1. Chest pain.

Any chest pain or tightness?

 •Onset: When did it start? How long have you had it this time? Had this type of pain before? How often?

 •Location: Where did the pain start? Does the pain radiate to any other spot?

 •Character: How would you describe it? Crushing, stabbing, burning, viselike? (Allow the person to offer adjectives before you suggest them.) (Note if uses clenched fist to describe pain.)

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Angina, an important cardiac symptom, occurs when the heart's own blood supply cannot keep up with metabolic demand. Chest pain also may have pulmonary, musculoskeletal, or gastrointestinal origin; it is important to differentiate.

A squeezing “clenched fist” sign is characteristic of angina, but the symptoms below may be anginal equivalents in the absence of chest pain.

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•Pain brought on by: Activity—what type; rest; emotional upset; after eating; during sexual intercourse; with cold weather?

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•Any associated symptoms: Sweating, ashen gray or pale skin, heart skips beat, shortness of breath, nausea or vomiting, racing of heart?

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Diaphoresis, cold sweats, pallor, grayness.

Palpitations, dyspnea, nausea, tachycardia, fatigue.

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•Pain made worse by moving the arms or neck, breathing, lying flat?

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Try to differentiate pain of cardiac versus noncardiac origin.

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•Pain relieved by rest or nitroglycerin? How many tablets?

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2. Dyspnea.

Any shortness of breath?

 •What type of activity and how much brings on shortness of breath? How much activity brought it on 6 months ago?

 •Onset: Does the shortness of breath come on unexpectedly?

 •Duration: Constant or does it come and go?

 •Seem to be affected by position: Lying down?

 •Awaken you from sleep at night?

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Dyspnea

Paroxysmal.

Constant or intermittent.

Recumbent.

Paroxysmal nocturnal dyspnea (PND) occurs with heart failure. Lying down increases volume of intrathoracic blood, and the weakened heart cannot accommodate the increased load. Typically, the person awakens after 2 hours of sleep with the perception of needing fresh air.

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 •Does the shortness of breath interfere with activities of daily living?

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3. Orthopnea.

How many pillows do you use when sleeping or lying down?

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Orthopnea is the need to assume a more upright position to breathe. Note the exact number of pillows used.

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4. Cough.

Do you have a cough?

 •Duration: How long have you had it?

 •Frequency: Is it related to time of day?

 •Type: Dry, hacking, barky, hoarse, or congested?

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•Do you cough up mucus? Color? Any odor? Blood tinged?

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Sputum production, mucoid or purulent. Hemoptysis is often a pulmonary disorder but also occurs with mitral stenosis.

•Associated with: Activity, position (lying down), anxiety, talking?

 •Does activity make it better or worse (sit, walk, exercise)?

 •Relieved by rest or medication?

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5. Fatigue.

Do you seem to tire easily? Able to keep up with your family and co-workers?

 •Onset: When did fatigue start? Sudden or gradual? Has any recent change occurred in energy level?

 •Fatigue related to time of day: All day, morning, evening?

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Fatigue from decreased cardiac output is worse in the evening, whereas fatigue from anxiety or depression occurs all day or is worse in the morning.

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6. Cyanosis or pallor.

Ever noted your facial skin turn blue or ashen?

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Cyanosis

pallor

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7. Edema.

Any swelling of your feet and legs?

 •Onset: When did you first notice this?

 •Any recent change?

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Edema

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•What time of day does the swelling occur? Do your shoes feel tight at the end of day?

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Cardiac edema is worse at evening and better in morning after elevating legs all night.

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•How much swelling would you say there is? Are both legs equally swollen?

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Cardiac edema is bilateral; unilateral swelling has a local vein cause.

•Does the swelling go away with: Rest, elevation, after a night's sleep?

 •Any associated symptoms, such as shortness of breath? If so, does the shortness of breath occur before leg swelling or after?

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8. Nocturia.

