Mosby's Guide to Physical Examination, 7th Edition

CHAPTER 10. Heart


image Tangential light source

image Skin-marking pencil

image Stethoscope with bell and diaphragm

image Centimeter ruler





Inspect precordium

Have patient supine, and keep light source tangential.
imageApical impulse

EXPECTED:Visible about midclavicular line in fifth left intercostal space. Sometimes visible only with patient sitting.

UNEXPECTED:Visible in more than one intercostal space; exaggerated lifts or heaves.

Palpate precordium

image Apical impulse

Have patient supine. With warm hands, gently feel precordium, using proximal halves of fingers held together or whole hand. As shown in figure on p. 114, methodically move from apex to left sternal border, base, right sternal border, epigastrium, axillae.

Locate sensation in terms of its intercostal space and relationship to midsternal, midclavicular, axillary lines.

EXPECTED:Gentle, brief impulse, palpable within radius of 1 cm or less, although often not felt.

UNEXPECTED:Heave or lift, loss of thrust, displacement to right or left; thrill.


Percuss precordium (optional)

Begin by tapping at anterior axillary line, moving medially along intercostal spaces toward sternal borders until tone changes from resonance to dullness. Mark skin with marking pen.

EXPECTED:No change in tone before right sternal border; on left, loss of resonance generally close to point of maximal impulse at fifth intercostal space. Loss of resonance may outline left border of heart at second to fifth intercostal spaces.

Auscultate heart

Make certain patient is warm and relaxed. Isolate each sound and each pause in cycle, and then inch along with stethoscope. Approach each of the five precordial areas shown in figure on p. 115 systematically, base to apex or apex to base, using each position shown in figures at right and below. Use diaphragm of stethoscope first, with firm pressure, then bell, with light pressure.






image Rate and rhythm

Assess overall rate and rhythm.

EXPECTED:Rate 60 to 90 beats per minute, regular rhythm.

UNEXPECTED:Bradycardia, tachycardia, dysrhythmia.

image S1

Ask patient to breathe comfortably, then hold breath in expiration.

Listen for S1 (best heard toward apex) while palpating carotid pulse. Note intensity, variations, effect of respiration, splitting. Concentrate on systole, then diastole.

EXPECTED:S1 usually heard as one sound and coincides with rise of carotid pulse. See table on p. 116.

UNEXPECTED:Extra sounds or murmurs.

image S2

Ask patient to breathe comfortably as you listen for S2 (best heard in aortic and pulmonic areas) to become two components during inspiration. Ask patient to inhale and hold breath.

EXPECTED:S2 to become two components during inspiration. S2 to become an apparent single sound as breath is exhaled. See table on p. 116.


EXPECTED:S2 splitting—greatest at peak of inspiration—varying from easily heard to nondetectable.

image S3 and S4

If needed, ask patient to raise a leg to increase venous return or to grip your hand vigorously and repeatedly to increase venous return.

EXPECTED:Both S3 and S4 quiet and difficult to hear. S3 has rhythm of Ken-tuc-ky; S4, Tenn-es-see.

UNEXPECTED:Increased intensity (and ease of hearing) of either.

imageExtra heart sounds

UNEXPECTED:Extra heart sounds—snaps, clicks, friction rubs, murmurs. See table on p. 117.

Assess characteristics of murmurs

Timing and duration, pitch, intensity, pattern, quality, location, radiation, respiratory phase variations


Heart Sounds According to Auscultatory Area


Extra Heart Sounds




Increased S3

Bell at apex; patient left lateral recumbent

Early diastole, low pitch

Increased S4

Bell at apex; patient supine or semilateral

Late diastole or early systole, low pitch


Bell at apex; patient supine or left lateral recumbent

Presystole, intense, easily heard

Mitral valve opening snap

Diaphragm medial to apex, may radiate to base; any position, second left intercostal

Early diastole briefly, before S3; high pitch, sharp snap or click; not affected by respiration; easily confused with S2

Ejection clicks

Diaphragm; patient sitting or supine


Aortic valve

Diaphragm, right second intercostal space

Early systole, intense, high pitch; radiates, not affected by respirations

Pulmonary valve

Diaphragm; left second intercostal right space

Early systole, less intense than aortic click; intensifies on expiration, decreases on inspiration

Pericardial friction rub

Diaphragm, widely heard, sound clearest toward apex

May occupy all of systole and diastole; intense, grating, machine-like; may have three components and obliterate heart sounds; if only one or two components, may sound like murmur




Left ventricular hypertrophy

Subjective Data:Initially asymptomatic, may cause shortness of breath or chest pain.

Objective Data:Vigorous sustained lift palpable during ventricular systole, sometimes over broader area than usual (by 2 cm or more). Displacement of apical impulse can be well lateral of midclavicular line and downward.

Right ventricular hypertrophy

Subjective Data:Fatigue, shortness of breath, syncope may indicte more severe disease.

Objective Data:Lift along left sternal border in third and fourth left intercostal spaces accompanied by occasional systolic retraction at apex. Left ventricle displaced and turned posteriorly by enlarged right ventricle.

Congestive heart failureMay be left or right sided: Left sided is either systolic or diastolic

Subjective Data:Fatigue, orthopnea, shortness of breath, edema.

