A Practical Guide to Clinical

Medicine
A comprehensive physical examination and clinical education site for medical
students and other health care professionals

Web Site Design by Jan Thompson, Program Representative, UCSD School of

Medicine; Content and Photographs by Charlie Goldberg, M.D., UCSD School of
Medicine and VA Medical Center, San Diego, California 92093-0611.

Introduction Exam of the Abdomen Write Ups

History of Present Male Genital/Rectal
Illness Exam
The Rest of the History The Upper Extremities
Vital Signs The Lower Extremities
The Eye Exam Musculo-Skeletal Exam
Head and Neck Exam The Mental Status Exam
The Lung Exam The Neurological Exam
Exam of the Heart Putting It All Together
Send Comments to: Charlie Goldberg,
  Medical Links
The Oral Presentation
Outpatient Clinics
Inpatient Medicine
Clinical Decision Making
Commonly Used Abbreviations
A Few Thoughts
References
M.D.

The "daVinci Anatomy Icon" denotes a link to related gross anatomy

pictures.

Exam of the Heart

The major elements of the cardiac exam include observation, palpation and, most
importantly, auscultation (percussion is omitted). As with all other areas of the
physical exam, establishing adequate exposure and a quiet environment are critical.
Initially, the patient should rest supine with the upper body elevated 30 to 45 degrees.
Most exam tables have an adjustable top. If not, use 2 or 3 pillows. Remember that
although assessment of pulse and blood pressure are discussed in the vital signs
section they are actually important elements of the cardiac exam.

Observation: Assessment for distention of the right Internal Jugular vein (IJ) is a
difficult skill. Its importance lies in the fact that the IJ is in straight-line
communication with the right atrium. The IJ can therefore function as a manometer,
with distention indicating elevation of Central Venous Pressure (CVP). This in turn is
an important marker of intravascular volume status and related cardiac function. The
focus here is on simply determining whether or not Jugular Venous Distention (JVD)
is present. A discussion of the a, c and v waves that make up the jugular venous
pulsations can be found elsewhere. These are quite difficult to detect for even the
most seasoned physician.
Why is JVD so hard to assess? The IJ lies deep to skin and soft tissues, which can
provide quite a bit of cover. Additionally, this blood vessel is under much lower
pressure then the adjacent, pulsating carotid artery. It therefore takes a sharp eye to
identify the relatively weak, transmitted venous impulses. A few things to remember:

1. Think anatomically. The right IJ runs between the two heads (sternal and
clavicular) of the sternocleidomastoid muscle (SCM) and up in front of the
ear. This muscle can be identified by asking the patient to turn their head to
the left and into your hand while you provide resistance to the movement. The
two heads form the sides of a small triangle, with the clavicle making up the
bottom edge. You should be able to feel a shallow defect formed by the
borders of these landmarks. Note, you are trying to identify impulses
originating from the IJ and transmitted to the overlying skin in this area. You
can't actually see the IJ. The External Jugular (EJ) runs in an oblique direction
across the sternocleidomastoid and, in contrast to the IJ, can usually be
directly visualized. If the EJ is not readily apparent, have the patient look to
the left and valsalva. This usually makes it quite obvious. EJ distention is not
always a reliable indicator of elevated CVP as valves, designed to prevent the
retrograde flow of blood, can exist within this vessel causing it to appear
engorged even when CVP is normal. It also makes several turns prior to
connecting with the central venous system and is thus not in a direct line with
the right atrium.
2. Take your time. Look at the area in question for several minutes while the
patient's head is turned to the left. The carotid artery is adjacent to the IJ, lying
just medial to it. If you are unsure whether a pulsation is caused by the carotid
or the IJ, place your hand on the patient's radial artery and use this as a
reference. The carotid impulse coincides with the palpated radial artery
pulsation and is characterized by a single upstroke timed with systole. The
venous impulse (at least when the patient is in sinus rhythm and there is no
tricuspid regurgitation) has three components, each associated with the
aforementioned a, c and v waves. When these are transmitted to the skin, they
create a series of flickers that are visible diffusely within the overlying skin. In
contrast, the carotid causes a single up and down pulsation. Furthermore, the
carotid is palpable. The IJ is not and can, in fact, be obliterated by applying
pressure in the area where it emerges above the clavicle.
3. Search along the entire projected course of the IJ as the top of the pressure
wave (which is the point that you are trying to identify) may be higher then
where you are looking. In fact, if the patient's CVP is markedly elevated, you
may not be able to identify the top of the wave unless they are positioned with
their trunk elevated at 45 degrees or more (else their will be no identifiable
"top" of the column as the entire IJ will be engorged). After you've found the
top of the wave, see what effect sitting straight up and lying down flat have on
the height of the column. Sitting should cause it to appear at a lower point in
the neck, while lying has the opposite effect. Realize that these maneuvers do
not change the actual value of the central venous pressure. They simply alter
the position of the top of the pulsations in relation to other structures in the
neck and chest.
4. Shine a pen light tangentially across the neck. This sometimes helps to
accentuate the pulsations.
5. If you are still uncertain, apply gentle pressure to the right upper quadrant of
the abdomen for 5 to 10 seconds. This elicits Hepato-Jugular Reflux which, in
pathologic states, will cause blood that has pooled in the liver to flow in a
retrograde fashion and fill out the IJ, making the transmitted pulsations more
apparent. Make sure that you are looking in the right area when you push as
the best time to detect any change in the height of this column of blood is
immediately after you apply hepatic pressure.
6. Once you identify JVD, try to estimate how high in cm the top of the column
is above the Angle of Louis. The angle is the site of the joint which connects
the manubrium with the rest of the sternum. First identify the supra-sternal
notch, a concavity at the top of the manubrium. Then walk your fingers
downward until you detect a subtle change in the angle of the bone, which is
approximately 4 to 5 cm below the notch. This is roughly at the level of the
2nd intercostal space. The vertical distance from the top of the column to this
angle is added to 5cm, the rough vertical distance from the angle to the right
atrium with the patient lying at a 45 degree angle. The sum is an estimate of
 the CVP. However, if you can simply determine with some accuracy whether
JVD is present or not, you will be way ahead of he game! Normal is 7-9 cm.

Bony Structures of the Chest

Finding the Angle of Louis:The wooden Q-tips highlight the different slopes of the
sternum and manubrium. The point at which the
Q-tips cross is the Angle of Louis.
 Determining the CVP
Video of patient with markedly
elevated central venous pressure.
Video simulation and discussion of
central venous pressure.

Take some time to look across the left chest and try to identify the transmitted
impulse caused by ventricular contraction, which may be apparent when contractions
are particularly vigorous.

Palpation: The palm of your right hand is placed across the patient's left chest so that
it covers the area over the heart. The heel should rest along the sternal border with the
extended fingers lying below the left nipple. Focus on several things:

Palpation of the Precordium to Determine the Location of the PMI

1. Can you feel a Point of Maximum Impulse (PMI) related to contraction at the
apex of the underlying left ventricle? If so, where is it located? After
identifying the rough position with the palm of your hand, try to pin down the
precise location with the tip of your index finger. The normal sized and
functioning ventricle will generate a penny sized impulse that is best felt in the
mid-clavicular line, roughly at the 5th intercostal space. If the ventricle
becomes dilated, most commonly as the result of past infarcts and always
associated with ventricular dysfunction, the PMI is displaced laterally. In cases
of significant enlargement, the PMI will be located near the axilla.
Occasionally, the PMI will not localize to any one area, which does not
necessarily indicate ventricular enlargement or dysfunction. Obesity and
COPD may also limit your ability to identify its precise location. Palpating
while the patient is in the left lateral decubitus position can make the PMI
more obvious.
2. What is the duration of the impulse? In the setting of hypertension or any other
state of chronic pressure overload, the ventricle hypertrophies and the PMI
becomes sustained (i.e. you feel the impulse for a longer period of time). This
is actually pretty subjective and can be tough to detect. Note that hypertrophy
and dilatation are not synonymous. They can exist separately or in conjunction
with one another.
3. How vigorous is the transmitted impulse? Processes associated with
ventricular hypercontractility (e.g. compensated mitral regurgitation or aortic
insufficiency that result in exceptionally large stroke volumes) generate an
impulse of unusual vigor.
4. Do you feel a thrill, a vibratory sensation produced by turbulent blood flow
that is usually secondary to valvular abnormalities? The feeling is similar to
that produced when you squeeze on a garden hose, partially obstructing the
flow of water. The location of the thrill will depend on the involved valve (e.g.
thrills caused by aortic stenosis are best felt toward the right upper sternal
border). If a loud murmur is detected during auscultation, you may then go
back and reassess for the presence of a thrill. In general, thrills are an
uncommon finding.
 *Palpation of the precordium of a female patient is best done by placing the
palm of your right hand directly beneath the patient's left breast such that the
edge of your index finger rests against the inferior surface of the breast. Make
sure that you tell that patient what you are about to do (and why) before
actually performing this maneuver. Remember that with age tissue turgor
often declines, causing the breasts to hang below the level of the heart.

