Physical Exam Pearls – 3 (Cardiac)

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Continuing a series of random tips I find useful in performing physical exam, organ system by system.  Last 2 postings we’ve covered Eye and HENT.  But we’ll hit the lungs later, since there’s a lot to mention about the HEART.

I meet lots of clinicians who feel insecure about cardiac exams.  Listening systematically is the key to comfort.

Rate & Rhythm

1.  Check them apically, with stethoscope, never by radial pulse

2.  If rhythm seems “Irregular,” watch patient breath as you listen

  • May be nothing more than Sinus Arrhythmia — heart rate increases physiologically as we breathe in, decreases as we breathe out.
  • Especially confounding if pt breathing fast due to hypoxia, anxiety, etc.

3.  Irregularly Irregular rhythm is Atrial Fib — if new, needs same-day EKG to confirm (same-day admission if symptomatic)

  • Listen carefully to make sure there’s no background regularity with skipped beats (get EKG), or lots of superimposed extra beats (PACs or PVCs, which would be benign)


4.  “Split S2”  — always listen for it in Pulmonic area (Left 2nd Intercostal Space)

  • It’s physiologic during inspiration: we all have it.  Don’t even chart on its presence.
  • The term “split” is misleading — it’s more like a mere loss of crispness during inspiration, (contrast it to the S2 sounding sharper during expiration).  Just a subtle “fuzziness”.
  • If S2 is split (i.e. “fuzzy”) with both inspiration & expiration, it’s a pathologic Wide, Fixed Split [see below].  May be best heard sitting/standing.
  •  Paradoxical Split = split which occurs during expiration (the reverse of normal), is also pathologic [see below]

5.  Wide Fixed Split S2 may be earliest sign of an Atrial Septal Defect (ASD)

  • May be accompanied by Split S1 (heard at lower left sternal border or apex)
  • ASD remains asymptomatic until exercise intolerance, A. Fib, ventricular overload, or irreversible Pulmonary Hypertension occurs (usually by age 40).
  • ASD can cause complications in scuba divers & high-altitude climbers
  • Moral:  Listen for Split S2 (normal vs. wide, fixed vs. paradoxical) in all patients

6.  Paradoxical Split S2 may be sign of cardiac outlet obstruction, e.g. Hypertrophic Cardiomyopathy (HCM)

  • Important for athletes with undiagnosed HCM, who may faint / die during exertion
  • Moral:  Listen for Split S2 (normal vs. wide, fixed vs. paradoxical) in all patients


I’ve never had a cardiology rotation, & lack the experience of having auscultated hundreds or thousands of abnormal hearts.  When it comes to asymptomatic incidentally-encountered murmurs, the main clinical question I face is whether or not to order an echocardiogram.  Since up to 50% of the world may have a benign murmur now & then, we don’t want to get echos reflexively.

7.  Detecting Murmurs  —  Listen for Silence

  • Area by area, auscultate first for S1, then for S2
  • Then listen carefully for silence between S1 & S2 (systole)
  • If there’s no silence, there’s a systolic murmur!!!
  • Then listen for silence between S2 & S1 (diastole), etc.

8.  If you find a murmur, characterize by 6 Descriptors

  • Grade (2/6, etc — see below)
  • Location  (Aortic, Pulmonic, Left 3rd / 4th Intercostal Space, Tricuspid, Mitral)
  • Timing (early diastolic, mid-systolic, etc — see below)
  • Quality (harsh, blowing, mechanical, etc; this is the only subjective descriptor)
  • Pitch (“high pitch” = heard best w/ diaphragm; “low” = w/ bell)
  • Radiation (to another area, R chest, epigastrium, back, etc)

8a.  Grade of murmur is not subjective, but rather strictly defined:

  • Grade I     =  You don’t hear it initially, then detect it
  • Grade II    =  You hear it right away
  • Grade III  =   You hear it right away, but louder than 2 (this is subjective)
  • Grade IV  =   Associated w/ a Thrill
  • Grade V   =   Thrill, & can hear it w/ stethoscope partly off chest
  • Grade VI  =   Thrill, & can hear it w/ stethoscope completely off chest
  • NOTE:  obviously, a beginner may say “Grade I,” whereas an experienced clinician would call it a “II”

8b.  Distinguishing Mid-Systolic from Early- and Pan-Systolic murmurs

  • If you can hear a distinct S1 and S2, the murmur is Mid-Systolic
  • Early-Systolic murmurs blend with S1, so you can’t truly hear it
  • Pan-Systolic (aka Holo-Systolic) murmurs blend with S1 and S2, so you can’t truly hear either of the 2 normal heart sounds
  • A picture may make this easier to conceptualize:


