Cardiovascular Examination

Color index
Important
Further explanation
Editing link
Done By: special thanks to:
Mohammad Alotaibi Moaath Alsheikh
Imp. points Before starting the examination:
 Confirm patient’s details
 Explain the examination
 Do WIPE:
 Wash your hands
 Introduce yourself
 Ask for Permission\ensure Privacy\Position the patient at 45°1
 Expose the patient’s chest
 Ask if the patient has any pain anywhere before you begin!
 Remember: always examine the patient from the right side.

What to do What to look for

1.General inspection:
connections e.g. nasogastric tube, oxygen mask or IV line
Comfortable at rest?  Does he look ill, in pain, has SOB
 Cachectic due to malignancy or severe HF
 syndromes that are associated with specific cardiac
disease + could be recognized by the patient’s
appearance:
-Marfan’s syndrome
-Down’s syndrome
-Turner’s syndrome

Inspect chest Scars, visible pulsations, Pectus excavatum or

Pectus carinatum
Inspect legs Scars, peripheral edema, missing limbs or toes

2.Hnads: Hands out + palms facing

downwards
-Ask the patient to place the nails of
their index fingers back to back:
 if healthy you should be able to observe
a small diamond shaped window
(Schamroth’s window)
Look for clubbing  When finger clubbing is present
this window is lost (Schamroth’s sign)
-causes of CLUBBING:
 Cyanotic congenital heart disease
 Lung abscess
 Ulcerative colitis & chron’s disease
 Bronchiectasis
 Bronchogenic carcinoma
 Infective endocarditis
 Nothing
 Graves

1.Why 45 for cardiac examination? Because it’s the usual position in which the jugular venous pressure
(JVP) is assessed + if the patient has PE and was laid flat, it might increase and impede breathing.
What to do What to look for

2.Hands cont..

Look for: -linear haemorrhages lying parallel

Splinter haemorrhages to the long axis of the nail.
-causes:
 bacterial endocarditis
 rheumatoid arthritis
 polyarteritis nodosa

Hands out + palms facing upwards:

Colour dusky bluish discoloration (cyanosis)

suggests hypoxia

Temperature cool peripheries may suggest poor cardiac output

Sweaty can be associated with acute coronary syndromes

Janeway lesions non-tender maculopapular

erythematous palm
pulp lesions –
Infective endocarditis

Osler’s nodes tender red nodules on

finger pulps / thenar
eminence –
Infective endocarditis

Capillary refill normal is <2 seconds –

if prolonged may
suggest hypovolemia

Xanthomata yellow or orange deposits of lipid

in the tendons caused by
hyperlipidemia
What to do What to look for
3.Pulses

Radial pulse Medial to the radius, using forefinger & middle finger
pulps, to assess rate & rhythm

Brachial & carotid pulses To assess volume & character

Check:
Normal, tachycardia or bradycardia?
Rate Pulse deficit1? Afib.

RHYTHM -Regular?
-Irregularly irregular or chaotic rhythm?
 NO pattern detected, e.g. A fib.
-regularly irregular? Sinus arrhythmia (normal
slowing of the pulse
with expiration)
-Bigeminal rhythm?
-Trigeminal rhythm?

Radio-radial delay: A delay is usually due to arterial occlusion by an

Palpate both radial pulses simultaneously atherosclerotic plaque or Aortic dissection
should occur at the same time in a healthy
adult.

Radio-femoral delay: A delay in the arrival of the femoral pulse wave

While palpating the radial pulse, place the suggests
fingers of your other hand over the femoral the diagnosis of coarctation of the aorta just distal to
pulse the origin of the subclavian artery

Collapsing (Waterhammer) pulse: associated with high stroke volume (high systolic bp)
First ensure the patient has no shoulder & low diastolic bp i.e. blood is returning to the LV very
pain>> Palpate the radial pulse>>Raise quickly (aortic regurgitation)
the arm above the head briskly>>Feel for -could be normal (fever/pregnancy), or in cardiac
a tapping impulse through the muscle bulk lesions (e.g PDA) or high output states (e.g anaemia
of the arm as blood empties from the arm / AV fistula / thyrotoxicosis)
very quickly in diastole, resulting in the
palpable sensation