5. Carotid Artery Palpation: This is of greatest value during the assessment of

aortic valvular and out flow tract disease (see below) and should thus be
performed after auscultation so that you know whether or not these problems
exist prior to palpation. However, for the sake of completeness it will be
described here. The carotids can be located by sliding the second and third
finger of either hand along the side of the trachea at the level of the thyroid
cartilage (i.e. adams apple). The carotid pulsation is palpable just lateral to the
groove formed by the trachea and the surrounding soft tissue. The quantity of
subcutaneous fat will dictate how firmly you need to push. The pulsations
should be easily palpable. Diminution may be caused by atherosclerosis, aortic
stenosis, or severely impaired ventricular performance. Do not push on both
sides simultaneously as this may compromise cerebral blood flow.

Auscultation: The following anatomic pictures will aid you in understanding the
principles of cardiac auscultation.
1. Become comfortable with your stethescope. There are multiple brands on the
market, each of which incorporates its own version of a bell (low pitched
sounds) and diaphragm (higher pitched sounds). Some have the diaphragm
and bell on opposite sides of the head piece. Others have the bell and
diaprhragm built into a single side, with the bell engaged by applying light
pressure and the diaphragm engaged by pushing more firmly. Adult, pediatric,
and newborn sizes also exist. And some combine adult and pediatric scopes
into a single unit. Take the time to read the instructions for your particular
model so that you are familiar with how to use it correctly. Several sample
stethescopes are pictured below. It's worth mentioning that almost any
commercially available scope will do the job. The most important "part" is
what sits betwen the ear pieces!
 Adult Stethoscope: Diaphragm
Adult Stethoscope and Bell
Incorporated Into Single Side.

Combination Adult & Pediatric

Newborn Stethoscope
Stethoscope
2. Engage the diaphragm of your stethescope and place it firmly over the 2nd
right intercostal space, the region of the aortic valve. Then move it to the other
side of the sternum and listen in the 2nd left intercostal space, the location of
the pulmonic valve. Move down along the sternum and listen over the left 4th
intercostal space, the region of the tricuspid valve. And finally, position the
diaphragm over the 4th intercostal space, left midclavicular line to examine
the mitral area. These locations are rough approximations and are generally
determined by visual estimation. In each area, listen specifically for S1 and
then S2. S1 will be loudest over the left 4th intercostal space (mitral/tricuspid
valve areas) and S2 along the 2nd R and L intercostal spaces
(aortic/pulomonic valve regions). Note that the time between S1 and S2 is
shorter then that between S2 and S1. This should help you to decide which
sound is produced by the closure of the mitral/tricuspid and which by the
 aortic/pulmonic valves and therefore when systole and diastole occur.
Compare the relative intensities of S1 and S2 in these different areas.

