ASSESSMENT OF THE

CARDIOVASCULAR SYSTEM

Sharoon rufan
Nursing Faculty ( shalamar nursing
college)
 OBJECTIVES
By the end of the unit, learners will be able to:
1. Describe the components of health history that should be elicited during the assessment of
cardiovascular system.
2. Identify the landmarks of the chest.
Describe the following:
 Pulse rate, rhythm and pulsation characteristics
 PMI
 Heart sounds
 Discuss systolic and diastolic murmurs
4. Assess the cardiovascular system systematically.
5. Document findings.
6. List the changes in cardiovascular system that is characteristics of aging process.
 ANATOMY OF THE HEART

 Four Chambers:
 Four Valves:
 Right atrium  Two atrio-ventricular (AV)

 Left atrium 1. Tricuspid

2. Mitral
 Right ventricle
 Left ventricle  Two semilunar (SL)
1. Pulmonic
2. Aortic
Blood Flow
 Relevant Subjective Data
1. Chest pain
2. Dyspnea (DOE, PND, Orthopnea)
3. Cough
4. Fatigue
5. Cyanosis or pallor
6. History of edema
7. Past cardiac history
8. Family cardiac history
9. Personal habits
10. Medications history
11. Smoking history
 Preparation for Assessment
 Room that is warm and “quiet”
 Examining table be positioned so that you can
stand on the patient’s right side
 Patient should wear a gown to ensure privacy
 A watch with seconds
 Stethoscope with diaphragm and bell
 BP apparatus
 Two scales
 A light source (torch)
 ASSESSMENT- CHEST PAIN
 Onset
 Duration
 Frequency
 Precipitating factors
 Location
 Radiation
 Quality
 Intensity
PNEUMONIC……PQRSTU

 P- Provocative and palliative

 Q- Quality and Quantity
 R- Region and radiating
 S- Severity
 T- Time
 U- Understanding
 PNEUMONIC….SOAPIER
 S- Subjective assessment
 O- Objective assessment
 A- Analysis / Diagnosis
 P- plan of the treatment
 I- Intervention
 E- Evaluation
 R- Review
 EXAMINATION SEQUENCE
Examination of the CVS consists of:
1. Examination of Pulses
2. Measurement of BP
3. Examination of Neck Vessels
4. Examination of Precordium by:
 Inspection
 Palpation
 Percussion
 Auscultation
 Assessment of the Peripheral Vascular System

A peripheral vascular examination is a medical

examination to discover signs of pathology in the
peripheral vascular system.
 TECHNIQUES USED TO ASSESS THE
PERIPHERAL VASCULAR SYSTEM
 Arms: Inspection: pain, skin changes, swelling.
Palpation – radial, ulnar & brachial pulses,
epitrochlear lymph nodes,
Perform the Allen’s Test.
 Legs: Inspection- pain, skin changes, swelling.
If calf pain, check the Homan’s Sign.
Palpation – femoral, poplitial, dorsalis.
pedis, posterior tibialis pulses.
If peritibial edema, press over tibia or medial malleolus
for 5 seconds (pitting edema).
 ALLEN’S TEST
 Instruct the patient to raise his/her hand and make a fist
for about 30 seconds.
 Using the fingers, apply pressure over ulnar and radial
arteries so as to occlude both the arteries.
 Ask the patient to open the hand in elevated position. It
should appear blanched (pallor can be observed at the
finger nails).
 Ulnar pressure is released and the color should return in
less than 7-seconds. If color returns as described above,
the Allen's test is considered to be "positive."
 ALLEN’S TEST

If color fails to return, the test is considered "negative"

and the ulnar artery supply to the hand is not sufficient.
The radial artery therefore cannot be safely pricked or
cannulated.
 HOMAN’S SIGN
 It is named after the American physician John Homan’s.

 A positive sign is present when there is pain in the calf

muscle on forceful and abrupt dorsiflexion of the
patient's foot at the ankle while the knee is extended.
 BUERGER’S TEST
 With the patient supine, raise his legs to about 45° at
the hip and hold for 2-3 minutes; the blood will drain
from the legs and will turn pale.
 After two minutes ask the patient to sit up and lower
the leg by hanging it off the side of the bed.
 Note the time it takes for color to return. Normally, it
takes less than one minute.
 If it takes longer, the test is positive for arterial
compromise to the lower extremity.
 TRENDELENBURG TEST
Purpose
This test is performed to determine the competency of the
valves between the superficial and deep veins of the legs in
patients with varicose veins.
Method
 Patient being in supine position, his leg is flexed at the hip and raised
above the heart level until the veins become empty.

