MEDICINE 1: CARDIAC PHYSICAL EXAMINATION
Dr. Vicky Turla | August 1, 2017
Transcribed by: Chua, Datugan, De Villa,
Miranda, Moss
Cardiac Physical
3.1b Examination
I.
II.
III.
IV.
V.
VI.
OUTLINE
Inspection and Palpation
A. Apical Area
B. Apical Impulse
C. Lower Sternal Area
D. Upper Sternal Area
E. Sternoclavicular Area
F. Epigastrium
G. Coarctation of Aorta
Percussion
Auscultatory Areas
Auscultation
A. The Bell Chestpiece
B. The Diaphragm
C. Patient Positions
D. Heart Sounds
E. Murmurs
1. Systolic Murmurs
2. Diastolic Murmurs
F. Shape
G. Principal Causes of Murmurs
H. Benign vs Pathologic Murmurs
I. Gradations of Murmurs
J. Timing
K. Amplitude
L. Duration
M. Location of Maximum Intensity of
Common Systolic Murmurs
N. Systolic Murmurs in Valvular Heart Disease
O. Diastolic Murmurs in Valvular Heart
Disease
Maneuvers
A. Valsalva Maneuver
Jugular Venous Pressure
A. Abdomino-jugular reflux
INSPECTION AND PALPATION
 Primary objective:
o Detect the character of right and left ventricular
impulse to help assess cardiac dynamics and
function.
 Inspection of anterior chest reveals:
o Apical impulse location
o Ventricular movements (left sided S3 or S4)
 Palpation of Precordium should include:
o Apical area
o Mid-precordial area
o Lower left and right Parasternal area
o Pulmonary and Aortic area
o Suprasternal area
o Epigastric area
 Left Ventricular impulse
o also known as apex beat
o this is the outward movement of the left
ventricular apical region
 Left Ventricular Isovolumic relaxation
o More rapid inward movement
o Begins before S2 (closure of Semilunar valves)
and continues up to the opening of the mitral
valve (mitral valve opening is characterized by a
rapid filling then followed by a slow filling).
 Apical impulse
o Furthest point leftward and downward
o Best guide to the heart’s overall size (because it
represents the left border of the heart)
o May not be visible
o Most easily felt left lateral decubitus position
(left side lying position)
 During palpation, use the finger pads flat or obliquely to
the body surface.
APICAL AREA
 Caused by forward and rightward rotation of the heart
on the start of ventricular systole, bringing the apex
against the chest wall
o 5th or (rarely) 4th ICS at or medial to the left
midclavicular line
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MEDICINE 1: CARDIAC PHYSICAL EXAMINATION
<10cm from the midsternal line or 3.5 to 4
inches from the midclavicular line
o May or may not be palpable in a normal person
(depends on the thickness of chest wall and
other factors)
o Most readily seen in a left side lying position
 Certain conditions where the normal impulse is felt
outside the midclavicular line:
 Pregnancy
 Obesity
 Ascites
 High left diaphragm
 Left ventricular hypertrophy
 Deformities of the thorax
 In young children, apex beat is often found in the 4th
ICS (just outside the midclavicular line).
o
APICAL IMPULSE
 It measures < 2.5 cm and occupies only one interspace
in a patient on supine position
 It is larger in left side lying position; however, a
diameter >3cm indicates LV enlargement
 Cardiac pulsations that are seen lateral to the left
midclavicular line often denotes cardiac enlargement
 Conditions that may cause Left cardiac displacement:
o left pulmonary fibrosis
o right-sided tension pneumothorax
o massive pleural effusion
o absent left pericardium
o thoracic deformity
LOWER STERNAL AREA
 Region where you can feel the right ventricle however
any considerable outward movement in this area is
usually due to RV enlargement.
 Normal RV does not produce a palpable thrust.
