Health Assessment Courses from New York University, Division of Nursing:

                Features study guides for health assessment and links

to case studies for the following topics:

                                History-taking & documentation

                                Techniques & Equipment


                                Head & neck

                                Lung & thorax



                                Male & female genitalia





                The Auscultation Assistant:  Review of cardiac sounds, murmurs & associated pathologies:

                UCLA site:



                Cardiology Pathology Index:  Myocardial Infarction Tutorial:  Pathology Slides




                Cardiovascular Disease:  Anatomy Review




                EKG Reviews & Links to Other EKG Sites:






Cardiovascular System:    

often described as a maze of tubing and a wondrous pump


Structures of Significance

                Heart and neck vessels

                                Aorta - arch & thoracic

                                Common carotid arteries

                                Internal jugular veins

                                Superior vena cava

                                Right atrium

                                Right ventricle

                                Pulmonary artery

                                Left atrium

                                Left ventricle







                                Tricuspid (AV) valve

                                Mitral (AV) valve

                                Pulmonic (SL) valve

                                Aortic (SL) valve


                Accessible arteries









Dorsalis pedis

                                Posterior tibial


                Accessible veins


                                Superficial & deep arm veins

                                Femoral (deep)

                                Popliteal (deep)

                                Great & small saphenous (superficial)


                Accessible lymphatic tissue

                                Cervical chains

                                Axillary chains








Functions of Significance


                                Cardiac Cycle

                                Conductive system

                Peripheral Vascular Circulation




                                Conserve fluid & plasma

                                Major part of the immune system

                                Absorb lipids from intestinal tract






Most Common Cardiovascular Problems

                Coronary Artery Disease (CAD)

                Hypertension (HTN) 

                                80% of US population

                Rheumatic Heart Disease (RHD)

                                Sequelae of beta hemolytic strep infections

                                Resulting valvular damage more likely seen in older adults,

                                                who may not have been treated for strep

                                Jones Criteria used to establish new diagnosis

                Bacterial Endocarditits (BE) 

                                bacteremia causes valvular damage

                Congenital Heart Disease (CHD)

                                Greatest portion diagnosed early in life



Cardiac History - What are the patient’s risk factors &/or symptoms?



·         Risk Factors (Noncorrectable)

What are the unmodifiable risk factors?

·         Age, sex, personality type

·         Family Hx. - sudden death, HTN, stroke or MI prior to 50,

severe hyperlipidemia,  DM      

·         PMH - arrhythmias, murmurs, CHF, rheumatic disease,

cardiac surgery, bleeding disorders, aneurysms, DVT

(deep vein thrombosis), emboli, or hypo-, hyperthyroidism

·         Diabetes mellitus (belongs in both lists)

·         Coronary artery disease (belongs in both lists)

·         Congenital heart defects


·         Risk Factors (Correctable)

What are the modifiable risk factors?

·         Smoking

·         Employment:  physical vs. emotional demands,

environmental hazards, stress management

·         Nutritional status:  body fat & type of diet

·         Anaerobic exercise

·         Estrogen replacement (if postmenopausal)

·         Drug use - alcohol, cocaine, prescription & OTC

·         Essential HTN

·         Hypercholesterolemia




















·         Hypertension Classifications:  NIH, 6th Report, 1997


Adults:   Category                                               Systolic (SBP)     Diastolic (DBP)  

·         Normal                                                           <130                        <85

·         High normal                                                  130-139                   85-89

·         Hypertension

Stage I (mild)                         140-159                   90-99       Lifestyle changes

Stage II (moderate)              160-179                   100-109   Lifestyle changes

Stage III (severe)                  180-209                   110-119   Medication

Stage IV (very severe)         ³210                        ³120



·         Normal:                          < 90th %ile              systolic & diastolic

·         High normal:                 90-95th %ile            systolic & diastolic

·         Hypertension:               > 95th %ile              systolic &





·         Arm Blood Pressure: May be 5-10 mm Hg higher in

                right arm than left arm:  greater differences between right &

                left arm may be associated with congenital aortic stenosis or

                acquired conditions, such as aortic dissection or obstruction

                of arteries of the upper arm

                                Supravalvular Aortic Stenosis:        HTN in Rt. Arm

                                & hypotension in lt. Arm




·         Leg Blood Pressure:  Arm & leg blood pressures are about

                equal during the first year of life & after that time the leg blood

                pressure is 15-20 mm Hg higher than arm blood pressure

                                Coarctation of Aorta:          Leg BP lower than arm BP




·         Pulse Pressure:

difference between systolic & diastolic blood pressures:

