Examination of the

Cardiovascular System
Erdem ÖZEL,Prof.,MD
 Cardiovascular exam
 Includes
 Appropriate history
 Vital Signs: Blood pressure; Pulse: rate, rhythm,
volume


skmattocheck
Assessment distal vasculature (legs, feet,
carotids)vascular disease (atherosclerosis) is a
systemic illness !
examination
Eical
 4 basic PE components:
 Observation, Palpation, Percussion (omitted in
cardiac exam) & Auscultation
 Appropriately/Respectfully
touching your patients
 Several Sources of Tension:
beingrespectful is reallyimportant

 Area examined reasonably exposed – yet patient

modesty preserved
 Palpate sensitive areas to perform accurate exam -
requires touching people w/whom you’ve little
acquaintance – awkward, particularly if opposite
gender
 Exam not natural/normal part of interpersonal
interactions - as newcomers to medicine, you’re
particularly aware & hence sensitivea good thing!
 Keys To Performing a Respectful &
Effective Exam
 Explain what you’re doing (& why) before doing it
 Expose minimum amount of skin necessary - “artful” use of
gown & drapes (males & females)

 Examining heart & lungs of female patients:

Ask patient to remove bra prior and/or learn to work around bra

 Expose side of chest to extent needed

Enlist patient’s assistancepositioning breasts to enable cardiac
exam

 Don’t rush
 PLEASE... don’t examine body parts thru gown:
 Poor technique
 You’ll missthings
 Observation

 Pay attention to:

deformitiesmaybe
 Chest shape any

 Shortness of breath (@ rest or walking)?

Sitting upright? Able to speak?
? Visible impulse on chest wall from vigorously
contracting ventricle (rare)
hypotrophy
Surface Anatomy
To make good
observation

EE
b
devidest No
I
Finding the sternal manubrium junction
(angle of Louis) important
identify
to

(Key to identfying valve areas)

Valves and Surface Anatomy

left

right

Areas of auscultation correlate w location of each valve

Where you listen will determine what you hear
 Palpation-Technique
 Fingers across chest, under
breast (explain 1st)
 Point of M aximal Impulse
 (PMI)apex ventricle that pin-
points w/finger tip; ~70% of
patients - if not palpable, repeat
w/patient on L side

 Size of LV – increased
dimension if PMI shifted to L of
mid-clavicular line
 Vigor of contraction
 Palpable thrill (rare) -
associated w/regurgitant or
stenotic murmurs (feels like
sensation when kink garden
hose)
fromvalves
problems
 Palpation-Technique
 Right ventricle:

 Vigor of contractility
 heel of R hand along
sternum

 Rarely abnormal with RV

(pulmonary hypertension)
Auscultation-using
part
your
most
important

stethescope
What Are We Listening For ?
 Normal valve closure
creates sound
 First Heart Sound =s S1
closure of Mitral,
Tricuspid valves
 Second Heart Sound =s
S2closure of Pulmonic,
Aortic valves
 What Are We Listening For ?
Contraction
 Systole =s time between
S1 & S2; Diastole =s time
between S2 & S1 relaxtion
 Normally, S1 & S2 =
distinct sounds
 Physiologic splitting =s 2
components of second
heart sound (Aortic &
Pulmonic valve closure)
audible w/inspiration

0.5 0.3
diastole systole
 Auscultation Technique
 Patient lying @ 30-45 degree incline
 Chest exposed (male) or loosely fitted gown
(female) • need to see area where placing
stethoscope

 Stethoscope must contact skin

 Stethoscope w/diaphragm (higher pitched sounds)
engaged
Remember –Don’t examine
thru clothing
Exam options-Female
patients
 Auscultation Technique
1. Start over Aortic area2nd Right Intercostal Space
(ICS) – Use Angle of Louis as landmark
intercostalspace
2. Pulmonic area (2nd L ICS)
3. Inch down sternal borderTricuspid area (4th L
ICS)
4. Inch towards Mitral area (4th ICS, mid-clavicular)
5. Listen in ~ 6 places - precise total doesn’t matter
– gives you sense of change In sounds as change
location
 Auscultation
 In each area, ask yourself:
 Do I hear S1? Do I hear S2? Which is louder & what
are relative intensities?