 A tourniquet is then applied around the upper thigh to compress the

superficial veins.

 The patient is then asked to stand on his feet in order to bring the leg
below the heart level.
 TRENDELENBURG TEST
Method Cont…
 Normally, the superficial saphenous veins will fill from below
within 3-5 seconds as blood from the capillary bed reaches the
veins.

 If the superficial veins fill more rapidly with the tourniquet in

place, there is valvular incompetence below the level of the
tourniquet in the deep veins.

 Superficial veins of the legs normally empty into deep veins.

 Retrograde filling occurs due to valvular incompetence leading to

varicose veins.
 EXAMINATION OF PULSES
Commonly felt pulses are carotid, brachial, radial, femoral,
popliteal, posterior tebial and dorsalis pedis.
 Radial: press the radial artery against the head of the radius
bone.
 Brachial: flex the patient arm and feel for the tendon of the
biceps, press on its medial side.
 Carotid pulse: place the thumb or fingers of your opposite hand
along the anterior border of the SCM muscle at the level of
laryngeal cartilage and press backwards.
EXAMINATION OF PULSES CONTINUE….
 Femoral pulse: Press with the thumb or finger along the
inguinal ligament.

 Popliteal pulse: Flex the knee at an angle of 120 degree and

push fingers of both hands into the popliteal fossa. It is
normally difficult to palpate.
 Dorsalis Pedis: Palpate in the proximal part of the first
intermetatarsal space.

 Posterior tebialis: Palpate behind the medial malleolus.

 WHAT TO LOOK FOR WHILE EXAMINING
THE PULSES?
 Rate (tachycardia, bradycardia, relative bradycardia). Make sure to count
for full one minute.
 Rhythm: Normally interval between the beats is constant and rhythm is
regular. If it is disturbed, becomes irregular.
1. Sinus arrhythmia
Pulse rate is faster during inspiration & slower during expiration
which is a normal phenomena. This may not be present in
patients with heart failure.
2. Occasional irregularity
Premature beats occur earlier than expected which is weak and
is followed by a longer pause. This is also a normal phenomena.
 CONTINUE….
3) Regularly irregular
Premature beats occur at a fixed interval e.g. after one normal beat
(bigeminy), after two normal beats (trigeminy).
4) Irregularly irregular
Beats occur irregularly & there is no pattern. Digoxin toxicity is the
most common cause of such arrhythmias.
5) Pulse deficit
The left ventricular contractions are weak and are not conducted to
the arteries, thus the pulse rate is slower than the heart rate counted
by auscultation. This difference is called pulse deficit (cause is atrial
fibrillation).
 VOLUME OF THE PULSE
This is the amplitude of the pulse wave and is determined by the
amount of displacement of the palpating finger.
Pulse volume could be normal (learned by experience), high (e.g. in
fever) or low volume (heart failure, hypovolemic shock).

Compare the volume of pulses of both side simultaneously except

for carotid arteries.
Radio-Femoral delay
Femoral pulse is weak and is delayed as
compared to radial pulse (as in coarctation
of the aorta).
 CHARACTER OF THE PULSE
 In some diseases the pulse wave has a specific wave form or character
which can be detected by palpating major pulses close to the heart.

1. Pulsus plateau (slow rising pulse)

It rises slowly & stays longer with the palpating finger (occurs in aortic
stenosis).

2. Water hammer pulse (collapsing pulse)

It is a high volume pulse with normal upstroke but rapid down stroke.
(seen in aortic regurgitation & VSD)

3. Pulsus bisferiens
Two systolic peaks are palpable in one pulse (seen in aortic stenosis & aortic
regurgitation).
 CHARACTER OF THE PULSE

4) Pulsus paradoxus
This is an exaggeration of a normal phenomenon in which pulse either
becomes weak or impalpable during inspiration. (seen in cardiac
temponade & constrictive pericarditis)

5) Pulsus alternans
A strong beat is followed by a weak beat but the interval between beats
is constant and rhythm is regular (SVT and ventricular failure).

6) Pulsus bigeminus
Similar to pulsus alternans but interval between the beats is
variable. Digoxin toxicity is the most common cause.
 MEASUREMENT OF B.P

 Patient should be resting and relaxed, sitting or lying on bed.