Do you awaken at night with an urgent need to urinate? How long has this been occurring? Any recent change?

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Nocturia

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9. Cardiac history.

Any past history of: Hypertension, elevated cholesterol or triglycerides, heart murmur, congenital heart disease, rheumatic fever or unexplained joint pains as child or youth, recurrent tonsillitis, anemia?

 •Ever had heart disease? When was this? Treated by medication or heart surgery?

 •Last ECG, stress ECG, serum cholesterol measurement, other heart tests?

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10. Family cardiac history.

Any family history of: Hypertension, obesity, diabetes, coronary artery disease (CAD), sudden death at younger age?

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11. Personal habits (cardiac risk factors).

 •Nutrition: Please describe your usual daily diet. (Note if this diet is representative of the basic food groups, the amount of calories, cholesterol,

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and any additives such as salt.) What is your usual weight? Has there been any recent change?

 •Smoking: Do you smoke cigarettes or other tobacco? At what age did you start? How many packs per day? For how many years have you smoked this amount? Have you ever tried to quit? If so, how did this go?

 •Alcohol: How much alcohol do you usually drink each week, or each day? When was your last drink? What was the number of drinks during that episode? Have you ever been told you had a drinking problem?

 •Exercise: What is your usual amount of exercise each day or week? What type of exercise (state type or sport)? If a sport, what is your usual amount (light, moderate, heavy)?

 •Drugs: Do you take any antihypertensives, beta-blockers, calcium channel blockers, digoxin, diuretics, aspirin/anticoagulants, over-the-counter or street drugs?

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Risk factors for CAD

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Additional History for the Pregnant Woman

1.

Have you had any high blood pressure during this or earlier pregnancies?

 •What was your usual blood pressure level before pregnancy? How has your blood pressure been monitored during the pregnancy?

 •If high blood pressure, what treatment has been started?

 •Any associated symptoms: Weight gain, protein in urine, swelling in feet, legs, or face?

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Additional History for the Pregnant Woman

2.

Have you had any faintness or dizziness with this pregnancy?

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Additional History for the Aging Adult

1.

Do you have any known heart or lung disease: Hypertension, CAD, chronic emphysema, or bronchitis?

 •What efforts to treat this have been started?

 •Usual symptoms changed recently? Does your illness interfere with activities of daily living

additional history for the aging adult

Do you take any medications for your illness such as digitalis? Aware of side effects? Have you recently stopped taking your medication? Why?

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Noncompliance may be related to side effects or lack of finances.

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additional history for the aging adult

3.

Environment:

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THE NECK VESSELS

Palpate the Carotid Artery

Located central to the heart, the carotid artery yields important information on cardiac function.

Palpate each carotid artery medial to the sternomastoid muscle in the neck (Fig. 19-16). Avoid excessive pressure on the carotid sinus area higher in the neck; excessive vagal stimulation here could slow down the heart rate, especially in older adults. Take care to palpate gently. Palpate only one carotid artery at a time to avoid compromising arterial blood to the brain.

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Carotid sinus hypersensitivity is the condition in which pressure over the carotid sinus leads to a decreased heart rate, decreased BP, and cerebral ischemia with syncope. This may occur in older adults with hypertension or occlusion of the carotid artery.

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palpate the carotid artery

Feel the contour and amplitude of the pulse. Normally the contour is smooth with a rapid upstroke and slower downstroke, and the normal strength is 2+ or moderate (see Chapter 20). Your findings should be the same bilaterally.

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Diminished pulse feels small and weak (decreased stroke volume).

Increased pulse feels full and strong in hyperkinetic states (see Table 20-1, Variations in Pulse Contour, on p. 519).

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Auscultate the Carotid Artery

For persons middle-aged or older or who show symptoms or signs of cardiovascular disease, auscultate each carotid artery for the presence of a bruit (pronounced bru′-ee) (Fig. 19-17). This is a blowing, swishing sound indicating blood flow turbulence; normally none is present.

