What subjective data is important when assessing the cardiovascular system?

Instruments needed for the cardiovascular examination are listed in . The examination involves inspection, palpation, and auscultation of the heart, arteries, and veins. The cardiac examination consists of evaluation of (1) the carotid arterial pulse and auscultation for carotid bruits; (2) the jugular venous pulse and auscultation for cervical venous hums; (3) the precordial impulses and palpation for heart sounds and murmurs; and (4) auscultation of the heart. The evaluation of the peripheral arteries, the aortic pulsation, elicitation of pulsus alternans, and a search for thrombophlebitis completes the cardiovascular examination ().

Special attention should be given to the patient's general appearance, since it can reflect the state of the circulation as well as noncardiac diseases that may involve the heart. The patient's color (pale, flushed, or cyanotic), facial features, body build, and obvious pulsations should be noted. The blood pressure and heart rate and rhythm are obtained with the vital signs, but must be integrated with the findings of the cardiovascular examination to arrive at the proper diagnosis.

Examination of the Heart

Carotid Arteries

Begin the cardiovascular examination by assessing the carotid arterial pulses (Chapter 20). They are ordinarily examined while the patient is breathing normally and reclining with the trunk of the body elevated about 15 to 30 degrees (). In order to examine the carotid arteries, the sternocleidomastoid (SCM) muscle should be relaxed and the head rotated slightly toward the examiner. The examiner places the forefinger or thumb, depending on individual preference, slightly over the artery in the groove just lateral to the trachea. Care should be taken always to palpate in the lower half of the neck in order to avoid the area of the carotid bulb, lest a hypersensitive carotid sinus reflex be evoked with resultant bradycardia and hypotension. It is important that the carotid pulses be palpated using light pressure, one side at a time, since bilateral carotid compression may produce cerebral ischemia and syncope; extreme caution should be exercised in patients who have a history of syncope or transient neurologic symptoms.

Figure 7.1

Examination of the carotid arterial pulse. Place the patient in the supine position with the trunk elevated approximately 30 degrees, the head turned slightly toward the side being examined and the chin elevated. Palpate the carotid artery by gently pressing (more...)

Listen to the heart with the stethoscope in order to identify the first (S1) and second (S2) heart sounds while simultaneously palpating the carotid artery. The heart sounds are used as reference points for the cardiac examination in order to determine which events occur in systole (between S1 and S2) and which in diastole (between S2 and S1). While listening to the heart sounds, the examiner carefully and slowly applies more and more pressure to the carotid artery until the maximum pulse is felt; palpation should be continued for 5 to 8 seconds. The examiner should then slowly release the pressure on the artery while attempting to form a mental image of the pulse wave. It may be possible to detect an anacrotic notch (halt on the upstroke) or a bisferiens pulse (bifid or double peak) more easily with light pressure than with heavy pressure. In patients with evidence of carotid arterial disease, palpation of the vessels obviously should be gentle.

Divide the carotid pulse wave into three parts: (1) ascending limb or upstroke; (2) peak; and (3) descending limb. Initially concentrate on the amplitude (size) of the carotid pulse and note whether it is normal, decreased, or increased. If necessary, use your own carotid pulse as a control. Next, direct attention to analysis of the pulse contour and note if there is a single or double peak, a shudder or thrill, and the location of the peak within systole (i.e., early, mid, or late). Then concentrate on the upstroke and note whether it is normal, rapid, or slow. Finally, concentrate on the down-stroke of the pulse, which is difficult to palpate reliably. If there is a rapid fall-off, for instance, the majority of the clownstroke will be completed during systole.

The normal carotid arterial pulse wave is illustrated in together with the heart sounds. The upstroke of the carotid tracing is moderately rapid and smooth, and begins just after the initial component of the first heart sound. The summit of the carotid pulse is smooth and dome shaped, and occurs approximately in the middle of systole. The descending limb from the systolic peak is usually less steep than the ascending limb. In most normal individuals, the carotid incisura or dicrotic notch is not palpable; however, one can usually sense a change to a less steep down-slope.

Figure 7.2

These graphics represent the normal cardiac pulsations and heart sounds. The jugular venous pulsation normally has 3 positive waves—the a, c, and v waves and 2 negative troughs—x and y troughs. The "a" wave is approximately synchronous (more...)