 Presence of palpable thrust may indicate:
o mitral stenosis
o pulmonic stenosis/regurgitation
o tricuspid stenosis/regurgitation
o right to left shunts
o pulmonary hypertension from any cause
 Hyperdynamic state of lower sternal area indicates:
o Pregnancy
o Anemia
o Thyrotoxicosis
o Fever
o Anxiety
UPPER STERNAL AREA
 Left Upper Sternal Border (LUSB)
o Pulmonary area
o Pulsations in this area are seen in or felt
normally in children and thin chested adults
o Abnormal pulsations may be due to:
 dilated pulmonary artery
 post stenotic dilatation(PS)
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MEDICINE 1: CARDIAC PHYSICAL EXAMINATION

increased pulmonary flow (Atrial Septal
Defect, Ventricular Septal Defect)
 pulmonary hypertension (LV failure,
mitral stenosis, primary pulmonary
hypertension)
 Right Upper Sternal Border (RUSB)
o Aortic area
o Seldom presents as obvious pulsations
o Dilatation of the ascending aorta
o Abnormal pulsations may be due to:
 Atherosclerosis
 post stenotic dilatation
 aortic regurgitation
 dissecting aneurysm
COARCTATION OF THE AORTA
STERNOCLAVICULAR AREA
 Not employed
 Palpation is used rather than percussion to estimate heart
size
 rarely pulsate, but when they do, it is a sign of aortic
disease like:
o Dissecting aneurysm
o tortuous innominate artery
o right sided aorta
o Aortic regurgitation
o any form of aortic aneurysm
 Posterior intercostal arteries (enlarged arteries) may be
visible and palpable.
PERCUSSION
AUSCULTATORY AREAS
EPIGASTRIUM
 Pulsations felt in this area are either:
o Aortic
o Hepatic
o Right ventricular
 Abdominal aortic pulsation is frequently visible over the
epigastrium in:
o Children
o Persons with a scaphoid abdomen
 Abnormal pulsations may be due to:
o Abdominal aneurysms
o Aortic regurgitation
o Right ventricular hypertrophy and dilation
o Tricuspid regurgitation may cause liver
pulsation in systole
o Liver pulsation late in diastole may indicate:
 tricuspid stenosis
 severe RV failure
 pulmonary hypertension
 Erb’s point is the auscultation location for heart
sounds and heart murmurs located at the third
intercostal space and the left lower sternal border.
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MEDICINE 1: CARDIAC PHYSICAL EXAMINATION
AUSCULTATION
 STETHOSCOPE:
 Ask the patient to sit up, lean forward, exhale completely
and stop breathing in expiration
Heart Sounds
The Bell Chestpiece
 For low frequency sounds
 Ex. Diastolic murmurs through mitral and tricuspid
valves, S3 and S4
o Q: How much pressure should be applied to the
bell chestpiece?
o A: Just enough to prevent room noise leak. Any
more pressure tightens the skin and tends to
damp out the low frequencies and make the bell
function like a diaphragm
The Diaphragm
 To damp low frequencies and unmask high frequencies
 Soft high frequency aortic and pulmonary blowing
diastolic murmurs and soft mitral regurgitation murmurs,
pericardial friction rubs, S1 and S2
 Splitting of first and second heart sounds and nonejection clicks
Patient Positions
 Listen to the precordium with the patient supine, turned
on the left side and sitting upright
 Lying on the left side bringing the ventricle closer to the
chest wall. Place the bell of your stethoscope lightly on
the apical impulse
 Ventricular systole is defined by the interval between
the first (S1) and second (S2) heart sounds
 The first heart sound (S1) includes mitral and tricuspid
valve closure
 Normal splitting can be appreciated in young patients
and those with right bundle branch block, in whom
tricuspid valve closure is relatively delayed
 Aortic and pulmonic valve closure constitutes the
second heart sound (S2)
 With normal or physiologic splitting, the A2–P2 interval
increases with inspiration and narrows during expiration.
 The third heart sound (S3) occurs during the rapid
filling phase of ventricular diastole
o present in normal subjects up to the ages of 2030, they represent pathology in older patients
 A left-sided S3 is a low-pitched sound best heard over
the left ventricular (LV) apex
 S3 - associated with left ventricular failure and is
caused by blood from the left atrium slamming into an
already overfilled ventricle during early diastolic filling
 A right-sided S3 is usually better heard over the lower
left sternal border and becomes louder with inspiration
 The fourth heart sound (S4) occurs during the atrial
filling phase of ventricular diastole and indicates LV
presystolic expansion
 S4 - created by blood trying to enter a stiff, noncompliant left ventricle during atrial contraction.
