In Partial Fulfilment of the Requirements in Advanced Adult Nursing

HEART AND NECK VESSELS ASSESSMENT

Prepared by:

Noemie Valerie Quilingin–Pileo

The Heart: Location

The heart is located in the chest between the lungs behind the sternum and above the diaphragm.

It is surrounded by the pericardium. Its size is about that of a fist, and its weight is about 250-300

g. Its center is located about 1.5 cm to the left of the midsagittal plane. Located above the heart

are the great vessels, namely, the superior and inferior vena cava, the pulmonary artery and vein,

as well as the aorta. The aortic arch lies behind the heart. The esophagus and the spine lie further

behind the heart.

The Heart: Anatomy and Physiology

The walls of the heart are composed of cardiac muscle, called myocardium. It also has striations

similar to the skeletal muscle. The heart is a cone-shaped muscle, about the size of a clenched

fist (12cm long and 9cm wide; weighs 250–390g in males and 200–275g in females), with four

chambers: the right and left atria and right and left ventricles. The atria form the upper chamber

of the heart and the ventricles the lower. This has special importance to the electric function of

the heart. The left ventricular free wall and the septum are much thicker than the right ventricular

wall. This is logical since the left ventricle pumps blood to the systemic circulation, where the

pressure is considerably higher than for the pulmonary circulation, which arises from right

ventricular outflow.

The heart has four valves. Between the right atrium and ventricle lies the tricuspid valve, and

between the left atrium and ventricle is the mitral valve. The pulmonary valve lies between the

right ventricle and the pulmonary artery, while the aortic valve lies in the outflow tract of the left

ventricle (controlling flow to the aorta).

The blood returns from the systemic circulation to the right atrium and from there goes through

the tricuspid valve to the right ventricle. It is ejected from the right ventricle through the

pulmonary valve to the lungs. Oxygenated blood returns from the lungs to the left atrium and

from there through the mitral valve to the left ventricle. Finally blood is pumped through the

aortic valve to the aorta and the systemic circulation.

Cardiac Cycle

The cardiac cycle comprises the physiological events needed for the heart to beat. The valves,

the hemodynamics (movement and pressure), and the conduction system work together in the

cardiac cycle. The cardiac cycle comprises the systolic and diastolic phases. The systolic phase is

the contraction or emptying phase, and the diastolic is the resting or filling phase. The atria and

ventricles alternate through the systolic and diastolic phases; while the atria are contracting, the

ventricles are relaxing, and vice versa.

The Heart: Conduction System

Located in the right atrium at the superior vena cava is the sinus node (sinoatrial or SA node)

which consists of specialized muscle cells. The sinoatrial node in humans is in the shape of a

crescent and is about 15 mm long and 5 mm. The SA nodal cells are self-excitatory, pacemaker

cells. They generate an action potential at the rate of about 70 per minute. From the sinus node,

activation propagates throughout the atria, but cannot propagate directly across the boundary

between atria and ventricles.

The atrioventricular node (AV node) is located at the boundary between the atria and ventricles;

it has an intrinsic frequency of about 50 pulses/min (40–60/min). However, if the AV node is

triggered with a higher pulse frequency, it follows this higher frequency. In a normal heart, the

AV node provides the only conducting path from the atria to the ventricles. Thus, under normal

conditions, the latter can be excited only by pulses that propagate through it.

Propagation from the AV node to the ventricles is provided by a specialized conduction system.

Proximally, this system is composed of a common bundle, called the bundle of His (named after

German physician Wilhelm His, Jr., 1863–1934). More distally, it separates into two bundle

branches propagating along each side of the septum, constituting the right and left bundle

branches. (The left bundle subsequently divides into an anterior and posterior branch.) Even

more distally the bundles ramify into Purkinje fibers (named after Jan Evangelista Purkinje) that

diverge to the inner sides of the ventricular walls. Propagation along the conduction system takes

place at a relatively high speed once it is within the ventricular region, but prior to this (through

the AV node), the velocity is extremely slow.

From the inner side of the ventricular wall, the many activation sites cause the formation of a

wavefront which propagates through the ventricular mass toward the outer wall. This process

results from cell-to-cell activation. After each ventricular muscle region has depolarized,

repolarization occurs. Repolarization is not a propagating phenomenon, and because the duration

of the action impulse is much shorter at the epicardium (the outer side of the cardiac muscle)

than at the endocardium (the inner side of the cardiac muscle), the termination of activity appears

as if it were propagating from epicardium toward the endocardium.