There are a variety of abnormal arterial pulses including the hypokinetic pulse commonly seen with left ventricular failure; the hyper kinetic pulse commonly seen with mitral or aortic regurgitation; and the bisferiens pulse seen with aortic regurgitation or hypertrophic cardiomyopathy. During routine palpation of the carotid pulse, pay particular attention to the amplitude of the pulse following any premature beat, A diminished pulse amplitude following a premature beat is suggestive of hypertrophic cardiomyopathy.

Auscultation should be performed along the course of the carotid artery in order to detect any bruits. (See and Chapter 18). The location of maximum intensity of the bruit should be noted, as well as the pitch and duration of the sound. It is necessary for the patient to stop breathing during auscultation to eliminate the harsh sounds of tracheal breathing that could mask a low-pitched carotid bruit.

Figure 7.3

Auscultation of the carotid artery. Lightly apply the bell of the stethoscope over the course of the carotid artery, from the base of the neck to angle of the jaw, during full expiration.

Jugular Veins

The jugular venous pulse (Chapter 19) is usually examined next. It includes observation of venous wave form, assessment of the response of the venous pressure to abdominal compression, estimation of the central venous pressure (CVP), and auscultation for cervical venous hums. Venous pulsations are examined by inspection of either the external or internal jugular veins, although the latter are generally more reliable because they more directly reflect right atrial hemodynamics.

The position of the patient is extremely important for the examination of the jugular veins (). Relax the neck muscles by placing a small pillow behind the neck. The head should not be rotated more than a few degrees, since rotation may tense the SCM muscle and obscure the transmission of venous pulsations. The trunk of the body should be elevated until maximal venous pulsations are noted. The degree of trunk elevation varies from subject to subject and must be established for each person. In most normal individuals, the maximum pulsation of the internal jugular vein is usually observed when the trunk is inclined to about 15 to 30 degrees. In patients with elevated venous pressure, it may be necessary to elevate the trunk more than 45 degrees to visualize the maximum venous pulsation. At times there is venous distention without visible waves and the pulsations are only seen with the patient upright at 90 degrees.

Figure 7.4

Anatomy of the blood vessels in the neck. Evaluation of the jugular venous pulse and the carotid artery are best accomplished with the patient supine, the neck muscles relaxed by placing a small pillow under the head and the trunk elevated until the maximal (more...)

Look for pulsations of the internal jugular vein by standing just behind the patient and looking down alongside the SCM muscle or by bending over in front of the patient and looking directly along the SCM muscles. Direct your study of the wave form to whichever internal jugular pulse is easier to see. For most patients, the right internal jugular vein is superior for accurate evaluation of the venous wave form. The internal jugular venous pulsations may be highlighted by shining a beam of light from a penlight tangentially across the skin overlying the left internal jugular vein. This technique may amplify the wave form by casting a shadow of its pulsations on the pillow or bed sheet behind the neck.

The normal jugular venous pulse consists of intermittent increases in the volume of blood in the veins caused by slowing or halting of blood flow in the right atrium. Because they are low-pressure impulses, venous pulsations are not palpable and therefore are interpreted by inspection rather than by palpation, in contrast to the carotid arterial pulse. Generally, internal and external jugular venous pulsations may be eliminated by applying gentle pressure below the point of observation. This procedure also may produce increased distention of the vein by blocking the flow of blood to the heart. The visible venous pulsations in the neck are slower and more undulating than the brisk, forceful arterial pulse waves. Respiration may produce marked changes in venous pulsations, whereas arterial pulses normally change relatively little. Under normal circumstances, inspiration decreases intrathoracic pressure and increases return of blood to the heart from the peripheral veins. The result is to reduce the mean level of venous pulsation and distention; the opposite occurs during expiration.

Abdominal pressure may also be used to distinguish venous from arterial neck pulsations. This test is best performed with the patient lying comfortably in bed at the optimal angle for observing the internal jugular venous pulsations. The patient is instructed to continue normal breathing in order to avoid performance of a Valsalva maneuver. Moderately firm pressure is then slowly applied for about 30 seconds with the palm of the hand pressing on the abdomen, usually on the right side (over the liver). Normally this maneuver produces no visible change in the arterial pulse, but a slight increase in the prominence of the jugular venous pulsations. In the presence of heart failure the jugular venous pulsations may be markedly increased. The response of jugular venous pulse to abdominal compression is known as the hepato-jugular reflux test. It is useful not only for distinguishing venous from arterial pulsations but also in unmasking occult abnormalities of circulatory function.

