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General Inspection
During the initial inspection, look for signs that may suggest cardiovascular disease.
Cyanosis: Bluish discoloration of the lips or extremities suggests hypoxemia, which may occur with congenital heart defects or severe heart failure.
Pallor: Pale skin may indicate anemia or reduced cardiac output.
Jugular Venous Distention (JVD): Visible distension of the jugular veins is a sign of increased central venous pressure, typically seen in right-sided heart failure or fluid overload.
Edema: Peripheral edema, particularly in the lower extremities, suggests right-sided heart failure or venous insufficiency.
Clubbing: Enlargement of the distal fingers, known as clubbing, may indicate chronic hypoxia associated with congenital heart disease or pulmonary conditions.
Palpation
Palpation of the precordium and peripheral pulses helps assess cardiac function and peripheral circulation.
Apical Impulse (Point of Maximal Impulse – PMI)
The PMI is normally located at the 5th intercostal space at the midclavicular line.
Displacement: A laterally displaced PMI suggests left ventricular hypertrophy or dilation, often due to hypertension or heart failure.
Size and quality: A sustained and forceful PMI suggests left ventricular hypertrophy, while a weak PMI may indicate dilated cardiomyopathy or pericardial effusion.
Peripheral Pulses
Assessing the rate, rhythm, and amplitude of peripheral pulses helps in identifying abnormalities in circulation and cardiac output.
Pulse Deficits: A pulse deficit occurs when the heartbeats do not match the radial pulse, suggesting arrhythmias like atrial fibrillation.
Pulsus Paradoxus: A marked decrease in systolic blood pressure during inspiration is a classic sign of cardiac tamponade or severe asthma/COPD.
Percussion
Percussion is less commonly used in modern cardiovascular exams due to the availability of imaging modalities but can still be useful in estimating heart size.
Cardiac borders: Percussion of the chest helps define the boundaries of the heart. A shift in the cardiac borders may indicate cardiomegaly or other structural abnormalities such as pericardial effusion.
Auscultation
Auscultation is one of the most critical components of the cardiovascular examination. It provides valuable insights into the mechanical and electrical activity of the heart, allowing clinicians to detect normal and abnormal heart sounds, murmurs, and other findings that may indicate underlying pathology.
Auscultatory Areas
Auscultation should be performed in specific areas of the chest that correspond to the locations where heart sounds and murmurs are most prominent.
Auscultatory Area
Location
Valve Assessed
Aortic Area
Right second intercostal space
Aortic valve
Pulmonary Area
Left second intercostal space
Pulmonary valve
Tricuspid Area
Left lower sternal border
Tricuspid valve
Mitral Area
Fifth intercostal space, midclavicular line
Mitral valve
Note: Proper auscultation involves listening with both the diaphragm and bell of the stethoscope. The diaphragm is used to hear higher-pitched sounds such as S1 and S2, while the bell is more effective for detecting lower-pitched sounds like S3, S4, and murmurs associated with mitral stenosis.
Heart Sounds
The heart produces two primary sounds during a normal cardiac cycle. During auscultation the first (S1) and second (S2) heart sounds are the primary sounds heard. These correspond to the closure of the heart valves during the cardiac cycle:
S1 is caused by the closure of the mitral and tricuspid valves at the onset of systole, best heard at the apex of the heart.
S2 corresponds to the closure of the aortic and pulmonic valves at the end of systole and is best heard at the base of the heart, near the second intercostal spaces.
Note: During inspiration, there may be physiological splitting of S2 due to delayed closure of the pulmonic valve. However, a wide or fixed splitting of S2 can be pathological and may indicate conditions such as right bundle branch block or atrial septal defect.
Extra Heart Sounds (S3 and S4)
Additional heart sounds may also be heard under certain pathological conditions:
S3 (ventricular gallop) occurs after S2 and suggests volume overload, as seen in heart failure. It is a low-pitched sound, best heard with the bell of the stethoscope at the apex.
S4 (atrial gallop) occurs just before S1 and is associated with a stiff or hypertrophied ventricle, commonly seen in hypertrophic cardiomyopathy or chronic hypertension. Like S3, it is best heard at the apex with the bell of the stethoscope.
Heart Sound
Timing
Associated Condition
Best Heard
S1
Beginning of systole
Normal closure of mitral/tricuspid valves
Apex of the heart
S2
End of systole
Normal closure of aortic/pulmonic valves
Base of the heart (2nd intercostal spaces)
S3
Early diastole
Heart failure, volume overload
Apex with bell of stethoscope
S4
Late diastole
Hypertrophic cardiomyopathy, hypertension
Apex with bell of stethoscope
Murmurs
Heart murmurs are caused by turbulent blood flow through the heart, often due to structural abnormalities such as valve stenosis, regurgitation, or septal defects. They are classified based on their timing within the cardiac cycle:
Systolic Murmurs
Systolic murmurs occur between the first heart sound (S1) and the second heart sound (S2), during ventricular contraction. Common conditions include:
Condition
Description
Location Heard Best
Radiation
Aortic Stenosis
Crescendo-decrescendo murmur (increases then decreases in intensity)
Right second intercostal space
Radiates to the neck
Mitral Regurgitation
Holosystolic (constant intensity throughout systole) murmur
Apex of the heart
Radiates to the axilla
Diastolic Murmurs
Diastolic murmurs occur between the second heart sound (S2) and the first heart sound (S1) of the next cycle, during ventricular filling. Common conditions include:
Condition
Description
Location Heard Best
Position for Optimal Hearing
Aortic Regurgitation
Decrescendo murmur (starts loud, then diminishes)
Left sternal border
Patient leaning forward
Mitral Stenosis
Low-pitched, rumbling murmur
Apex of the heart
Left lateral decubitus position
Continuous Murmurs
Continuous murmurs occur throughout the cardiac cycle, both during systole and diastole, indicating abnormal blood flow that persists continuously. A common condition associated with a continuous murmur is:
Condition
Description
Location Heard Best
Patent Ductus Arteriosus
A continuous “machinery-like” murmur heard throughout systole and diastole
Left upper sternal border
Key Characteristics of Murmurs
Timing: Is the murmur systolic, diastolic, or continuous?
Location: Where is the murmur heard best (e.g., aortic area, mitral area)?
Radiation: Does the murmur radiate to other regions (e.g., neck, axilla)?
Intensity: Graded on a scale of 1 to 6, with 1 being barely audible and 6 being heard with the stethoscope lifted off the chest.
Pericardial Rubs
A pericardial friction rub is a scratching or grating sound caused by inflamed pericardial layers rubbing against each other. It is often heard in patients with pericarditis.
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