Download Lecture 1: LYMPHATICS

OMM Exam 1 Block 4
Lecture 1: LYMPHATICS
Define lymphatic system and lymph node.
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The great integrator of all bodily fluids” “Second circulatory system”
HIS NOTES
a. Mostly passive system
i. relies on arterial pressure, muscle contraction (peripheral pumps),
thoracoabdominal and pelvic diaphragms
ii. system of one-way valves
iii. Some intrinsic contractile activity (7-12/min)
b. We would die within 24 hours from toxin buildup if it stopped functioning
Lymphatic Fluid
a. Ultrafiltrate that leaks out of arterial capillaries into the interstitium and back into
lymphatic vessels
b. Lymph consists of:
i. Lymphocytes (the primary cell of lymph)
ii. Protein and salts
iii. Postprandial water
iv. Soluble fats
v. Clotting factors
vi. Bacteria and smaller viruses
Central Immune Responses
a. Stimulation of B & T cells
b. Ag delivery to lymph nodes or lymph organs
i. Lymphatic drainage of Ag or macrophages containing Ag
ii. *lymph stasis or lymphedema weaken antigenic stimulation (immune
response)
Extracellular Fluid
a. Provides the environment in which cellular exchanges of gases and nutrients take
place.
Inflammation
a. Generalized response of the body to injury or infection.
b. Vasodilatation, increased capillary permeability
Healing Process
a. Inflammatory exudate and mediators removed
i. Fibroblastic activity decreases
b. Lack of lymphatic drainage
i. Increased inflammatory exudate in peripheral tissue
ii. Increased scarring & fibrosis
1. Ex: Chronic inflammatory diseases (RA, etc.)
2. Fibrotic diseases (post op adhesions-abdominal exudate)
Sympathetics Stimulation
a. Increases lymphatic flow
b. * Primary role may be to modify immune response
c.
Define anatomical distribution and drainage of the lymphatic system.
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Anatomy – organized lymphatic tissue
a. Spleen
b. Thymus
c. Tonsils
d. Appendix
e. Visceral Lymphoid tissues
i. GI, pulmonary and liver
f. Lymph Nodes
Fxns
a. Maintaining fluid balance
i. Average of 30 liters of fluid filters out of capillaries every day
ii. 90% of this (27 liters) is resorbed back into capillaries
iii. 10% of this (3 liters) is resorbed by the lymphatic system
iv. Think: removal of protein from extracellular space
b. Purification and cleansing of tissues
c. Defense
i. B-Cell and T-Cell lymphatic systems
d. Nutrition
i. Approximately 50% of all plasma proteins are carried here
ii. Nutrient binding
iii. Fats, cholesterol, chylomicrons
e. Summary
i. Removes fluid, particulates, extravasated proteins from the interstitium.
ii. Maintains osmotic balance between extracellular, intracellular, and
intravascular fluids.
iii. *Virtually all vascularized tissues have lymphatic capillaries that provide
lymph drainage.
Rate of lymph flow (drainage)
a. Severely limits or determines rate of:
i. Blood supply
ii. Delivery of antibodies
iii. Centrally produced mediators
iv. Medication delivery
v. O2 and nutrients necessary to fuel cellular activities
Valve anatomy – lymphatics have more valves
a. Valves
i. One way flow of fluid from extracellular to initial lymphatics
1. Prevents reflux
ii. More valves in lymphatics than veins
b. Smooth muscle begins where valves begin
i. Thickens proximally
ii. Has: tunica intima, media, adventitia
Define horizontal diaphragm.
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Define and discuss the relationship of the lymphatic system to horizontal diaphragms.
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Demonstrate an appropriate general and region-specific examination of the lymphatic system
including lymph nodes and “terminal drainage areas.”