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A bruit indicates turbulence due to a local vascular cause, such as atherosclerotic narrowing.

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carotid artery

Keep the neck in a neutral position. Lightly apply the bell of the stethoscope over the carotid artery at three levels: (1) the angle of the jaw, (2) the midcervical area, and (3) the base of the neck (see Fig. 19-17). Avoid compressing the artery because this could create an artificial bruit, and it could compromise circulation if the carotid artery is already narrowed by atherosclerosis. Ask the person to take a breath, exhale, and hold it briefly while you listen so that tracheal breath sounds do not mask or mimic a carotid artery bruit. (Holding the breath on inhalation will also tense the levator scapulae muscles, which makes it hard to hear the carotids.) Sometimes you can hear normal heart sounds transmitted to the neck; do not confuse these with a bruit.

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A carotid bruit is audible when the lumen is occluded by [image] to [image]. Bruit loudness increases as the atherosclerosis worsens until the lumen is occluded by [image]. After that, bruit loudness decreases. When the lumen is completely occluded, the bruit disappears. Thus absence of a bruit does not ensure absence of a carotid lesion.

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A murmur sounds much the same but is caused by a cardiac disorder. Some aortic valve murmurs (aortic stenosis) radiate to the neck and must be distinguished from a local bruit.

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Inspect the Jugular Venous Pulse

From the jugular veins you can assess the central venous pressure (CVP) and thus judge the heart's efficiency as a pump.

Stand on the person's right side because the veins there have a direct route to the heart.

Traditionally we have been taught to use the internal jugular vein pulsations for CVP assessment.

However, you may use either the external or the internal jugular veins because measurements in both are similar.²⁷

You can see the top of the external jugular vein distention overlying the sternomastoid muscle or the pulsation of the internal jugular vein in the sternal notch.

Position the person supine anywhere from a 30- to a 45-degree angle, wherever you can best see the top of the vein or pulsations.

 In general, the higher the venous pressure is, the higher the position you need.

Remove the pillow to avoid flexing the neck; the head should be in the same plane as the trunk.

Turn the person's head slightly away from the examined side, and direct a strong light tangentially onto the neck to highlight pulsations and shadows.

Note the external jugular veins overlying the sternomastoid muscle.

In some persons, the veins are not visible at all, whereas in others they are full in the supine position.

As the person is raised to a sitting position, these external jugulars flatten and disappear, usually at 45 degrees.

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Unilateral distention of external jugular veins is due to local cause (kinking or aneurysm).

Full distended external jugular veins above 45 degrees signify increased CVP as with heart failure.

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Now look for pulsations of the internal jugular veins in the area of the suprasternal notch or around the origin of the sternomastoid muscle around the clavicle. You must be able to distinguish internal jugular vein pulsation from that of the carotid artery. It is easy to confuse them because they lie close together. Use the guidelines shown in Table 19-1.

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Estimate the Jugular Venous Pressure

Think of the jugular veins as a CVP manometer attached directly to the right atrium. You can “read” the CVP at the highest level of pulsations (Fig. 19-18).

 Use the angle of Louis (sternal angle) as an arbitrary reference point, and compare it with the highest level of the distended vein or venous pulsation.

Hold a vertical ruler on the sternal angle.

Align a straight edge on the ruler like a T-square, and adjust the level of the horizontal straight edge to the level of pulsation.

Read the level of intersection on the vertical ruler; normal jugular venous pulsation is 2 cm or less above the sternal angle.

Also state the person's position, for example, “internal jugular vein pulsations 3 cm above sternal angle when elevated 30 degrees.”

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Elevated pressure is a level of pulsation that is more than 3 cm above the sternal angle while at 45 degrees. This occurs with heart failure.

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jugular venous pressure

If you cannot find the internal jugular veins, use the external jugular veins and note the point where they look collapsed.

