Physical Exam
Cardiac examination reveals a loud S1, normal S2, and an opening snap. There is a regular rhythm
with a grade 2/6 holosystolic murmur at the cardiac apex radiating to the axilla (= MR) , and a low-
pitched 3/6 middiastolic murmur following the opening snap that accentuates presystole (=MS)

An ejection click in close proximity to the S1 is heard along the left sternal border and second left
intercostal space, which decreases in intensity with inspiration. A grade 4/6 early systolic murmur that
increases with inspiration is best heard in the second left intercostal space without radiation to the
carotid arteries. No diastolic murmur is noted = PS

The jugular venous pulse contour demonstrates a prominent a wave. A right ventricular lift and systolic
thrill are present. An ejection click is noted and is close to the S1, suggesting severe pulmonary valve
stenosis. This sound decreases in intensity during inspiration (the only right-sided sound that
decreases during inspiration). An early systolic murmur is noted over the pulmonary area. The
electrocardiogram demonstrates right ventricular hypertrophy and right axis deviation. The chest
radiograph demonstrates pulmonary artery dilatation. The diagnosis can be confirmed by
echocardiography.

-A bicuspid aortic valve is a more common cause of an ejection click than is congenital pulmonary
valve disease, and it is associated with the development of aortic stenosis. Aortic stenosis is
characterized by small and late carotid pulsations, a late-peaking systolic murmur loudest in the
second right intercostal space, absent splitting of S2, and a sustained apical impulse. The murmur
characteristically radiates to one or both carotid arteries

-The characteristic physical examination finding in atrial septal defect is fixed splitting of the S2. Equal
a and v waves may be noted on jugular venous assessment. A right ventricular impulse is present. An
ejection click may be audible if the pulmonary artery is enlarged but is less common than in patients
with pulmonary stenosis. A pulmonary midsystolic murmur and a tricuspid diastolic flow rumble may
be heard owing to increased flow through the valves from the left-to-right shunt.

-Chronic mitral valve regurgitation is characterized by a holosystolic murmur at the apex that radiates
to the axilla without respiratory variation.
Tricuspid valve regurgitation causes a holosystolic murmur noted at the left sternal border. This
characteristically increases with inspiration, but marked right ventricular hypertrophy and right axis
deviation would not be expected on the electrocardiogram with this valvular lesion. The jugular venous
pulse contour demonstrates a prominent v wave with tricuspid regurgitation, rather than a prominent a
wave.

-A grade 3/6 late systolic apical murmur is heard that radiates toward the left axilla. Moving from a
squatting position to a standing position increases murmur intensity. Following a Valsalva maneuver,
the murmur intensity decreases = MR

-Cardiac examination reveals an S3 gallop at the apex and a grade 3/6 midsystolic murmur along the
lower left sternal border that accentuates with a Valsalva maneuver and diminishes with a hand-grip
maneuver = HOCM
early diastolic low-pitched sound after the S2 with a diastolic murmur at the apex = turned out to have
an atrial septal myxoma causing functional MS. the opening sound in this patient is a low-pitched
sound associated with a left atrial myxoma, a so-called “tumor plop.”

-Rheumatic mitral stenosis on auscultation can cause an early high-pitched diastolic sound (an opening
snap) and a diastolic decrescendo murmur

Left atrial myxoma causes fever, night sweats, and weight loss, and may embolize

Heart rhythm is regular with a summation gallop. A grade 4/6 continuous murmur is heard over the
precordium that accentuates during diastole. = This patient has aortic valve endocarditis. There is
echocardiographic evidence of paravalvular extension with abscess (echolucency) and color Doppler
evidence of an aorto-cavitary fistula from the aortic root to the right ventricle. There are multiple,
mobile echodensities on the aortic valve, with moderate aortic valvular regurgitation.

grade 2/6 midsystolic murmur that does not radiate, heard best at the second right intercostal space
= aortic sclerosis.

