PHCL 326
Hadeel Alkofide
April 2011
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Head & Neck
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The HEENT, or Head, Eye, Ear, Nose & Throat Exam is
usually the initial part of a general physical exam, after
the vital signs
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Like other parts of the physical exam, it begins with
inspection, & then proceeds to palpation
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It requires the use of several special instruments in
order to inspect the eyes & ears, & special techniques to
assess their special sensory function
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Head & Neck
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Head & Neck
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Skull
Hair
Scalp & Face
Neck
Nose
Ears
Hearing
Mouth & Pharynx
Eyes
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Head & Neck
Inspection
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Inspect the skull for size, shape & evidence of
trauma
Palpation
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Palpate the skull for lumps, bumps & evidence
of trauma
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Head & Neck
Inspection
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Inspect for quantity& distribution
Palpation
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Palpate the hair for texture (fine, dry, oily)
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Head & Neck
Scalp
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Inspect scalp for lesions & scales
Face
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Inspect the face for expression, symmetry,
movement, lesions & edema
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Head & Neck
Inspection
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Inspect the neck for symmetry, masses, goiter or scars
Palpation
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Palpate the trachea with the thumb on one side & the
index & middle finger on other side of trachea
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Trachea: should be midline
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Deviation may be sign of a mass or a tension
pneumothorax
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Head & Neck
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Head & Neck
Inspection
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Inspect external nose for symmetry,
inflammation & lesions
Palpation
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Palpate the frontal, ethmoid & maxillary
sinuses for tenderness
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Head & Neck
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Head & Neck
Inspection
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Inspect external ear for lesions, trauma, & size
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Inspect ear canal & tympanic membrane with otoscope
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Inspect the canal for foreign bodies, discharge, color &
edema
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Inspect the tympanic membrane for color & perforation
Palpation
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Palpate the external ear for nodules
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Head & Neck
Simple
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Assess the ability of the patient to hear a
sequence of equally accented words/numbers
(3-5-2-4) whispered from a distance of a couple
of feet
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Head & Neck
Rinne Test
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Compares bone & air conduction
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Place tip of vibrating tuning fork on the mastoid process
behind the ear
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Ask the patient to indicate when he no longer hears the
vibrating turning fork
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Hold the fork in front but not touching the ear canal to test
air conduction
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Normally patient can hear vibration better than feeling them
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Head & Neck
Weber Test
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Place the tip of a vibrating fork on the center of
patient's forehead
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Normally sound is heard equally in both ears
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Head & Neck
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Head & Neck
Inspection
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Inspect the lips & mucosa for color, ulcerations,
hydration & lesions
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Inspect the teeth & gums for color, bleeding,
inflammation, caries, missing teeth, ulcerations
& lesions
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Head & Neck
Inspection
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Inspect the tonsils for color, exudates, lesions &
ulcerations
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Inspect the sides of the tongue for color,
symmetry, ulceration & lesions
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Note the odor of breath (examples?)
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Head & Neck
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Head & Neck
Inspection
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Inspect the external & internal structures of the
eyes & assess visual acuity
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General acuity can be obtained by reading a
general sentence from any printed material
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The Snellen eye chart provides more accurate
assessment
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Head & Neck
Inspection
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Test peripheral visual fields with the
confrontation technique
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Assess extraocular muscles movement
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Head & Neck
Inspection
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Inspect the pupil size, shape & equality
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Assess iris for abnormal pigments or deposits
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Test pupil reaction to light
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Head & Neck
Inspection
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Inspect the retinal blood vessels & optic disc,
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Equipment needed
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Inspection
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Palpation
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Percussion
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Auscultation
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Pulmonary Function Test (Spirometry)
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Stethoscope
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Peak flow meter
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Observe the rate, rhythm, depth, & effort of breathing.