Be aware that the technique of estimating venous pressure is difficult and is not always a reliable predictor of CVP.

Consistency in grading among examiners is difficult to achieve.

If venous pressure is elevated or if you suspect heart failure, perform hepatojugular reflux (Fig. 19-19).

Position the person comfortably supine, and instruct him or her to breathe quietly through an open mouth.

Hold your right hand on the right upper quadrant of the person's abdomen just below the rib cage.

Watch the level of jugular pulsation as you push in with your hand. Exert firm sustained pressure for 30 seconds.

This displaces venous blood out of the liver sinusoids and adds its volume to the venous system.

If the heart is able to pump this additional volume (i.e., if no elevated CVP is present), the jugular veins will rise for a few seconds and then recede back to the previous level.

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If heart failure is present, the jugular veins will elevate and stay elevated as long as you push.

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THE PRECORDIUM

Inspect the Anterior Chest

Arrange tangential lighting to accentuate any flicker of movement.

Pulsations.

You may or may not see the apical impulse, the pulsation created as the left ventricle rotates against the chest wall during systole. When visible, it occupies the fourth or fifth intercostal space, at or inside the midclavicular line. It is easier to see in children and in those with thinner chest walls.

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A heave or lift is a sustained forceful thrusting of the ventricle during systole. It occurs with ventricular hypertrophy as a result of increased workload. A right ventricular heave is seen at the sternal border; a left ventricular heave is seen at the apex (see Table 19-8, Abnormal Pulsations on the Precordium, p. 492).

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Palpate the Apical Impulse (This used to be called the point of maximal impulse, or PMI. Because some abnormal conditions may cause a maximal impulse to be felt elsewhere on the chest, use the term apical impulse specifically for the apex beat.) (Jarvis, Carolyn. Physical Examination and Health Assessment, 6th Edition. Saunders, 032011. p. 472).

Localize the apical impulse precisely by using one finger pad (Fig. 19-20, A). Asking the person to “exhale and then hold it” aids the examiner in locating the pulsation. You may need to roll the person midway to the left to find it; note that this also displaces the apical impulse farther to the left (Fig. 19-20, B).

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Note:

_ Location—The apical impulse should occupy only one interspace, the fourth or fifth, and be at or medial to the midclavicular line

_ Size—Normally 1 × 2 cm

_ Amplitude—Normally a short, gentle tap

_ Duration—Short, normally occupies only first half of systole

Cardiac enlargement:

_ Left ventricular dilation (volume overload) displaces impulse down and to left and increases size more than one space.

_ A sustained impulse with increased force and duration but no change in location occurs with left ventricular hypertrophy and no dilation (pressure overload) (see Table 19-8).

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The apical impulse is palpable in about half of adults. It is not palpable in obese persons or in persons with thick chest walls. With high cardiac output states (anxiety, fever, hyperthyroidism, anemia), the apical impulse increases in amplitude and duration.

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Not palpable with pulmonary emphysema due to overriding lungs.

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Palpate Across the Precordium

Using the palmar aspects of your four fingers, gently palpate the apex, the left sternal border, and the base, searching for any other pulsations (Fig. 19-21). Normally none occur. If any are present, note the timing. Use the carotid artery pulsation as a guide, or auscultate as you palpate.

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A thrill is a palpable vibration. It feels like the throat of a purring cat. The thrill signifies turbulent blood flow and accompanies loud murmurs. Absence of a thrill, however, does not necessarily rule out the presence of a murmur.

Accentuated first and second heart sounds and extra heart sounds also may cause abnormal pulsations.

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Percussion

Percussion is used to outline the heart's borders, but it has been displaced by the chest x-ray or echocardiogram. Evidence shows these are more accurate in detecting heart enlargement. When the right ventricle enlarges, it does so in the anteroposterior diameter, which is better seen on x-ray film. Evidence from numerous comparison studies shows the percussed cardiac border correlates “only moderately” with the true cardiac border.²⁷ Also, percussion is of limited usefulness with the female breast tissue or in an obese person or a person with a muscular chest wall.

