Writing Up the Physical Examination

Listed here are examples of the write-up for the examination of the heart.

• No abnormal jugular venous distention or abnormal jugular wave forms are present. The PMI is in the fifth intercostal space, midclavicular line. Si and S2 are normal.* Physiologic splitting is present. No murmurs, gallops, or rubs are heard. There is no clubbing, cyanosis, or edema.

• The jugular venous pressure is elevated. There is a prominent 'V wave present in the neck. The jugular vein is distended 8 cm above the sternal angle at 45°. The PMI is in the sixth intercostal space, anterior axillary line. Sx is soft. S2 is widely split on inspiration and expiration. A grade III/VI, high-pitched, holo-systolic murmur is heard at the apex with radiation to the axilla. A palpable S3 is present at the apex. There is 2+ pitting edema on the shins bilaterally. No cyanosis or clubbing is present.

• No abnormal jugular venous distention is seen. The PMI is in the fifth intercostal space, midclavicular line. Sx is normal. S2 is soft. An S4 is present at the apex. A grade IV/VI, harsh, medium-pitched, crescendo-decrescendo murmur, beginning slightly after Sx and ending before S2, is present at the aortic area. This murmur radiates to both carotid arteries. No clubbing, cyanosis, or edema is present.

• The jugular venous pressure is very elevated. The jugular vein is distended to the jaw margin when the patient is seated at 90°. The PMI is in the fifth intercostal space, midclavicular line. Sx is accentuated. S2 is normal. An RV{ rock is present at the left lower sternal border. There is a grade II/VI, low-pitched, diastolic rumble heard at the apex, best heard in the left lateral decubitus position. A grade III/VI, high-pitched, holosystolic murmur is heard at the left lower sternal border, which increases in intensity with inspiration. A right ventricular S3 may be present at the left lower sternal border.{ There is 4+ pitting sacral edema. No cyanosis or clubbing is present.

*The descriptors for Sx and S2 are normal, increased, decreased, widely split, narrowly split, fixed split, or paradoxically split. Never indicate that Sj and S2 are present. {Right ventricular.

{Notice that in this example the examiner stated that a finding may be present.

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