Blood pressure: -HTN? Hypotension? Low bp is considered normal

Often you won’t be expected in pregnancy, desirable in diabetics
to do it due to time restraints but make -Narrow pulse pressure is associated with Aortic
sure to mention that you’d ideally like to Stenosis
measure blood pressure in both arms. Wide pulse pressure is associated with Aortic
Regurgitation
1.heart rate counted by the stethoscope is higher than that observed at the periphery,
because there are beats where diastole is short for adequate filling>> too small volume of
blood is ejected during systole>>pulse is not felt at the wrist
What to do What to look for
4. Face
Look for:
Could be due to:
jaundice -CHF>hepatic congestion
-prosthetic valve>hemolysis
Corneal arcus hyperlipidemia>which increase the risk of cardiovascular
Xanthelasma insult

Central cyanosis bluish discolouration of lips + underneath tongue

Angular stomatitis iron deficiency anemia

5.neck
Carotid pulse:
-Assess character & volume. e.g. slow rising character in
often advised to auscultate for a bruit
aortic stenosis
before palpating as theoretically
-Never palpate both carotid arteries simultaneously
palpation might dislodge a plaque>>
because it may compromise the brain blood flow
a stroke.
Jugular venous pressure: Raised JVP (>3cm above sternal angle) may indicate:
 patient is positioned at 45° • Fluid overload
 Ask patient to turn their head away • Right ventricular failure
from you • Tricuspid regurgitation
 Observe the neck for the JVP • constrictive pericarditis
(located inline with the • Cardiac tamponade
sternocleidomastoid)
 Measure the JVP: number of cm
from sternal angle to the upper
border of pulsation
Hepatojugular reflux: Positive result (the rise in JVP is sustained & ≥4cm)
 Press firmly with the palm over the suggest:
middle of the abdomen for 10 sec -Right ventricular failure
 Observe the JVP for a rise -elevated left atrial pressures are (left ventricular
 In healthy individuals this should failure)
last no longer than 1-2 cardiac -Tricuspid regurgitation
cycles (it should then fall)
Large a waves: a wave is caused by the right atrial pressure transmitted
to the jugular veins during right atrial systole, causes of
large a wave include:
• complete heart block (right atrium contracting against
the closed tricuspid valve)
• tricuspid stenosis
• right ventricle hypertrophy
• pulmonary valve stenosis
What to do What to look for
6.Praecordium
 INSPECTION
position of the scar can be a clue to the type of lesion:
• Sternotomy:CABG / valve surgery
Scars: • Clavicular: Pacemaker
• lateral thoracotomy scars: closed mitral valvotomy
pectus carinatum
Chest wall deformities

pectus excavatum
Visible pulsations forceful apex beat may be visible –
apex beat. Its normal position is in the hypertension/ventricular hypertrophy
fifth left intercostal space, 1cm medial
to the midclavicular line

 PALPATION The normal apex beat gently lifts the palpating fingers.
 Localize the apex beat -There are a number of types of abnormal apex beats:
 Use firm pressure with the tips of  pressure loaded (heaving): apex beat is a forceful
your fingers  and sustained impulse, ventricular hypertrophy e.g. AS
 Lift the heel of your hand off the or HTN.
patient’s sternum  volume loaded: beat is displaced, diffuse, non-
The character, but not the position, of sustained impulse, ventricular dilatation e.g. MR
the apex beat may be more easily  dyskinetic apex beat: uncoordinated impulse, left
assessed when the patient lies on the ventricular dysfunction e.g. MI
left side.  double impulse apex beat: hypertrophic
cardiomyopathy
The tapping apex beat: when the first
heart sound is actually palpable mitral or tricuspid
stenosis.
-Displaced laterally or inferiorly, or both, this usually
indicates enlargement
-Non-palpaple apex beat due to a thick chest wall,
emphysema, pericardial effusion, shock (or death) and
dextrocardia (the heart is located on the right side)

Heaves Normally no impulse or a slight inward impulse is felt

A parasternal impulse felt when the In case of LVH & severe left atrial enlargement the heel of
heel of the hand is rested just to the the hand is lifted off the chest wall with each systole
left of the sternum with the fingers
lifted slightly off the chest

Thrills palpable murmurs felt over aortic valve & apex beat
caused by turbulent blood flow
What to do What to look for
6.Praecordium
 PERCUSSION
Can be done to define the cardiac
outline and detect cardiomegaly
but not usually used.