9.  Mitral Stenosis — a special case.  It’s almost always due to prior rheumatic fever, which is rare in the developed world, but not uncommon among immigrants.  Confers significant risk of chronic A. Fib, Stroke, Pulmonary HTN, and complications in Pregnancy

  • The low-pitched diastolic murmur is very subtle
  • Auscultate with bell, at apex, with patient lying on left side
    • Be sure there’s a perfect seal w/ bell on chest
  • Listen for a soft diastolic rumble, either just after S2, or just before S1
  • Inch the stethoscope, bell-diameter by -diameter, to the axilla, paying careful attention to diastole
  • If you think you hear something, push bell into skin, converting it to a diaphragm.  The “soft rumble” should disappear.  Ease up so it’s a bell again, rumble should reappear.  Repeat a few times to confirm it for yourself.
  • I perform this maneuver on patients the first time I examine them, especially immigrants from underdeveloped countries

10.  What murmurs require Echos?

  • All diastolic murmurs
  • All Grade 4-6 murmurs (i.e. those with thrills)
  • Early- and Pan-Systolic murmurs
  • Murmurs that get louder during inspiration (right-heart disease)
  • HCM murmur gets softer if a patient goes from standing to squatting, & increases when they stand again (important for sports physical)

Obviously, if you’re in doubt, get an echo.  But the following point may be helpful:

10.  What murmur can be called “physiologic” or “functional,” and DOES NOT require an echo?

  • Grade 3 (or less) mid-systolic murmur heard best at the lower-left sternal border

10. a.  By the way, don’t use such medical jargon with patients, because it sounds weird & generates anxiety (people tend to worry when you mention “heart”).

  • Tell the patient they have a “normal murmur,” that’s nothing more than the sound of blood streaming through the heart
  • If I’m not sure about a murmur & order an echo, I explain to the patient, “Sometimes I hear a murmur & know right away that it’s normal, sometimes I know right away it means disease, & sometimes I just don’t know (like yours), so I order an echo,”
  • If you tell a patient they have a murmur, reassure them that murmurs have nothing to do with chest pain or heart attacks.


11.  Presence of S3 and S4  —  low-pitched sounds (heard best with bell)

  • Useful primarily in suspected heart failure
  • S3 may be present in healthy young adults and in pregnancy
  • S4 may be present in older adults without heart disease

12.  Auscultate with bell at apex (PMI) with pt. rolled slightly onto left side

  • Listen carefully in diastole, first for an extra sound right after S2 (= S3), then right before S1 (=S4)
  • If you think you hear something, push bell into skin, converting it to a diaphragm.  The extra sound should disappear.  Ease up so it’s a bell again, the sound should reappear.  Repeat a few times to confirm it for yourself.

Jugular Venous Distention  (JVD)

13.  JVD  =  elevation of JV Pulsation (JVP)

  • Useful if suspect Heart Failure; abnormal = >5 cm above sternal angle (ridge where manubrium joins body of sternum)
  • Identify JVP by its 2 waves (vs. 1 pulsation of carotid)
  • Seek JVP with pt reclined at 45°.  If no JVP visible:
    • May mean no JVD… OR
    • May mean JVP is real high, past the ear
    • So sit pt. up at 90°; then no visible JVP = no JVD
  • Hepatojugular Reflux as sign of Right heart failure
    • Place pt at 45°, find JVP
    • Press on RUQ for 15 secs
    • JVP rises >3 cm = Right heart failure
  • NOTE:  Analysis of JVP can be much more complex, identifying the 2 waves by their ascents & descents.  The above description is the minimum level, at which I feel able.

 Summary of Cardiac Auscultation

1.  Listen in one spot (where lub-dub are clear) for Regular Rhythm (see #2-3 above)

2.  Count the Rate

3.  Listen in Aortic Area with diaphragm:
  • Identify the S1.  Then the S2.
  • Then listen in Systole for silence; no silence = murmur
    • If Murmur present, characterize it (see #8 above)
  • Then listen in Diastole for silence; no silence = murmur (etc.)
4.  Listen in Pulmonic Area with diaphragm:
  • Same as above
  • Also listen for physiologic (i.e. normal) Split S2 (see #4-6 above)

5.  Listen at 3rd & then 4th Intercostal Spaces, Tricuspid Area (lower left sternal border), and Mitral Area (apex) as for Aortic Area

6.  Consider:  Roll pt. onto Left Side to auscultate in Diastole with Bell
  • Heart Failure pt. (for S3/S4 gallop — see #11-12 above)
  • Immigrant from 3rd World on 1st visit (for Mitral Stenosis — see #9 above)

Next posting we move up to Lungs & down to Abdomen.

2 responses to “Physical Exam Pearls – 3 (Cardiac)

  1. Thanks! Very interesting.

  2. Very helpful! thanks

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