Cardiovascular system examination

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Here is a comprehensive guide to the Cardiovascular System Examination, synthesized from Harrison's and Goldman-Cecil Medicine.

Cardiovascular System Examination

1. General Approach & Vital Signs

Before the focused cardiac exam, note:

Pulse rate and rhythm — tachycardia, bradycardia, or irregularity
Blood pressure (both arms) — a discrepancy suggests aortic dissection or atherosclerotic disease of the great vessels; if coarctation is suspected, measure in a leg as well
Pulsus paradoxus — >10 mmHg drop in systolic BP on inspiration is typical of pericardial tamponade
Respiratory rate — tachypnoea and laboured breathing suggest pulmonary oedema; Cheyne-Stokes respirations indicate advanced heart failure

General appearance may reveal clues: Marfan syndrome, Turner syndrome, Down syndrome, or systemic conditions like hyperthyroidism (exophthalmos), myotonic dystrophy (ptosis, AV block), or scleroderma.

2. Ophthalmologic Examination

Finding	Association
Diabetic/hypertensive retinopathy	Diabetes, hypertension
Roth spots	Infective endocarditis
Retinal artery beading	Severe hypercholesterolaemia
Blue sclerae	Osteogenesis imperfecta → aortic dilation, MVP
Retinal artery occlusion	Left atrial thrombus, myxoma, atherosclerotic emboli
Exophthalmos	Hyperthyroidism

3. Jugular Venous Pressure (JVP) & Waveform

The JVP is the single most important bedside measurement for estimating volume status. The internal jugular vein is preferred (the external jugular is valved and not directly in line with the SVC/RA). Venous pulsations above the clavicle in the sitting position are clearly abnormal (the clavicle-to-RA distance is ≥10 cm).

A distance >4.5 cm above the sternal angle (angle of Louis) at 30° elevation is considered elevated. Note: bedside estimates are in cmH₂O; convert to mmHg by dividing by 1.36.

JVP Waveform Components

Component	Mechanism	Clinical pearl
a wave	Right atrial presystolic contraction (after P wave, before S1)	Absent in AF; cannon a wave = AV dissociation (VT vs SVT discriminator)
c wave	Tricuspid valve pushed into RA during early systole	Small, often not visible
x descent	Fall in RA pressure after tricuspid opens	Prominent in tamponade
v wave	Atrial filling during ventricular systole	Accentuated in tricuspid regurgitation
y descent	Tricuspid opens → ventricular filling	Rapid y descent in constrictive pericarditis; absent/blunted in tamponade

Distinguishing venous from arterial pulsation: The venous waveform is usually biphasic (vs monophasic carotid), changes with posture and inspiration, and is obliterable with gentle pressure.

4. Arterial Pulse

Assess the carotid pulse for volume, contour, and timing:

Pulse character	Significance
Pulsus bisferiens (double peak in systole)	Severe AR ± AS, HOCM
Pulsus alternans	Severe LV dysfunction
Pulsus paradoxus (>10 mmHg inspiratory drop)	Cardiac tamponade, severe asthma
Small, slow-rising (parvus et tardus)	Aortic stenosis
Bounding, collapsing	Aortic regurgitation, hyperdynamic states
Pulsus bigeminus	Bigeminal ectopy

5. Precordial Inspection & Palpation

Apex beat (Point of Maximal Impulse, PMI): Normally in the 5th intercostal space, mid-clavicular line. A laterally displaced impulse indicates LV dilatation; a sustained impulse suggests LV hypertrophy.
Right ventricular heave/lift at the lower left sternal border suggests RV enlargement (e.g., pulmonary hypertension, RV failure).
Thrills are palpable murmurs (grade ≥4/6) — felt over aortic/pulmonary areas or at the apex.
A loud P2 that can be palpated at the 2nd left interspace suggests pulmonary hypertension.

