Physical Exam: Heart Sounds and & Murmurs

Peripheral edema Jugular venous distension (see JVP below) Pulmonary crackles (suspect CHF) Cardiac S3 Positive hepatojugular reflux

Pitting edema: click for larger image

Associated signs:

• Water hammer pulse
  Due to the large stroke volume and "aortic runoff" of blood from the aorta back into the left ventricle, there is a sudden rise and abrupt collapse of peripheral arterial pulse. The term water - hammer pulse comes from the similar sensation of a water- hammer, a Victorian toy.

  To detect this, the radial pulse of a supine patient with arm at side is firmly palpated with slight pressure until the pulse is obscured. The arm is then raised over the patient's head, with the arm perpendicular to the supine patient.

• Increased pulse pressure
  Refers to the difference between the systolic pressure and the diastolic pressure. Normal is defined as 50-60. A pulse pressure greater than 80 mmHg has a likelihood ratio of 10.9 A pulse pressure less than 60 has a LR of 0.2.

• Pistol shot femoral pulse
  Refers to short, loud, snapping sounds with each pulse with auscultation over the femoral, brachial, or radial pulse.

• Peripheral pulsation
  Quincke's: pulsating capillary refill in slightly compressed fingernail bed
  deMusset's sign: bobbing of head with each heart beat
  Lighthouse sign: fluctuating forehead flushing

Algorithm for probability of moderate to severe aortic stenosis in the presence of a typical murmur.

Jugular Venous Pressure (JVP)

• When elevated, suspect right-sided heart failure.
• If high JVP, also examine jugular waveforms further for constrictive pericarditis and check pulsus paradox.

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