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R Lymphatic and Thoracic duct
a. Histologically like a medium-sized vein, but
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b. More smooth mm, More valves
Collecting ducts
a. Largest trunks drain into venous system
b. (Left) Thoracic duct
i. drains into left subclavian vein
ii. drains ¾ of body’s lymph
c. Right lymphatic duct
i. drains into right subclavian vein
ii. drains ¼ (right upper quadrant) of body’s lymph and heart/lungs
Superficial vs deep nodes
a. Superficial (Palpable)
i. Cervical, axillary, supraclavicular, epitrochlear, inguinal
b. Deep (Non-Palpable)
i. Intrathoracic, intraabdominal, pelvic, deep cervical
Regional Lymphatic Nodes
a. Peripheral Midline  Cervico-thoracic junction  Jugular or Subclavian veins.
Important cerv nodes – anterior cervical, post cervical (more viral infxn), occipital (think
scalp wound), postauricular (mastoiditis), preauricular (viral conjunctivitis)
Drainage
a. Superficial drainage  proximal noes at: axilla (UA), inguinal (LE)
b. Deep drainage  popliteal space (good area for obstruction), Sibson’s fascia
(supraclavicular)
i. Synovial fluid is drained by lymphatics
HEART AND LUNGS BELOW – will be a test question
Pressure gradients
a. Inhalation
i. Lowers intra-lymphatic pressure producing a gradient for influx of fluid
(negative intra-thoracic pressure)
b. Abdomen (resting position)
i. Lymphatics are open
1. Peristalsis
2. Downward movement of diaphragm increases lymphatic flow (positive
intra-abdominal pressure)
VIII.
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Pumping
a. “Intrinsic myogenic pump”
i. Smooth muscle  peristaltic waves
ii. Pacemaker  spontaneous contractions
b. Other ways to improve lymphatic propulsion Production of lymph
i. * any treatment to enhance lymph formation improves lymphatic
drainage.
c. Endotoxin
i. Strong negative effect on lymph pumping activity
ii. Ex: septic shock
What decreases lymphatic flow?
a. Increased venous pressure
b. Congestion in and around the nodes
c. Examples:
i. Popliteal region
ii. Pectoral region
d. Post-nodal (efferent) vessels follow fascial planes
Terminal Drainage Sites used to Dx Regions of Tissue Congestion
a. Supraclavicular Space “Head and Neck” (L supraclavicular node = Virchow’s node…)
b. Posterior Axillary Fold “Arm”
c. Epigastric Area “Abdomen and Chest”
d. Inguinal Area “Lower Extremity”
e. Popliteal Area “Leg”
f. Achilles Tendon “Foot”
Synthesize how to incorporate such examination within the confines of problem-focused examination.
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Pathophysiology
a. Poor fxn
b. Congestion
c. Edema
i. Lymphadenopathy
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Two broad categories of OMT lymphatic techniques
a. Remove restrictive barriers
b. Promote/augment flow of lymphatics
Goals of OMT: increase venous and lymphatic return
a. Balance the system to restore function
b. Removing edema
c. Proper fluid dynamics
d. Increased resorption of fluids
e. Increased circulation and respiration
f. Decreased proteins in the interstitium
g. Facilitation from a more beneficial pH balance
h. Maintain proper immune response
Sequencing Tx
a. A thorough lymphatic treatment includes techniques from both categories, starting with
the removal of restrictive impediments to lymphatic flow
b. Release of the central lymphatic system should be accomplished first, followed by
release of the periphery
i. This decreases likelihood of exceeding the system’s innate 7mmHg maximum
increase in capability of handling increased flow
c. Begin by releasing thoracic inlet, then abdominothoracic diaphragm, and then pelvic
diaphragm
d. Lymphatic treatments should be accompanied by a release of all respiratory restrictions
as well as restrictions of muscles, joints, and the abdomen
Absolute CONTRAINDICATIONS
a. Anuria
b. Necrotizing fasciitis
c. Fx sites
Relative CONTRAINDICATIONS
a. Cancer – no study has shown increased risk of spread
i. Exercise (recommended)-promotes lymphatic flow
