Cardiovascular assessment requires more than careful examination. You need to correctly identify and interpret individual findings, fit them together in a logical pattern, and correlate your cardiac findings with the patient's blood pressure and heart rate, carotid upstroke and JVP, the arterial pulses, the remainder of your physical examination, and the patient's history. Evaluating systolic murmurs illustrates this point.

Integrated Assessment: Systolic Murmurs

An asymptomatic teenager might have a grade 2/6 midsystolic murmur in the 2nd and 3rd left interspaces. Because this suggests a pulmonic murmur you should assess the RV for hypertrophy by carefully palpating the left parasternal area. Because pulmonic stenosis and atrial septal defects can cause this murmur, auscultate carefully for a split S2, any ejection sounds, and variation with inspiration. Listen to the murmur after the patient sits up. Look for evidence of anemia, hyperthyroidism, or pregnancy that could cause such a murmur by increasing the flow across the aortic or the pulmonic valve. If all your findings are normal, your patient probably has a functional murmur—one with no pathologic significance.

Integrating this information allows you to generate a differential diagnosis about the origin of the murmur and pursue further evaluation.

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