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General examination of a pt with suspected heart disease should include vital signs (respiratory rate, pulse, blood pressure) and observation of skin color (e.g., cyanosis, pallor, jaundice), clubbing, edema, evidence of decreased perfusion (cool and diaphoretic skin), and hypertensive changes in optic fundi. Examine abdomen for evidence of hepatomegaly, ascites, or abdominal aortic aneurysm. An ankle-brachial index (systolic bp at ankle divided by arm systolic bp) <0.9 indicates lower extremity arterial obstructive disease. Important findings on cardiovascular examination include:


  • Pulsus parvus: Weak upstroke due to decreased stroke volume (hypovolemia, LV failure, aortic or mitral stenosis [MS]) (Fig. 110-1)

  • Pulsus tardus: Delayed upstroke (aortic stenosis)

  • Bounding (hyperkinetic) pulse: Hyperkinetic circulation, aortic regurgitation, patent ductus arteriosus, marked vasodilation

  • Pulsus bisferiens: Double systolic pulsation (aortic regurgitation, hypertrophic cardiomyopathy)

  • Pulsus alternans: Regular alteration in pulse pressure amplitude (severe LV dysfunction)

  • Pulsus paradoxus: Exaggerated inspiratory fall (>10 mmHg) in systolic bp (pericardial tamponade, severe obstructive lung disease)

FIGURE 110-1

Carotid artery pulse patterns.


Jugular venous distention develops in right-sided heart failure, constrictive pericarditis, pericardial tamponade, obstruction of superior vena cava. JVP normally falls with inspiration but may rise (Kussmaul sign) in constrictive pericarditis. Abnormalities in examination include:

  • Large “a” wave: Tricuspid stenosis (TS), pulmonic stenosis (PS), atrioventricular (AV) dissociation (right atrium contracts against closed tricuspid valve)

  • Large “v” wave: Tricuspid regurgitation, atrial septal defect

  • Steep “y” descent: Constrictive pericarditis

  • Slow “y” descent: TS


Cardiac apical impulse is normally localized at the fifth intercostal space, midclavicular line. Abnormalities include:

  • Forceful apical thrust: Left ventricular hypertrophy

  • Lateral and downward displacement of apex impulse: Left ventricular dilatation

  • Prominent presystolic impulse: Hypertension, aortic stenosis, hypertrophic cardiomyopathy

  • Double systolic apical impulse: Hypertrophic cardiomyopathy

  • Sustained “lift” at lower left sternal border: Right ventricular hypertrophy

  • Dyskinetic (outward bulge) impulse: Ventricular aneurysm, large dyskinetic area post MI, cardiomyopathy




Loud: Mitral stenosis (MS), short PR interval, hyperkinetic heart, thin chest wall (Fig. 110-2). Soft: Long PR interval, heart failure, mitral regurgitation, thick chest wall, pulmonary emphysema.

FIGURE 110-2

Heart sounds. A. Normal. S1, first heart sound; S2, second heart sound; A2, aortic component of the second heart sound; P2, pulmonic component of the second heart sound. B. Atrial septal defect with fixed splitting of S2. C. Physiologic but wide splitting of S2 with right bundle branch block. D. Reversed or paradoxical splitting of S2 with left bundle branch block. E. Narrow splitting of S2 with pulmonary hypertension. (From NO Fowler: Diagnosis ...

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