Note whether the expiratory phase is prolonged
Listen for obvious abnormal sounds with breathing
such as wheezes
Observe for retractions & use of accessory muscles
(abdominals)
Observe the chest for asymmetry, deformity, or
increased anterior-posterior (AP) diameter
Confirm that the trachea is near the midline
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Identify any areas of tenderness or deformity by
palpating the ribs & sternum
Assess expansion & symmetry of the chest by placing
your hands on the patient's back, thumbs together at
the midline, & ask them to breath deeply
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Percuss over intercostal spaces to assess lung
density
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Percuss over intercostal spaces to assess lung
density
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Posterior Chest
Anterior Chest
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Percussion Notes & Their Meaning
Flat or Dull
Pleural Effusion or
Pneumonia
Normal
Healthy Lung or Bronchitis
Hyperresonant
Emphysema or
Pneumothorax
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Breath Sounds
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Using a stethoscope
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Instruct patient to breath deeply & slowly
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Use a systematic approach, compare each side to the
other, document when & where sounds are heard
Normal breath sounds: tracheal, bronchovesicular,
bronchial, & vesicular
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Breath Sounds: Normal Sounds
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Trachea: tracheal
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Large central bronchi: bronchovesicular
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Small airways distal to central bronchi: bronchial
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Small lateral airways: vesicular
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Breath Sounds: Abnormal Sounds
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Wheeze - may be heard with or without stethoscope
high-pitched squeaky musical sound; usually not
changed by coughing; Document if heard on
inspiration, expiration, or both
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Noise is caused by air moving through narrowed or partially
obstructed airway
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Heard in asthma
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Breath Sounds: Abnormal Sounds
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Stridor - may be heard without stethoscope, shrill
harsh sound on inspiration ; is an inspiratory wheeze
associated with upper airway obstruction (croup)
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Laryngeal obstruction
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Breath Sounds: Abnormal Sounds
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Crackles - heard only with stethoscope (rales):
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These are high pitched, discontinuous sounds similar to the
sound produced by rubbing your hair between your fingers
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May clear with cough
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Most commonly heard in bases; easier to hear on inspiration
(but occurs in both inspiration & expiration)
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Breath Sounds: Abnormal Sounds
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Gurgles - heard only with stethoscope (rhonchi):
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Low pitched, coarse wheezy or whistling sound
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Usually more pronounced during expiration when air moves
through thick secretions or narrowed airways
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Sounds like a moan or snore; best heard on expiration (but
occur both in & out)
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Any extra sound that is not a crackle or a wheeze is probably a
rhonchi
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Most common of the Pulmonary Function Tests (PFTs)
Measures lung function, specifically the of the amount
(volume) &/or speed (flow) of air that can be inhaled
& exhaled
Spirometry is an important tool which can helpful in
assessing conditions such as asthma, pulmonary
fibrosis, cystic fibrosis, & COPD
It can be used as a baseline or a post bronchodilator
test (Post BD), & is an important part in diagnosing
asthma versus COPD
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Abbreviation
Name
Description
FVC
Forced Vital The volume of air that can forcibly be blown
Capacity
out after full inspiration, measured in liters
FEV1
The maximum volume of air that can forcibly
Forced
blow out in the first second during the FVC,
Expiratory
measured in liters. Along with FVC it is
Volume in 1
considered one of the primary indicators of
Second
lung function
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Abbreviation
Name
Description
• The ratio of FEV1 to FVC
• Normal: 75–80%
FEV1/FVC
FEV1%
• In obstructive diseases (asthma, COPD,
chronic bronchitis, emphysema) FEV1 is
diminished because of increased airway
resistance to expiratory flow and the FVC
may be increased this generates a reduced
value (<80%, often ~45%)
• In restrictive diseases (such as pulmonary
fibrosis) the FEV1 & FVC are both reduced
proportionally & the value may be normal or
even increased
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Abbreviation
Name
Description
PEF
Peak
Expiratory
Flow
The maximal flow (or speed) achieved during
the maximally forced expiration initiated at
full inspiration, measured in liters/second
FEF 25–75% or
25–50%
Forced
Expiratory
Flow 25–
75% or 25–
50%
• The average flow (or speed) of air coming
out of the lung during the middle portion of
the expiration (also sometimes referred to as
the MMEF, for maximal mid-expiratory flow)
• In small airway diseases such as asthma
this value will be reduced, perhaps <65% of
expected value
• This may be the first sign of small airway
disease detectable
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Abbreviation
Name
Description
FIF 25–75% or
25–50%
Forced