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Cardiac enlargement is due to increased ventricular volume or wall thickness; it occurs with hypertension, CAD, heart failure, and cardiomyopathy.

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Auscultation

Identify the auscultatory areas where you will listen. These include the four traditional valve “areas” (Fig. 19-22). The valve areas are not over the actual anatomic locations of the valves but are the sites on the chest wall where sounds produced by the valves are best heard. The sound radiates with the direction of blood flow.

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The valve areas are:

_ Second right interspace—aortic valve area

_ Second left interspace—pulmonic valve area

_ Left lower sternal border—tricuspid valve area

_ Fifth interspace at around left midclavicular line—mitral valve area

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auscultation

Do not limit your auscultation to only four locations.

Sounds produced by the valves may be heard all over the precordium.

(For this reason, many experts even discourage the naming of the valve areas.)

Thus learn to inch your stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex.

 Or start at the apex and work your way up. Include the sites shown in Fig. 19-22.

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Recall the characteristics of a good stethoscope (see Chapter 8). Clean the endpieces with an alcohol wipe; you will use both endpieces. Although all heart sounds are low frequency, the diaphragm is for relatively higher pitched sounds and the bell is for relatively lower pitched ones.

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auscultation

Before you begin, alert the person: “I always listen to the heart in a number of places on the chest. Just because I am listening a long time, it does not necessarily mean that something is wrong.”

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After you place the stethoscope, try closing your eyes briefly to tune out any distractions. Concentrate, and listen selectively to one sound at a time. Consider that at least two, and perhaps three or four, sounds may be happening in less than 1 second. You cannot process everything at once. Begin with the diaphragm endpiece and use the following routine: (1) note the rate and rhythm, (2) identify S₁ and S₂(3) assess S₁ and S₂ separately, (4) listen for extra heart sounds, and (5) listen for murmurs.

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Note the Rate and Rhythm.

The rate ranges normally from 50 to 90 beats per minute. (Review the full discussion of the pulse in Chapter 9 and the normal rates across age-groups.) The rhythm should be regular, although sinus arrhythmia occurs normally in young adults and children. With sinus arrhythmia, the rhythm varies with the person's breathing, increasing at the peak of inspiration and slowing with expiration. Note any other irregular rhythm. If one occurs, check if it has any pattern or if it is totally irregular.

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Premature beat—an isolated beat is early, or a pattern occurs in which every third or fourth beat sounds early.

Irregularly irregular—no pattern to the sounds; beats come rapidly and at random intervals.

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When you notice any irregularity, check for a pulse deficit by auscultating the apical beat while simultaneously palpating the radial pulse. Count a serial measurement (one after the other) of apical beat and radial pulse. Normally, every beat you hear at the apex should perfuse to the periphery and be palpable. The two counts should be identical. When different, subtract the radial rate from the apical and record the remainder as the pulse deficit.

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A pulse deficit signals a weak contraction of the ventricles; it occurs with atrial fibrillation, premature beats, and heart failure.

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Identify S₁ and S₂.

This is important because S₁ is the start of systole and thus serves as the reference point for the timing of all other cardiac sounds. Usually, you can identify S₁ instantly because you hear a pair of sounds close together (lub-dup), and S₁ is the first of the pair. This guideline works, except in the cases of the tachydysrhythmias (rates >100 per minute). Then the diastolic filling time is shortened, and the beats are too close together to distinguish. Other guidelines to distinguish S₁ from S₂ are:

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_ S₁ is louder than S₂ at the apex; S₂ is louder than S₁ at the base.

_ S₁ coincides with the carotid artery pulse. Feel the carotid gently as you auscultate at the apex; the sound you hear as you feel each pulse is S₁ (Fig. 19-23).

_ S₁ coincides with the R wave (the upstroke of the QRS complex) if the person is on an ECG monitor.