6. Auscultation

Auscultatory Areas

Aortic area — 2nd right intercostal space
Pulmonary area — 2nd left intercostal space
Tricuspid area — lower left sternal border
Mitral area (apex) — 5th ICS, mid-clavicular line

First Heart Sound (S1)

Caused by mitral (M1) and tricuspid (T1) valve closure
Loud S1 → MS with pliable leaflets, hyperdynamic states
Soft S1 → Long PR interval, severe MS with calcified leaflets, LV dysfunction
Variable S1 → AF, complete heart block (cannon beat)

Second Heart Sound (S2)

A2 (aortic closure) precedes P2 (pulmonary closure)
Physiologic splitting: widens on inspiration (increased RV filling delays P2); narrows on expiration

S2 Pattern	Cause
Fixed splitting	Atrial septal defect (ASD)
Wide splitting	RBBB, pulmonary stenosis
Reversed/paradoxical splitting	LBBB, RV pacing, severe AS, HOCM, acute ischaemia (components audible on expiration, narrow on inspiration)
Narrow/single S2	Pulmonary hypertension (loud P2 ≥ A2)
Absent P2	Severe pulmonary stenosis

Heart sound patterns showing normal splitting, ASD fixed splitting, RBBB wide splitting, reversed splitting in LBBB/AS, and narrow fixed splitting in pulmonary hypertension

Added Sounds

Systolic:

Ejection click (early systolic, high-pitched) → bicuspid aortic or pulmonary valve; pulmonic ejection sound is the only right-sided event that decreases with inspiration
Non-ejection click (mid-systolic click) → MVP; click-murmur complex moves away from S1 on squatting (increased preload) and toward S1 on standing

Diastolic:

Sound	Timing	Cause	Key feature
Opening snap (OS)	Early diastole, after S2	Mitral stenosis	A2-OS interval inversely proportional to severity (shorter = higher LAP)
S3 (ventricular gallop)	Early diastole	Elevated LVEDP, severe LV dysfunction	Low-pitched, at apex; normal in young adults; correlated with poor prognosis
S4 (atrial gallop)	Late diastole (presystolic)	Reduced LV compliance (HTN, ischaemia)	Low-pitched; indicates diastolic dysfunction; absent in AF
Pericardial knock	Early diastole, after OS	Constrictive pericarditis	High-pitched; exaggerated y descent in JVP
Tumour plop	Diastolic	Atrial myxoma	Positional

Heart Murmurs

Systolic murmurs:

Murmur	Character	Best heard	Radiation	Dynamic clues
Aortic stenosis (AS)	Harsh, crescendo-decrescendo	2nd RSB	Neck (carotids)	Louder with squatting; softer with Valsalva
HOCM	Crescendo-decrescendo	LLSB	—	Louder with Valsalva/standing; softer with squatting
Mitral regurgitation (MR)	Holosystolic, blowing	Apex	Axilla/back	—
Tricuspid regurgitation (TR)	Holosystolic	LLSB	—	Increases with inspiration (Carvallo's sign)
MVP	Late systolic ± click	Apex	—	Click moves to S1 on standing
VSD	Holosystolic, harsh	LLSB	—	—
Pulmonary stenosis	Ejection systolic	2nd LSB	—	Ejection click that softens on inspiration

Diastolic murmurs (always pathological):

Murmur	Character	Best heard	Radiation	Dynamic clues
Aortic regurgitation (AR)	Early diastolic, blowing, decrescendo	3rd LSB (leaning forward, expiration)	—	Austin Flint murmur at apex
Mitral stenosis (MS)	Mid-diastolic, low-pitched rumble	Apex (bell)	—	Louder with left lateral decubitus + exercise
Tricuspid stenosis (TS)	Mid-diastolic	LLSB	—	Increases with inspiration
Pulmonary regurgitation	Early diastolic	2nd/3rd LSB	—	Graham Steell murmur in PAH

Dynamic auscultation manoeuvres:

Manoeuvre	Effect	Useful for
Valsalva (strain phase)	↓ preload	HOCM louder; MVP click earlier; others softer
Squatting	↑ preload + afterload	HOCM softer; MVP click later
Standing	↓ preload	HOCM louder; MVP click earlier
Inspiration	↑ RV filling	Right-sided murmurs louder (TR, TS, PS)
Leg raising	↑ preload	Similar to squatting
Amyl nitrite	↓ afterload	AS louder; AR softer
Handgrip	↑ afterload	MR, AR, VSD louder; HOCM softer

7. Peripheral Examination

Abdomen

Hepatomegaly — right heart failure; an enlarged pulsatile liver = severe tricuspid regurgitation / markedly elevated right heart pressure
Ascites — advanced right heart failure
Abdominal aorta pulsation — screen for AAA in appropriate patients

