Heart & Lung Exam: Sounds, Maneuvers, JVP & Lung Patterns

Maneuvers narrow the differential; echocardiography confirms it

AS aortic stenosis, MR mitral regurgitation, AR aortic regurgitation. Inspiration raises right-sided venous return and lowers left-sided flow. Valsalva strain shrinks the LV and cuts venous return. Handgrip raises afterload. Squatting raises venous return and afterload. Squat-to-stand also makes the obstructive HCM murmur louder (95% sensitivity, 84% specificity, Lembo 1988). Each valve's own murmur is on its valve sheet.

Elevated = more than about 3 cm above the sternal angle

Merck examines at 45° and gives an upper limit of 4 cm above the sternal notch. The classic add-5-cm conversion to CVP underestimates: the sternal angle sits a mean 8 cm (30°) to 9.8 cm (60°) above the mid-right atrium. Sustained abdominojugular reflux signals a dilated, poorly compliant RV or obstructed RV filling. Merck: normally falls back within 3 respiratory cycles or 15 seconds; Chua Chiaco 2013: persistence beyond 10 seconds is abnormal. Kussmaul sign can also occur in heart failure and tricuspid stenosis. Elevated venous column: right heart failure, volume overload, tamponade, constrictive pericarditis, tricuspid stenosis or regurgitation, SVC obstruction, poor RV compliance. A low column suggests hypovolemia.

Pulsus paradoxus: measure by slow cuff deflation

Pulsus paradoxus also occurs in constrictive pericarditis, restrictive cardiomyopathy, severe asthma, COPD and severe pulmonary embolism. A difference up to 15 mmHg between arms is normal; more suggests aortic dissection or peripheral vascular disease (15 mmHg is only the upper limit of normal; the Aortic Dissection sheet cites differences sometimes above 30 mmHg in dissection). An ankle-brachial index of 0.90 or less suggests peripheral artery disease.

Merck calls S4 always abnormal; other references accept an S4 in older adults from age-related stiffening. Treat it as pathologic in the young. Murmur grades: systolic 1–6 (grade 3 loud without a thrill, grade 4 loud with a thrill, grade 6 audible with no chest contact); diastolic 1–4.

ILD interstitial lung disease. Exam sensitivity for effusion is probably low. See Pneumothorax for tension physiology. Atelectasis gives decreased breath sounds and, when large, dullness and decreased chest excursion; signs are often absent when it is minimal. COPD gives wheezing, prolonged expiration, decreased heart and lung sounds from hyperinflation and a barrel chest; jugular distention with leg edema suggests right heart failure from chronic lung disease.