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Used when we cannot fell the pulse
(especially apical pulse)
Under these circumstances, cardiac dullness

may occupy large area

Starting well to the left, percuss for

resonance toward cardiac dullness in the

3rd, 4th, 5th, and 6th ICS
Rewarding and important skill of PE, that
leads directly to several clinical diagnosis
Auscultory area:

2nd right interspace aortic area

2nd left interspace pulmonic area
Lower left sternal border tricuspid area
Apex mitral area
Caveats for the auscultory area:
Some authorities discourages the use of the
areas, since murmur of more than 1 origin may
occur in the given area
The area may not be applicable to dextrocardiac
patient or anomalies of the great vessels
Pattern may also altered in enlarge heart
Important things regarding usage of
Diaphragm is better for picking up relatively
high pitched sound
Listen through out the pericordium
Pressing it firmly against the chest
Ex: S1 & S2
Bell is more sensitive to low pitch sound
Use at the apex then move medially along the
lower border of the sternum
Apply it lightly, just enough to trap air around
the rim
Ex: murmur of mitral stenosis, S3 and S4
Pressing the bell firmly on the chest and
strecthing the skin at the same time will
makes it function like diaphragm
This technique is useful in differentiating S3 &
S4 from Ej, OS and midsystolic click
Listen to the entire pericordium while
patient lying supine
For new patient use 2 other position

To listen for mitral stenosis and aortic

Patient lying on left side
Ask the patient to roll to the side into the
left lateral decubitus position
Place the stethoscope (bell) lightly on the
apical impulse
Patient sit up and leaning forward
Ask the patient to sit up, lean forward and
stop breathing on expiration
Pressing the stethoscope (diaphragm) on
the chest
Listen along the left sternal border and apex
Pausing periodically to allow the patient to
Throughout the examination, take time to
auscultate at each auscultatory area
Concentrate on each even in the cardiac

Listen to the following sound:

S1 note intensity, splitting

Normal splitting is apparent in the lower
border of the sternum
S2 note intensity
S2 split listen in the 2nd & 3rd left ICS
Ask the patient to breath quietly and slightly
more deeper than normal
Are there any splitting?
If not, ask the patient breath deeper and sit
up position
Note the following:
Width of the split
Timing of split
Intensity of the A2 and P2
Extra sound during systole
Note the location, timing, intensity, pitch and
effects of respiration on it
Ex: Ej and systolic murmur
Extra sound during diastole
Note the location, timing, intensity, pitch and
effects of respiration on it
Ex: S3 and S4
Systolic and diastolic murmur
Murmur has longer duration
Heart Murmur
Decide whether its a systolic or diastolic murmur
Systolic murmur falling b/n S1 and S2
Midsystolic begins after S1 and stops before S2
Pansystolic during the whole systolic cycle
Late systolic begins in the mid- and continue until S2
Diastolic murmur falling b/n S2 and S1
Early diastolic starts on S2 and fades before S1
Mid-diastolic starts short after S2 and fades or merge
into late diastolic murmur
Late diastolic starts late and continues until S1
Continues murmur starts on systolic and
continues until S2, into but not necessarily
throughout diastole
Ex: patent ductus arteriosus
Both systolic and diastolic components
Ex: pericardial friction rubs & venous hums
Crescendo murmur grows louder
Decrescendo murmur grows softer
Crescendo-decrescendo murmur first rise in
intensity then falls
Plateau murmur same intensity throughout
Location of maximal intensity
Determine by the origin of the murmur
Describe using relation to the ICS, sternum,
paex, midsternal, midclavicular or any of the
axillary lines
Explore the area of the murmur and determine
other place which its present
Usually grade with 6 points scale and express as a
Ex: 2/6 2 being the intensity of the murmur; 6 being
the scale were using
Grade 1 very faint, only if the listener tuned in
Grade 2 Quiet, but heard immediately upon placing
of stethoscope
Grade 3 moderately loud
Grade 4 loud, with palpable thrill
Grade 5 very loud, with thrill; can be heard when
the stethoscope slightly off the chest
grade 6 very loud, with thrill; maybe heard with
stethoscope off the chest
Pitch high, medium, or low
Quality blowing, harsh, rumbling or musical
Note on Cardiovascular Assessment
Good cadiovascular exam requires more
than observation
Always correlate findings with BP, Arterial

pulse, venous pulse, JVP, other PE and

Special Techniques
Aids in Identifying Systolic murmur
Standing & squatting
Standing decrease venous return and peripheral
resistance decrease arterial pressure, CO, SV, and
volume in left ventricle
Squatting opposite effect
Identifying prolapse mitral valve
Distinguishing hypertrophic cardiomyopathy from
aortic stenosis
Valsalva manuever
Straining against a close glottis will cause decrease in
venous return (same effect as standing)
Release of effort has the opposite effect
Pulsus alternans
Suspect of left-sided heart failure
Check for alternating amplitudes of pulse
Best in radial and femoral artery
BP cuff: more sensitive
After raising the pressure, lower it slowly to
the systolic level and below it
Note for alternative loud and soft korotkoff
Note for sudden doubling of apparent heart
Patient should breath quietly or stop breathing
in the mid-respiration
Up right position may accentuate the
Paradoxical pulse
Suspect a pericardial tamponade
Check using BP cuff
Greater than normal drop in systolic pressure
during inspiration
As the patient breaths quietly, lower the
pressure slowly until the systolic level
Note the pressure of the 1st sound
Lower the pressure again, until the sound is
heard throughout the cycle of respiration
Note the pressure
N: the pressure b/n the 2 is not more than 3-4
Pericardial tamponade: difference of >10