ii. Lymphatic Cancer (lymphoma, splenomegaly, etc) - be judicious
b. Infections
i. Ex: mononucleosis with splenomegaly overwhelming bacterial infection (sepsis,
osteomyelitis)
c. Circulatory
i. DVT, hemorrhage
Techniques to remove restrictive barriers and promote/augment flow of lymph
a. Craniocervical junction (occipito-atlantal)
b. Open thoracic inlet (area of greatest restriction)
i. Removes restrictive impediments
c. Rib raising
i. Reduces hypersympathetic activity to the lymphatic vessels and mobilization of
the ribs enhances respiration
d. Doming abdominal diaphragm
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i. Improves the ability of this major fibromuscular diaphragm to produce effective
pressure gradients between thoracic and abdominal cavities, therefore
promoting and augmenting lymphatic flow
e. Ischiorectal fossa release (Dome Pelvic Diaphragm)
i. Improves the ability of the pelvic diaphragm to produce effective pressure
gradients between pelvic and thoracic cavities, therefore promoting and
augmenting lymphatic flow
f. Correcting Somatic Dysfunctions in areas of concern
i. Removes restrictive barriers
g. Lymphatic Pump Techniques
i. Promotes and augments lymphatic flow
h. Direct Pressure Techniques
i. Promotes and augments lymphatic flow
Opening thoracic inlet
a. Many neurovascular structures pass through here
b. Know that this is the first area to address with lymphatic techniques
THORACOABDOMENAL DIAPHRAGM
a. Ischiorectal Fossa Release and Dome Pelvic Diaphragm
i. Distention of the pelvic diaphragm must be in phase with the continual
movements of the thoracic diaphragm and also with the transient changes in
intrapelvic pressure
ii. This aids in free flow of fluids within the vascular and lymphatic channels of the
pelvic region
iii. Curl hand around ischial tuberosity
iv. Lymphatic flow depends on elasticity of the pelvic floor
v. The pelvic floor must compensate for respiratory pressures and the transient
increase of pressure caused from coughing, sneezing, hiccups, pregnancy etc
vi. A rigid pelvic floor leads to dysfunction
Thoracic Lymphatic Pump (once you’ve removed all the impediments)
a. Increases negative intra-thoracic pressure
i. Increases R lymphatic and thoracic duct flow
ii. Stimulates lymph formation in abdomen & thorax
b. Upper or lower thoracic pump. Person takes deep breath, when they bbreath out, I
pump down to try to improve elastic recoil.
c. Improves the ability of this structure to produce effective pressure gradients
d. Cisterna chyli lies directly below the thoracoabdominal diaphragm
e. Doming the thoracoabdominal diaphragm
i. Direct fascial technique
1. Encourage pressure gradients between thoracic and abdominal areas
2. This in turn helps venous and lymphatic return
ii. Myofascial technique
f. Pedal Pumps (feet)
i. Can be done with plantar flexion or dorsiflexion
ii. Moves fluid
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iii. Helps pelvic diaphragm move (must release pelvic diaphragm first)
iv. Helps with
1. CHF
2. Pregnancy
3. Hospitalized patients
Rib raising
a. Sympathetic chain lies ant to rib heads; affecting these produces systemic effects
b. Supine
i. Good for hospitalized patients or bedridden
c. Thoracic duct also closely associated with this area
d. Cisterna chyli is a dilatation of the thoracic duct at its inferior pole
i. This drains all of the lower extremities, pelvis and abdomen
e. Focus pressure on erector spinae muscles and transverse processes
f. Can be done seated or supine
Pectoral traction technique
a. Assists in opening the thoracic inlet
b. Encourages venous and lymphatic return through the right lymphatic and thoracic ducts
c. Helps to expand fascial barriers
Review postural considerations and horizontal planes in relation to the lymphatic examination.
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Lecture 2: Examination of the Chest Wall, Thoracic and Rib Cage
Recall and describe the structural and functional anatomy of the thoracic spine and rib cage.