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Listen to S₁ and S₂ Separately.

Note whether each heart sound is normal, accentuated, diminished, or split. Inch your diaphragm across the chest as you do this.

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First Heart Sound (S₁).

Caused by closure of the AV valves, S₁ signals the beginning of systole. You can hear it over the entire precordium, although it is loudest at the apex (Fig. 19-24). (Sometimes the two sounds are equally loud at the apex, because S₁ is lower pitched than S₂.)

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Causes of accentuated or diminished S₁ (see Table 19-3, Variations in S₁, on p. 487).

Both heart sounds are diminished with conditions that place an increased amount of tissue between the heart and your stethoscope: emphysema (hyperinflated lungs), obesity, pericardial fluid.

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You can hear S₁ with the diaphragm with the person in any position and equally well in inspiration and expiration. A split S₁ is normal, but it occurs rarely. A split S₁ means you are hearing the mitral and tricuspid components separately. It is audible in the tricuspid valve area, the left lower sternal border. The split is very rapid, with the two components only 0.03 second apart.

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Second Heart Sound (S₂).

The S₂ is associated with closure of the semilunar valves. You can hear it with the diaphragm, over the entire precordium, although S₂ is loudest at the base (Fig. 19-25).

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Accentuated or diminished S₂ (see Table 19-4, Variations in S₂, on p. 488).

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Splitting of S₂.

A split S₂ is a normal phenomenon that occurs toward the end of inspiration in some people. Recall that closure of the aortic and pulmonic valves is nearly synchronous. Because of the effects of respiration on the heart described earlier, inspiration separates the timing of the two valves’ closure, and the aortic valve closes 0.06 second before the pulmonic valve. Instead of one DUP, you hear a split sound—T-DUP (Fig. 19-26). During expiration, synchrony returns and the aortic and pulmonic components fuse together. A split S₂ is heard only in the pulmonic valve area, the second left interspace.

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When you first hear the split S₂, do not be tempted to ask the person to hold his or her breath so that you can concentrate on the sounds. Breath holding will only equalize ejection times in the right and left sides of the heart and cause the split to go away. Instead, concentrate on the split as you watch the person's chest rise up and down with breathing. The split S₂ occurs about every fourth heartbeat, fading in with inhalation and fading out with exhalation.

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A fixed split is unaffected by respiration; the split is always there.

A paradoxical split is the opposite of what you would expect; the sounds fuse on inspiration and split on expiration (see Table 19-5, Variations in Split S₂, p. 488).

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Focus on Systole, Then on Diastole, and Listen for any Extra Heart Sounds.

Listen with the diaphragm, then switch to the bell, covering all auscultatory areas (Fig. 19-27). Usually these are silent periods. When you do detect an extra heart sound, listen carefully to note its timing and characteristics. During systole, the midsystolic click (which is associated with mitral valve prolapse) is the most common extra sound (see Table 19-6). The third and fourth heart sounds occur in diastole; either may be normal or abnormal (see Table 19-7).

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A pathologic S₃ (ventricular gallop) occurs with heart failure and volume overload; a pathologic S₄ (atrial gallop) occurs with CAD (see Table 19-7, Diastolic Extra Sounds, pp. 490-491, for a full description).

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Listen for Murmurs.

A murmur is a blowing, swooshing sound that occurs with turbulent blood flow in the heart or great vessels. Except for the innocent murmurs described, murmurs are abnormal. If you hear a murmur, describe it by indicating these following characteristics:

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Murmurs may be due to congenital defects and acquired valvular defects. Study Tables 19-9 and 19-10, pp. 492-497, for a complete description.

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Timing.

It is crucial to define the murmur by its occurrence in systole or diastole. You must be able to identify S₁ and S₂ accurately to do this. Try to further describe the murmur as being in early, mid-, or late systole or diastole; throughout the cardiac event (termed pansystolic, holosystolic/pandiastolic, or holodiastolic); and whether it obscures or muffles the heart sounds.