 Interval between S1 & S2 (systole) is shorter then

between S2 & S1 (diastole)

 Can also determine timing by simultaneously

feeling pulse (a systolic event)

 Listen for physiologic splitting of 2nd heart sound

w/inspiration
 Murmurs
 Murmurs: Sound created by
turbulent flow across valves:
 Leakage (regurgitation) when
valve closed
blockage
 Obstruction(stenosis) to flow
when normally open

 Systolic M urmurs:
 Aortic stenosis
 Mitral regurgitation
 (Pulmonary stenosis, Tricuspid
regurgitation)

 Diastolic M urmurs:

TEIFI
 Aortic regurgitation
 Mitral stenosis
 (Pulmonary regurgitation,
Tricuspid stenosis)
stem's

he could ask
important
 Murmurs
 Characterized by: position in cycle, quality, intensity, location, radiation; can try
to draw it’s shape:

 IntensityScale:
1 –barely audible 2- readily audible 3- even louder 4- loud + thrill 5- audible with
only part of

 diaphragm on chest 6 – audible w/out stethoscope

 Intensity doesn’t necessarily correlate w/severity

 Some murmurs best appreciated in certain positions:

 Mitral: patient on L side; Aortic: sitting up and leaning forward

• Example – Mitral Regurgitation: H olosystolic, loudest in mitral area, radiates
towards axilla.
 51 Physiologic sounds
51
Extra Heart Sounds & S3-S4

Tthologic
Ventricular sounds, occur during diastole
sounds

 normal in young patient (~ < 30 yo)

 usually LV, rarely RV
 S3follows S2
caused by blood from LA colliding w/”left over”
blood in LV • associated w/heart failure.
 S4precedes S1
caused during atrial systole
when blood squeezed into non-compliant LV •
associated w/HTN
 Extra Heart Sounds & S3-
S4
 S3 & S4 are soft, low pitched
 Best heart w/bell, laid over LV, w/patient lying on
L side (brings apex of heart closer to chest wall)

 Abnormal beyond age ~30

 When present, S3 or S4 are referred to as “gallops”
 Auscultation- An Ordered
Approach
 Do I hear S1? Do I hear S2?
 Listen in each major valvular area – think about which sound
should be loudest in each location (S1 loudest region of TV &
MV, S2 loudest AV & PV)

 Do I hear physiologic splitting of S2? with inspiration experasion

 Do I hear something before S1 (an S4) or after S2 (an S3)?

 Do I hear murmur in systole? In diastole?
 If a murmur present, note:
 intensity,character,duration,radiation
 As listen, think about mechanical events that generate the
sounds.
 Carotid Arteries
 Anatomy
 Palpation (ea side
separately!)
 Rhythm
 Fullness
 Auscultation
 Radiation of murmurs

 ? Intrinsic atherosclerosis
– may produce
“shsshhing” noise known
as bruit
 Jugular Venous Pressure
(JVP)
 Anatomy of Internal
Jugular Vein
 Straight line with RA

 Manometerreflecting
Central Venous Pressure
(CVP)
 JVP Technique
 Find correct area – helps to
first identify SCM & triangle
it forms w/clavicle
 Look for multi-phasic
pulsations (‘a’, ‘c’ & ‘v’
waves)
 Isolate from carotid
pulsations, respirations
 Tangential lighting
 Hepatojugular reflux (gentle
pressure over liver pushes
blood back into IJ & makes
pulsations more apparent)
 JVP Technique
 JVP =s 5cm (height sternal
manubrium jxn is above
RA) + vertical distance
from sternal manubrium
jxn to top of pulse wave