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T spine General Characteristics
a. Thoracic Cage
i. 12 vertebrae, 12 pairs of ribs, and sternum
ii. Clavicle and scapulae are considered upper extremity
b. Mild kyphotic curvature
i. Can become more acute with age, osteoporosis
1. Leads to biomechanical problems → compensatory adaptations in other
regions of the body and with posture
c. Vertebrae increase in size as you move caudally
i. Corresponding to increased weight bearing
Two anatomic causes for relative immobility of the thoracic spine:
a. intimate connection of the T spine to the rib cage, ribs and sternum, via the
costovertebral articulations.
b. ratio of intervertebral disk height to vertebral body height is small(1:5) which greatly
reduces intersegmental motion.
i. Know diff b/t dermatome, myotome, slcerotome.
Embryology
a. Centrum becomes vertebral body
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b. There’s a very detailed slide (12)
Osteology stuff
a. Remember BUM BUL BUM (cervical, thoracic, lumbar orientation of superior facets)
i. Backward upward medial = cervical & lumbar
ii. Backward upward lateral = thoracic
b. Vertebral unit
i. The vertebral unit is given the name of the superior member of the unit.
1. Ex: motion or somatic dysfunction of “T2” means the motion of T2 on
T3.
c. Vertebral size increases as you move caudad from the cervical spine corresponding to
increased weight bearing.
d. T-Spine somatic dysfunction related to rib somatic dysfunction!
i. Treat T-Spine before ribs!
1. Upper: T1-T4
2. Middle: T5-T9
3. Lower: T10-12
e. Spinal unit
i. Spinal motion: a unit consisting of two vertebrae and associated soft tissues
ii. Vertebrae: anterior body, anterior and posterior ligaments
iii. Vertebral canal with ligamentum flavum, interspinous ligaments, supraspinous
ligaments.
iv. Capsular ligaments for facet articulations also contribute to stability and
limitation of motion
v. Ligaments with high elastin content can store kinetic energy that can be used to
help restore segment to original position
vi. Intervertebral discs: fibrocartilage annulus fibrosis bound with hyaline cartilage
above and below to each segment, enclosing a gelatinous core, nucleus
pulposus that acts to distribute and redirect stress and store energy.
f. Atypical vertebrae
i. One entire facet on vertebrae 1, 10,11,12
ii. No facet on transverse
iii. process of
iv. vertebrae 11, 12
g. Functional landmarks
i. Suprasternal notch - lies anterior to the vertebral body of T2
ii. Angle of Louis - anterior toT4 at level of second rib anteriorly
1. aortic arch lies superior
2. bifurcation of trachea lies posterior
iii. Xiphoid Process - anterior toT9
iv. Spine of scapula - lies posterior to T3
v. Inferior angle of scapula - lies posterior to T8/T7
Muscles –
a. superficial Layer
i. Trap, lat dorsi, rhomboid maj and minor
b. Intermediate
i. Erector spinae (I L S)
ii. Serratus post superior and inferior
c. Deep
i. Semispinalis thoracis, rotatores longus and brevis, etc
d. Innervation – post curtenous branches…LOOK AT SLIDE.
Recall Fryette’s principles and how they apply to the thoracic region.
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Remember somatic dysfxn = Impaired or altered function of related components of the
somatic system: skeletal, arthrodial and myofascial structures, and related vascular,
lymphatic and neural elements.*
1st Principle
a. When sidebending is attempted from neutral (anatomical) position, rotation of
vertebral bodies follows to the opposite direction.
2nd Principle
a. When sidebending is attempted from non-neutral (hyperflexed or hyperextended)
position, rotation must precede sidebending to the same side.
3rd Principle
a. Motion introduced in one plane limits and modifies motion in the other planes.
Demonstrate both a screening and segmental evaluation of the T-Spine.
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See LAB
Explain and review anterior and posterior landmarks in the thoracic region.