Because the intrinsic rate of the sinus node is the greatest, it sets the activation frequency of the

whole heart. If the connection from the atria to the AV node fails, the AV node adopts its

intrinsic frequency. If the conduction system fails at the bundle of His, the ventricles will beat at

the rate determined by their own region that has the highest intrinsic frequency.
Cardiovascular System Assessment

Assessment of the cardiovascular system includes a comprehensive health history and physical

examination. The health history will enable you to identify any cardiovascular symptoms and

risk factors, and the physical assessment will help in evaluating the normal functioning of the

heart and detect any abnormalities. Note that if there is a problem of the cardiovascular system,

every other system will be affected. Be alert for changes in other systems that may reflect

cardiovascular problems.

Health History

This involves collecting biographical data and asking the patient about the current health, past

health, review of systems, and family and psychosocial history as it relates to the cardiovascular

system.

Past Health History (Guide Questions)

A. Childhood illnesses

Do you have a history of rheumatic  May cause rheumatic heart

fever or frequent streptococcal disease
infections?

Do you have any congenital heart  May have direct correlations to

defects? present status

Do you have a murmur?  Murmurs are very common

during childhood. They are
often innocent but may indicate
pathology
B. Hospitalizations/surgeries

Have you ever been hospitalized for

cardiovascular problems?

Have you ever had an ECG?  An ECG can be used to establish

baseline and comparative data and
to evaluate the status of chronic
cardiovascular disease
Have you ever had surgery?

C. Serious injuries

Have you been in an accident recently?  Blunt chest trauma or

acceleration/deceleration may have
caused to myocardial contusion or
pericardial tamponade

D. Serious/chronic illnesses

Do you have a history of diabetes, HTN, or  If controlled, these cardiac risk

hyperlipidemia? factors are alterable

Do you have a history of chronic  Long-standing respiratory disease

respiratory disease? often leads to cardiac involvement

Do you have a history of renal disease or  Can affect cardiovascular system

bleeding disorders?

E. Immunizations

Did you get a flu shot or Pneumovax this  For patients with chronic
year? cardiovascular disease, flu or
pneumonia can place added stress
on an already compromised cardiac
status, resulting in decompensation

F. Allergies

Do you have allergies (iodine or  Allergies to foods, drugs, or

shellfish)? environmental factors may influence
 treatment
G. Medications

Are you taking any prescribed or OTC  Assess patient’s compliance with
medications, including herbal treatment plan
supplements?  Drugs such as digoxin diuretics
nitrates, antihypertensives, and
anticoagulants may cause a variety
of symptoms, eg., arrhythmias, GI
upset, headaches, cramps, dizziness,
etc.
Family History

Familial/genetically linked cardiovascular disorders

Does your family have a history of:  Positive family history is an

 Familial hyperlipoproteinemia uncontrollable risk factor for CAD
 HTN, CAD, or MI  An inherited autosomal dominant
 Diabetes, HTN, or renal disease trait that may increase risk for
 Genetically linked cardiac disorders CAD at an early age
such as Marfan’s syndrome  An inherited autosomal-dominant
 Mitral valve prolapse trait characterized by elongation of
bones that often has associated
cardiovascular abnormalities
 Causes one or both leaflets to
billow into the atrium during
ventricular systole. Runs in
families

Review of Systems

General health survey

Have you experienced fatigue or activity  Chronic cardiovascular disease

intolerance? (chronic CHF) causes decreases CO,
impaired circulation, and decreased
oxygen and often leads to early
fatigue and difficulty performing
ADLs
Have you had influenza, other recent  Influenza or other recent illness can
illness, or weight gain? cause CMP
 Sudden weight gain may indicate
fluid retention
Integumentary
Skin

Have you had any changes in skin texture  Skin changes may indicate vascular
color, or temperature? insufficiency

Do you have any sores or ulcers that  Poor wound healing may signal
won’t heal? diabetes, which is a risk factor for
CAD
Have your ankles swollen or your shoes  Edema is associated with vascular
become tight? disease and CHF

Nails

Have your nails changed in shape or in  Clubbing and cyanosis may reflect
color? chronic cardiopulmonary problem

HEENT
Head

Do you have headaches?  May indicate HTN, a risk factor for

CAD
Do you have dizzy spells?  Syncopal attacks may occur with
vascular disease or cardiac
arrhythmias or may be a medication
Eyes side effect

Have you experienced visual problems  Double vision and temporary loss of
such as blurred vision, double vision, vision are associated with HTN,
colored spots? transient ischemic attack,
cerebrovascular insufficiency, and
digitalis toxicity
Ears