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A systolic murmur may occur with a normal heart or with heart disease; a diastolic murmur always indicates heart disease.

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Loudness.

Describe the intensity in terms of six “grades.” For example, record a grade ii murmur as “ii/vi.”

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Grade i

Grade ii

Grade iii

Grade iv

Grade v

Grade vi

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Pitch.

Describe the pitch as high, medium, or low. The pitch depends on the pressure and the rate of blood flow producing the murmur.

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Pattern.

The intensity may follow a pattern during the cardiac phase, growing louder (crescendo), tapering off (decrescendo), or increasing to a peak and then decreasing (crescendo-decrescendo, or diamond shaped). Because the whole murmur is just milliseconds long, it takes practice to diagnose any pattern.

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Quality.

Describe the quality as musical, blowing, harsh, or rumbling.

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The murmur of mitral stenosis is rumbling, whereas that of aortic stenosis is harsh (see Table 19-10).

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Location.

Describe the area of maximum intensity of the murmur (where it is best heard) by noting the valve area or intercostal spaces.

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Radiation.

The murmur may be transmitted downstream in the direction of blood flow and may be heard in another place on the precordium, the neck, the back, or the axilla.

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Posture.

Some murmurs disappear or are enhanced by a change in position.

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Some murmurs are common in healthy children or adolescents and are termed innocent or functional. Innocent indicates having no valvular or other pathologic cause; functional is due to increased blood flow in the heart (e.g., in anemia, fever, pregnancy, hyperthyroidism). The contractile force of the heart is greater in children. This increases blood flow velocity. The increased velocity plus a smaller chest measurement makes an audible murmur.

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The innocent murmur is generally soft (grade ii), midsystolic, short, crescendo-decrescendo, and with a vibratory or musical quality (“vooot” sound like fiddle strings). Also, the innocent murmur is heard at the second or third left intercostal space and disappears with sitting, and the young person has no associated signs of cardiac dysfunction.

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Although it is important to distinguish innocent murmurs from pathologic ones, it is best to suspect all murmurs as pathologic until they are proved otherwise. Diagnostic tests such as ECG, phonocardiogram, and echocardiogram are needed to establish an accurate diagnosis.

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Change Position.

After auscultating in the supine position, roll the person toward his or her left side. Listen with the bell at the apex for the presence of any diastolic filling sounds (i.e., the S₃ or S₄) (Fig. 19-28).

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S₃

S₄

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Ask the person to sit up, lean forward slightly, and exhale. Listen with the diaphragm firmly pressed at the base, right, and left sides. Check for the soft, high-pitched, early diastolic murmur of aortic or pulmonic regurgitation (Fig. 19-29).

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Murmur of aortic regurgitation sometimes may be heard only when the person is leaning forward in the sitting position.

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The Pregnant Woman

The vital signs usually yield an increase in resting pulse rate of 10 to 15 beats per minute and a drop in blood pressure from the normal prepregnancy level. The BP decreases to its lowest point during the second trimester and then slowly rises during the third trimester. The BP varies with position. It is usually lowest in the left lateral recumbent position, a bit higher when supine, and highest when sitting.

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Suspect pregnancy-induced hypertension with a sustained rise of 30 mm Hg systolic or 15 mm Hg diastolic under basal conditions.

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the pregenant woman

Inspection of the skin often shows a mild hyperemia in light-skinned women because the increased cutaneous blood flow tries to eliminate the excess heat generated by the increased metabolism.

Palpation of the apical impulse is higher and lateral compared with the normal position, because the enlarging uterus elevates the diaphragm and displaces the heart up and to the left and rotates it on its long axis.

