An arrhythmia is an abnormal heart sound usually detected using a sphygmomanometer
SummaryHistory and general examinationHistory [1]
General examination [1]Appearance
Skin and mucous membranes
Hands
Face
NeckOther
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Blood pressure
24-hour ambulatory blood pressure measurement can be helpful in establishing the average and peak blood pressure values during daily activities. Interpretation
Jugular venous pressureJugular venous pressure (JVP) can be used to estimate central venous pressure (CVP) and provides information about fluid status and cardiac function. Approach [1]Interpretation [1]Height
CharacterA normal JVP waveform consists of three waves (a, c, v) and two descents (x, y).
PulsesA pulse wave is produced by ventricular contraction during systole. Approach [1]
The thumb of the examiner should never be used to take the pulse because its own strong pulse might be mistaken for the patient's pulse. Palpation [1]The pulse should be assessed for rate, rhythm, character, volume, the speed of upstroke, and delay.
Auscultation [1]Chest inspectionCardiac palpationApex beat [1]The apex beat (apex impulse) is the outermost and lowermost palpable cardiac impulse on the chest wall. Palpation of the apex beat [1]
Chest percussionAlthough cardiac percussion can provide some information about the size and shape of the heart, it is very unreliable and dependent on the examiner and is thus of limited clinical use. Cardiac auscultationApproach [1]
Auscultatory locations [1]"All Physicians Earn Too Much" (Aortic, Pulmonary, Erb point, Tricuspid, Mitral) Heart soundsNormal heart sounds [1]Extra heart sounds [1]
Gallops that originate from the left side of the heart (the most common) become softer with inspiration, while those that originate from the right side become louder. Changes in intensity [9]Increased or decreased intensity (loudness) of the heart sounds may indicate certain pathologies. S1 intensity
S2 intensity
Splitting of heart sounds [1]If the aortic and pulmonary valves do not close simultaneously, an apparent splitting of S2 can be heard upon auscultation.
Additional sounds [1]The presence of an aortic ejection click can be used to differentiate a pathological systolic murmur of aortic stenosis from a flow murmur. When the click is present, the murmur is pathological. The absence of a click in patients with prosthetic valves may indicate valve failure. Heart murmursOverview [1]
Functional and pathological murmursMurmurs may be functional or pathological. Location and radiation [1]
Timing [1]
Diastolic murmurs are almost always pathological. Diastolic murmurs may require certain maneuvers to make them more apparent, e.g., letting the patient sit and lean forward to intensify the murmur of aortic regurgitation. Intensity [1]The intensity refers to the loudness of the murmur on auscultation (grades I–VI). While most grade III and above murmurs are pathological, the intensity of a murmur does not always correlate to the severity of the underlying lesion. For example, a larger VSD produces a softer murmur than a small VSD, and a murmur of severe aortic stenosis may disappear if a patient develops left heart failure. All diastolic murmurs and any grade II and above systolic murmurs require further echocardiographic evaluation. Configuration [1]The configuration describes the change in intensity (loudness) of a murmur, which is determined by the pressure gradient driving the turbulent flow.
The frequency of a murmur is determined by the velocity of turbulent flow, which is in turn affected by the pressure gradient. Maneuvers [1]Certain maneuvers may be performed to elicit a change in the intensity of a murmur.
Exceptions to maneuversIn the following conditions, maneuvers that increase preload decrease the intensity of the murmurand vice versa.
Maneuvers that decrease LV preload (e.g., inspiration, Valsalva maneuver) usually decrease the intensity of murmurs arising from the left side of the heart, except in HOCM and MVP, in which a decrease in LV preload increases the intensity of the murmur. Audio clip examples of murmursDiagnosticsImaging [13]Chest x-ray (heart)The heart shadow can be viewed on a chest x-ray. Echocardiography
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