1. A “sustained” apex beat (or apical impulse, also once called “PMI” or Point of Maximal Impulse) corresponds mainly to left ventricular hypertrophy, and is therefore sometimes seen in persons with long-standing hypertension, or aortic stenosis (in both cases, the cardiac muscle works against an increased load, and thickens—but not a good thing for the heart, even if it is for your biceps). “Sustained” means that the impulse lifts your finger or stethoscope through all, or almost all, of the systolic interval. It can be a clue to how long a person has had high blood pressure, or how well has been its control. But a sustained apical impulse can also be encountered in the dilated heart of cardiomyopathy. When assessing whether an apex beat is “sustained,” you must do this with the patient supine. Apex beats may be “brought out” (made easier to locate) with the patient on the left side, but this position alters their quality. Only about 40% of persons in the supine position will show a palpable apex beat.
2. The often quiet, low-pitched sound of the S3 (lub –dub-duh) is sometimes heard most easily with the patient in the left lateral decubitus position (halfway rolled on left side), listening at the area of the apex beat (if one can be felt), with the bell of the stethoscope held lightly. Applying pressure with the bell makes the skin a “diaphragm” and can filter out the low-pitched sound. Three are several sounds that can be mistaken for an S3, such as a widely split S2 (as occurs in right bundle-branch block). But the widely split S2 will usually be heard well at the base, and comprises a pair of high-pitched sounds. The S3 is a sign of left ventricular failure, though it can be heard in persons with mitral regurgitation who are not in active failure. Oddly, a sort of variable S3 can often be heard in perfectly healthy young persons (ie, under 20-y-o).
3. In general, the second heart sound is louder at the “base” areas (2nd interspaces), and the S1 at the “apical” areas, though in many normal persons this distinction is not all that clear. The second heart sound tends to have more distinct “splitting,” which increases with inspiration.
4. There exists considerable confusion and some debate about how to position the patient in order to see the jugular pulsation or vein. Most examiners will start at 30 or 45 degrees. The height of the top of the visible vein, or the height of the pulsation, in relation to the “sternal angle” (marker for the right atrium) does not vary much with the angle of the patient. Neck veins (ie, pulsation or top of visible column) seen up to the angle of the jaw with the patient sitting up will usually be persuasive evidence for fluid overload or cardiac failure.
5. Depending perhaps upon its cause, the diastolic “blowing” murmur
of aortic regurgitation (lub – dub - WOOOOO) may be best heard in various
patients anywhere from the right second interspace (traditional “aortic
area”) to the apex. But very often this sound is most readily heard at
the 3rd to 4th left interspace. Whereas aortic regurgitation at one time was
usually a result of rheumatic valvular disease, today it is often from the “bicuspid”
aortic valve; and there are other causes.