Inspiratory
Flow 25–
75% or 25–
50%
This is similar to FEF 25–75% or 25–50%
except the measurement is taken during
inspiration
FET
Forced
Expiratory
Time
This measures the length of the expiration in
seconds
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Inspection
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Palpation
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Auscultation (Heart Sounds)
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Chest for visible cardiac motion
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Estimate Jugular Venous Pressure (JVP)
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Patient supine & head elevated to 15-30 degrees
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JVP is the distance b/w highest point at which
pulsation can be seen & the sternal angle
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JVP
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JVP
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An indirect measure of right atrial pressure
Measured in centimeters from the sternal angle & is
best visualized with the patient's head rotated to the
left
Described for its quality & character, effects of
respiration, & patient position-induced changes
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Physical Landmarks
 Suprasternal notch
 Sternum
 Manubriosternal
angle – Angle of
Louis
 Intercostals Spaces
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Palpate for (Point of Maximal Impulses) PMI; easiest if
patient sits up & leans forward
Has a diameter of ≈ 2cm & located with 10 cm of the
midsternal line
Palpate for general cardiac motion with fingertips and
patient in supine position
Palpate for radial, carotid, brachial, femoral & other
peripheral pulses
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See figure 4-12 for peripheral pulses
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With a stethoscope
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Use diaphragm to assess higher pitched sounds
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Needs a lot of practice & experience
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Listen in a quiet area or to close eyes to reduce
conflicting stimuli
See also figure 4-10 for auscultatory Sites
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The auscultatory Sites are close to but not the same
as the anatomic locations of the valves
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Aortic area 2nd ICS at the right sternal border
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Pulmonic  2nd ICS at the left sternal border
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Tricuspid  lt lower sternal border
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Mitral  cardiac apex
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Heart sounds are characterized by location,
pitch, intensity, duration, & timing within the
cardiac cycle
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High-pitched sounds such as S1 & S2, murmurs of
aortic & mitral regurgitation, & pericardial friction rubs
are best heard with the diaphragm
The bell is preferred for low-pitched sounds such as S3
& S4
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S1: Closure of AV
valves (mitral and
tricuspid valves: M1
before T1)
Correlates with the
carotid pulse
Loudest at the cardiac
apex
Can be split but not
often
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S2: Closure of
Semilunar valves (aortic
& pulmonic)
Loudest at the base of
the heart
May have a split sound
(A2 before P2)
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S1 & S2 assessed in all four sites in upright and supine
position
S1 precedes and the S2 follows the carotid pulse
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S3…
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Due to volume overload
Due to Rapid ventricular
filling: ventricular gallop
S1 -- S2-S3 (Ken--tuc-ky)
S4…
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Due to pressure overload
Due to slow ventricular
contraction: atrial gallop
S4-S1 — S2 (Ten-nes—see)
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S3…
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Low-pitched sound
Heard at apex of the heart
Caused by rapid filling &
stretching of the left ventricle
Characteristic of volume
overloading, such as in CHF
(especially left-sided heart
failure), tricuspid or mitral
valve insufficiency
S4…
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A dull, low-pitched
postsystolic atrial gallop
Caused by reduced
ventricular compliance
Best heard at the apex in the
left lateral position
Present in conditions such as
aortic stenosis, hypertension,
cardiomyopathies, &
coronary artery disease
Less specific for CHF than S3
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Turbulent blood flow across a valve or a disease such
as anemia or hyperthyroidism
Listen for murmurs in the same auscultatory sites
APETM
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Systolic b/w S1 & S2
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Diastolic b/w S2 & S1
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They are classified by
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Timing & duration within the cardiac cycle (systolic,
diastolic, & continuous)
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Location
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Intensity
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Shape (configuration or pattern)
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Pitch (frequency)
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Quality, & radiation
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Grade I: barely audible
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Gr II: audible but quiet and soft
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Gr III: moderated loud, without thrust or thrill
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Gr IV: loud, with thrill
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Gr V: louder with thrill, steth on chest wall
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Gr VI: loud enough to be heard before steth on chest
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