The normally visible jugular venous pulsations consist of two outward pulsations or positive waves ("a" and "v") and two descents or collapses or negative waves ("x" and "y") as shown in . The "c" wave, a positive wave that follows the "a" wave, may be recorded, but is seldom seen at the bedside. The carotid pulse may be used to time venous pulsations, but the heart sounds generally are preferable at the bedside. The "a" wave, the larger of the two visible positive waves, begins before S1 and precedes the upstroke of the carotid pulse. The negative "x" and "y" waves occupy systole and diastole, respectively. The "v" wave occurs in late systole virtually synchronous with S2. Frequently, it is easier to visualize jugular descents because they are the largest and fastest movements.

The internal jugular veins are also used to estimate central venous pressure. The technique is similar to that for evaluation of the internal jugular venous wave form (). The patient is examined at the optimum degree of trunk elevation for inspection of the venous pulse. While the patient is breathing gently or preferably at the end of a normal expiration, the highest point of visible pulsation of the internal jugular vein is determined (). The CVP can then be estimated by measuring the vertical distance between the midright atrium and the top of the column of venous blood in relation to a fixed reference point, the sternal angle (of Louis). The vertical distance between the top of the column of venous blood and the level of the sternal angle is normally 2 cm. For convenience at the bedside, the sternal angle is chosen as a reference point because it has a relatively constant relationship, in all positions, to the midpoint of the right atrium (i.e., 5 cm above the mid-right atrium).

Figure 7.5

Estimation of the central venous pressure (CVP). Place the patient in the supine position with the head slightly elevated on a pillow to relax the sternocleidomastoid muscle. Elevate the trunk by adjusting the head of the bed so as to maximize the internal (more...)

The normal CVP is less than or equal to 7 cm H2O (i.e., 5 + 2 cm). The most common cause of an elevated CVP is failure of the right ventricle secondary to failure of the left ventricle. Earlobe and rarely eyeball pulsations are evidence of markedly elevated venous pressure.

Central venous pressure may also be estimated by examining the veins of the dorsum of the hand. To perform this determination, the patient should be in either a sitting or lying position at a 30-degree elevation or greater, and the hand should be kept below the level of the heart long enough for the veins of the dorsum of the hand to become distended. The arm is then slowly and passively raised while the physician observes the veins. Care should be taken that the arm is not flexed excessively at either the shoulder or the elbow and that the upper arm is not constricted by-clothing. Normally, the veins will be seen to collapse when the level of the dorsum of the hand reaches the sternal angle or the level of the suprasternal notch. The vertical distance above the sternal angle at which the veins collapse should be recorded as well as the position of the patient during the test.

Auscultation at the base of the neck, just above the clavicle and lateral to the clavicular attachment of the SCM muscle, with the patient sitting, enables one to determine if a cervical venous hum is present (Chapter 18). The cervical venous hum is a continuous whining or roaring noise throughout systole and diastole produced by the flow of blood through the internal jugular veins. It occurs more frequently on the right than on the left, but may be present bilaterally. It is loudest with the patient sitting, during inspiration, and in diastole. It may be increased by turning the head away from the side being auscultated. It is obliterated by applying light pressure directly above the point of auscultation, the Valsalva maneuver, compression of the internal jugular vein, or lying down. An arterial bruit, in contrast, is loudest in systole, unaffected by light pressure, the Valsalva maneuver, and the patient's changing position. The venous hum is a frequent finding in normal individuals, but may also be a clue to high-output states (e.g., thyrotoxicosis).

Precordial Movements and Thrills

The precordial examination, performed next, consists of inspection and palpation of the anterior chest wall. Precordial movements (Chapter 21) should be evaluated at the apex (left ventricle), lower left parasternal edge (right ventricle), upper left (pulmonary artery) and upper right (aorta) parasternal edges, and epigastric and sternoclavicular areas (). It is best to examine the precordium with the patient supine because if the patient is turned on the left side, the apical region of the heart is displaced against the lateral chest wall, distorting the chest movements. Inspect the chest wall by positioning yourself on the patient's right side and looking tangentially across the fourth, fifth, and sixth intercostal spaces. Ask the patient to take a deep breath and then to exhale slowly as you look for a discrete area of apical movement. The following are the factors to be considered about any precordial movement that can be seen or felt: (1) location; (2) amplitude; (3) duration; (4) time of the impulse in the cardiac cycle; and (5) contour.

