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Look for signs of distress!
Vital signs
Take blood pressure lying, sitting (both arms), standing 0___1___2___
Take pulse and respiration rate 0___1___2___
Lips for cyanosis 0___1___2___
Nail beds check for: cyanosis, pulsations, clubbing 0___1___2___
Check palms soles: Osler & Janeway lesions 0___1___2___
Check eye grounds: observe retinal vessel/disc 0___1___2___

Position patient supine with head of bed elevated to 30-45 degrees
Inspect JVP >4cm/hepatojugular reflex by palpation 0___1___2___
Carotid pulses 0___1___2___
Carotid arteries for bruits 0___1___2___
Palpate thyroid gland front and back (sitting) 0___1___2___
Inspect anterior chest regarding cardiac function 0___1___2___
Palpate the following for thrills, lifts, heaves; supine position:
Right 2
interspace 0___1___2___
Sternal angle and Left 2
interspace 0___1___2___
Left sternal border (3
, 4
and 5
interspaces) 0___1___2___
Apex/PMI in left lateral decubitus position 0___1___2___

Auscultate with the diaphragm; supine position:
Right 2
interspace 0___1___2___
Left 2
interspace 0___1___2___
Left sternal border, 3
interspace 0___1___2___
Left sternal border, 4th interspace 0___1___2___
Left sternal border, 5th interspace 0___1___2___
Apex/PMI 0___1___2___
Auscultate with the bell:
Apex/PMI supine & left lateral decubitus Turn to Left lateral position while listening 0___1___2___
Auscultate with the diaphragm
Sitting leaning forward Right and left 2
interspace in deep expiration 0___1___2___
Auscultate the lung bases 0___1___2____
Peripheral Pulses
Radial Pulse 0___1___2___
Brachial Pulse 0___1___2___
Femoral Pulse 0___1___2___
Popliteal Pulse 0___1___2___
Posterior Tibial Pulse 0___1___2___
Dorsalis Pedis 0___1___2___
Check for edema 0___1___2___
Overall Sequence and Flow of Cardiac/Vascular Exam Poor Fair Good Outstanding
Additional tests:

Inhalation: drop in intrathoracic pressure, increasing capacity of pulmonary circulation, prolonging
ejection time. affects closure of pulmonary valve (Carvallo's maneuver), detects murmurs originating
in right heart, increase intensity of tricuspid regurgitation murmur

Hand grip maneuver: performed by clenching the fist forcefully for a sustained time until fatigued
I ncreases afterload by squeezing the arterioles and increasing total peripheral resistance,
Increased murmur intensity
Aortic Regurgitation
Mitral Regurgitation
Ventricular Septal Defect
Mitral valve prolapse
Decreased murmur intensity:
Aortic Stenosis
Mitral Stenosis?
Hypertrophic Cardiomyopathy

Mitral valve prolapse: The click and murmur are delayed because of increased left
ventricular volume

Valsalva maneuver moderately forceful attempted exhalation against a closed airway
Decreases preload;
Decreased murmur intensity:
Aortic Stenosis
Pulmonic Stenosis
Tricuspid Regurgitation
Increased murmur intensity:
Hypertrophic cardiomyopathy, dynamic subvalvular left ventricular outflow obstruction ;
mitral valve prolapse

Squatting maneuver:
I ncreases afterload also increases preload by increase venous return
decreases the murmur of hypertrophic Cardiomyopathy

Abrupt standing

"cooing dove" Aortic insufficiency murmur due to rupture of an aortic cusp secondary to bacterial
endocarditis or trauma

Classical descriptions of valve auscultation areas:
Mitral area: cardiac apex, 5th intercostal space (ICS) in the midclavicular line
•Mitral valve prolapse, regurgitation, and stenosis; Still’s murmur, aortic stenosis

Tricuspid area: 4-5th ICS, left sternal edge
•Tricuspid regurgitation, ventricular septal defect (VSD), Still’s murmur, hypertrophic cardiomyopathy.

Pulmonary area: 2nd ICS, left sternal edge
•Pulmonary regurgitation and stenosis, ASD, TAPVR, PDA, and pulmonary flow murmurs.

Aortic area: 2nd ICS, right sternal edge
•Aortic stenosis, benign aortic systolic murmur

Blood pressure
Why take the blood pressure lying, sitting and standing? Ans. Postural hypotension is a major problem.

If leg pulses are weak or absent take Bp in legs

Janeway lesions non-tender, small erythematous or
hemorrhagic macular or nodular lesions on palms or soles few
millimeters in diameter
infective endocarditis, septic emboli, microabscesses
Osler's nodes painful, red, raised lesions on palms
and soles. Associated with infective endocarditis,
systemic lupus erythematosus, marantic
endocarditis, disseminated gonococcal infection,
distal to infected arterial catheter
Caused by immune complex deposition
Roth's spots retinal hemorrhages white or pale
centers composed of coagulated fibrin.
Caused by immune complex mediated
vasculitis often result from bacterial
endocarditis. leukemia, diabetes, pernicious
anemia, ischemic events, HIV retinopathy

Nail clubbing deformity of fingers and fingernails, disease of heart and lungs

Schamroth's window test When distal
phalanges of corresponding fingers of
opposite hands are directly apposed (place fingernails of same finger on opposite hands
against each other, nail to nail) small diamond-shaped "window" is normally apparent
between nailbeds. If window is obliterated, test is positive clubbing is present.