Auscultation of the heart sounds shows changes caused by the increased blood volume and workload:

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_ Heart sounds

Exaggerated splitting of S₁ and increased loudness of S₁

A loud, easily heard S₃

_ Heart murmurs

A systolic murmur in 90%, which disappears soon after delivery

A soft, diastolic murmur heard transiently in 19%

A continuous murmur from breast vasculature in 10%

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The Aging Adult

A gradual rise in systolic blood pressure is common with aging; the diastolic blood pressure stays fairly constant with a resulting widening of pulse pressure.

Some older adults experience orthostatic hypotension, a sudden drop in blood pressure when rising to sit or stand.

Use caution in palpating and auscultating the carotid artery. Avoid pressure in the carotid sinus area, which could cause a reflex slowing of the heart rate.

Also, pressure on the carotid artery could compromise circulation if the artery is already narrowed by atherosclerosis.

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When measuring jugular venous pressure, view the right internal jugular vein. The aorta stiffens, dilates, and elongates with aging, which may compress the left neck veins and obscure pulsations on the left side.

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the aging adult

The chest often increases in anteroposterior diameter with aging. This makes it more difficult to palpate the apical impulse and to hear the splitting of S₂. The S₄ often occurs in older people with no known cardiac disease. Systolic murmurs are common, occurring in over 50% of aging people.

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Occasional premature ectopic beats are common and do not necessarily indicate underlying heart disease.

When in doubt, obtain an ECG.

However, consider that the ECG records for only one isolated minute in time and may need to be supplemented by a test of 24-hour ambulatory heart monitoring.

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The S₃ is associated with heart failure and is always abnormal over age 35 years (see Table 19-7).

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Characteristics of Jugular Versus Carotid Pulsations

Internal Jugular Pulse

location: Lower, more lateral, under or behind the sternomastoid muscle

quality:

Undulant and diffuse, two visible waves per cycle

respiration: Varies with respiration; its level descends during inspiration when intrathoracic pressure is decreased

palpable: no

pressure: Light pressure at the base of the neck easily obliterates

position of person: Level of pulse drops and disappears as the person is brought to a sitting position

Carotid Pulse

location: Higher and medial to this muscle

quality: Brisk and localized, one wave per cycle

respiration: does not vary

palpable: yes

pressure:  no change

position of person: unaffected

Clinical Portrait of Heart Failure

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Decreased cardiac output

Signs and symptoms

Onset

acute,

chronic,

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Systolic Extra Sounds

ejection click

The ejection click occurs early in systole at the start of ejection because it results from opening of the semilunar valves.

Normally, the SL valves open silently, but in the presence of stenosis (e.g., aortic stenosis, pulmonic stenosis), their opening makes a sound.

It is short and high pitched, with a click quality, and is heard better with the diaphragm.

The aortic ejection click is heard at the second right interspace and apex and may be loudest at the apex.

Its intensity does not change with respiration.

The pulmonic ejection click is best heard in the second left interspace and often grows softer with inspiration.

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systolic extra sounds

Aortic Prosthetic Valve Sounds

As a sequela of modern technologic intervention for heart problems, some people now have iatrogenically induced heart sounds.

The opening of a mechanical aortic ball-in-cage prosthesis produces an early systolic sound.

This sound is less intense with a tilting disk prosthesis and is absent with a biologic tissue prosthesis (e.g., porcine).

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systolic extra sounds

midsystolic click

Although it is systolic, this is not an ejection click.

It is associated with mitral valve prolapse, in which the mitral valve leaflets not only close with contraction but balloon back up into the left atrium.

During ballooning, the sudden tensing of the valve leaflets and the chordae tendineae creates the click.

The sound occurs in mid- to late systole and is short and high pitched, with a click quality.

It is best heard with the diaphragm, at the apex, but also may be heard at the left lower sternal border.

The click usually is followed by a systolic murmur. The click and murmur move with postural change; when the person assumes a squatting position, the click may move closer to S₂, and the murmur may sound louder and delayed.

The Valsalva maneuver also moves the click closer to S₂.

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diastolic extra sounds