(left ventricular hypertrophy)
 Location of maximal intensity
o Site where the murmur originates
o Where you hear the murmur best
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MEDICINE 1: CARDIAC PHYSICAL EXAMINATION
 Radiation or transmission from the PMI
o Reflects the site of origin, intensity of the
murmur and direction of blood flow
 Intensity - Graded on a 6-point scale and expressed as a
fraction
 Pitch – high, medium or low
 Quality – blowing, harsh, rumbling and musical
 Often related to blood flow across the semilunar valves
Murmurs
 Holosystolic
 Starts with S1 and stops at S2 without a gap between
heart murmur and heart sounds
 Often occur with regurgitant (backward) flow across the
atrioventricular valves
 Heart murmurs - caused by audible vibrations that are
due to increased turbulence from accelerated blood flow
through normal or abnormal orifices, flow through a
narrowed or irregular orifice into a dilated vessel or
chamber, or backward flow through an incompetent
valve or a congenital defect
 Timing within the cardiac cycle
o Systolic murmurs begin with or after the first
heart sound (S1) and terminate at or before the
component (A2 or P2) of the second heart
sound (S2) that corresponds to their site of
origin (left or right, respectively).
o Diastolic murmurs begin with or after the
associated component of S2 and end at or
before the subsequent S1.
o Continuous murmurs are not confined to
either phase of the cardiac cycle but instead
begin in early systole and proceed through S2
into all or part of diastole
 The accurate timing of heart murmurs is the first step in
their identification. The distinction between S1 and S2
and, therefore, systole and diastole is usually a
straightforward process but can be difficult in the setting
of a tachyarrhythmia, in which case the heart sounds can
be distinguished by simultaneous palpation of the carotid
upstroke which should closely follow S1.
 Late systolic murmur
 Starts in mid or late systole and persists up to S2
 Murmur of mitral valve
A. Systolic Murmurs
B. Diastolic Murmurs
 Midsystolic murmur
 Begins after S1 and stops before S2
 Brief gaps are heard between the murmur and heart
sounds
 Early diastolic murmur
 Starts after S2 without a discernible gap and then fades
before S1
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MEDICINE 1: CARDIAC PHYSICAL EXAMINATION
Shape
 determined by its intensity overtime
 Mid-diastolic murmur
 Starts a short time after S2 and then fade away
 Reflect turbulent flow across the atrioventricular valves
 Late diastolic (presystolic) murmur
 Starts late in diastole and continues up to S1
 Reflect turbulent flow across the atrioventricular valves
o
Crescendo – grows louder (Ex. presystolic murmur
of MS)
o
Decrescendo – grows softer (Ex. Early diastolic
murmur of AR)
o
Crescendo-decrescendo – rise in intensity then
falls (Ex. Midsystolic murmur of AS and innocent
flow murmurs)
o
Plateau murmur – same intensity throughout (Ex.
Pansystolic murmur of MR)
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MEDICINE 1: CARDIAC PHYSICAL EXAMINATION
Principal Causes of Heart Murmurs
 Continuous murmurs can be:
o Physiological- murmurs occurring only without any
structural abnormality at that level (mammary soufflé
heard during pregnancy or cervical venous hum
most commonly heard in sitting position, in the
supraclavicular fossa, in healthy children)
o Pathological- secondary to changes that allow the
passage of blood from a high pressure area into a
low pressure area, or increased resistance in the
arterial circulation by a severe fixed arterial stenosis
Benign vs Pathologic Murmurs
Benign
 Asymptomatic
 Benign murmurs have normal peripheral pulses, without
evidence of palpable ventricular enlargement
(heaves/lifts or a laterally displaced point of maximal
impulse) or thrills
 Heart sounds are key: diagnosis of a benign murmur
should be made in the context of normal splitting heart
sounds, without gallops, clicks, or snaps
 early to mid-systolic
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MEDICINE 1: CARDIAC PHYSICAL EXAMINATION
Gradations of Murmur
 GRADE I – very faint, may not be heard in all positions
 GRADE II – quiet, but heard immediately after placing
the stethoscope on the chest
 GRADE III – moderately loud
 GRADE IV – loud with palpable thrill
 GRADE V – very loud, with thrill. Maybe heard with
the stethoscope partly off the chest
 GRADE VI – very loud, with thrill. Maybe heard with
the stethoscope entirely off the chest
•
•
•
•
Duration
•
•
•
Timing
hyperthyroidism
severe anemia
Pressure overload of the LV (aortic stenosis)
volume overload of the LV (mitral regurgitation)
Sustained high-amplitude impulse that is normally
located suggests LVH from pressure overload
Laterally displaced – volume overload
Sustained low-amplitude – dilated heart of
cardiomyopathy
Sustained Low Amplitude
 Timing
o Systolic murmur – falling between S1 and S2
o Diastolic murmur – falling between S2 and S1
o Murmurs that coincide with the carotid upstroke
are systolic
o Systolic murmurs - usually midsystolic or
pansystolic
 May occur in normal hearts
Location of Maximum Intensity of Common
Systolic Murmurs
Amplitude
 Small and feels like a gentle tap
 Increased amplitude:
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MEDICINE 1: CARDIAC PHYSICAL EXAMINATION
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


YELLOW- Aortic stenosis
PURPLE- Pulmonic Stenosis
GREEN- Tricuspid Regurgitation
RED-Mitral Regurgitation
Diastolic Murmurs in Valvular Heart Disease
Systolic Murmurs in Valvular Heart Disease




AORTIC AREA= Aortic Regurgitation
PULMONIC AREA= Pulmonic Regurgitation
TRICUSPID AREA= Tricuspid Stenosis
MITRAL AREA= Mitral Stenosis, Atrial Myoma
MANEUVERS
 Changes in position, such as squatting, sudden standing,
the valsalva maneuver, and hand gripping can all
influence the aforementioned characteristics of a
murmur by changing the preload, afterload, and chamber
size
 This is an invaluable tool because murmur characteristics
often overlap, and these maneuvers can result in
predictable changes.