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Thoracic Apertures: Inet vs Outlet
a. The thoracic cavity communicates with the neck and upper limb through the superior
thoracic aperture also known as the (boney) thoracic inlet
i. Trachea, esophagus, major vessels and nerves pass through here
ii. Lymphatic drainage for the whole body drains into the venous system
immediately posterior to the medial end of the clavicle and 1st rib
iii. 6.5 x 11 cm in the adult, sloping antero-inferiorly
iv. Boundaries:
1. posterior by T1 vertebra
2. Laterally by medial margins of 1st ribs and costal cartilages
3. Anteriorly by superior/posterior border of manubrium
v. Anatomical thoracic inlet
1. T1, 1st ribs, sternal manubrium
vi. Functional thoracic inlet
1. T1-4, ribs 1&2, manubrum
b. Thoracic inlet fascia
i. The cervicothoracic (diaphragm) fascia covers the thoracic inlet.
ii. It is the deep fascia of the scalenus muscle group
1. Including variably fibrous bands, this fascia inconsistently includes
muscle fibers from scalenus minimus. This fascial covering of the
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superior dome of the lung is also referred to as Sibson’s Fascia (Grey’s
Anatomy).
iii. Sibson’s fascia is the final area of obstruction of the 2 great lymphatic ducts
(Thoracic & R Lymphatic).
c. Thoracic Outlet
i. The thoracic outlet (bony) is often referred to the area bounded by the:
ii. Scapulae
iii. 1st ribs
iv. clavicles.
v.
A compression syndrome can act upon the neurovascular bundle as it
travels from the scalene triangle to the neck.
vi. Subclavian artery
vii. Subclavian vein
viii. Brachial plexus
ix. Thoracic Outlet Syndrome (TOS) common AREAS FOR OBSTRUCTION
1. Ant & Middle Scalenes
2. Costoclavicular
3. Pectoralis minor & upper ribs
Functional Classification
a. CervicoThoracic (CT) Junction: C7 – T3
b. “Typical Thoracics”: T4-T9
c. ThoracoLumbar (TL) Junction: T10-L2
d.
Describe the motion characteristics of the T-Spine.
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Muscles
a. Backward bending (extension)
i. Interspinales thoracis
b. Backward bending (extension) when acting Bilaterally
i. Intertransversari thoracis
ii. Multifidus
iii. Longissimus thoracis
iv. Iliocostalis thoracis
c. Backward bending & Rotation (to opposite side)
i. Semispinalis thoracis
ii. Rotatores thoracis
d. Sidebending (lateral flexion)
i. Longissimus thoracis
ii. Intertransversari thoracis
iii. Iliocostalis thoracis
e. Sidebending and Rotation (to opposite side)
i. Multifidus
f. Flexion- abdominal muscles
Thoracic Motion
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a. Motion limited
i. to minimize interference with respiration
ii. to minimize interference with cardiac function
iii. because of ribs
b. The architecture of the posterior segment acts to guide and limit the motion that can
occur between the vertebrae.
c. Orientation of the facets varies through the column
d. Load bearing in the posterior segment can be significant when the spine is
hyperextended, and during forward bending when coupled with rotation
Simple vs Coupled Motion
a. Physiologically normal movements in any of the primary directions induces additional
motion vectors as a consequence of the facet orientation: compound movement:
i. F/E, SB, R.
b. Pure flexion and extension of a vertebral unit is the exception to this = simple
movement or “sagittal plane.”
i. F/E
General Motions – summary
a. Cervicals: C2-7: flexion, extension, sidebending and rotation. (varies thru region)
b. Thoracics: rotation > SB > flexion/extension
c. Lumbars: flexion/extension > SB > rotation
i. So rotation greatest in Cerv and upper thoracics; Flex greatest in cervs, lower
thoracic, lumbars
Thoracics = Think ROTATION
a. Greatest motion: Rotation
i. the orientation of the thoracic superior articular facets (“BUL” backwards/
upward/lateral)
allows them to glide relative to each other with an axis of
rotation near the center of the vertebral body
ii. Limited by multiple ligamentous tensions
b. Next greatest is SIDEBEND
i. articular facets of the articular processes of any two adjacent vertebrae slide
relative to each other
ii. Limited by articular processes on the side of movement, contralateral ligamenta
flava, intertransverse ligaments, RIBS and STERNUM
c. Second least motion – Forward Bend (flex)
i. Interspace between the two vertebrae opens out posteriorly, the nucleus is
displaced posteriorly
ii. Limited by the extensor mm., interspinous ligaments, ligamenta flava, posterior
longitudinal ligament
d. Least – Backbend (extend)
i. Vertebrae approximate posteriorly
ii. Intervertebral disc expands anteriorly as it is compressed posteriorly
iii. Limited by the impact of the articular processes and the spinous processes
(shingle effect)
Describe the rule of 3’s and how this is helpful in identifying a segmental level (ID spinous process)
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T1-T3 - come out LEVEL w/ Trans process
T4-6 – ½ way up to get on corresponding TP
T7-9 – come out laterally and you’re one TP of the one below
T10-12
a. Summary
i. 1-3: SP of each is about the same horizontal plane as the TP of each vertebra
ii. 4-6: SP project slightly downward; the tip of the SP lies in a plane halfway
between that vertebra's TP and the TP of the vertebra below it
iii. 7-9: SP project moderately downward; the tip of the SP is in a plane with the TP
of the vertebra below it
iv. 10-12: have SP that project from a position similar to T9 and rapidly regress until
the orientation of the SP of T12 is similar to that of T1.