·         usual adult pulse pressure is between 30 – 40 mm Hg 

(even as high as 50 mm Hg):  example:  pulse pressure

may widen with systolic hypertension, may widen with

increased intracranial pressure

·         may be wider in children  (between 20 – 50 mm Hg):

examples:  wide pulse pressure more than 50 mm Hg in

children may indicate congestive heart failure:

narrow pulse pressure less than 10 mm Hg  may

indicate aortic stenosis




·         Orthostatic Hypotension:          Decrease in systolic BP of

                20-30 mm Hg or more when changing from supine to standing

                position, & increase in pulse of 10-20 bpm:  sudden drops may

                result in fainting.  Dizziness & faintness from orthostatic

                hypotension may occur when taking antihypertensive

medications, volume depleted, confined to bed or in the elderly




·         Korotkoff sounds:       Turbulant sounds of partial obstruction

of arterial flow

Phase I:                  sharp tapping sound (systolic)

Phase II:                 change to soft swishing sound

Phase III:               sounds more crisp & intense

Phase IV:               muffled tapping (first diastolic)

closer to true diastolic in children:

record for diastolic in children <13 yrs

Phase V:                 cessation of sound (2nd diastolic)

closer to true diastolic in adults:

record for diastolic in children >13 yrs

& adults

American Heart Association recommends

Recording systolic/1st diastolic/2nd diastolic


·         Auscultatory gap:

silence caused by disappearance of Korotkoff sounds after

initial appearance and are then heard 10-15 mm Hg later:

can be mistaken for lower SBP reading (point of reappearance):

can be associated with decreased peripheral flow, such as

hypertension or aortic stenosis



·         Pulse:  Common Definitions & Abnormalities


Pulse Deficit:               A difference between the apical &

peripheral pulse.(peripheral pulse rate subtracted from

apical pulse): normally “zero;” or no difference: 

a pulse deficit indicates weak pulses/heart beats


Bigeminal Pulse:        Normal pulse is followed by premature

contractions, which are weaker than the normal pulse. 

Rhythm is irregular.  Possible causes:  premature ventricular

contraction or atrial contraction


Pulses Alterans:         Pulses have large amplitude beats

followed by pulses of low amplitude.  Rhythm remains

normal.  Possible cause:  left sided congestive heart failure


Pulsus Paradoxus:      An exaggeration of the normal

paradoxical pulse, defined as a normal fall of approximately

5 mm. Hg. in systolic arterial blood pressure during inspiration,

as compared to expiration.  A difference of more than

10 mm. Hg  is abnormal pulsus paradoxus.  Possible causes:

cardiac tamponade, constrictive pericarditis, obstructive

lung disease.  It is tested better by BP evaluation of systolic

pressure than by pulse palpation.


Palpitations: Unpleasant sensations of awareness of

the heartbeat:  described as skipped beats, racing, fluttering,

pounding or irregularity:  may result from rapid acceleration

or slowing of heart, increased forcefulness of cardiac

contraction:  not necessarily associated with heart disease





·         Cholesterol Issues


·         Serum Lipid Levels:                          

·         Used to determine risk for coronary heart disease

·         TCHOL:                Total cholesterol                  Elevations increase risk

·         TG:                         Triglycerides                         Elevations increase risk

·         LDL:                      Low density lipoprotein      Elevations increase risk

·         HDL:                      High density lipoprotein     Elevations decrease risk



Serum Lipids:  Optimum Levels

Measured in mg/dl


                                                                Adults                                    Children

                TCHOL (acceptable)           <200                                        <170

                                 (borderline)          200-239                                   170-199

                                (high)                     >240                                        >200


                Triglycerides                       <200                                        <150


                LDL        (70% of total)        <130                                        <110

                                (acceptable)          <110

                                (borderline)           110-120

                                (high)                     >130



                HDL       (25% of total)        >35                                          >35





·         Cholesterol & Children:

·         Universal screening not recommended

·         Yes:                Family history of cholesterol >240,

premature CVD

·         Yes:                Lifestyle risk factors





·         Heart

Base:      (upper)   aortic & pulmonic area

Apex:      (lower)    mitral area

Left side:                high pressure flow

Right side:             low pressure flow

·         Pericardium (pericardial sac)

·         Anchors:      

Bottom to diaphragm

Top to upper sternum

·         Visceral or epicardial sac (inner lining):

Insensitive to pain

·         Parietal (outer lining)

Innervated by phrenic nerve & sensitive to pain



·         Impulse Conduction:

·         Heart is innervated by autonomic nervous system

·         Sympathetic:                 stimulates

·         Parasympathetic:          slows

·         Sinoatrial (SA) node:   located in right atria,

Generates impulses that travel through the

conduction system & produce cardiac muscle contractions

·         Atrioventricular (AV) node:       located  in the atrial septum

·         Bundle of His:               right & left bundle branches

·         Purkinjie fibers:             located in ventricular myocardium,

where ventricular contraction takes place


·         Location of left ventricular apex & PMI (point of maximum impulse)


·         Adults:           5th ICS, MCL

·         Infants:          4th ICS, left of MCL

·         Pregnancy:   PMI moves 1-2 cms left of MCL & up to

4th ICS


·         Cardiac Auscultation:                listening areas

·         Stethoscope:                 diaphragm:            high pitched sounds

bell:                         low pitched sounds

listen:                     to one sound at a time,

                                over valvular areas


·         Aortic:                           2nd ICS, RSB          S2 is loudest

·         Pulmonic:                     2nd ICS, LSB           S2 is loudest

·         Erbs Point:                    3rd ICS, LSB

·         Tricuspid:                     4th ICS, LSB           S1 is loudest

·         Mitral (Apex)                5th ICS, MCL          S1 is loudest



·         Consider Cardiac Cycle When Listening


·         S1:                  Represents ventricular contraction & ejection:

S1 sound is produced by closing of

Atrial ventricular (AV) valves:

Tricuspid & Mitral valves


·         S2:                  Represents ventricular relaxation & filling:

S2 sound is produced by closing of

Semilunar valves:

Aortic & Pulmonic valves


·         When a clicking or snapping sound is heard, it

Usually means that damaged valves are heard

Upon opening rather than upon closing (which

Essentially reverses the valvular sound patterns:


S1:          called an “ejection click”

The sound is produced by the opening

of damaged semilunar valves

(aortic or pulmonic)


S2:          called “opening snap”

                The sound is produced by the opening

                of damaged atrial ventricular (AV) valves

                (tricuspid or mitral):

                Example:                Mitral stenosis produces

                                                An S2 opening snap




·         Continued:  Cardiac Cycle:


S3:          Can be normal in children & young adults

                Over 30 years of age:           “Ventricular Gallop”

                Associated with CHF


                Rhythm simulation:


                SLOSH- ING- IN   TENN- E-   SSEE

                S1            S2     S3 S1         S2   S3



S4:          Possible to be normal in children & young adults

                Over 30 years:       noncompliant or stiff ventricle

                Hypertrophy of ventricle, CHF, CAD


                Rhythm simulation:


                A-   STIFF- WALL              KEN-  TU-  CKY

                S4    S1         S2                     S4         S1    S2





·         Sinus Arrhythmia:     Normal rhythm

Normal splitting of S2

·         Refers to the physiologic splitting of S2

(reflects the time delay between closure

of the aortic and pulmonic valves)

·         S2 split “widens” or increases during

an inspiratory breath (heart rate slows)

·         S2 split “narrows” or decreases with

breath expiration (heart rate increases)




·         Abnormal S2 split & selected examples:

See text for additional examples


·         Wide:             delayed emptying of right ventricle &

delayed closure of pulmonic valve

Examples:  Right Bundle Branch Block,

Pulmonic stenosis


·         Fixed:             split of S2 is affected by respiration

Example:  ASD


·         Paradoxical:

Physiologic split reverses:

Narrows with inspiration &

Widens with expiration

Example:  Left Bundle Branch Block,

Aortic Stenosis



·         Jugular Venous Pressure


·         Reflects pressures in right side of heart

·         Assess the internal jugular vein if possible

·         Venous pulsations are visible, but not palable

·         Pulsations best visible with patient sitting a

45 degree angle  (45-60)