Have you experienced ringing in your  Tinnitus is associated with

ears? cerebrovascular insufficiency

Have you experienced nosebleeds?  Epistaxis is associated with HTN

Throat

Have you experienced frequent strep  Beta-hemolytic streptococcal

throats? infection is associated with RHD
Respiratory

Do you experience breathing difficulties?  Dry cough, SOB, dyspnea on

exertion, paroxysmal nocturnal
dyspnea, orthopnea, and cough are
symptoms of left-sided CHF

Do you have a history of COPD?  Chronic COPD can result in cardiac

involvement, such as pulmonary
HTN and right-sided CHF

Gastrointestinal

Have you experienced RUQ pain, nausea,  GI upset and RUQ pain may
or GI upset? accompany right-sided CHF
 GI complaints are associated with
medications such as digitalis
Genitourinary

Have you experienced changes in  CHF leads to decreased renal

urination, such as waking up at night to go perfusion during the day; but at
to the bathroom? night, when the patient is in a
recumbent position, fluid moves
from the interstitial spaces back into
circulatory system, increasing renal
blood flow and causing diuresis
Reproductive (nocturia)

Female
Are you postmenopausal?  Increases CAD risk

Do you use oral contraceptives or are you  Oral contraceptives/estrogen

on hormone replacement therapy? supplements are associated with
thrombus formation

During pregnancy, did you have  HRT is associated with increased

gestational diabetes or pregnancy-induced risk of cardiovascular disease
HTN?  Increased risk for developing
diabetes later in life, which increases
risk for CAD

Male
Do you have problems with impotence or  Impotence/erectile dysfunction may
sexual performance? be caused by vascular disease,
diabetes, or medication
Do you have chest pain during sexual  Sexual activity increases the heart’s
activity? workload and can precipitate an
angina attack

Musculoskeletal

Do you have muscle weakness?  Chronic cardiovascular disease may

result in weakness secondary to
decreased use

Do you experience leg-muscle cramps  Intermittent claudication is

when walking? associated with arterial insufficiency

Neurological

Do you experience fainting episodes, loss  Syncopal attacks may signal vascular
of consciousness, or headaches? problems or cardiac arrhythmias

Do you experience behavioral changes  HTN or chronic CHF may cause

such as confusion, decreased attention hypoxia and impair cerebral
span, or loss of memory? circulation

Endocrine
 Diabetes is a known risk factor for
Do you have diabetes or thyroid disease? CAD. Hyperthyroid disease can lead
to hypertrophic CMP

Lymphatic

Have you had bleeding problems?  Anemia increases the heart’s

workload. Polycythemia increases
risk for thrombus, HTN, and
cardiopulmonary disease

Have you had a recent infection?  CMP

Psychosocial Profile

Health practices and beliefs/self-care activities

Do you get annual physicals?  Determines preventive practices

Do you see a doctor or nurse regularly?  Ascertains compliance with

treatment programs

What medications are you taking and  Identifies teaching needs

why?

Typical day

What is your typical day? Has it changed  Activity can correlate with energy
over the last year? For example, are there level
activities you find difficult to do or unable  Chronic heart disease decreases
to do? energy levels
 Changes in ADLs may reflect
patient’s attempt to adapt to
progression of illness

Nutrition/weight patterns

Do you have weight problems—for  Obesity is a risk factor for CAD

example, obesity or a sudden weight  Sudden weight increases are usually
increase? associated with fluid retention

What did you eat the last 24 hrs?  24-hr recall helps identify diets high
in cholesterol and sodium, which
may contribute to cardiovascular
disease

Do you get chest discomfort after eating?  Large, heavy meals can precipitate
an angina attack in patients with
CAD

Do you have anorexia, loss of appetite, or  May indicate right-sided CHF or be

nausea? a side effect or toxic effect of
cardiac medications
Activity/exercise patterns

Do you exercise routinely?  A gradual decrease or change in

activity or exercise patterns is seen
in patients with chronic
cardiovascular disease

Do you have chest discomfort after certain  Exercise can precipitate angina
types of activity or exercise? attacks in patients with CAD
 May identify need for referral for
cardiac rehabilitation

Recreation/pets/hobbies

Do you have pets or hobbies? What kinds?  Pets and hobbies can be a good way
to reduce stress

Sleep/rest patterns

Do you awaken during the night to go to  Nocturia is associated with CHF

the bathroom?