 AUSCULTATION
 Aortic valve – 2nd intercostal
space – right sternal edge
 Pulmonary valve – 2nd
intercostal space – left sternal
edge
 Tricuspid valve – 5th
intercostal space – lower left
sternal edge
 Mitral valve – 5th intercostal
space – midclavicular line (apex
beat)
It Starts in the mitral area with the
bell of the stethoscope>then turn it
to the diaphragm and listen>next
go to the Tricuspid >Pulmonary
>Aortic.
Listening carefully in each position
with the diaphragm.

First heart sound:  LOUD S1:

-has two components  when the mitral or tricuspid valve cusps remain wide open
corresponding to mitral and to the end of diastole and shut forcefully with systole
tricuspid valve closure, but usually (normal mitral valve cusps approach each other at the end
only one sound is audible. of diastole as the filling slows down)
S1 indicates the beginning of  e.g. MS: narrowed valve orifice limits the filling, so the
ventricular systole + occurs just filling doesn't slow towards the end of diastole>the valves
before or coincident with the don’t approach each other>shut forcefully
upstroke of the carotid pulse (so  Other causes of a loud S1 is tachycardia reduced diastolic
any murmur detected with the filling time.
pulse is systolic murmur)  SOFT S1: occurs with
 first-degree heart block>Prolonged diastolic filling time
 Left BBB>delayed onset of left ventricular systole
 mitral regurgitation>failure of the leaflets to close normally

second heart sound: -Aortic valve (A2) closing slightly before the pulmonary valve
-softer, shorter and at a slightly (P2), and this splitting more prominent with inspiration due
higher pitch than S1 + marks the to increased RV stroke volume
end of systole.  Loud aortic component (A2): systemic HTN + AS
 loud pulmonary component (P2): pulmonary HTN
 soft A2: aortic regurgitation
What to do What to look for
6.Praecordium Splitting: best detected in the pulmonary area
occurs when there is any delay in right ventricular emptying
 AUSCULTATION E.g. Right bundle branch block, pulmonary stenosis , VSD
Second heart sound: cont (increased right ventricular volume load) and mitral
regurgitation (more rapid left ventricular emptying>earlier
aortic valve closure).
 fixed splitting (no respiratory variation): ASD (increased
venous return>blood escape to left atrium>no or slight
increase in RV stroke volume)
 Paradoxical (Reversed) Splitting:
when P2 before A2 in expiration, causes: Left BBB (delayed
left ventricular depolarization), aortic stenosis, coarctation of
the aorta (delayed left ventricular emptying) or large patent
ductus arteriosus (increased LV volume load)

• ADDED SOUNDS
Third heart sound -low-pitched + best heard with the bell of the stethoscope
best heard at the apex -audible during the rapid entry of blood from the atrium to the
+ the patient in the left lateral ventricle
decubitus position + at end -Occurs in volume-loaded conditions or in a ventricle that
expiration is already stretched and overfilled owing to systolic
dysfunction
 HF (Systolic and/or diastolic ventricular dysfunction)
 Ischemic heart disease
 Hyperkinetic states - Anemia, fever, pregnancy,
thyrotoxicosis, AV fistula
 MR or TR
 Could be heard in healthy young (a thin chest wall to
permit the easy transmission of S3)