LAB NOTES from this week : ? do later.
Lecture 3: Heart Sounds
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Auscultation Skills
a. Style Points
i. Squeeze earpieces to hear better
ii. Don’t ask about heart disease after you listen (freaks out the patient)
iii. Watch your facial expression
iv. Isolate the sounds - don’t try to hear them all at once
b. Stethoscope parts
i. Earpieces – face forward
ii. Bell – good for hearing low pitched sounds (apply w/ light pressure)
iii. Diaphragm 0 good for hearing higher pitched sounds (apply w/ firm pressure)
c. Cardiac Cycle – hemodynamics
i. In diastole, blood flows into the R and L atria and ventricle via vena cava and
pulmonary vein respectively
ii. End diastolic volume – how much the ventricle can hold just before contraction
of the atria begins (measurement of ventricle compliance)
iii. At the start of systole, atria contract to fill the ventricle further (“atrial kick”),
then mitral and tricuspid valves click shut (1st heart sound) when ventricle
pressure becomes greater than atrial pressure
iv. Ventricles contract and push blood to body (left vent to aorta) or lungs (R vent
to pulm artery)
v. When contraction ceases and ventricular pressure is lower than pressure in the
outflow track, the aortic and pulmonic valves close (2nd heart sound)
d. Relate auscultation to cardiac cycle
i. Know that big cardiac cycle graph Dr. A uses all the time
e. Terminology
i. Base of heart
ii. Apex of heart
iii. Precordium – ant chest wall overlying heart
iv. Listening posts – 4 sites
v. PMI – point of maximal impulse (where you feel the heart beat through the skin
the most)
f. Normal Heart Sounds
i. 1st – mitral/tricusp closes
ii. 2nd – pulm and aortic valve closes
1. Erb’s point is the place where S2 is loudest
2. Physiologic splitting of S2
a. With inspiration, pulm artery pressure decreases.
b. Venous return to R heart increases
c. Pulmonary vlave remains opwn longer, resulting in a splot S2
d. Split resolves w/ exhalation
iii. Being systematic
1. Most start at right 2nd intercostal space (aortic listening post), then inch
from R to L (pulmonic post). Then, inch down along the L sternal border
to the 5th intercostal space (tricuspid listening post) then along the 5th
intercostal space to the mid-clavicular line (mitral post)
iv. Note that the interval b/t S1 and S2 is shorter than the interval b/t S2 and the
next S1
g. Describing heart sounds
i. Rate and rhythm regular
1. Normal heart sounds
2. Too fast = tachycardia
3. Too slow = bradycardia
ii. If irregular
1. Regularly irregular
2. Irregularly irregular (ie, A Fib)
h. Patient positioning
i. Upright – standing
1. Like sports physical
2. Makes innocent murmurs less audible
ii. Seated – most commonly used
iii. Left lateral decubitus – brings L ventricle close to the cheat wall. Auscultate w/
the bell in this position. At the apex, mitral valve murmers are accentuated
i. Auscultation of the lungs
i. Do ant AND post lung fields (both R and L sides)
ii. Should be standing on the R side of the patient
iii. Auscultate the skin, tell pt to “open your mouth and take deep quiet breaths in
and out”
1. Older pts can get light-headed or hyperventilate w/ repeated deep
breathing so warn them.