 BP cuff should be wide enough to cover about two third of

the arm length.

 Remove all the clothing from the upper arm.

 Apply the cuff closely to the upper arm so that its lower
border is not less than 2.5 cm above the cubital fossa &
tubing is on the medial side.

 Now apply palpatory versus auscultatory method.

 MEASUREMENT OF B.P CONTINUE….
 Normal values of B.P
In adults <130/85 is normal, 130/85 -139/89 is high normal
and 140/90 or above is HTN.

 Pulse pressure
It is the difference between systolic and diastolic pressure (normal range is
30-60 mmHg).

 Silent Gap
In some hypertensive patients, the Korotokoff sounds
disappear for sometime between systolic and diastolic
pressure.This is called silent gap.
 THE NECK VESSELS
 The Carotid Artery
 The Jugular Venous
Pulse & Pressures

 Jugular vein has

2 components:
(a) internal jugular
(b) external jugular
 THE NECK VESSELS
A. Carotid Arteries

 Palpate low in the neck to

avoid the carotid sinus.
 Palpate only one side at a
time to avoid compromising
blood flow to the head.
 Auscultate using the bell of
the stethoscope.
ASSESSMENT OF THE JUGULAR VEIN
 Purpose

To measure the “central venous pressure”

 Method:
Position the patient at 45 degree angle at the hip.
Turn head slightly away.
Use a strong light tangentially.
Observe the external jugular vein over the sternocleidomastoid
muscle.
Locate the internal jugular vein pulsations.
Determine the highest point of pulsations.
 SPECIFIC PROCESS FOR JVP
MEASUREMENT

 Locate the “angle of Louis” (sternal angel)

 Make a “T square” with two scales.
 Read the level of intersection.

The normal jugular venous

pressure is 3 cm or less above
the sternal angle at 45 degree.
 CAUSES OF RAISED JVP

 Right ventricular failure

 Constrictive pericarditis and pericardial effusion
 Tricuspid valve disease
If neck veins are distended but non-pulsatile, cause is
obstruction of the superior vena cave.
Kussmaul Sign
In constrictive pericarditis, the JVP instead of falling, rises during
inspiration. The downward movement of diaphragm compresses the
congested liver, increasing venous return, but right atrium cannot
expand due to rigid pericardium and thus JVP rises.
 HEPATO-JUGULAR REFLUX
 This is measured if the CVP is elevated or CHF is suspected.

 Keep the patient in supine position. Instruct him to breathe

quietly with mouth open.

 With your right hand on the patient’s RUQ, just below the rib
cage, exert firm consistent pressure for 30 seconds.

 Watch the level of the jugular venous pressure.

 Normally the jugular pulsation rises but recedes back.

 Abnormally, the pressure elevates and stays.

 THE HEART (PRECORDIUM)

 Precordium: It is the part of the chest that overlies

the heart.
Inspection
 Look for any chest deformity, bulging of precordium, scars
particularly along the sternum or intercostal spaces (indicates
previous cardiac surgery).
 Pulsations of apex beat
 Pulsations along the parasternal border due to right ventricular
hypertrophy.
 Pulsations in the left second intercostal space due to dilatation of
Pulmonary artery.
 CONTINUE….
 Pulsations in the right 2nd ICS due to aneurysm of the aorta.
 Pulsations in the suprasternal notch due to aortic regurgitation.

Palpation
 Use the flat of the palm starting from the lower part of the left side of
the chest, then along the left parasternal border & finally upper part of
the right side of the chest.
 Note the following:
 Apex beat
 Left parasternal heave
 Palpable heart sounds
 Thrill (palpable murmur)
 Palpable pericardial rub
 PALPATION CONTINUE….
The Apex Beat: It is defined as the outermost & lowermost part of the
precordium where a definite cardiac impulse is felt.
Location of apex beat
 Normally it is located in the 5th ICS, 1cm medial to the Mid-clavicular line (MCL).
 In children less than 7-years of age, the apex beat is located in the 4th intercostal space,
lateral to the mid clavicular line.
 Shift of apex beat occurs if left ventricle is enlarged.
Causes of impalpable apex beat can be:
 Thick chest wall
 Emphysema
 Pericardial effusion
 Dextrocardia (Heart is in the right chest and therefore, apex beat will be palpable on the
right side)
 PALPATION CONT…
Character of the Apex Beat
Normally apex beat is neither forceful (tapping) nor does it lift the palpating finger (heaving).

