A good cardiovascular examination requires more than observation. You need to think about the possible meanings of your individual observations, fit them together in a logical pattern, and correlate your cardiac findings with the patient's blood pressure, arterial pulses, venous pulsations, jugular venous pressure, the remainder of your physical examination, and the patient's history.
Evaluating the common systolic murmur illustrates this point. In examining an asymptomatic teenager, for example, you might hear a grade 2/6 midsystolic murmur in the 2nd and 3rd left interspaces. Since this suggests a murmur of pulmonic origin, you should assess the size of the right ventricle by carefully palpating the left parasternal area. Because pulmonic stenosis and atrial septal defects can occasionally cause such murmurs, listen carefully to the splitting of the second heart sound and try to hear any ejection sounds. Listen to the murmur after the patient sits up. Look for evidence of anemia, hyperthyroidism, or pregnancy that could produce such a murmur by increasing the flow across the aortic or the pulmonic valve. If all your findings are normal, your patient probably has an innocent murmur—one with no pathologic significance.
In a 60-year-old person with angina, you might hear a harsh 3/6 midsystolic crescendo-decrescendo murmur in the right 2nd interspace radiating to the neck. These findings suggest aortic stenosis, but could arise from aortic sclerosis (leaflets sclerotic but not stenotic), a dilated aorta, or increased flow across a normal valve. Check the apical impulse for left ventricular enlargement. Listen for aortic regurgitation as the patient leans forward and exhales.
Assess any delay in the carotid upstroke and the blood pressure for evidence of aortic stenosis. Put all this information together to make a tentative hypothesis about the origin of the murmur.
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