Auscultation of the Heart

3. In younger patients, you should also be able to detect physiologic splitting of

S2. That is, S2 is made up of 2 components, aortic (A2) and pulmonic (P2)
valve closure. On inspiration, venous return to the heart is augmented and
pulmonic valve closure is delayed, allowing you to hear first A2 and then P2.
On expiration, the two sounds occur closer together and are detected as a
single S2. Ask the patient to take a deep breath and hold it, giving you a bit
more time to identify this phenomenon. The two components of S1 (mitral and
tricuspid valve closure) occur so close together that splitting is not
appreciated.
4. You may find it helpful to tap out S1 and S2 with your fingers as you listen,
accentuating the location of systole and diastole and lending a visual
component to this exercise. While most clinicians begin asucultation in the
aortic area and then move across the precordium, it may actually make more
sense to begin laterally (i.e. in the mitral area) and then progress towards the
right and up as this follows the direction of blood flow. Try both ways and see
which feels more comfortable.

Univeristy of Utah, Review of Cardiac Physiology

5. Listen for extra heart sounds (a.k.a. gallops). While present in normal subjects
up to the ages of 20-30, they represent pathology in older patients. An S3 is
most commonly associated with left ventricular failure and is caused by blood
from the left atrium slamming into an already overfilled ventricle during early
diastolic filling. The S4 is a sound created by blood trying to enter a stiff, non-
compliant left ventricle during atrial contraction. It's most frequently
associated with left ventricular hypertrophy that is the result of long standing
hypertension. Either sound can be detected by gently laying the bell of the
stethoscope over the apex of the left ventricle (roughly at the 4th intercostal
space, mid-clavicular line) and listening for low pitched "extra sounds" that
either follow S2 (i.e. an S3) or precede S1 (i.e. an S4). These sounds are quite
soft, so it may take a while before you're able to detect them. Positioning the
patient on their left side while you listen may improve the yield of this exam.
The presence of both an S3 and S4 simultaneously is referred to as a
summation gallop.

Listening for Extra Heart Sounds

6. Murmurs: These are sounds that occur during systole or diastole as a result of
turbulent blood flow. Traditionally, students are taught that auscultation is
performed over the 4 areas of the precordium that roughly correspond to the
"location" of the 4 valves of the heart (i.e. aortic valve area ='s the 2nd Right
Intercostal Space, pulmonic valve area ='s the 2nd LICS, tricuspid valve area
='s 4th LICS, and mitral valve area ='s 4th LICS in the midclavicular line).
This leads to some misperceptions. Valves are not strictly located in these
areas nor are the sounds created by valvular pathology restricted to those
spaces. So, while it might be OK to listen in only 4 places when conducting
 the normal exam, it is actually quite helpful to listen in many more when any
abnormal sounds are detected. If you hear a murmur, ask yourself:
a. Does it occur during systole or diastole?
b. What is the quality of the sound (i.e. does it get louder and then softer;
does it maintain the same intensity throughout; does it start loud and
become soft)? It sometimes helps to draw a pictoral representation of
the sound.
c. What is the quantity of the sound? The rating system for murmurs is as
follows:
 1/6… Can only be heard with careful listening
 2/6… Readily audible as soon as the stethescope is applied to
the chest
 3/6… Louder then 2/6
 4/6… As loud as 3/6 but accompanied by a thrill
 5/6… Audible even when only the edge of the stethescope
touches the chest
 6/6… Audible to the naked ear
Most murmurs are between 1/6 and 3/6. Louder generally (but
not always) indicates greater pathology.
d. What is the relationship of the murmur to S1 and S2 (i.e. when does it
start and stop)?
e. What happens when you march your stethescope from the 2nd RICS
(the aortic area) out towards the axilla (the mitral area)? Where is it
loudest and in what directions does it radiate? By moving in small
increments (i.e. listening in 8 or 10 places along the chest wall) you
will be more likely to detect changes in the character of a particular
murmur and thus have a better chance of determining which valve is
affected and by what type of lesion.
7. Auscultation over the carotid arteries (see under aortic stenosis for additional
information): In the absence of murmurs suggestive of aortic valvular disease,
you can listen for carotid bruits (sounds created by turbulent flow within the
blood vessel) at this point in the exam. Place the diaphragm gently over each
carotid and listen for a soft, high pitched "shshing" sound. It's helpful if the
patient can hold their breath as you listen so that you are not distracted by
transmitted tracheal sounds. The meaning of a bruit remains somewhat
controversial. I was taught that bruits represented turbulent flow associated
with intrinsic atherosclerotic disease… and that the disappearance of a bruit
which was previously present was a sign that the lesion was progressing (i.e.
further encroachment on the lumen of the vessel). However, a number of
studies provide evidence that atherosclerotic disease is frequently absent when
a bruit is present as well as the reverse situation. This is actually of clinical
importance because recent data suggest that it may be beneficial to surgically
repair carotid disease in patients who have significant stenosis yet have not
experienced any symptoms (e.g. Transient ischemic attacks or strokes. Surgery
in these settings has already proven to be beneficial). Thus, it is becoming
increasingly important to determine the best way of identifying asymptomatic
carotid artery disease... and carotid auscultation may, in fact, not be the
mechanism of choice!
 The Auscultation Assistant is an excellent heart sound simulation site
developed at UCLA. Press the "Back" button to return to this page.
Blaufuss Multimedia Heart Sounds Tutorial. Press the "Back" button to
 