Tapping apex beat

 It is forceful but palpating finger is not displaced which feels like hard
knock on the other side of a closed door.
 Cause is palpable loud S1 e.g. in mitral stenosis.

Heaving apex beat

 Palpating finger is lifted.
 Causes are aortic stenosis, HTN, aortic regurgitation.
 PALPATION CONTINUE….
Left Parasternal Heaves
 Place your hand vertically along the left parasternal border, if it moves with
each cardiac contraction, left parasternal heave is present.
 Cause is right ventricular enlargement.

Palpable Heart Sounds

 S1 is palpable at the apex in mitral stenosis and is called tapping apex beat.
 Pulmonary component of S2 (P2) is palpable at pulmonary area in pulmonary
HTN.
 Aortic component of S2 (A2) may be palpable in the aortic area in systemic
HTN.
 PALPATION CONTINUE….
Thrill
 A loud murmur becomes palpable and is called a thrill. It can
resemble the purring of a cat.

 Thrills which are timed with carotid pulsations, are called systolic &
those which alternate with carotid pulsations, are diastolic
thrills.

 Thrills are best appreciated when the patient leans forward,

holding his breath in expiration.

 Causes could be mitral stenosis, mitral regurgitation,, aortic

stenosis, aortic regurgitation, pulmonary stenosis and VSD.
 PALPATION CONTINUE….
Palpable Pericardial Friction Rub
 Pericardial friction rub becomes palpable in acute
pericarditis and is best felt at left sternal border near
xiphoid area and over tricuspid area.
 It is best appreciated in sitting and leaning forward
position.
 PERCUSSION
 Percuss for the right border laterally to medially in the 2nd
to 5th ICS starting from MCL.

 On the right side, normal cardiac dullness is lateral to the

right lateral edge of the sternum in the 4th ICS.

 For the left border, percuss in the 3rd to 5th ICS laterally to
medially, starting in the axilla.

 On the left side, normal cardiac dullness is medial to mid-

clavicular line in the 4th ICS.
 AUSCULTATION (HEART SOUNDS)
Normal Heart Sounds
S1 – Produced due to closure of the mitral & tricuspid valves
when the ventricles contract.
 It marks the beginning of systole.
 The mitral is the major component, the tricuspid
component is relatively quiet.
 Its maximum intensity is at the apex
 AUSCULTATION (HEART SOUNDS)

Normal Heart Sounds

S2 – Produced due to closure of the aortic and
pulmonic valves when the ventricles relax.
 It denotes the beginning of diastole.
 The pulmonary component is localized to
pulmonary area while aortic component is
audible all over the precordium with maximum
intensity at A1 area.
 AREAS OF AUSCULTATION
Sounds produced at a particular valve are more clearly
audible at a particular part of the precordium.
For each valve there is a different such site & is named after
that valve at that area.
 Mitral area corresponds to the apex
 Tricuspid area is close to the lower part of the sternum at 4th
intercostal space on the left side.
 Pulmonary area left 2nd ICS close to the sternum.
Two aortic areas
 Aortic 1 (A1): Right 2nd ICS close to the sternum
 Aortic 2 (A2) or Erb’s Point: Left 3rd ICS close to the sternum
 AUSCULTATION (HEART SOUNDS)
How to differentiate between S1 & S2
 Palpate the carotid artery while auscultating.
 The sound which comes just before the carotid pulsations is
S1 & the one that comes after the carotid pulsations is S2.
 Concentrate on S1 while auscultating at apex and tricuspid
area.
 Concentrate on S2 while auscultating at aortic and
pulmonary area.
CHARACTERISTICS OF HEART SOUNDS

 Frequency (pitch): high or low

 Intensity (loudness): loud or soft
 Duration: very short hear sounds or longer periods
of silence
 Timing: systole or diastole
 EXTRA HEART SOUNDS
S3 – This occurs immediately after S2, thus called S3.
 S3 occurs when rapidly rushing blood flow from the atria
is suddenly decelerated by the ventricle when it reaches
its elastic limit.
 In a normal ventricle, this can happen with excessive
volume of incoming blood, as can occur in hyper-
dynamic states or volume-loaded conditions.
 In children, young adults and during pregnancy it may
arise from rapid flow of column of blood against the
ventricular wall & is considered normal.
 EXTRA HEART SOUNDS
 With decreased compliance of the ventricle e.g.
Congestive Heart Failure, a normal amount of blood
entry during diastole can challenge ventricular elasticity
& generate the S3.
 S3 can be physiologically present in persons younger
than 40 years who often have a thin chest wall to permit
the easy transmission of S3.
 In the presence of heart failure, S3 is a bad prognostic
sign.
 EXTRA HEART SOUNDS
Giving the sound of a galloping horse, S3 is also called
Ventricular gallop.
Patient’s Position
It is best heard at the cardiac apex. Patient should be in left
lateral decubitus position for maximal auscultation of S3.
Use the bell of stethoscope (it is a low pitch sound)
 EXTRA HEART SOUNDS
S4 - This occurs at the end of diastole, just before the next S1,
thus called S4.