Extremities

Pitting oedema — dependent; graded 0–3+; from elevated right-sided filling pressures → increased hydrostatic pressure → transudation; must exclude other causes (calcium channel blockers, venous insufficiency, hypoproteinaemia)
Cool extremities → low cardiac output or peripheral arterial disease
Clubbing → cyanotic congenital heart disease, infective endocarditis
Peripheral cyanosis → low cardiac output; central cyanosis (tongue) → right-to-left shunt, respiratory failure
Splinter haemorrhages, Osler nodes, Janeway lesions → infective endocarditis
Xanthelasma, corneal arcus → hyperlipidaemia

Summary: Structured Examination Sequence

General appearance (dyspnoea, cyanosis, pallor, syndromic features)
Vital signs (HR, BP both arms, RR, SpO₂)
Hands (clubbing, cyanosis, splinters, peripheral pulses)
Face/eyes (retinal changes, malar flush of MS, xanthelasma)
Neck (JVP waveform and height, carotid pulse character)
Precordium — inspect, palpate (apex, heaves, thrills), auscultate (S1, S2, added sounds, murmurs) with dynamic manoeuvres
Lung bases (bibasal crepitations → pulmonary oedema; pleural effusion → heart failure)
Abdomen (hepatomegaly, ascites, aortic pulsation)
Legs (oedema, temperature, peripheral pulses)
Completion: request BP lying/standing, 12-lead ECG, CXR, bedside echo

Sources: Harrison's Principles of Internal Medicine 22E (2025), p. 1904–1908; Goldman-Cecil Medicine, International Edition, p. 391

14 area where auscultation is proceed with idenfication of murmur

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cardiac auscultation areas precordium murmur locations diagram

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Here is a comprehensive breakdown of the 14 areas of cardiac auscultation and the murmurs identified at each.

14 Areas of Cardiac Auscultation & Murmur Identification

The 14 Auscultatory Areas

Cardiac auscultation extends well beyond the classic 4 valve areas. The complete examination covers 14 zones across the precordium and beyond.

Zone Map (Anterior Chest)

Murmur locations and radiation directions on the precordium — Aortic (right upper sternal border → neck), Pulmonary (left upper sternal border), VSD (left lower sternal border), Vibratory/Still's (LLSB), MR (apex → axilla), HCM (LLSB → right)

The 14 Areas: Location, Anatomy & Murmurs

#	Area	Location	Valve/Structure	Key Murmurs Heard
1	Aortic area	2nd right intercostal space (ICS), right sternal border	Aortic valve	AS (harsh ejection systolic, radiates to carotids); bicuspid aortic valve ejection click
2	Pulmonary area	2nd left ICS, left sternal border	Pulmonary valve	PS (ejection systolic, click that softens on inspiration); PR (Graham Steell murmur — early diastolic in PAH)
3	Erb's point	3rd left ICS, left sternal border	Aortic + pulmonary	AR best heard here (early diastolic, blowing, decrescendo — lean forward, hold expiration); also AS radiation
4	Tricuspid area	4th–5th left ICS, lower left sternal border (LLSB)	Tricuspid valve	TR (holosystolic, increases with inspiration — Carvallo's sign); TS (mid-diastolic, increases with inspiration); VSD
5	Mitral area (Apex)	5th left ICS, mid-clavicular line	Mitral valve	MR (holosystolic, blowing, radiates to axilla); MS (mid-diastolic rumble, low-pitched, best with bell in left lateral decubitus); S3, S4 gallops; MVP click
6	Left axilla	Mid-axillary line	—	Radiation of MR (posterior/anterior leaflet MR); differentiates MR from AS
7	Left infraclavicular area	Below left clavicle	Pulmonary artery	PDA murmur (continuous, machinery); radiation of PS
8	Right infraclavicular / right 1st ICS	Below right clavicle	Aorta	Aortic ejection click radiation; systemic arteriovenous fistula
9	Left sternal border (mid)	3rd–4th left ICS	RVOT/LVOT	HOCM (crescendo-decrescendo, radiates to LLSB and apex, not to neck); differentiates from AS by manoeuvres
10	Right sternal border	Right 3rd–4th ICS	—	Dextrocardia murmurs; right-sided AS in dextrocardia; some aortic murmurs
11	Carotid arteries (neck)	Over carotid bifurcation	—	Radiation of AS; carotid bruits (arterial, systolic); distinguish from Gallavardin phenomenon (AS murmur at apex mimicking MR)
12	Back (interscapular)	Between scapulae, left > right	Aorta, coarctation	Coarctation of aorta (continuous murmur); PDA; collateral vessel bruits in coarctation
13	Epigastrium / xiphoid	Subxiphoid / epigastric	Tricuspid, RV	Tricuspid murmurs (TR/TS) in some patients; RVOT murmurs; aortic stenosis radiation in obese patients
14	Right 2nd ICS (sternal angle)	Upper right sternal border	Aortic root	Aortic stenosis (again, classical area); aortic sclerosis; aortic aneurysm flow murmur

Many exam frameworks list 5 primary areas + accessory areas. The full 14-area system ensures no murmur is missed, particularly those with unusual radiation or right-sided pathology.