iv. Listen w/ diaphragm
v. Start at the apex and alternate side to side in at least 6 sites
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vi. Note wheeze, rhonchi, consolidation
1. If you’re uncertain if you hear an abnormality, ask the pt to say “E”
(because in pneumonia, it will sound like “A”)…this is called egophony
Lung Sounds
a. Once you know what normal is, listen for these sounds
i. Wheeze aka sibilant wheeze
1. High pitched, almost musical
2. Inspiration or expiration
3. Usually asthma or chronic bronchitis
4. Treated w/ inhaled Beta 2 agonist
ii. Rhonchi = secretions in large airways or narrowing produced in large airways
produce sonorous sounds (almost like a bubbling), usually heard in expiration;
can clear with coughing
1. Think: right upper lobe pneumonia x-ray
2. Bronchitis or diseases producing secretions may cause
3. In cases where there is consolidation, egophony may be heard
iii. Egophony – think pneumonia
1. See above
iv. Pleural rub
v. Crackles (rales) = crackles produced by air moving thru smaller airways, sounds
like hair rolled between fingers or cellophane crumpled, usually heard in
inspiration
1. CHF, Pulmonary fibrosis, bronchiectasis, chronic bronchitis
vi. Whispered pectoriloqy
vii. Stridor = obstruction of upper airway causes hi-pitched sound
1. Causes
a. Infectious causes: croup and epiglottitis most common
i. If signs of these, DO NOT use tongue depressor, cause
you will trigger gag reflex and cause edema that closes
airwat
b. Foreign bodies
c. Chemical burns, trauma
2. Due to obstruction, kids may adopt “sniffling position” to keep airway
open
3. If present, obtain X-ray to determine if foreign body present
Heart Sounds
a. Things to listen for
i. Normal 1 and 2 heart sounds
1. Remember Erb’s point is the location where S2 is loudest
ii. A fib
iii. Physiologic splitting
1. Usually heard at left 2nd intercostal space; split is intermittent w/
respiratory cycle
2. Pathologic splitting of S2
a. Any patho that causes the pulm valves to remain open longer
causes a fixed split
b. R or L Bundle Block – causes fixed splitting by delaying
contraction of the ventricle, w/o other ex. Usually S1 will be
faint
c. Atrial septal defect - fixed splitting due to hole in atria which
shifts blood from L side to right, w/ early midsystolic murmur
d. There is NO resolution of splitting w/ expiration; split remains
fixed
rd
iv. 3 heart sound
1. Occurs immediately after S2
2. L ventricular gallop usually heard best over the apex w/ the bell of the
stethoscope in L lateral decubitus position. Usually SOFTER during
inspiration
3. R ventricular gallop is best heard over the L sternal border and is
LOUDER during inspiration
4. Can be normal in people under 30; older indicates heart failure. Sounds
from stopping ventricular filling due to over-full ventricles
5. Produces a rhythm similar to the cadence of the word “Kentucky” with
the “ky” representing S3
th
v. 4 heart sound
1. Extra heart sound just after atrial contraction and immediately before
S1. Produces a rhythm classically compared to the cadence of the word
“Tennessee” – the first syllable represents S4
2. Almost always patho. If problem is RIGHT ventricle, the abdominal
sound is best heard at the lower left sternal border, louder w/ exercise
and deep inspiration
3. If the LEFT ventricle is the problem, the sound is best heard at left
lateral decubitus position and will be louder w/ pt holding expiration
vi. Heart Murmur in general
1. Look for timing – when u hear and what immediately precedes it
2. Duration – how long does it last in the cardiac cycle
3. Location – where do you hear it?
4. Radiation – where does it go?
5. Intensity – graded
a. Grade 1 – barely audible, cardiologist can hear
b. Grade 2 – little louder, *if you can hear it, it’s at least Grade 2
c. Grade 3 – clearly audible, no thrill
d. Grade 4 – thrill palpable (a thrill – you can palpate the chest wall
