Inspection (from the foot of the bed)
- Chest wall deformity (pectus excavatum, carinatum)
- Scars (thoracotomy, pacemaker)
- Heaves (ventricular hypertrophy) and lifts
- Visible apical beat
- Impulses (under xiphoid – can mean RVH or Aorta)
Palpation
- Using finger pads, palpate for apex impulse (PMI) – accurately measure MCL
- Location, size – one ICS
- Amplitude – if increased, suggests volume/pressure overload
- Duration – check in relation to carotid pulse (> 2/3 systole → sustained, LVH) – If carotid is delayed = parvus et tardus → AV stenosis
- Thrills – palpate at each of the 4 valve zones = grade 4 murmur
- Heaves (with heel of hand)
- Left sternal border → LVH
- PV → pulmonary hypertension
- AV → systemic hypertension
- Inferior to xiphoid – RVH
Auscultation
* listen specifically for one sound at a time
* calibrate your timing to the radial pulse
S1
- Louder → ↓ PR interval, ↑CO, ↑HR
- Quieter → ↑ PR interval, MR, severe MS
- Splitting → RBBB
S2
- Splitting ↑ by continued inspiration (while patient not holding in breath)
- Loud S2 → hypertension (systemic or pulmonary circulation)
- Wide split S2 – RBBB, PS
- Fixed split – ASD
- Paradoxical – LBBB, severe AS
- S1 > S2 in LLSB
- S2 > S1 in LUSB
S3 (ventricular gallop)
- Lightly use bell at apex, best heard in LLD
- Can be normal in young people and the pregnant
- Noted in volume overload, increased transvalvular flow (TR, MR)
S4 (atrial gallop)
- lower pitched
- Indicates stiff LV- LVH, post-MI
Ejection click – between S1 and S2
Carotid bruit
Pericardial friction rub
MURMUR – TIMING, SHAPE, INTENSITY, RADIATION
| TYPE | CHARACTER | BEST HEARD | RADIATION |
| AS | systolic, crescendo-decrescendo | – AV, lean forward
– ↓ with Valsava |
– carotids, clavicle |
| AR | – early diastolic,
– decrescendo |
– L 2-4 ICS
– lean forward |
– apex |
| MS | – mid diastolic rumble | – apex, LLD | – no radiation |
| MR | – pansystolic | – apex | – L axilla |
| VSD | – pansystolic, harsh | – L sternal border | |
| PDA | – continuous | – aortic valve | – L clavicle |
* AR murmur best heard with patient sitting up and leaning forward
Intensity:
- 1/6 = not heard by the medical student
- 2/6 = faint
- 3/6 = loud but no thrill
- 4/6 = thrill present
- 5/6 = heard with edge of scope in contact with skin
- 6/6 = heard with scope off of the chest
Special tests
- ↑ blood flow to heart (leg raise, squatting)
- ↑ AS, ↓HoCM, ↓MR
- ↓ blood flow to heart (Valsalva)
- ↓ AS, ↑ MR, ↑HoCM