Cyanosis: blue coloration of skin/ mucous membranes due to deoxygenated hemoglobin
< or = to 2.5 g/dL in blood vessels near skin surface
Causes: Arterial obstruction, vasoconstriction, Raynaud's phenomenon, Reduced cardiac
output (heart failure, hypovolaemia), Venous obstruction (deep vein thrombosis)

Central cyanosis Peripheral cyanosis

Auscultation essential part of even a cursory cardiac exam. Listening to the heart
gather information about 1) rate/rhythm, 2) value functioning (e.g. stenosis,
regurgitation/insufficiency), 3) anatomical defects (atrial septal defects, ventricular septal
defect (VSD), hypertrophy)

In describing/documenting a murmur, characterize 6 properties of abnormal heart sound:
1) Location of heart sound on chest (where heard loudest can you hear sound at all)
2) Timing/duration of the heart sound (i.e. early diastolic, pan systolic, etc.)
3) Grade or intensity of the heart sound (i.e.1-6 (see table below))
4) The quality and shape of the heart sound (i.e. musical crescendo, harsh snap, etc.)
5) Radiation of the sound
6) Maneuvers

Auscultation over 4 general areas on anterior chest, begin with patient in supine position.

4 percordial areas examined with diaphragm, including:

Aortic region (between the 2nd and 3rd intercostal spaces at the right sternal border)
Pulmonic region (between the 2nd and 3rd intercostal spaces at the left sternal border)
Tricuspid region (between the 3rd, 4th, 5th, 6th intercostal spaces at left sternal border)
Mitral region (apex; between 5
/6th intercostal spaces in mid-clavicular line)
After initial exam in supine positions, additional maneuvers should be accomplished:
Have patient turn onto left side (left decubitus position) listen with bell at apex for mitral
stenosis (low pitched diastolic murmur)
Have patient sit upright re-examine base of heart with diaphragm
Have patient lean forward, exhale, hold breath. Listen second/third intercostal spaces at
right sternal (aortic)/left sternal (pulmonic) areas for aortic regurgitation.

Jugular venous pressure measurement
Jugular venous pulse wave

Murmur Grades
Grade Description
Grade 1/6 Very faint
Grade 2/6 Loud enough to be generally heard
Grade 3/6 Moderate (louder then grade 2)
Grade 4/6 Loud, palpable thrill
Grade 5/6 Very loud, thrill, heard with stethoscope partly off chest
Grade 6/6 Very loud, thrill. heard with stethoscope entirely off chest

Murmur Descriptions
Crescendo, Decrescendo, Crescendo/Decrescendo, Continuous, Holosystolic
Harsh, Blowing, Rumbling
Description Possible Diagnosis
Systolic ejection murmur Normal, pulmonic, or aortic stenosis
Early diastolic murmur Aortic regurgitation
Ejection Sound Aortic valve disease
Pansystolic murmur Tricuspid or mitral regurgitation
Late diastolic murmur Tricuspid or mitral stenosis
Systolic click with late systolic murmur Mitral valve prolapse
Opening snap with diastolic rumble murmur Mitral stenosis
S3 Normal in children occurs in heart failure
S4 Physiological and in various diseases

The list of cardiac auscultation sounds include:
Normal sinus rhythm (at rates of ~60, ~90, ~130, and ~180 beats per minutes).
Split S, Split S2, Split S1 with Split S2, S3, S4
Functional (innocent) murmur
Quadruple Gallop (at rates of ~40, ~55, and ~100 beats per minute), Summation Gallop
Aortic Insufficiency (regurgitation), Aortic Stenosis
Atrial Fibrillation, Bigeminy
Atrial Septal Defect, Patent Ductus Arteriosus , Ventricular Septal Defect
Coarctation of the Aorta, Ebstein's Abnormality
Ejection Click, Mitral Insufficiency (regurgitation), Mitral Prolapse, Mitral Stenosis
Pericardial Friction Rub
Pulmonic Insufficiency (regurgitation), Pulmonary Stenosis
Systolic murmur (early) Systolic murmur (late) Systolic murmur (pansystolic)
Tricuspid Insufficiency (regurgitation), Tricuspid Stenosis
Venus Hum

S1 closure of tricuspid and mitral values. Closure simultaneous single S1 heard, loudest
at apex. Both physiological and pathological, split S1. Split S1 closure of the two valves
does not occur together. Splitting of S1 best heard in tricuspid area not effected by
respiration or other maneuvers that increase intrathoracic pressure.
Split S1 associated with pathological conditions, right bundle branch block.

S2 closure of aortic and pulmonary values. simultaneous single S2 heard, loudest at base.
Both physiological and pathological, split S2. Physiological S2 splitting with closing of
aortic valve precedes closing of pulmonic valve normal. Physiological S2 splitting
exaggerated by inspiration lowers intrathorasic pressure causes more blood to be drawn
from superior/inferior vena cava. Increase venous return to right ventricle, it takes longer
to empty, leading to delay in closure of pulmonic valve. Physiological S2 splitting best
heard in pulmonic region between second/third intercostal spaces at left sternal border.

Pathological split S2 occur in three types:
wide split (increased from normal split S2 which lasts throughout the cardiac cycle)
fixed split (split S2 that does not vary with respiration), paradoxical or reverse split
(split S2 disappears with inspiration and reappears with expiration)
Pathological split S2 related to several underlying causes: pulmonic stenosis (wide split),
right bundle branch block (wide split), atrial septal defect (fixed split), right ventricular
failure (fixed split), left bundle branch block (paradoxical or reverse split)

S3 at end of rapid filling period of ventricle during beginning of (ventricular) diastole.
S3, occurs after S2. Left sided S3 (best heard apex with bell left lateral decubitus
position), right sided S3 (best bell in tricuspid region supine position during inspiration)
S3 either physiological or pathological. Normal S3 is common in: Children, young adults
(sometimes up to age 35-40), third trimester of pregnancy
Abnormal S3 (S3 anyone above 40) (ventricular gallop) associated with:
decreased myocardial contraction, myocardial failure, volume overload of ventricle
(mitral or tricuspid regurgitation)