and feel the vibration of the murmur)
e. Grade 5 – audible w/ stethoscope partly off the cheast and thrill
f. Grade 6 – audible w/o stethoscope (ie, metallic aortic ball valve)
6. Pitch – hi or low?
7. Quality – musical? Harsh?
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vii. Stenosis murmur - general
1. When the valve becomes stiff or the opening narrow
2. When fluid flows across the narrow opening, flow sound produced is
the murmur (like water rushing by a ‘kink’ in a garden hose)
viii. Aortic stenosis
1. What = Harsh SYSTOLIC crescendo-decrescendo murmur, best heard @
R upper sternal border, 2nd intercostal space
a. Radiation to the carotid aa bilaterally (sound should be
transmitted forward (away) from the heart
2. Etio
a. 50% is age-related calcification of aortic valve
b. 30-40% from congenital bicuspid aortic valves
3. Sx only present w/ severe stenosis (progressive dyspnea on exertion,
syncope, chest pain, heart failure)
4. What to hear: distinct S1, murmur, distinct S2.
5. Graph stuff
a. Narrowing of the aortic valve requires a marked increase in
systolic pressure w/in the L ventricle to drive blood thru the
stenotic valve orifice…
b. when severe, the aortic pulse curve is deformed. Aortic
pressure pulse is narrow, and there’s a slow rise during systole,
w/ notching on the upstroke (anacrotic notch)-this pulse if
called pulsus parvus (small) and pulsus tardus (late)
ix. Mitral stenosis
1. What = a diastolic murmur. Low-pitched diastolic rumble. Best heard
over the L 5th intercostal space at the apex, in the left lateral decubitus
position. May be an opening snap heard, which comes from the forceful
opening of the mitral valve
2. Etio
a. Mostly from diseased valves as a consequence of rheumatic
fever…also bacterial endocarditis
3. Sx = only w/ severe (dyspnea and pulm HTN)
4. What to hear – S1 and S2 are distinct, no sound b/t them. Hear a 3rd
heart sound (opening snap) followed by the rumbling murmur
5. Causes an impediment to blood flow into the L ventricle. As the valve
stiffens, there is more pressure that must build up in the L atrium before
it snaps open
6. As the pressure gradient increases, the amount of time necessary to fill
the ventricle w/ blood increases. If the diastolic filling period is
insufficient, pressure will build up in the L atrium leading to pulm
congestion. Eventually, there will be a L atrial enlargement and possible
A fib.
x. Hypertrophic cardiomyopathy bonus murmur
1. Common cause of sudden cardiac death in athletes.
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2. Best heard over the mitral listening post, when there is less volume in
the ventricle
3. Valsalva maneuver increases thoracic pressure and decreases blood
return to the heart, making the murmur louder.
4. Squatting down increases blood return to the heart and makes the
murmur softer.
xi. Aortic regurgitation - a diastolic murmur (aka ‘insufficiecy’)
1. Soft, early diastolic decrescendo murmur, best heard at R upper sternal
border, 2nd intercostal space.
2. Caused by leaking of the aortic valve, resulting in blood flow from the
aorta back into the ventricle after ventricular contraction.
3. Sx
a. Dyspnea on exertion, orthopnea, angina, paroxysmal nocturnal
dyspnea
4. What to hear
a. Distinct beginning of the murmur immediately after S@,
gradually diminishes in intensity (decrescendo). Murmur ends
distinctly before the beginning of the next S1
xii. Mitral regurgitation – a systolic murmur
1. High-pitched, blowing, holosystolic murmur best heard at the apex.
2. Radiates to the axilla. Most common form of valvular heart disease
3. If it happens acutely, it may cause dyspnea and CHF; chronic causes are
usually compensated and asymptomatic.
4. Note: the tricuspid regurg murmur is similar but is best heard at the L 5th
intercostal space at the sternum
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