Figure 7.6

Anteroposterior view of the chest indicating the major precordial areas to be examined. Try to detect by both inspection and palpation any abnormal pulsations that the underlying cardiac chambers and great vessels may produce. Auscultation is routinely (more...)

Locate the apex impulse by placing the palm and fingers of your right hand over the left precordium in the fourth, fifth, and sixth intercostal spaces near the midclavicular line (). If unable to palpate an impulse, move your hand laterally to the anterior axillary line. If still unable to locate the impulse, ask the patient to roll onto the left side and attempt to palpate the apex as just described (). Always state in which patient position the apex impulse was identified because the left lateral decubitus position distorts a normal apex and makes it appear or feel unduly sustained. If still unable to locate the apex impulse, inspect the right precordium in a manner similar to that used for the left precordium. On rare occasions the impulse may be visible in the right chest, providing the initial clue to the presence of dextrocardia.

Figure 7.7

Examination of the apex impulse in the supine position. Place the patient in the supine position elevating the trunk approximately 30–45 degrees. Position yourself on the patient's right side and place the flat part of your right hand over the (more...)

Figure 7.8

Examination of the apex impulse with the patient in the left lateral decubitus position. If the apex impulse cannot be located with the patient supine, ask the patient to roll to his left side and attempt to palpate the apex with the fingers of your right (more...)

Record the location of the apex impulse by noting its distance from either the midsternal or midclavicular line and the intercostal space in which it is felt. Also record the approximate diameter (cm) of the apex. The amplitude and duration of the apical pulsation may be more important than its location and size; therefore, state whether the impulse is of normal, increased, or diminished force and whether it occupies half or more than half of systole. If necessary, palpate your own apex impulse for comparison. In addition, if a single pulsation is palpated, determine whether its force is uniform throughout systole or whether there is a late systolic accentuation or bulge.

In a normal individual the apex impulse is a tapping, early systolic outward thrust that occurs in the fifth intercostal space in the midclavicular line. It is localized to a small area not more than 1 to 2 cm (dime-sized) in diameter. The outward thrust is brief, lasting about one-half of systole, and is of minimal amplitude. Normally, diastolic pulsations are not palpable. Left ventricular hypertrophy, for instance, results in exaggeration of the normal left ventricular thrust both in amplitude and duration. It is nondisplaced, sustained (occupying more than one-half of systole), and 2 to3 cm (quarter-sized). Left ventricular dilation, in contrast, results in downward and lateral displacement of the apex below the fifth interspace.

The lower left parasternal region of the chest is best evaluated by looking at the chest from the side and by placing the heel of the hand over or just to the left of the sternum (). If a left parasternal impulse or lift is appreciated, determine if the impulse is sustained throughout systole, vigorous or slight, and begins with or after the onset of the apex impulse. Determine its onset by placing your right hand over the apex impulse and your left palm over the left parasternal impulse. The right ventricle is really an anterior structure, and when enlarged, it may lift the anterior portion of the chest including the sternum. In normal individuals the parasternal region usually retracts (moves inward) during ejection and is not palpable.

Figure 7.9

Palpation of the left parasternal impulse. Place the patient in the supine position with the trunk elevated 30–45 degrees. Place the heel of your right hand, with the hand slightly cocked up, together with downward pressure (arrow) of your left (more...)

Right ventricular hypertrophy and/or dilation results in a sustained systolic lift of the lower parasternal region of the chest. This lift is present in patients with high right ventricular pressure (pulmonary arterial hypertension or pulmonic stenosis) or volume overload (tricuspid regurgitation or atrial septal defect), but is infrequently seen in chronic lung disease if right-sided heart failure is not present. The pulsations of the main pulmonary artery are also often visible and palpable, especially in patients with parasternal pulsations.

Patients with acute myocardial infarction or with angina pectoris may have an outward paradoxical precordial movement that often can be seen or palpated at the apex, the anterior precordium, or in an "ectopic" area. The impulse is usually sustained throughout systole, frequently with a second systolic bulge, and is often difficult to distinguish from that of left ventricular hypertrophy by palpation alone if the bulge occurs in the region of the apex. In order to time systolic and diastolic cardiac movements accurately, it is essential to inspect and palpate the precordium while actually listening to the heart sounds.