return to this page.
This University of Washington site also provides a variety of simulated
heart sounds. Press the "Back" button to return to this page.
In addition, there is an excellent heart sound tutorial CD ROM called, The
Physiological Origins of Heart Sounds and Murmurs available at the OLR.
8. Identifying the Most Common Murmurs:
9. 1. Systolic Murmurs: In the adult population, these generally represent either
aortic stenosis or mitral regurgitation. To distinguish between them, remember
the following:
10. Murmurs of Aortic Stenosis (AS):
a. Tend to be loudest along the upper sternal borders and get softer as you
move down and out towards the axilla. There is, however, a
phenomenon referred to at the Gallavardin Effect which can cause
murmurs of AS to sound as loud towards the axilla as they do over the
aortic region. When this occurs, the shape of the sound should be
similar in both regions, helping you to distinguish it from MR (see
below).
b. Have a growling, harsh quality (i.e. get louder and then softer.. also
referred to as a crescendo decrescendo, systolic ejection, or diamond
shaped murmur). When the stenosis becomes more severe, the point at
which the murmur is loudest (i.e. its peak intensity) occurs later in
systole, as it takes longer to generate the higher ventricular pressure
required to push blood through the tight orifice.

c. Are better heard when the patient sits up and exhales.

d. Are heard in the carotid arteries and over the right clavicle. Radiation
to the clavicle can be appreciated by simply resting the diaphragm on
the right clavicle. To assess for transmission to the carotids, have the
patient hold their breath while you listen over each artery using the
diaphragm of your stethescope. Carotid bruits can be confused with the
radiating murmur of aortic stenosis. In general, carotid bruits are
softer. Also, murmurs associated with aortic pathology should be
audible in both carotids and get louder as you move down the vessel,
towards the chest. In settings where carotid pathology coexists with
aortic stenosis, a loud transmitted murmur associated with a valvular
 lesion may overwhelm any sound caused by intrinsic carotid disease,
masking it completely.
e. Carotid upstrokes refer to the quantity and timing of blood flow into
the carotids from the left ventricle. They can be affected by aortic
stenosis and must be assessed whenever you hear a murmur that could
be consistent with AS. This is done by placing your fingers on the
carotid artery as described above while you simultaneously listen over
the chest. There should be no delay between the onset of the murmur,
which marks the beginning of systole, and when you feel the pulsation
in the carotid. In the setting of critical (i.e. very severe) aortic stenosis,
small amounts of blood will be ejected into the carotid and there will
be a lag between when you hear the murmur and feel the impulse. This
is referred to as diminished and delayed upstrokes (a.k.a. parvus et
tardus), as opposed to the full and prompt inflow which occurs in the
absence of disease. Mild or moderate stenosis does not alter the
character of carotid in-flow.
f. Sub-Aortic stenosis is a relatively rare condition where the obstruction
of flow from the left ventricle into the aorta is caused by an in-growth
of septal tissue in the region below the aortic valve known as the aortic
outflow tract. It causes a crescendo-decrescendo murmur that sounds
just like aortic stenosis. As opposed to AS, however, the murmur is
louder along the left lower sternal border and out towards the apex.
This makes anatomic sense as the obstruction is located near this
region. It also does not radiate loudly to the carotids as the point of
obstruction is further from these vessels in comparison with the aortic
valve. You may also be able to palpate a bisferiens pulse in the carotid
artery (see under aortic insufficiency). Furthermore, the murmur will
get softer if the ventricle is filled with more blood as filling pushes the
abnormal septum away from the opposite wall, decreasing the amount
of obstruction. Conversely, it gets louder if filling is decreased. This
phenomenon can actually be detected on physical exam and is a useful
way of distinguishing between AS and sub-aortic obstruction. Ask the
patient to valsalva while you listen. This decreases venous return and
makes the murmur louder (and will have the opposite effect on a
murmur of AS). Then, again while listening, squat down with the
patient. This maneuver increases venous return, causing the murmur to
become softer. Standing will cause the opposite to occur. You need to
listen for 20 seconds or so after each change in position to really
appreciate any difference. Because the degree of obstruction can vary
with ventricular filling, sub-aortic stenosis is referred to as a dynamic
outflow tract obstruction. In aortic stenosis, the degree of obstruction
that exists at any given point in time is fixed.