Murmur Timing Reference

Principal heart murmur patterns: A=presystolic (MS/TS), B=holosystolic (MR/TR/VSD), C=aortic ejection (with click), D=pulmonary ejection (with split S2), E=early diastolic (AR/PR), F=mid-diastolic with opening snap (MS), G=mid-diastolic with S3, H=continuous

Murmur Identification by Timing

Systolic Murmurs

Murmur	Timing	Quality	Location	Radiation	Manoeuvre
Aortic Stenosis (AS)	Mid-systolic (ejection)	Harsh, crescendo-decrescendo	2nd RSB (Area 1)	Carotids (Area 11)	Louder squatting; softer Valsalva
Pulmonary Stenosis (PS)	Mid-systolic (ejection)	Soft-harsh	2nd LSB (Area 2)	Left shoulder	Ejection click softens on inspiration
HOCM	Mid-systolic	Harsh	LLSB/apex (Area 9)	Apex, not carotids	Louder Valsalva/standing; softer squatting — key differentiator from AS
Mitral Regurgitation (MR)	Holosystolic	Blowing	Apex (Area 5)	Left axilla (Area 6)	—
Tricuspid Regurgitation (TR)	Holosystolic	Blowing	LLSB (Area 4)	—	Louder on inspiration (Carvallo's sign)
VSD	Holosystolic	Harsh	LLSB (Area 4)	—	—
MVP	Late systolic ± click	High-pitched	Apex (Area 5)	—	Click moves toward S1 on standing
Innocent/Still's murmur	Mid-systolic, vibratory	Musical, "twanging"	LLSB (Area 4)	—	Softer sitting/standing; no thrill
ASD	Mid-systolic	Soft	2nd LSB (Area 2)	—	Fixed split S2 is the hallmark

Diastolic Murmurs (always pathological)

Murmur	Timing	Quality	Location	Radiation	Special Technique
Aortic Regurgitation (AR)	Early diastolic	Blowing, decrescendo	3rd LSB / Erb's (Area 3)	—	Lean forward + hold expiration; Austin Flint murmur at apex
Pulmonary Regurgitation (PR)	Early diastolic	Blowing	2nd LSB (Area 2)	—	Graham Steell murmur = PR in pulmonary hypertension
Mitral Stenosis (MS)	Mid-late diastolic (± presystolic accentuation)	Low-pitched rumble	Apex (Area 5)	—	Bell of stethoscope; left lateral decubitus; exercise
Tricuspid Stenosis (TS)	Mid-diastolic	Low-pitched	LLSB (Area 4)	—	Louder on inspiration; opening snap

Continuous Murmurs

Murmur	Location	Key Feature
PDA	Left infraclavicular / 2nd LSB (Area 7)	Machinery murmur, peaks at S2
Coarctation of aorta	Back/interscapular (Area 12)	Also systolic murmur anteriorly; delayed femoral pulse
AV fistula / venous hum	Variable	Obliterated by compression

Dynamic Manoeuvres Summary

Manoeuvre	Preload	Afterload	Murmurs that increase
Valsalva (strain)	↓↓	↓	HOCM, MVP (click earlier)
Squatting	↑↑	↑	AS, MR, TR, VSD; HOCM softer, MVP click later
Standing	↓	—	HOCM, MVP
Inspiration	↑ RV	—	TR, TS, PS, PR (all right-sided)
Handgrip	—	↑↑	MR, AR, VSD; HOCM softer
Amyl nitrite	↑	↓↓	AS, HOCM, TR, PS

Grading of Murmur Intensity (Levine Scale)

Grade	Description
1/6	Barely audible, requires concentration
2/6	Soft but readily heard
3/6	Moderately loud, no thrill
4/6	Loud + palpable thrill
5/6	Very loud, heard with stethoscope partially off chest
6/6	Heard without stethoscope

Thrills are present at grade ≥ 4/6 and represent palpable turbulence.

Sources: Harrison's Principles of Internal Medicine 22E (2025), p. 1904–1912; Harrison's 21E, p. 1165–1168

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