·         Measure highest level of pulsations,

From the sternal angle

·         Pressures > 3-4 cms above the sternal angle

are elevated





·         Chest Pain

·         Palpitations or other irregularities of rhythm

·         Dyspnea

·         Syncope

·         Fatigue

·         Dependent edema

·         Hemoptysis

·         Cyanosis






·         Pain

·         Changes in skin temperature  color

·         Edema

·         Ulceration

·         Emboli

·         Stroke

·         Dizziness


What symptoms of abnormalities are present?     (Document OLD CART)

                Chest pain




                Syncope or near syncopal episodes







                Leg ulcerations - atrophy, hair loss

                Diabetic neuropathy (esp. without sweat)








·         Cardiac Pain

·         Levine’s sign

·         Exertion, emotion, eating, cold or stress:  before pain

·         Substernal, retrosternal

·         Mild to severe, diffuse

·         Deep, pressure, squeeze, heavy, strangle

·         May radiate:  jaw, arms, neck, back

·         Stereotyped for individual:

Variations indicate change, unstable angina

·         Subsides with rest, Nitroglycerine


Angina:                 Episodic, “seizes:

                                Duration short:  2-3 minutes

                                Range: > 1 & > 10 minutes


Acute MI:              Steady, deep pain:  chest constriction, crushing

                                Lasts 20 minutes or longer

                                May not be relieved by nitroglycerine

                                Nausea, vomiting, diaphoresis

                                May occur at rest, with exertion or stress



·         Pericarditits Pain

·         Deep, constant or pleuritic

·         Pericardial friction rub

·         Increases with cough

·         Sharp, stabbing

·         Fever or recent infection

·         Shallow breathing, sitting up, leaning forward relieves





·         Pulmonary Pain

·         Onset gradual or sudden (days: viral:   hours: bacterial)

·         Fever, infection, cough (sputum, blood)

·         Pain over lung fields

·         Mild to severe, sharp ache

·         Air hunger, dyspnea, restlessness

·         Splinting, moist air, rest, heat, sitting ;up may relieve




·         Respiratory Movement Pain

·         Pleurisy, overuse, trauma

·         Sharp, burning, stabbing, shooting, deep

·         Crushing or tearing sensations




·         Musculoskeletal:  Chest Wall Pain

·         Tenderness to palpation of chest wall

·         Chest wall maneuvers may precipitate pain

·         Examples:       rib fracture, arthritis,

muscle spasm or myositis, chostrochondritis,

slipping cartilage





·         Gastrointestinal

·         Gradual or sudden onset

·         Esophagitis & gastritits may occur after eating, leaning over

·         Pain may be burning, retrosternal, epigastric or radiate

·         Mild to severe

·         Intermittent or continuous

·         Food, antacid, standing, belching may relieve

·         Emotional stress, caffiene, spices, heavy meals

·         Cold liquids, alcohol, exercise, smoking may aggravate




·         Palpitations:  Arrhythmias:  Consider

·         Cardiac

·         Thyrotoxicosis

·         Hypoglycemia

·         Fever

·         Anemia

·         Anxiety

·         May not indicate serious disease

·         Other factors:  caffeine, tobacco, drugs










·         Arteries

·         Atherosclerosis:  ischemia & aneurysms

·         Microvascular disease:  diabetes, ischemia,

peripheral neuropathy

·         Ischemia of extremities


·         Veins

·         Venous stasis:  pigmentation, dermatitis, cellulitis, ulceration

·          Thrombus formation



·         Lymphatics

·         Generalized palpable lymph nodes:  3 or more lymph node chains:

Systemic disease processes

·         Lymphangitis:  thin red steaks on skin

·         Lymphedema:  obstruction of lymphatic flow



·         Pain

·         Intermittent claudication:  atherosclerosis,

Lower extremity pain during exercise, at rest

·         Pseudoclaudication:  musculoskeletal disease in lumbar area



·         Skin Changes

·         Arterial insufficiency:  cool, pale

·         Venous insufficiency:  warm, erythematous, erosions

Increased pigmentation, swelling, aching or heaviness in legs



·         Edema

·         Lymphedema:  painless, “heaviness,” firm, nonpitting,

Rough skin texture



·         Ulceration

·         Arterial insufficiency:  painful, discrete edges,

erythematous if infected, occur rapidly with trauma

·         Venous insufficiency:  stasis ulceration, diffusely reddened,

Thickened cobblestone appearance, slowly developing



·         Emboli

·         Results from stasis & hypercoagulability

·         Consider:  bedrest, CHF, obesity, pregnancy,

oral contraceptive:  associated with thrombus & emboli



·         Neurologic Symptoms:  due to arterial occlusive processes



·         Dyspnea:  Consider

·         Cardiac:   Left ventricular failure, mitral stenosis

·         Paroxsysmal nocturnal dyspnea:  CHF

·         Orthopnea:  CHF

·         Dyspnea with exertion

·         Pulmonary etiology

·         Emotional

·         High altitude

·         Anemia



·         Syncope:  Consider

·         Fainting, dizziness, blackout

·         Cardiac etiology

·         Metabolic etiology

·         Psychiatric etiology

·         Neurologic etiology

·         Vasovagal-vasodepression:  during periods of emotional strain

·         Micturation-visceral reflex:  males, straining with nocturnal

Urination, associated with alcohol consumption

·         Cough:  post-tussive, with COPD

·         Carotid sinus sensitivity:  carotid pressure, older adults



·         Fatigue:  Consider

·         Decreased cardiac output

·         CHF

·         Mitral valve disease

·         Anxiety & depression

·         Anemia or chronic diseases



·          Dependent Edema:  Consider

·         CHF

·         Worse as day progresses

·         SOB

·         Edema rating:

·         1+ = 2 mm

·         2+ = 4 mm

·         3+ = 6 mm

·         4+ = 8 mm



·         Hemoptysis:  Differentiate

·         Hemoptysis:  red-pink, frothy

·         Hematomesis:  dark, coffee ground



·         Cyanosis:  Consider

·         In lower extremities:  differential: R to L shunt:  PDA

·         Peripheral:     cyanosis of extremities

·         Central:          cyanosis of mouth & mucous membranes,

indicating fall in O2 saturation

Physical Examination - Inspection.  Palpation.  Auscultation

                Vital signs

                                Pulse rate - frequency, regularity & amplitude

                                Blood Pressure - both arms, use correct cuff size







·         Skin

·         Cold, clammy perspiration in low-output states

·         Widespread vasodilatation in high-output states

·         Pallor suggests anemia

·         Tight, smooth, shiny skin in scleroderma

·         Cyanosis from either reduced Hbg in the arterial blood

        or to decreased blood flow



Lesions & further inspection


·         Xanthomata:         firm yellow colored masses,

                                        associated with hypercholesterolemia

·         Tendons:      located on finger, Achilles & plantar tendons

·         Tuberous:      located on hands

·         Eruptive:        acute, associated with uncontrolled diabetes, 

                                located on abdomen buttocks, elbows, knees & back


·         Erythema marginatum:      in febrile patient:

erythematous rash, with disc-shaped, raised edges

May be associated with rheumatic fever:

·         Autoimmune reaction to group A

beta hemolytic streptococcal pharyngitis

that involves joints, skin, brain, serous

surfaces & heart

·         Major manifestations:

·         Carditis (new systolic murmur)

·         Polyarthritis

·         Chorea

·         Erythema marginatum

·         Subcutaneous nodules

·         Diagnostic tests:

·         Throat culture:  strep +

·         Antistreptolysin-O-titer + (ASLO)

·         Sedimentation rate:  elevated

·         EKG & chest x-ray


·         Rheumatoid nodules:                  subcutaneous nodules,

associated with rheumatoid arthritis

(firm nontender, usually located on

extensor surfaces of over tendons)




·         Nails

·         Splinter hemorrhages:  associated with endocarditis

·         Clubbing:               associated with cyanotic congestive heart

                                        disease (CHD), chronic pulmonary disease,

                                        cirrhosis of liver



·         Face, Eyes, Ears


·         Xanthelasma:        yellow plaques on eyelids,

                                        associated with hypercholesterolemia

·         Arcus senilis:        white-gray ring around exterior portion of iris:

                                        normal in older adult: 

                                        associated with hypercholesterolemia (under 40 yrs)

·         Lens displacement:              Marfan’s Syndrome:

                                                        Genetic disorder,

                                                        associated with congenital heart disease

                                                        (aortic regurgitation) & other physical


                                                                        Lens displacement

                                                                        Arachnodactyly (increased length of

                                                                                        distal areas, fingers, feet…)

                                                                        Chest:  pectus excavatum or carinatum

                                                                        High arched palate

·         Hypertelorism:      wide set eyes

                                        may be associated with CHD & other syndomes,

                                        such as supravalvular aortic stenosis

·         Ear creasing:         before age 60



·         Mouth & Neck


·         Petichiae on palate:      associated with bacterial endocarditis, in

                                                                acute phase

                                                                also look for nail splinter hemorrhages

·         High arched palate:      Marfan’s syndrome

·         Webbed Neck:              Congenital, Turner’s Syndrome,

                                                Associated with coarctation of aorta



·         Fundoscopic Exam  (Keith-Wagener changes)


                KW I:                     minimal arteriolar narrowing

                KW II:                    nicking + KW I

                KW III:                  flame hemorrhages, cotton wool patches + KW I, II

                KW IV:                  papilledema + KW  I, II, III












·         Extremities & Lesions


·         Rheumatic nodules

·         Osler’s nodes:              tender, erythematous, red-blue-purple nodules,

                                                                on distal pads of fingers, associated with

                                                                bacterial endocarditis or connective tissue disease

·         Xanthoma tuberosum

·         Varicose veins

·         Leg ulcers:                     differentiate between arterial & venous (see p. 12)

·         Ear creasing before 60

·         Aarachnodactyly:        Marfan’s syndrome (CHD)





·         Abdominal & Vascular Assessment   (arms, legs, abdomen)


·         Ascities:        shifting dullness

·         Bruits:            abdominal (ARIF)

carotid & temporal (auscultate before palpating)

·         Pulses:           arteries

·         Pulsating aorta

·         Systemic venous congestion:    dilated vessels

hepatomegally or tenderness

friction rub

·         Jugular venous distention:         JVD by inspection

JVP by measurements above 3-4 cms

·         Hepatojugular reflux:                   abdominal manual compression test:

with patient supine & mouth open,

manual pressure is applied over liver. 

Resulting increase in JVD is

associated with right ventricular failure

·         Skin temperature:                         & characteristics (warmth, hair growth)

·         Edema:                                           Pitting:   fluid retention      

                                                                                Firm, nonpitting:   lymphedema

·         Deep vein thrombosis (DVT):    unilateral swelling, venous distention,

                                                                                increased warmth, tenderness

                                                                                Homan’s sign:  squeezing of affected

                                                                                calf or slow doriflexion of ankle produces

                                                                                calf pain
















·         Precordium:                 Observation & Palpation

                                                Inspect - apical impulse, heave

                                                Palpate - PMI, thrills, pericardial areas for thrusts or thrills

                                                Auscultate - five pericardial areas,

                                                (aortic, pulmonic, Erbs, tricuspid, mitral)

                                                bell/diaphram, one sound at a time


·         Non Quiet Precordium:             areas & limited examples

·         Aortic:

        Sharp pulsation:   HTN

        Thrill:      aortic stenosis

·         Pulmonic:

                Sharp pulses:        HTN

                Thrill:      pulmonic stenosis

                Forceful:                emphysema, pneumonia

·         LLSB (Tricuspid, epigastric area)         

                Strong pulsations or thrusts:

                Rt. Ventricular hypertrophy

·         Apical:

                Thrill:      mitral stenosis

                PMI left of MCL or below 5th ICS:

                Cardiac enlargement


·         Auscultation


·         Abnormalities:                     rate & rhythm


·         Heart Sounds

                                S1 - closure of AV valves

                                S2 - closure of SL valves

                                S2 splits






·         Abnormalities in S1 & S2


                                Diastolic extra sounds

                                                S3 - ventricular gallop (CHF)

                                                S4 - atrial gallop (CAD< HTN)

                                                summation sound or gallop

                                                Opening snap - mitral stenosis                                         


                                Systolic extra sounds

                                                Ejection click – aortic or pulmonic stenosis

Midsystolic click – squatting may move closer to S2







·         Murmurs


·         Timing:                   S1 or S2

·         Duration:               early, mid, late, pan

·         Intensity:               I – VI rating scale


·         Pitch:                      soft, high, low, harsh…

·         Location:               near valves, where heard best

·         Radiation:              ie, back, shoulders…

·         Relationships:       to body position, respirations

(changes in murmur)