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MEDICINE 1: CARDIAC PHYSICAL EXAMINATION
 Inspiration can accentuate right-sided murmurs such as
tricuspid regurgitation, but not left-sided murmurs
A. Isometric handgrip (30 seconds)
 Increase afterload and preload; however, it appears as
though afterload is increased proportionally more than
preload. Hence, this maneuver is most useful for
discerning mitral valve regurgitation from aortic stenosis.
o This maneuver decreases the pressure gradient
across the aortic valve, and thus decreases the
intensity of the aortic stenosis murmur; similarly,
a regurgitant mitral valve will see increased
backward blood flow because of the increased
forward resistance encountered by the pumping
left ventricle, and so its intensity will increase
B. Sudden standing from a supine position
 Gravity will decrease venous return to the heart
(decreases preload -- decrease in diastolic and stroke
volumes - decrease in blood pressure) (blood pressure =
heart rate x stroke volume x systemic vascular resistance).
The heart compensates by increasing the heart rate to
maintain blood pressure. There are more heartbeats, but
less blood flow per beat, and thus most systolic murmurs
will decrease in intensity
 The
important
exception
is
hypertrophic
cardiomyopathy, where the murmur increases in
intensity - because the murmur is due to the narrowing
of the left ventricular outflow tract
C. Squatting from an erect/standing position
 The muscle contractions caused by squatting literally
squeeze venous blood to the heart, thus increasing
preload
 Muscle contractions also compress arterioles and thus
increase systemic vascular resistance (afterload)
 In this case, most systolic murmurs will increase in
intensity because the ventricles will have a higher
diastolic and stroke volume.
 Hypertrophic cardiomyopathy - decrease in intensity
because the outflow tract becomes wider
 Murmur of aortic stenosis may not become
accentuated because squatting may increase afterload
more so than preload, thereby dissipating its
transvalvular pressure gradient
 Tetralogy of fallot, an increased venous return will
cause an increased pressure gradient through the
pulmonary valve, increasing the intensity of its
pulmonary stenosis murmur
VALSALVA MANEUVER
 Straining phase of the valsalva - best for analyzing
murmur
 Raises intrathoracic pressure, which compresses the caval
veins and decreases venous return to the heart, and thus
decreases stroke volume. This in turn leads to a
compensatory increase in heart rate. This causes similar
findings to sudden standing from a supine position
 Patient in the lateral decubitus position (tends to
accentuate mitral murmurs because it brings the left
ventricle closer to the stethoscope)
 Exercise can accentuate holosystolic murmurs such as
mitral regurgitation and VSD, but not tricuspid
regurgitation
 Palpating continuous murmurs: a venous hum
disappears with compression of the internal jugular vein;
a mammary soufflé murmur disappears with pressure
from a stethoscope.