Do you awaken with SOB?  PND is associated with CHF

Do you awaken with chest pain?  Angina may occur during rest
(nocturnal angina and Prinzmetal’s
angina). During the rapid eye
movement (REM) cycle of sleep,
myocardial oxygen demands
increase. This may explain the high
incidence of MIs in the early
morning hours

Do you snore?  The incidence of sudden cardiac

death is higher in patients with sleep
apnea

Personal habits

Do you smoke cigarettes? How many  Smoking cigarettes is a known risk

packs per day and for how many years? factor for CAD. Nicotine increases
catecholamine release, which leads
to vasoconstriction and increased
 HR and BP. This increases the
heart’s workload, and increased
carbon monoxide levels result in
decreased oxygen supply

Do you use street drugs such as cocaine?  “Crack” heart: cocaine increases
catecholamine release, which
increases HR and the heart’s
workload. May result in MI, CHF,
or CMP

Do you drink alcohol? How many glasses  Alcohol abuse can lead to increased
a day? pulse and BP, CMP, CAD, HTN,
and stroke

Occupational health patterns

What is your job? Are you currently  Cardiac limitations may prevent
working? patient from working

How many hours a day do you usually  Helps establish cardiovascular

work? Does your job make physical workload and devise an activity
demands? plan

Are you exposed to smoke, noise, extreme  May cause cardiovascular

temperatures, or dust? symptoms

Environmental health patterns

Where do you live? Are there stairs?  As CAD progresses, patient may
have difficulty within own
environment. Referrals may be
indicated
 Identify discharge or home-care
needs

Roles/relationships/social supports

Do you belong to any church or  Chronic cardiovascular disease may

community groups? affect patient’s ability to perform
What is your role in family, church, and role tasks. Roles may change as
community? disease progresses, and referrals
What are your support systems? may be needed. Patient may isolate
 self as disease progresses, becoming
homebound as a “cardiac cripple.”
 Be alert for signs of depression

Sexuality patterns

How has your cardiovascular problem  Fear of heart damage may cause
affected your sex life? patients and spouses to avoid sex or
become impotent
 Antihypertensives or antianginal
medications may also cause
impotence

Stress and coping

What do you do when you feel upset,  Stress increases CAD risk by
angry, frustrated, or stressed out? increased stimulation of sympathetic
nervous system
 Volatile emotions such as anger also
increase sympathetic nervous
system response, which in turn
increases the heart’s workload

Physical Assessment

Preparing the Patient

 Explain the need to expose the anterior chest: female clients may keep breasts covered

and may simply hold the left breast out of the way when necessary.

 Explain the need to assume several different positions for the examination.

Positions:

1. Supine position with the head elevated to about 30 degrees (for auscultation and

palpation of the neck vessels and inspection, palpation, and auscultation of the

precordium).
 2. Left lateral position (for palpation of the apical impulse and if the examiner is

having trouble locating the pulse with the client in the supine position).

3. Left lateral and sitting-up and leaning-forward position (auscultation of abnormal

heart sounds)

Note: Make sure you explain to the client that you will be listening to a heart in a number of

places and that this does not necessarily mean that anything is wrong.

Equipment

 Stethoscope with bell (for a low-pitched sound) and diaphragm (for a high-pitched sound)

 Small pillow

 Sphygmomanometer

 Thermometer

 Marking pen

 Penlight or movable exam light

 Watch with second hand

 Ruler in cm

General Survey

General Appearance

 Chronological age

 Weight distribution and muscle composition

 Facial expression

 Posture or assumed position of comfort

  Dress and grooming

 Body stature

 Muscle wasting

 Abnormal movements

Vital Signs

 BP

 Pulse

 Respiratory rate

 Temperature

Height and weight

 Height

 Weight

Heart and Neck Vessels Assessment

INSPECTION

A. Neck

 Differentiate carotid and jugular veins

NORMAL FINDINGS:

 Carotid arteries and IJV run parallel to the sternocleidomastoid muscle, whereas the EJV

crosses the sternocleidomastoid muscle

 Carotids have visible pulsations, jugulars have undulated wave

 Carotids have palpable pulsations, jugulars easily obliterated

 Carotids not affected by respirations, jugulars are

  Carotids not affected by position, jugulars normally only visible when client is supine

ABNORMAL FINDINGS:

o Large, bounding visible pulsations in the neck at the suprasternal notch (indicating HTN,

aortic stenosis, or aneurysm)

o Abnormal venous waveforms [giant A waves—tricuspid stenosis, right ventricular

hypertrophy, cor pulmonale; absent A wave—atrial fibrillation]