Fourth heart sound --low-pitched + best heard with the bell of the stethoscope
best heard at the apex -generated by sudden deceleration of the jet of blood as it
enters a ventricle with decreased compliance.
+ the patient in the left lateral
 Ventricular hypertrophy - LV hypertrophy (systemic
decubitus position + at end hypertension, hypertrophic cardiomyopathy, AS); RV
expiration hypertrophy (pulmonary hypertension, pulmonary stenosis
[PS])
 Ischemic heart disease

opening snap high-pitched diastolic sound produced by rapid opening of the

mitral valve in MS & best heard at the apex

systolic ejection click high-pitched, in congenital aortic or pulmonary stenosis

where the valve remains mobile

non-ejection systolic click high-pitched, mid-systolic click from mitral valve prolapse
What to do What to look for
6.Praecordium Characteristics helps with the diagnosis
 AUSCULTATION
 Timing:
Systolic murmurs:
MURMURS
may be pansystolic, midsystolic (ejection systolic) or late systolic.
results from turbulent pansystolic murmur: extends throughout Systole, its loudness and
flow across valves pitch do not vary during systole
EXAMPLE: mitral regurgitation, VSD.
midsystolic ejection murmur: does not begin right at the first heart
sound; its intensity is greatest in midsystole
EXAMPLE:crescendo–decrescendo murmur in AS
late systolic: MVP
Diastolic murmurs:
early diastolic murmur: decrescendo murmur in AR
(loudest early because this is when aortic artery pressure is highest)
mid-diastolic murmur: MS & atrial myxoma (the tumour mass
obstructs the valve orifice)
PreSystolic murmur:
It’s an extension of the mid-diastolic murmurs of mitral stenosis due to
atrial contraction before systole.
continuous murmurs:
extend throughout systole and diastole, produced when a communication
exists between two parts of the circulation with a permanent pressure
gradient so that blood flow occurs continuously.
Causes: PDA, Coronary arteriovenous fistula in Haemodialysis patients
pericardial friction rub:
caused by movement of inflamed pericardial surfaces; it is a result of
pericarditis. louder when the patient is sitting up and breathing out. It tends
to come and go,
 Area of greatest intensity: the place on the praecordium where
murmur is heard most easily is a guide to its origin. But some may radiate
e.g. MR tend to radiate towards the axillae & Aortic stenosis murmur
radiate to the carotid arteries
 Loudness and pitch
loudness and harshness of the murmur (and the presence of a thrill)
correlate with the severity
 Dynamic manoeuvres & murmurs
HOCM MVP AS MR

Valsalva or standing (decreases

preload)
Squatting, leg raise or lying down
(increases preload)
Hand grip (increases afterload)
What to do What to look for
6.Praecordium
 AUSCULTATION
Auscultation of the neck Systolic Bruits:
Ask the patient to stop breathing murmurs of aortic stenosis, soft carotid bruit sometimes
and talking for a brief period to audible with severe MR or pulmonary stenosis.
remove the competing noise. A bruit due to carotid stenosis. To make sure that it’s from the
use the bell. carotids, Move the stethoscope from point to point onto the
chest wall; if the bruit disappears, it is likely the sound arises
from the carotid
7.The back inspiratory crackles, pleural effusion or scral
-Percussion and auscultation of edema:
the lung bases. Signs of Heart failure or valvar diseases
-While the patient is sitting up,
feel for pitting oedema of the
sacrum,
8.The abdomen Splenomegaly, ascites or enlarged tender liver:
Heart failure, hepatic veins congestion and Distension of the
liver capsule is said to be the cause of liver tenderness.
 liver is pulsatile:
Tricuspid regurgitation. Right ventricular systolic pressure
wave is transmitted to the hepatic veins
10.Lower limb
Inspect EDEMA, Scars, pallor or ulcers.

check the pulse-go proximal  FEMORAL PULSE (mid inguinal point is located halfway
to distal. between the ASIS & the pubic symphysis)
 POPLITEAL PULSE (inferior region of the popliteal fossa)
 POSTERIOR TIBIAL PULSE (posterior to the medial
malleolus of the tibia)
 DORSALIS PEDIS PULSE

check the sensation paresthesia

acute limb ischaemia.

FINALLY:
Thank the patient
Wash hands
Summaries the findings

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