The early diastolic and late diastolic (presystolic) precordial movements are the visible and palpable counterparts of the third (S3) and fourth (S4) heart sounds, respectively. They may be felt at the cardiac apex with the patient in the left lateral decubitus position. Careful inspection of the precordium with the naked eye or observing the motions of a wooden stick taped over the cardiac apex best demonstrates any precordial impulses that correlate with audible S3 and S4 sounds. The right-sided S4, seen and felt at the lower left sternal edge, occurs slightly earlier in diastole than the left-sided S4. It often correlates with a very prominent jugular "a" wave and a sustained outward movement (lift) in the lower left parasternal area.

Heart murmurs that can be palpated are referred to as thrills (Chapters 26 and 27). The diastolic rumble of mitral stenosis and the systolic murmur of mitral regurgitation may be palpated at the cardiac apex. The harsh systolic murmur of aortic stenosis may cut across the palm of the hand toward the right side of the neck, while the thrill of pulmonic stenosis cuts across the palm of the hand to the left side of the neck. The thrill due to ventricular septal defect is usually located in the third and fourth intercostal spaces near the left sternal border. Heart sounds may also be palpable. For instance, the loud S1 of mitral stenosis may be palpated at the apex.

Heart Sounds and Murmurs

Auscultation (Chapters 22–28) of the heart is performed after examining the jugular venous pulse, carotid pulse, and precordial movements because acoustic events can best be interpreted after the other components of the cardiac examination have been evaluated. Auscultation of the heart should, therefore, not be performed as an isolated event because heart sounds, murmurs and pulse tracings must all be integrated in order to understand normal and altered cardiac physiology and anatomy. Attempt to study two and occasionally three aspects of the cardiac examination simultaneously. Then pictorially display the heart sounds and correlate them, by use of a diagram, with any murmurs heard, the jugular venous wave form, the carotid pulse, and the apex impulse to best understand the patient's cardiac problem ().

Proper use of a quality stethoscope is essential for an accurate auscultatory examination. The important parts of the stethoscope are the ear pieces, the tubing, and the chest pieces. The ear pieces must fit the ear canal snugly without going to an uncomfortable depth. The tubing should be as short as possible, but long enough to be comfortable and convenient for the user; 10 to 12 inches is an ideal length. The chest pieces, the bell, and the diaphragm should be combined into one housing. A diaphragm pressed firmly on the chest filters out low-frequency vibrations and amplifies high-frequency vibrations. It is routinely used to hear the first and second heart sounds, systolic murmurs, and the diastolic murmur of aortic regurgitation. The bell should be applied to the chest with very light pressure, barely creating an air seal, so low-frequency sounds and murmurs are appreciated. It is used to hear the third and fourth heart sounds and the diastolic murmur (rumble) of mitral stenosis. A trumpet-shaped bell is much better than a shallow one.

Auscultation usually begins at the aortic area (upper right sternal edge). The stethoscope is then moved sequentially to the pulmonary (upper left sternal edge), tricuspid (lower left sternal edge), and mitral (apex) areas. It is helpful to palpate the carotid pulse or apex impulse simultaneously to time the acoustic events as systolic or diastolic. A finger on the carotid artery will sense the systolic thrust that is virtually coincident with S1. Use of a more distant artery for this purpose leads to error because of the time it takes the pulse wave to reach the periphery.

The heart sounds are usually the first auscultatory events identified. They are brief, discrete, auditory vibrations of varying intensity (loudness) and frequency (pitch). The first heart sound (Chapter 22) identifies the onset of systole. It is normally split into mitral (M1) and tricuspid (T1) components that are temporally related to closure of the respective atrioventricular (A-V) valves. The second heart sound (Chapter 23) identifies the end of systole and the onset of diastole. It is normally split into aortic (A2) and pulmonic (P2) components that are temporally related to closure of the respective semilunar valves. The second sound is louder than S1 in the aortic listening area; S1 is louder at the apex.