** SEE ADDENDUM FOR THE TABLE
 A diastolic murmur is never benign
 The higher the intensity (i.e. grade 4 or more) the more
likely it is pathological
 Benign murmurs change significantly with different
patient positions
 Finally, if investigations are performed they should reveal
no abnormalities on ECG, CXR, echocardiogram, or
other imaging modalities
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MEDICINE 1: CARDIAC PHYSICAL EXAMINATION
JUGULAR VENOUS PRESSURE
 JVP is the single most important bedside measurement
from which to estimate the volume status
 Internal jugular vein is preferred because the external
jugular vein is valved and not directly in line with the
superior vena cava and right atrium.
 Venous pressure traditionally has been measured as the
vertical distance between the top of the jugular venous
pulsation and the sternal inflection point (angle of
Louis)
 A distance >4.5 cm at 30° elevation is considered
abnormal
 Normally, JVP falls with inspiration due to reduced
pressure in the expanding thoracic cavity and the
increased volume afforded to right ventricular expansion
during diastole
 Kussmaul sign suggests impaired filling of the right
ventricle due to either fluid in the pericardial space or a
poorly compliant myocardium or pericardium. This
impaired filling causes the increased blood flow to back
up into the venous system, causing the jugular vein
distension (JVD) and is seen clinically in the internal
jugular veins becoming more readily visible
 Kussmaul’s sign - either a rise or a lack of fall of the
JVP with inspiration and is classically associated with
constrictive pericarditis
 Also reported in patients
1. restrictive cardiomyopathy, massive pulmonary
embolism, right ventricular infarction, and
advanced left ventricular
systolic heart
failure
 Pulsus paradoxus is measured by noting the difference
between the systolic pressure at which the Korotkoff
sounds are first heard (during expiration) and the systolic
pressure at which the Korotkoff sounds are heard with
each heartbeat, independent of the respiratory phase
 Pulsus paradoxus - refers to a fall in systolic pressure
>10 mmHg with inspiration that is seen in patients with
pericardial tamponade but also is described in those with
massive pulmonary embolism, hemorrhagic shock,
severe obstructive lung disease, and tension
pneumothorax
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MEDICINE 1: CARDIAC PHYSICAL EXAMINATION
Abdomino-Jugular Reflux
 Normally the jugular venous pressure rises with
expiration and falls with inspiration as the negative
intrathoracic pressure increases
 Paradoxical venous filling or Kussmaul sign – veins
fill with inspiration and empty with exhalation.
 In normal persons, jugular venous pressure rises less
than 3 cm H2O and only transiently while abdominal
pressure is continued, whereas in right or left ventricular
failure or tricuspid regurgitation the jugular venous
pressure remains elevated
 Occurs in: cardiac failure, cardiac tamponade from
pericardial effusion, hemopericardium
a heartbeat or two, before returning to normal.
This negative result would be indicated by a lack of
swelling of the jugular vein.
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References
Dra. Vicky Turla’s Lecture and PowerPoint
Bates’ Guide to Physical Examination and
History Taking 12th Edition
Braunwald: Heart Disease: A Textbook of
Cardiovascular Medicine, 6th ed.
Harrison’s Principle of Internal Medicine 19th ed.
Batch 2019’s Transcription
Technique for Examining Hepatojugular Reflux (HJR)
 Hepatojugular reflux is the distention of the neck veins
precipitated by the maneuver of firm pressure over the
liver.
 It is seen in tricuspid regurgitation, heart failure due to
other non-valvular causes, and other conditions
including constrictive pericarditis, cardiac tamponade,
and inferior vena cava obstruction.
 The HJR maneuver may be performed as follows:
1. The patient is positioned supine with an
elevation of the head at 45 degrees.
2. Look at the jugular pulsations during quiet
respirations. (baseline JVP)
3. Apply gentle pressure (30-40 mmHg) over the
right upper quadrant or middle abdomen for
atleast 10 seconds.
4. Repeat the JVP.
5. An increase in JVP of >3cm is a positive HJR
Test.
 NOTE: Normal subjects will have a decrease in JVP
with this maneuver since venous return to heart is
reduced. The jugulars venous pressure may transiently
rise then return to normal or decease within 10 seconds.
 The clinician presses firmly over either the right upper
quadrant of the abdomen or over the center of the
abdomen for 10 seconds with a pressure of 20 to 35 mm
Hg while observing the swelling of the internal jugular
vein in the neck and also observing to be sure the patient
does not perform a Valsalva maneuver
 On an otherwise healthy individual, the jugular venous
pressure remains constant or temporarily rises for
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MEDICINE 1: CARDIAC PHYSICAL EXAMINATION
ADDENDUM
Diagram of Principal Heart Murmurs
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