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Cardiac Physical exam
Imagine there’s
no Echo
It’s easy if you
try…
Arterial Pulses
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Paradoxus - tamponade, asthma
Parvus et Tardus - aortic stenosis
Asymmetric - aortic dissection
Diminished or absent - PAD, coarctation
• Bisferiens - aortic insufficiency, HCM
• Alternans - severe LV dysfxn, bigemminy
The Neck Veins
http://www.youtube.com/watch?v=tJzBKdKg2k0
Abdominal Jugular Test
• Press firmly for 10 seconds
• If CVP > 4 cm for 10 seconds (or falls > 4
cm with release of pressure) POSITIVE
• Pos AJR is an accurate sign of elevated
LEFT ATRIAL PRESSURE (LR = 8.0)
Sustained Left lower parasternal
movements (i.e. Heave)
• Can be caused by RV volume overload,
MR
• If they are excluded, can be associated
with degree of pulmonary HTN
– RV pressure > 50 (+LR 3.6)
Heart Sounds
• S1 - closing of mitral and tricuspid valves
– Incr with short PR, MS, hyperdynamic LV
• S2 - closing of aortic and pulmonic valves
– splitting
• S3 - increased early diastolic filling pressure
– Can be normal in kids and athletes
– Depressed EF (LR – 3.8; not very sensitive, very
specific)
• S4 - decrease ventricular compliance
– Never normal, ie LVH, ischemia, AS
How to Describe a Murmur
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Intensity
Pitch
Quality
Configuration
Location
Timing
Intensity
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I/VI : Faint, only heard with special effort
II/VI : Immediately identified
III/VI : Moderately loud
IV/VI : Loud with a palpable thrill
V/VI : One edge of stethoscope on chest
VI/VI : No stethoscope required
Pitch
• High
– MR, AI
• Low
– MS, Gallops
Quality
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Harsh
Rumbling
Scratchy
Blowing
Musical
Squeaky
Configuration
• Crescendo
– Severe AS, MVP
• Decrescendo
– AI
• Crescendo-decrescendo (diamond shaped)
– Innocent murmur
• Plateau
– MR
Location
• Apex
• Bases
• Parasternal
– Right or left
– Which ICS
• Does it radiate?
Timing
• Systolic/Diastolic
– Early
– Mid
– Late
– Holo
• Continuous
Murmurs
• Systolic
– Flow murmurs, AS, PS, MR, TR, VSD
• Diastolic
– AI, PI, MS, TS
• Continuous
– Patent ductus arteriosus
Aortic Stenosis
Mitral Regurgitation
Aortic Regurgitation
Exam Maneuvers
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Respiration
Standing
Squatting
Valsalva
Hand Grip
Post Ectopic Beats
Amyl Nitrate
Murmurs
• All murmurs:
– louder with increased flow (ie recumbency, squatting)
– and softer with decreased flow (ie valsalva, standing)
– except MVP and HCM
• MVP vs HCM
– sustained handgrip: MVP louder
HCM softer
• Right sided murmurs increase with inspiration
• Left sided murmurs louder during expiration
• All diastolic murmurs are abnormal (echo)
Respiration
• Inspiration increases venous return to the
right heart, and decreases return to the left
heart
• Inspiration increases the split of S2
– P2 moves farther away from A2
• Inspiration increases the intensity of right
sided Murmurs and Gallops
– TR  Carvallo’s sign
Standing
• Decreases venous return, stroke volume,
arterial blood pressure
– AS
decreased
– MR/TR decreased
– VSD
decreased
– MVP earlier click, longer murmur
– HCM  INCREASED
Squatting
• Increases preload, afterload, and arterial
pressure
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MR/TR increased
VSD increased
AI increased
AS variable
MVP delayed click, shorter increased murmur
HCM  DECREASED
Valsalva
• Decreased venous return, ventricular volumes,
stroke volumes, arterial pressure
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AS/PS decreased
AI/PI decreased
MR/TR decreased
MS/TS decreased
MVP earlier click, longer murmur
HCM  INCREASED
20-30 Sec Handgrip
• Increased SVR, arterial pressure, cardiac
output, LV volume
– AS
DECREASED
– MR/MS increased
– AI
increased
– VSD
increased
– MVP later click, shorter murmur
– HCM
decreased
Post ectopic beat
• Increased ventricular volume and contractility
(effect of increased contractility > increased
volume)
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MR  NO CHANGE
AS/AI increased
HCM
increased
TR
increased
MVP earlier click, longer murmur
• Effect of contractility > volume
Murmurs with names
• Austin Flint
– Late diastolic murmur in aortic insufficiency of jet
causing vibration of anterior mitral valve leaflet or
antero-apical wall
• Graham Steell
– Early diastolic murmur of pulmonic insufficiency in the
setting of pulmonary HTN
• Carey-Coombs
– Mid-diastolic apical murmur of inflammation of the
mitral leaflets in the carditis of rheumatic fever
Extra Heart Sounds
Splitting of S2
• Physiologic split
– Splits during inspiration
• Widened split
– RBBB (Late P2), MR (early A2)
• Fixed split
– ASD
• Paradoxic split (delayed A2)
– LBBB, AS, HCM