Objective Data:Congestion in pulmonary or systemic circulation. Can develop gradually or suddenly with acute pulmonary or systemic edema.

Cor pulmonale

Subjective Data:Tachypnea, fatigue, exertional dyspnea, cough hemoptysis.

Objective Data:Left parasternal systolic lift and loud S2 in pulmonic region, evidence of pulmonary disease.

Myocardial infarction

Subjective Data:Deep substernal or visceral pain, often radiating to jaw, neck, left arm (although discomfort is sometimes mild); women may experience milder and different symptoms.

Objective Data:Dysrhythmias; S4 often present. Heart sounds distant, with soft, systolic, blowing murmur; pulse possibly thready; varied blood pressure (although hypertension usual in early phases).


Subjective Data:Initially symptoms vague; fatigue, dyspnea, fever, palpitations. Symptoms may progress.

Objective Data:Cardiac enlargement, murmur, gallop rhythms, tachycardia, dysrhythmias, pulsus alternans.

Conduction disturbances

Subjective Data:Transient weakness, syncope, strokelike episodes, palpitations.

Objective Data:Labile heart rates.

Atherosclerotic heart disease

Subjective Data:Maybe be asymptomatic or cause angina pectoris, shortness of breath, and palpitations.

Objective Data:May cause myocardial insufficiency, dysrhythmias, congestive heart failure.


Subjective Data:Substernal pain or intense pressure radiating at times to neck, jaws, arms, particularly left arm, often accompanied by shortness of breath, fatigue, diaphoresis, faintness, syncope. Cessation of activity may relieve pain.


Objective Data:No pathognomonic exam findings, tachycardia, hypertension, diaphoresis, decresed S1 intensity, S4.

Chest Pain

Type of Chest Pain



Substernal; provoked by effort, emotion, eating; relieved by rest and/or nitroglycerin


Precipitated by breathing or coughing; usually described as sharp


Burning, substernal, occasional radiation to shoulder; nocturnal occurrence, usually when lying flat; relief with food, antacids, sometimes nitroglycerin

From a peptic ulcer

Almost always infradiaphragmatic and epigastric; nocturnal occurrence and daytime attacks; should not be relieved by food; unrelated to activity


Usually under right scapula, prolonged in duration; will trigger angina more often than mimic it

From arthritis/bursitis

Usually of hours-long duration; local tenderness and/or pain with movement


Associated with injury; provoked by activity, persists after activity; painful on palpation and/or movement

Musculoskeletal (chest)

Intensified or provoked by movement, particularly twisting or costochondral bending; long lasting; often associated with local tenderness


Associated with or occurring after anxiety; poorly described, located in intramammary region

Data from Samiy et al, 1987; Harvey et al, 1988.

Pediatric Variations




Assess characteristics of murmurs

Timing and duration, intensity, pattern, quality, location, radiation, respiratory phase variations.

In children it is necessary to distinguish innocent murmurs from organic murmurs caused by congenital defect or rheumatic fever.




Chest pain

Subjective Data:Unlike in adults, chest pain in children and adolescents is seldom caused by a cardiac problem. It is very often difficult to find a cause, but trauma, exercise-induced asthma and use of cocaine, even in a somewhat younger child, as in the adolescent and adult, should be among the considerations.

Objective Data:Exam usually normal.

Congenital defects

Tetralogy of Fallot

Subjective Data:Dyspnea with feeding, poor growth, exercise intolerance, tetralogy spells.

Objective Data:Parasternal heave and precordial prominence, cyanosis, systolic ejection murmur heard over third intercostal space, sometimes radiating to left side of neck. Single S2.

Ventricular septal defect

Subjective Data:Tachypnea, symptoms of right-sided congestive heart failure, poor growth, recurrent respiratory infections.

Objective Data:Arterial pulse small, jugular venous pulse unaffected, regurgitation occurs through septal defect, resulting in holosystolic murmur that is frequently loud, coarse, high-pitched, best heard along left sternal border in third to fifth intercostal spaces. Distinct lift often discernible along left sternal border and apical area. Does not radiate to neck.

Patent ductus arteriosus (PDA)

Subjective Data:Asymptomic if small, larger PDAs cause dyspnea on exertion.

Objective Data:Neck vessels dilated and pulsate, and pulse pressure wide. Harsh, loud, continuous murmur with machine-like quality, heard at first to third intercostal spaces and lower sternal border. Murmur usually unaltered by postural change.

Atrial septal defect

Subjective Data:Often asymptomatic, congestive heart failure in adults.

Objective Data:Systolic ejection murmur, best heard over pulmonic area that is diamond-shaped, often loud, high in pitch, and harsh. May be accompanied by brief, rumbling, early diastolic murmur. Does not usually radiate beyond precordium. Systolic thrill may be felt over area of murmur along with palpable parasternal


thrust. S2 may be split fairly widely. Particularly significant with palpable thrust and occasional radiation through to back.


Heart. No visible pulsations over precordium. Point of maximal impulse (PMI) palpable at the fifth intercostals (ICS) in the midclavicular line (MCL), 1 cm in diameter. No lifts, heaves, or thrills felt on palpation. S1 is crisp. Split S2 increases with inspiration. No audible S3, S4, murmur, click, or rub.