Murmurs of Mitral Regurgitation (MR):

g. Sound the same throughout systole.

h. Generally do not have the harsh quality associated with aortic stenosis.
In fact, they sound a bit like the "shshing" noise produced when you
pucker your lips and blow through clenched teeth.
i. Get louder as you move your stethescope towards the axilla.
 j. Will get even louder if you roll the patient onto their left side while
keeping your stethescope over the mitral area of the chest wall and
listening as they move. This maneuver brings the chamber receiving
the regurgitant volume, the left atrium, closer to your stethescope,
accentuating the murmur.
k. Get louder if afterload is suddenly increased, which can be
accomplished by having the patient close their hands tightly. MR is
also affected by the volume of blood returning to the heart. Squatting
increases venous return, causing a louder sound. Standing decreases
venous return, thereby diminishing the intensity of the murmur.

Sometimes murmurs of aortic stenosis and mitral regurgitation co-exist, which

can be difficult to sort out on exam. Moving your stethescope back and forth
between the mitral and aortic areas will allow for direct comparison, which
may help you decide if more then one type of lesion is present or if the quality
of the murmur is the same in both locations, changing only in intensity (i.e.
consistent with a one valve problem).

2. Diastolic Murmurs: Tend to be softer and therefore much more difficult to

hear then those occurring during systole. This makes physiologic sense as
diastolic murmurs are not generated by high pressure ventricular contractions.
In adults they may represent either aortic regurgitation or mitral stenosis,
neither of which is too common. While systolic murmurs are often obvious,
you will probably not be able to detect diastolic murmurs on your own until
you have had them pointed out by a more experienced examiner.

Aortic Regurgitation (AR); a.k.a. Aortic Insufficiency (AI):

 l. Is best heard along the left para-sternal border, as this is the direction
of the regurgitant flow.
m. Becomes softer towards the end of diastole (a.k.a. decrescendo).
n. Can be accentuated by having the patient sit up, lean forward and
exhale while you listen.
o. Occasionally accompanies aortic stenosis, so listen carefully for
regurgitation in patients with AS.
p. Will cause the carotid upstrokes to feel extraordinarily full as
significant regurgitation increases ventricular pre-load, resulting in
ejection of an augmented stroke volume. AI can also produce a double
peaked pulsation in the carotids known as a bisferiens pulse, which is
quite difficult to appreciate. Feeling your own carotid impulse at the
same time that you're palpating the patient's may accentuate this
finding. In cases of co-existent AS and AI, a bisferiens pulse suggests
that the AI is the dominant problem. It may also be present with sub-
aortic stenosis (see above), helping to distinguish it from AS.