 Normal < 8 cm
Lower Extremity Vascular Exam-General
observation incl. femoral region
 Expose both legs, noting:
asymmetry, muscle
atrophy, joint (knee, ankle)
abnormalities
 Focus on Femoral Area:
 Inspect - ? Obvious
swellingfemoral hernia v
large lymph nodes (rare)
 Palpate lymph nodes
 Femoral Region
 Identify femoral pulse

 Listen over femoral artery

with diaphragm
stethescope for bruits (if
suggestion vascular
disease by hx, exam)
 Popliteal Pulse
 W/knee slightly bent, push
fingers into popliteal
fossaassess popliteal
artery Relevant if distal
pulses diminished
 Vascular Disease of the
Lower Leg
 Components:
 outflow(arterial)
 return(venous,lymphatic)

 Clinical Presentations:
 Arterial:
 pain (supply-demand)
 wound healing
 RFs for atherosclerosis
 Venous:
 Edema
 Local v systemic etiology

 Lymph (relatively uncommon):

 Lymphedema:
From obstruction, disruption
Clinical Appearance –Varies with type of
vascular disease
 Feet and Ankles
 Lower leg & feet @ greatest
risk atherosclerosis (in
particular if vascular dz risk
factors: DM, HTN, Smoking,
Hyperlipidemia, age, known
dz elsewhere)
 Observe
 ? swelling (edema),
discoloration, ulcers, nail
deformities
 Look @ bottom of feet,
between toes (problem
areas)

 Symmetry?
 Feet and Ankles
 Palpation
 Temperature: Use back of examining hand -
warminflammation; coolatherosclerosis &/or hypo-
perfusion
 Capillary refill: push on end of toe or nail bed &
releasecolor returns in < 2-3 seconds;
longeratheroscloerosis &/or hypo-perfusion
 Feet and Ankles-Edema
 Change in balance of starling
forces (pressures in vessels v
tissues; oncotic forces in vessels v
tissues): Edema
 Local leg problems:
 Deep Vein Thrombosis
 Infection
 Trauma
 Lymphatic obstruction
 Systemic problems:
 Heart failure
 Pulmonary disease (pulmonary
hypertension, sleep apnea,
thrombosis, etc.)
 Kidney disease
 Liver disease
 Venous stasis
 Quantifying edema
 A marker of volume status.
 Trace (minimal): subtle loss of tendons on top of
foot, contours maleolous

 Scales (none validated or compared)

 0 to 4+
 Depth of pitting left (after applying pressure w/a
finger) in mm
 Extent of edema (e.g. limited to feet v up to knee)
Quantifying edema
 Dorsalis Pedis Pulse
 Palpate Dorsalis Pedis
pulse
 Just lateral to extensor
tendon great toe
 Use pads of 2-3 fingers of
examining hand
 Push gently
 If unsure whether feeing
your pulse v patient’s,
measure your carotid or
their radial w/other hand
 Graded 0 (not detectable)
to 2+ (normal)
 Posterior Tibial Pulse
 Palpate Posterior Tibial
Pulse
 Located posterior to
medial malleolous
 Start on top of malelous &
work towards Achilles
tendon
 Use pads of 2-3 fingers,
pushing gently
 Same rating scale as for
dorsalis pedis
 Summary
 Wash hands; gown & drape appropriately

 Inspect precordium Palpation of RV and LV; Determination PMI

 Auscultation – patient @ 30 degrees

 S1 and S2 in 4 valvular areas w/diaphragm
 Try to identify physiologic splitting S2
 ? Murmurs
 Assess for extra heart sounds (S3, S4) w/bell over LV

 Carotid artery palpation, auscultation

 Jugular venous pressure assessment

 General lower extremity observation

 Assess femoral area (palpation for nodes, pulse); auscultation over femoral artery

 Knees – color, swelling; popliteal pulse

 Assess ankles/feet (color, temperature, pulses, edema, cap refill