 S4 occurs when there is an increase in the force of atrial

contraction.
 Situations in which rapid filling is reduced due to an
impairment in ventricular relaxation can result in an
increased atrial contraction.
 Chronic hypertension is the most common cause of
a fourth heart sound.
 EXTRA HEART SOUNDS
 S4 is always pathologic & is termed as atrial gallop.
 Etiologies
 Left-Sided: hypertension, aortic stenosis, angina pectoris.
 Right-Sided: pulmonary hypertension, pulmonic stenosis.
 Position
 It is best heard at the cardiac apex with the patient is in left
lateral decubitus position & holding his breath.
 Use bell to listen as it is a low pitch sound.
 SPLITTING OF THE HEART SOUNDS
 Usual Splitting
 As the right-sided heart events (contraction of right
atrium, opening of tricuspid valve, contraction of right
ventricle, relaxation etc.) usually occur slightly later than
those on the left.
 Instead of a single heart sound, two distinct components
are audible during inhalation, the first from aortic valve
closure (A2) and the second from the pulmonic valve
closure (P2).
 During exhalation, these two components are fused into a
single sound, S2.
 SPLITTING OF THE HEART SOUNDS

 During inhalation, S2 splits into its two distinctly audible

components A2 and P2.
 Splitting of S2 is due to increased capacitance in the
pulmonary vascular bed during inhalation, which prolongs
ejection of blood from the right ventricle, delaying closure
of the pulmonic valve (P2).
 Ejection of blood from the left ventricle is relatively shorter,
so A2 occurs slightly earlier.
 SPLITTING OF THE HEART SOUNDS
 A2 is normally louder, reflecting the high pressure in the
aorta. It is heard throughout the precordium.
 P2, in contrast, is relatively soft, reflecting the lower
pressure in the pulmonary artery.
 P2 is heard best in its own area—the 2nd and 3rd left
interspaces close to the sternum.
 It is here (2nd and 3rd left interspaces) that splitting of the
second heart sounds should be searched for.
 SPLITTING OF THE HEART SOUNDS
Fixed Splitting
In ASD, blood flows from left atrium to the right atrium, thus right
sided stroke volume is increased and P2, is delayed, resulting in wide
splitting of S2.
As blood constantly flows from left to right atrium, the differential
effect of respiration on stroke volume of both sides of the heart is lost.
Thus the interval between A2 and P2 remains constant during
inhalation & exhalation and thus splitting is fixed.
 SPLITTING OF THE HEART SOUNDS
Reverse Splitting
If left ventricular emptying is delayed to the extent that closure of the
aortic valve occurs after closure of the pulmonic valve, the effect of
respiration on splitting of S2 is reversed, i.e.
It is more during exhalation and less during inhalation. This is called
reverse splitting.
Causes are:
 Left Bundle Branch Block
 Severe aortic Stenosis
 SEQUENCE FOR AUSCULTATION
A. Begin with the diaphragm. Note at each area:
1. Rate & rhythm
2. Identify S1 and S2
3. Assess S1 and S2 separately
4. Listen for extra heart sounds (i.e. S3,S4)
5. Listen for murmurs
B. Repeat above using the bell.
 METHOD OF AUSCULTATION
 Auscultate whole of the precordium, starting from the apex,
moving up along the left parasternal border to the
pulmonary area & then to the A1 area.
 Patient be in supine position, auscultate first with
diaphragm and then with the bell.
 For pulmonary and A2 area, patient should sit up and lean
forward and use the diaphragm.
 For murmur of pulmonary regurgitation, patient should
hold breath in inspiration while for murmur of aortic
regurgitation, in expiration.
 LOOK FOR THE FOLLOWING WHILE
AUSCULTATING
S1
Its maximum intensity is at the apex.
S2
Its pulmonary component is localized to pulmonary area while aortic
component is audible all over the precordium with maximum intensity
at the A1 area.