Mitral Stenosis (MS):

q. Heard best towards the axilla

r. Can be accentuated by having the patient role onto their left side while
you listen with the bell of your sthethescope.
s. Associated with a soft, low pitched sound preceding the murmur,
called the opening snap. This is the noise caused by the calcified valve
"snapping" open. It can, however, be pretty hard to detect.

Auscultation, an ordered approach:

Try to focus on each sound individually and in a systematic fashion. Ask
yourself: Do I hear S1? Do I hear S2? What is their relative intensities in each
of the major valvular areas? Is S2 split physiologically? Are there extra sounds
before S1or after S2 (i.e. an S4 or S3)? Is there a murmur during systole? Is
there a murmur during diastole? If a murmur is present, how loud is it? What
is its character? Where does it radiate? Are there any maneuvers which affect
its intensity? Remember that these sounds are created by mechanical events in
the heart. As you listen, remind yourself what is happening to produce each of
them. By linking auscultatory findings with physiology, you can build a case
in your mind for a particular lesion.

Interrelationship of Cardiac Events & Sounds

 This diagram courtesy of Dr. Wilbur Lew, Department of Medicine, San
Diego VA Medical Center.

A few final comments about auscultation:

1. Pulmonic valve murmurs are rare in the adult population and, even
when present, are difficult to hear due to the relatively low pressures
generated by the right side of the heart.
2. Tricuspid regurgitation (TR) is relatively common, most frequently
associated with elevated left sided pressures which are then transmitted
to the right side of the heart (though a number of other processes can
cause TR as well). In this setting, both mitral and tricuspid
regurgitation often co-exist. The murmur of MR is generally louder
then that of TR, again due to the higher pressures on the left side of the
heart. It can therefore be difficult to sort out if there is co-existent TR
when MR is present. Try to listen along both the low left and right
sternal borders (areas where the tricuspid valve is best assessed) and
compare this to the mitral area. Move your stethoscope slowly across
the precordium and note if there is any change in the
character/intensity of the murmur. TR murmurs are also accentuated by
 inhalation, which increases venous return and therefore flow across the
valve.
3. Patients with COPD (emphysema) often have very soft heart sounds.
Air trapping and subsequent lung hyperinflation results in a posterior-
inferior rotation of the heart away from the chest wall and causes the
interposition of lung between the chest wall and heart. In this setting,
heart sounds can be accentuated by having the patient lean forward and
fully exhale prior to listening. Furthermore, in any patient with
particularly "noisy" breath sounds, it may be helpful to ask them to
hold their breath (if they're able) while you examine the heart.
4. Rubs: These are uncommon sounds produced when the parietal and
visceral pericardium become inflamed, generating a creaky-scratchy
noise as they rub together. The classic rub is actually made up of three
sounds, associated with atrial contraction, ventricular contraction, and
ventricular filling. In reality, its rare to hear all 3 components (more
commonly, 2 are apparent). They can be accentuated by listening when
the patient sits up, leans forward and exhales, bringing the two layers
in closer communication. I feel compelled to mention this finding only
because a common short hand for reporting the results of the cardiac
exam comments on the absence of "Gallops, murmurs, or rubs,"
implying (incorrectly) that rubs are a frequent finding.
5. If a patient has an abnormal heart sound due to a structural defect that
has been quantified by echocardiography, make sure that you compare
your findings to those identified during the study. This is a great way
of learning!
6. Don't get frustrated! Auscultation is a difficult skill to "master" and we
are all continually refining our techniques. Take your time. Make sure
the room is quiet. Be patient. Ask for help frequently. Read about
particular murmurs and their pathophysiology when you encounter
them. A number of the more subtle findings (e.g. an S3 or S4) can be
very difficult to identify when the patient is tachycardic, a not
uncommon scenario as this is one of the compensatory mechanisms for
dealing with the dysfunction that has generated these findings in the
first place. Re-examination after the patient has made clinical
improvement may be more revealing.

In general, many of the above techniques are not used when examining every patient.
If the exam is normal, it would be neither efficient nor revealing to put a patient
through all of these maneuvers. The goal is to have a "bag of skills" at your disposal
that you can reach into and employ to better define abnormalities when they present
themselves.
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