-an irregularly irregular rhythm, a loud S1, normal S2, and an opening snap. A grade 2/6 holosystolic
murmur is heard at the cardiac apex radiating to the axilla, and a low-pitched diastolic murmur is
heard following the opening snap=MS + MR

The carotid upstroke is brisk and collapses quickly (AR). The apical impulse is displaced (LV dilation).
There is a grade 2/6 early systolic murmur noted at the second right intercostal space (bicuspid aortic
v). A grade 3/6 high-pitched decrescendo diastolic murmur is noted along the left sternal border and
toward the apex (AR). There is evidence of nailbed pulsation (AR). Femoral pulsations are full,
collapse quickly (AR), and there is no lag between the radial and femoral pulsations
If there is increased stroke volume of the left ventricle due to volume overload, an ejection systolic
'flow' murmur may also be present when auscultating the same aortic area. Unless there is
concomittant aortic valve stenosis, the murmur should not start with an ejection click.

There may also be an Austin Flint murmur, a soft mid-diastolic rumble heard at the apical area. It
appears when regurgitant jet from the severe aortic insufficiency renders partial closure of the anterior
mitral leaflet.

history of an unrepaired ventricular septal defect with associated Eisenmenger syndrome. The jugular
venous pulse contour demonstrates a prominent a wave. The carotid examination is normal. The
cardiac apex is not displaced. There is a +2 parasternal impulse (RV enlargement). The pulmonic
component of the S2 is accentuated (pulm HTN). There is no S3 or S4. A soft systolic murmur is
noted at the left sternal border (VSD), and an ejection click is noted at the second left intercostal
space (pulmonic opening against high Pulm pressure). No diastolic murmur is noted. Digital clubbing
and cyanosis are present.

a sustained apical impulse; normal S1; and a single, soft S2 (absent A2 = severe AS). An S4 is
present. There is a grade 3/6 early-onset systolic, late-peaking murmur that is heard best at the right
upper sternal border and radiates to the left carotid artery. Carotid pulses are delayed. = AS

grade 2/6 holosystolic murmur at the cardiac apex radiating toward the left axilla.=MR
Kussmaul sign (accentuated jugular venous pressure during inspiration) and an early diastolic sound
(pericardial knock). These findings help to confirm constrictive pericarditis

-Grade 2/6 early peaking systolic murmur at the right upper sternal border and the left clavicular
region that does not radiate to the right clavicle or neck=left subclavian artery stenosis

the jugular venous pulse contour demonstrates equal a and v waves. The apical impulse is not
displaced. There is an impulse noted along the left sternal border right-sided chamber enlargement.
The S1 is normal. The S2 is split throughout the respiratory cycle right-sided chamber enlargement
fixed split S2 A grade 2/6 midsystolic murmur is noted at the second left intercostal spacepulmonic .
There is a grade 2/6 diastolic rumble noted at the lower left sternal border tricuspid rumble. Both of
these murmurs increase with inspiration= ASD The right-sided murmurs increase with inspiration due
to the increased systemic venous return.

the jugular venous pulse contour demonstrates equal a and v waves. The apical impulse is not
displaced. There is an impulse noted along the left sternal border right-sided chamber enlargement.
The S1 is normal. The S2 is split throughout the respiratory cycle right-sided chamber enlargement
fixed split S2 A grade 2/6 midsystolic murmur is noted at the second left intercostal spacepulmonic .
There is a grade 2/6 diastolic rumble noted at the lower left sternal border tricuspid rumble. Both of
these murmurs increase with inspiration= ASD The right-sided murmurs increase with inspiration due
to the increased systemic venous return.

Grade 2/6 decrescendo diastolic murmur at the left sternal border.=bicuspid aortic with moderate AR
-prominent a wave, A palpable early systolic murmur is noted over the second left intercostal space.
There is a grade 4/6 midsystolic murmur noted at the left sternal border. The pulmonic component of
the S2 is not audible= Pulmonic stenosis

-normal S1 and a single S2. There is a grade 3/6 systolic ejection murmur on examination heard at the
right upper sternal border that radiates to the left carotid artery. Carotid pulses are delayed.=AS
She has a mild right ventricular heave, a single S2, and a soft diastolic murmur at the base that
increases in intensity with inspiration.=PI

A continuous grade 4/6 systolic and diastolic murmur is noted over the left side of the chest and
primarily over the second left intercostal space.= PDA