S1 comes with carotid pulsations while S2 comes after

carotid pulsations.
 LOOK FOR THE FOLLOWING WHILE
AUSCULTATING
 Opening Snap
 In mitral stenosis, if valve leaflet motion is restricted, the mitral valve
opening may produce a sharp high pitched sound soon after S2 called
opening snap (OS) with maximum intensity medial to the apex.
 Ejection systolic click
 These are sharp systolic sounds produced due to the opening of
abnormal aortic and pulmonic valves and are heard soon after S1. The
aortic click is best heard at A1 area and apex while pulmonary click is
best heard at pulmonary area (in aortic & pulmonary valve stenosis).
 CONTINUE….
 Mid systolic click
 A sharp sound produced in mid systole due to mitral valve prolapse.
 Pericardial Rub
 A superficial scratchy sound audible both in systole and diastole due
to rubbing of the two surfaces of the pericardium in pericarditis.
 It is prominent at the left lower sternum.
 Rub usually disappears once pericardial effusion has developed.
 CONTINUE….
 Carotid bruit
 This is a sound similar to murmur, but that is produced outside the
heart.
 It may be either due to excessive blood flow (e.g. thyrotoxicosis) or
narrowing of a vessel (e.g. atherosclerosis).

 Venous Hum
 A continuous murmur like sound audible in the neck due to kinking of
larger neck veins. It is common in children.
 MURMURS
Abnormal sounds, of longer duration as compared to normal
heart sounds. Any of the following mechanisms may be
responsible.
 Velocity of blood increases across a normal valve (e.g.
exercise, thyrotoxicosis).
 Flow of normal amount of blood across a narrowed valve
(e.g. aortic or mitral stenosis)
 Structural defect in the valves or an unusual opening occurs
in the chambers (ASD,VSD).
 Back flow of blood across abnormal valves (aortic and
mitral regurgitation).
 SYSTOLIC MURMURS (TWO TYPES)
 Pansystolic
 It starts with S1 & goes up to or beyond S2. (mitral and
tricuspid regurgitation, VSD).
 Ejection Systolic Murmur
 It starts slightly after S1 ends before S2. (Aortic and
pulmonary stenosis).
 DIASTOLIC MURMURS (TWO TYPES)
 Mid Diastolic Murmur
 It is audible in the middle of diastole (Mitral and tricuspid stenosis,
ASD).
 Early Diastolic Murmur
 It is audible soon after S2 (aortic and pulmonary regurgitation).
 PAROXYSMAL NOCTURNAL DYSPNEA
 Paroxysmal refers to symptoms that come on and pass quickly.
 Nocturnal refers to occurring at nighttime or during sleep.
 Dyspnea refers to difficult or uncomfortable breathing.
 PND causes difficulty breathing during sleep, causing people to wake up due to
shortness of breath.
 GRADING OF MURMURS
Murmurs are graded according to their intensity. Use VI point grading
scale and record as a fraction i.e. I/VI or II/VI)

 Grade I – audible with great difficulty, in a quiet room.

 Grade II – clearly audible, but not loud
 Grade III – moderately loud, easy to hear but without thrill
 Grade IV – loud, associated with a thrill, palpable on the chest wall
 Grade V – very loud, audible even with with one corner of the
stethoscope lifted off the chest wall
 Grade VI – heard with entire stethoscope lifted off the chest wall.
 SITE OF MAXIMUM INTENSITY
A murmur may be audible all over the precordium
depending upon its loudness but its maximum intensity is
at its site of origination.
For example, murmur of mitral regurgitation is loudest at
the apex while that of tricuspid regurgitation is loudest its
own area.
 REFERENCES

1. Mangione S, Nieman Z “Cardiac Auscultatory Skills on Internal Medicine and

Family Practice Trainees: A Comparison of Diagnostic Proficiency” JAMA. Vol.
278. No. 9, 1997: p717-722.

2. Nasir SA and Inayatullah M. Bedside Techniques: Methods of clinical

examination. 2006; 3rd edition: Saira publishing; Multan. Pp. 106-136.

3. Clinical Methods, 3rd edition: The History, Physical and Laboratory

Examinations [online data base] retrieved from;
http://www.ncbi.nlm.nih.gov/books helf/ br.fcgi? book=cm