In the aortic area, listen for the first and second heart sounds, the aortic ejection sound, and the murmurs of aortic stenosis and aortic regurgitation with the stethoscope diaphragm. Then move the diaphragm to the second and third left intercostal spaces in order to appreciate the aortic and pulmonic components of S2, the pulmonary ejection sound, and the murmurs of pulmonic stenosis and pulmonary and aortic regurgitation. Continue to the fourth and fifth intercostal spaces along the left sternal border and listen for the murmurs of tricuspid regurgitation and tricuspid stenosis and the murmur produced by ventricular septal defect. Right ventricular S3 and S4 sounds (gallops) can best be heard in this area with the stethoscope bell. The diaphragm should be moved to the third and fourth intercostal spaces to the right of the sternum to judge whether a murmur of aortic regurgitation is louder along the left or right sternal border.

The diaphragm should then be positioned at the cardiac apex where S1 and S2 should again be studied. An aortic ejection sound, a mid to late systolic click, the opening snap of mitral stenosis, the systolic murmur of mitral regurgitation, and occasionally the high-pitched murmur of aortic regurgitation are also heard in this area with the diaphragm.

The bell of the stethoscope should then be positioned over the apical impulse with the patient turned to the left lateral position to listen for low-frequency diastolic sounds and murmurs.

Have the patient exercise (5 to 10 sit-ups), or cough if myocardial infarction is suspected, to "bring out" the murmur of mitral stenosis and the S3 and S4 gallop sounds. The third and fourth heart sounds (Chapters 24 and 25) are low pitched and may be audible as well as palpable. They are best heard at the cardiac apex when generated from the left ventricle and at the lower left sternal edge when generated from the right ventricle.

The technique known as inching may help determine whether extra cardiac sounds are systolic or diastolic. The examiner moves the stethoscope inch by inch from the aortic area to the apex while focusing attention on S2. Determine whether the extra sound precedes (systolic) or follows (diastolic) S2. The acoustic events can best be appreciated by a careful review of the hemodynamic curves of the cardiac cycle.

Several additional areas should be ausculted (), including (1) the inferior edge of the sternum and epigastrium, especially in patients with chronic obstructive lung disease, in whom heart sounds and murmurs are difficult to hear in the more conventional listening areas; (2) the first and second intercostal spaces below the left midclavicular area for the continuous (systolic and diastolic) murmur of patent ductus arteriosus; (3) the interscapular area of the back for the systolic murmur of coarctation of the aorta; (4) over the lung areas; (5) over the head, eyes, liver, sacrum, abdomen, as well as over tumors or bony overgrowths; and (6) over all scars to identify the continuous murmur of a peripheral A-V Fistula.

Figure 7.10

Anteroposterior view of the chest showing some additional areas shaded for auscultation. The first and second left intercostal spaces at the mid clavicular line (MCL). The fifth intercostal space to the right of the sternum. The epigastric area just below (more...)

Murmurs (Chapters 26 and 27) are prolonged series of auditory vibrations that should be characterized according to (1) timing in the cardiac cycle (systolic, diastolic, continuous); (2) intensity (loudness); (3) frequency (pitch); (4) configuration (shape); (5) duration (long or short); (6) radiation (to other auscultatory areas); and (7) variation, if any, with respiration or other maneuvers (position change, Valsalva, etc.).

The classic way to time murmurs and heart sounds is with a finger on the carotid arterial pulse. The heart sound virtually coinciding with the carotid upstroke (pulse) is Sl and the heart sound just after the carotid pulse is S2. The intensity of a murmur is graded I to VI with I faint, III loud, IV palpable, and VI loud enough to be heard with the stethoscope just off the chest. The frequency of a murmur varies from low (rumbling) to mid (harsh) to high (blowing). The configuration is described as crescendo (increases progressively in intensity), decrescendo (decreases progressively in intensity), crescendo-decrescendo (diamond-shaped), or plateau (even). Of all the parameters by which a murmur is analyzed, its time of occurrence in the cardiac cycle and the precordial area of maximal intensity are easiest to learn and thus are most reliable.

The influence of respiration on the second sound is extremely important. The examiner will wish to note respiratory variation both during quiet breathing and at times during exaggerated breathing. The interval between the two audible components of S2 normally increases on inspiration and virtually disappears on expiration. The Valsalva maneuver may be used to exaggerate the effects of respiration. Variation in the cardiac cycle, as with atrial fibrillation or heart block, may also exert profound influences on S2 and on S1. When S2 is split, determine the relative loudness of each component (A2 and P2).

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