·         Pericardial friction rub



·         Intensity Grading of Murmurs  (I – VI)


I               Barely audible

II             Soft, but easily audible

III            Louder, no thrill

IV            Thrill, loud, audible with stethoscope

V             Thrill, audible with stethoscope barely touching

VI            Thrill, audible without stethoscope








·         Respiration

·         Inspiration - venous return enhanced &

right-sided murmurs may increase

·         Expiration - Decrease in venous return &

right- sided murmurs may decrease. 

Left sided murmurs may increase


·         Valsalva Maneuver

During straining phase, venous return diminishes,

 left ventricular volume & BP are  reduced

Hypertrophic obstructive cardiomyopathy &

mitral valve prolapse murmurs increase &

 aortic stenosis murmurs decrease


·         Standing from Squatting

Left ventricular volume is reduced secondary to reduced venous return

Mitral valve prolapse may be enhanced & in absence of murmur

may produce mitral insufficiency murmur.

Hypertrophic obstructive cardiomyopathy murmur

increases & aoritc stenosis murmur decreases


·         Passive Leg Raising

Increased venous return & increased left

ventricular & right ventricular volume

May enhance murmur of tricuspid regurgitation

·         Handgrip

After one minute of patients strongest possible grip

May reduce murmur of aortic stenosis,

increase murmur of aortic regurgitation

& mitral regurgitation.

 May increase murmur of VSD



·         Arterial Occlusion

Bilateral, upper arms, 20-40 mm hg above BP

Intensity noted after 20 seconds

May increase murmur of mitral regurgitation



“Innocent” Murmurs

Systolic (except for venous hum)

Common - Children, teenage & high output conditions

Grade III or less

Pulmonary or LLSB

Altered by position

Absence of cardiac enlargement

Normal EKG or chest X-ray

Short, Systolic, Soft

If in doubt - echo

Physiologic splitting of S2



·        Children - Physiologic Murmurs

Still’s Vibratory Murmur - Systolic, LLSB & apex,

intensifies during supination, early school age

Venous Hum - Continuous at clavicles,

disappears with supination, compression of jugular vein

or turning head, early school years

Pulmonary Flow Murmur - older children,

LUSB, louder in supine position

PPP -Physiologic Peripheral Pulmonic Stenosis Murmur   - newborns



·        Children - Common Organic Murmurs




Pulmonic Stenosis

Aortic Stenosis

Coarctation of Aorta













                                S3 - may be first sign

                                tachycardia, with decreased BP

                                cool, moist, pale skin

                                dyspnea with orthopnea, decreased O2 saturation

                                adventitious breath sounds



                                decreased urine output



·        Diagnostic Evaluation


·         History & Physical Exam


·         12 Lead EKG

EKG changes reflection ischemia, injury & infarction

Ischemia:              Inverted T- wave

                                S-T segment depression

Injury:                   ST elevation

Infarction:             Significant Q-wave


·         Chest X-ray


·         Arterial Blood Gases


·         Lab Data:                       CBC & differential




Serum Lipids


·         Cardiac enzymes:        Initial for acute MI

CPK (creatinine phosphokinase)

Begins to rise in 3-6 hours:

Peaks from 12-24 hours

Returns to normal in 3-5 days

LDH (lactate dehydronenase)

Begins to rise within 12 hours:

Peaks from 36-72 hours

Returns to normal within 10 days

CK-MB (creatinine kinase & it’s


Rises within 4-6 hours

Peaks  from 18-24 hours

Returns to normal within 36-72 hours


·         Echocardiogram

·         Exercise Treadmill Test

·         Exercise Thallium Test

·         Cardiac Catheterization

·         Ancillary Tests:          such as upper GI, abdominal sonogram,

acid secretion tests








Common abnormalities

                Clinical portrait of CHF

                                S3 - may be first sign

                                tachycardia, with decreased BP

                                cool, moist, pale skin

                                dyspnea with orthopnea, decreased O2 saturation

                                adventitious breath sounds



                                decreased urine output