A thorough physical examination can provide clues to the presence and severity of cardiovascular disease, and alert one to the presence of life-threatening conditions even before the results of any diagnostic workup are available.

General Appearance

Dyspnea, tachypnea, use of accessory respiratory muscles, discomfort from pain, diaphoresis, and cyanosis may all indicate underlying cardiac disease.

Pulse

The pulse should be examined for rate, regularity, volume, and character. Some abnormalities in the character of the pulse may be diagnostic for certain cardiovascular conditions:

• Irregularly irregular: Atrial fibrillation, multifocal atrial tachycardia.
• Collapsing: Aortic insufficiency
• Bisferiens (double impulse): Combined aortic stenosis (AS) and insufficiency
• Pulsus parvus (weak) et tardus (delayed): Severe aortic stenosis
• Pulsus altenans (alternating strong and weak pulse): Severe LV dysfunction
• Pulsus paradoxus (marked inspiratory decrease in strength of pulse): Cardiac tamponade, pericardial constriction, severe obstructive airway disease.

Jugular Venous Pressure (JVP)

The jugular venous pulsation is best visualized with the patient lying with the head tilted up 30-45°. The central venous pressure can be estimated by adding 5 cm (the vertical distance between the center of the right atrium (RA) and the sternal angle) to the maximum vertical height of the pulsations above the sternal angle. The JVP is elevated in heart failure and not identifiable in volume depletion. When heart failure is present, firm pressure over the abdominal right upper quadrant will cause persistent elevation of the JVP (hepatojugular reflux). Characteristic abnormalities of the jugular venous waveforms occur in a variety of cardiac disorders (Figure 4-1).

Inspectioon and palpation of the chest

The point of maximal impulse (PMI) of the LV apex should be located and palpated. It is usually in the 5 ^th intercostal space at the mid-clavicular line; it is displaced laterally with right ventricle (RV) dilation and inferolaterally with LV dilation. It is diffuse with dilated cardiomyopathy or LV aneurysm, and may demonstrate a double impulse with hypertrophic cardiomyopathy, AS, or hypertension. A left parasternal heave may be evident with RVH.

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Auscultation of the chest

Heart Sounds
The entire precordium should be systematically examined for normal heart sounds (S_l and S₂), gallops (S₃ or S₄), and other additional sounds (e.g., clicks, snaps).
These auscultatory findings are strongly correlated with specific cardiac disorders (see Table 4-1).

The second heart sound comprises the aortic valve (A2) and pulmonic valve (P2) closure sounds, and is abnormal in a variety of disease states. Normally, P2 follows A2, and the split widens with inspiration. A widely split S2 that still varies normally with respiration may result from right bundle branch block (RBBB), severe RV failure, or severe pulmonary hypertension.

Wide splitting that does not vary with respiration (fixed splitting) is characteristic of an atrial septal defect (ASD). Paradoxical splitting (splitting that narrows with inspiration) is a feature of LBBB, patent ductus arteriosus (PDA), and severe AS.

Murmurs
Murmurs usually arise from blood flow across an abnormal valve, but can also be the result of increased blood flow across a normal valve. The origin of a murmur can often be inferred from its auditory character, its timing within the cardiac cycle (see Table 4-2), and its area of maximal intensity (see Figure 4-2). Various maneuvers may be performed at the bedside to clarity the nature of a particular murmur (see Table 4-3).

Murmur intensity can be graded on a scale of one to six. A grade 1 murmur is barely audible, a grade 2 murmur is easily audible, a grade 3 murmur is loud, and grade 4 to grade 6 murmurs are all associated with palpable precordial thrills. Grade 4 murmur can be heard only with the stethoscope firmly on the chest, grade 5 murmurs can be heard with just the edge of the stethoscope on the chest, and grade 6 murmurs can be heard without the stethoscope.

Several general principles worth remembering during cardiac auscultation are:

• Aortic events are best heard with the patient leaning forward and at end expiration.
• Mitral events are best heard in the left lateral position, during expiration.
• With the exception of the pulmonary ejection click, all right-sided events are louder with inspiration.
• Left-sided events are usually louder with expiration.

Pericardial friction rubs may be mistaken for systolic and diastolic murmurs. They tend to have a scratchy quality and vary significantly with respirations. Classically there are three components of a pericardial rub:

• an atrial systolic component
• a ventricular systolic component
• a ventricular diastolic component

Frequently, however, only one or two components are heard.

The Lungs
It is essential to examine the lungs in every cardiac patient, paying special attention to the following features:

• inspiratory crackles (rales)-indicate left heart failure
• bronchospasm (wheezing)-may indicate penbronchial edema (“cardiac asthma”)
• diminished breath sounds and dullness to percussion at the lung bases- may represent pleural effusions

Several other physical findings are worth noting:

• Hepatomegaly, ascites, and peripheral edema may reflect RV failure.
• A pulsatile liver is seen with Tricuspid regurgitation.
• Central cyanosis is commonly associated with congenital heart disease, whereas peripheral cyanosis is associated with diminished cardiac output.
• Digital clubbing may be seen with congenital cyanotic heart disease and endocarditis.