apex beat”.

- Tricuspid: left 4th intercostal space parasternal line “tricuspid area”.

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• 4. Problems in valves:
• Stenosis: Thickening of the valve & adhesions due to any pathology to
endocardium that decrease the valve opening.
• Regurge: Affection of muscles and tendons that decrease the tone so the valve
becomes loose permitting blood to return again.
• Prolapse: Backward displacement of the valve.

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B) murmurs
• Abnormal musical sound produced due to turbulence of the blood flow as a result of passing
of blood through stenosed valve, regurged valve or septal defect.

- Murmur is 3 types: systolic, diastolic & machinery (continuous)

➢ So systolic murmur occur with systole seen in : -Pulmonary stenosis, aortic stenosis,
tricuspid regurge, mitral regurge.

➢ So diastolic murmur occur with diastole seen in: -Pulmonary regurge, aortic regurge,
tricuspid stenosis, mitral stenosis.

➢ Finally what is machinery murmur continuous in systole and diastole : - This is a continuous
murmur appears in cases of PDA.

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☞ For example: what type of murmur in aortic stenosis? - In aortic stenosis the
problem is in opening. - And aortic valve opens in systole. - Then this is a
systolic murmur.
☞ Another example: what type of murmur in pulmonary regurge? - In
pulmonary regurge the problem is in closing. - And pulmonary valve closes in
diastole. - So this is a diastolic murmur.
• ➢ Grades of murmur: Heard only. 5 grades
• Palpate carotid pulse with one hand while auscultation for timing-> S1 with
carotid upstroke
• N.B:
• Mitral murmur @ apex in Lt lateral position
• Aortic murmur @ aortic area in sitting with leaning forward

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C) pericardial rub
• -Abnormal sound heard during systole.
• -Occurs in cases of pericarditis.
• -Superficial frictional sound.
• if dull hold breathing ( DD For pleurisy)

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