B. Measuring the jugular venous pressure

 Position the patient with the head of bed at 30–45-degree angle

 Place a ruler vertically, perpendicular to the chest at the angle of Louis (sternal

angle)

 Identify the highest level of the jugular vein pulsation; if unable to see pulsations,

use the highest level of jugular vein distention

 Place another ruler horizontally at the point of the highest level of the venous

pulsation

 Measure the distance up from the chest wall

NORMAL FINDINGS:

 Positive carotid pulsations. JVP 2 cm at 45-degree angle

 Jugular venous wave undulated, easily obliterated, varies with position change and

respiration

ABNORMAL FINDINGS:

o Elevated JVP (right-sided CHF, constrictive pericarditis, tricuspid stenosis, or superior

vena cava obstruction)

o Low JVP (hypovolemia)

 C. Precordium

 Look for pulsations on the precordium, paying particular attention to the apex

area

NORMAL FINDINGS:

 Positive pulsation at the apex (may note slight pulsations over the base in thin adults and

children)

ABNORMAL FINDINGS:

o Pulsations to the right of the sternum or at the epigastric or sternoclavicular areas (aortica

aneurysm)

o Apical pulsation displaced toward the axillary line (left ventricular hypertrophy)

PALPATION

A. Neck

Palpating the carotid

 Lightly palpate each carotid separately

 Note rate, rhythm, amplitude, contour, symmetry, elasticity, and thrills

NORMAL FINDINGS:

 Rate (depends on age)

 Rhythm (regular)

 Amplitude (strong, +2 or +3 pulses may normally be seen in high-output states such as

exercise)

 Symmetry (pulses equal)

  Elasticity (carotid soft and pliable)

Palpating the jugulars

 Palpate the jugular veins and check direction of fill

NORMAL FINDINGS:

 Occluding under the jaw , the jugular should flatten, but the wave form will become more

prominent

 Occluding above the clavicle, the jugular normally distends while the jugular wave

diminishes

Testing abdominojugular (hepatojugular) reflux

 Position the patient at 45-degree angle, place hands over the mid-abdominal area,

and apply 20 to 30mmhg of pressure for about 15 to 30 seconds. Estimate the

pressure by placing a partially inflated BP cuff on the abdomen under your hand

 Look at the jugular veins while applying pressure, note increase vein distention,

and return to normal upon release of pressure

NORMAL FINDINGS:

 Negative abdominojugular reflux

 Jugulars are easily obliterated and fill appropriately

ABNORMAL FINDINGS:

o Cardiac rates >100bpm (sinus tachycardia, SVT; causes include CHF, drugs – atropine,

nitrates, epinephrine, isoproterenol, nicotine and caffeine – hypercalcemia)

o Cardiac rates <60bpm (sinus bradycardia heart block; causes include MI, drugs [digoxin,

quinidine, procainamide, beta-adrenegenic inhibitors] and hyperkalemia)

o Irregular rhythm ( arrhythmia)

 o Unequal pulses (obstruction or occlusion)

o Stiff, cordlike arteries ( atherosclerosis)

o Positive abdominojugular reflux (right-sided CHF, tricuspid regurgitation, tricuspid

stenosis, constrictive pericarditis, cardiac tamponade, inferior vena cava obstruction, and

hypervolemia)

B. Precordium

 Identify and palpate each cardiac site for pulsations, thrusts, heaves and thrills

1) Apex (left ventricle area), or mitral area fifth intercostal space,

midclavicular line

2) LLSB (tricuspid area), fourth to fifth intercostal space at left sternal border

3) LLSB (tricuspid area), fourth to fifth intercostal space at left sternal border

4) Base left (pulmonic area), second intercostal space left sternal border

5) Base right (aortic area), second intercostal space right sternal border

6) Epigastric area below the xyphoid process

NORMAL FINDINGS:

 Apex (left ventricular area): PMI or LVI is 1–2 cm, amplitude small, duration

nonsustained, systolic. Negative thrills. Amplitude may be normally increased in high-

output states, such as exercise. Apical pulsation may not always be palpable. Left lateral

displacement of PMI may occur during the last trimester of pregnancy

 LLSB: May not be palpable, although small, nonsustained, systolic impulse may be

palpated, especially in thin patients. Negative thrills

 Epigastric area: Positive slight pulsation may be normal, no diffusion. Palpations not

palpable at base left, pulmonic area, and base right aortic area, except in thin patients
ABNORMAL FINDINGS:

o Enlargement and displacement of PMI (ventricular hypertrophy with dilation)

o Apical impulse located on right side of precordium (dextrocardia, a heart located on right

side, often associated with congenital heart disease)

o Enlarged apical pulsation without displacement >2–2.5 cm with patient supine or >3 cm

with patient in left lateral recumbent position (ventricular enlargement, HTN, aortic

stenosis)

o Sustained pulsation (hypertrophy, HTN, overload, CMP)

o Presystolic impulse (may correlate with S4 and be seen with aortic stenosis)

o Early diastolic impulse (may correlate S3 and be seen with CHF)

o Diffuse, sustained impulse displaced downward and laterally (congestive CMP)

o Thrills (murmur)

o Right ventricular impulse with increased amplitude and duration (pulmonary stenosis or

pulmonary HTN)

o Palpable lifts or heaves (right ventricular hypertrophy)

o Pulsations felt on the fingerprints (may come from the right ventricle, indicating right

ventricular hypertrophy)

o Large diffuse epigastric pulsation (abdominal aortic aneurysm)

o Accentuated pulsation in pulmonic area (pulmonary HTN)

o Accentuated pulsation in aortic area (HTN or aneurysm)

PERCUSSION

A. Precordium
  Use indirect or mediate percussion to determine cardiac borders

NORMAL FINDINGS:

 Dullness at third, fourth, fifth ICS to left of the sternum at midclavicular line

ABNORMAL FINDINGS:

o Left sternal border extends to mid-axillary lines in an enlarged, dilated heart

AUSCULTATION

A. Neck

 Have client hold breath

 Auscultate the carotid with the bell portion of the stethoscope for bruits

 Auscultate the jugulars with the bell portion of the stethoscope for venous hums

NORMAL FINDINGS:

 Negative bruits

 Positive carotid bruit may be normal in children and is associated with high-output states

 Negative venous hum

 Positive venous hum may be normal in children

ABNORMAL FINDINGS:

o Bruit suggests carotid stenosis. Murmurs can also radiate up to the neck from the heart, as

in aortic stenosis

B. Precordium

 Auscultate at apex

 Note rate, rhythm, extra sounds or murmurs

 Auscultate at each site (apex, LLSB, Erb’s point, base left and base right)
  Note S1, S2, extra sounds or murmurs

 Listen at each site with both the bell and the diaphragm

NORMAL FINDINGS:

 Apex

 Rate (depends on age)

 Rhythm (regular; S1 > S2; high-pitched systolic, short duration. No extra sounds)

 Psychological S3 and S4 may be heard in children and young adults without heart

disease

 LLSB

 S1 > S2 plus split S1

 Erb’s point

 No aortic murmurs

 Base

 Base right (aortic)

 Base left (pulmonic)

 S1 < S2

 + split S2 on inspiration at pulmonic area

 Murmurs

 Innocent grade 2/6 systolic, blowing murmurs often heard in children

 Innocent systolic murmurs may also be heard during pregnancy

ABNORMAL FINDINGS:

o Apex

 Bradycardia rates <60bpm or tachycardia rates >100bpm

  Irregular rhythm (arrythmia)

 Accentuated S1 (high-output states, mitral or tricuspid stenosis)

 Diminished S1 (first-degree heart block, CHF, CAD)

 Variable S1 (atrial fibrillation)

 S3, low-pitched, early diastolic sound (CHF)

 S4, low-pitched, late-diastolic sound (CAD, HTN, MI)

 Quadruple rhythm, S3 + S4 with fast rate is called a summation gallop

o LLSB (tricuspid)

 Wide split (RBBB)

 Mid-systolic ejection click, a high-pitched systolic sound (MVP)

 Opening snap, a high-pitched diastolic sound (mitral or tricuspid stenosis, VSD,

PDA)

 Pericardial friction rub, a high-pitched systolic and diastolic sound (pericarditis or

postoperative cardiac surgery)

o Erb’s point

 Aortic murmurs

o Base

 Diminished S2 (incompetent aortic or pulmonic valves and low-output states)

 Ejection click, a high-pitched systolic sound (aortic or pulmonic stenosis)

 Accentuated S2 (associated with HTN or pulmonary HTN)

 Wide split S2 (occurs with RBBB, pulmonic stenosis, ASD, VSD)

 Fixed split S2, a split with no respiratory variation (ASD, VSD, CHF)
  Paradoxical split S2, occurs during expiration (left bundle branch block or aortic

stenosis)

o Murmurs

 Systolic and diastolic murmurs