This presentation deals with clinical examination of Cardio vascular system

1. CARDIO
VASCULAR
SYSTEM
EXAMINATION
Dr Akshay Shetty
Asst. Professor
Dept of Panchakarma
SSRAMCH Inchal

2. Contents
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Objectives Introduction Inspection Palpation
Percussion Auscultation Summary Conclusion
References

3. Objectives
By the end of the presentation the learners must be able to
1. State Introduction of CVS examination
2. Demonstrate Inspection of CVS
3. Demonstrate Palpation of CVS
4. Demonstrate Percussion of CVS
5. Demonstrate Auscultation of CVS
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4. Introduction
• In medicine, the cardiac examination, also precordial exam, is performed as
part of a physical examination or when a patient presents with chest pain
suggestive of a cardiovascular pathology. It would typically be modified
depending on the indication and integrated with other examinations
especially the respiratory examination.
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5. Cont..
• Several Sources ofTension: – 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!
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6. Points to be remembered for 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 clothing prior
(can’t hear well through fabric) –
• Expose side of chest to extent needed – Enlist patient’s assistance positioning
breasts to enable cardiac exam
• Don’t rush, act in a callous fashion, or cause pain
• PLEASE… don’t examine body parts thru gown: –
• Poor technique –You’ll miss things
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7. Inspection
• Positioning
• The patient is positioned in the supine position tilted up at 45 degrees if the
patient can tolerate this.The head should rest on a pillow and the arms by their
sides.
• The level of the jugular venous pressure (JVP) should only be commented on in
this position as flatter or steeper angles lead to artificially elevated or reduced
level respectively.
• Also, left ventricular failure leads to pulmonary edema which increases and may
impede breathing if the patient is laid flat.
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8. Cont…
• General Inspection:
Inspect the patient status whether he or she is comfortable at rest or obviously
short of breath.
Inspect the neck for increased jugular venous pressure (JVP)or abnormal waves.
Any abnormal movements such as head bobbing.
There are specific signs associated with cardiac illness and abnormality however,
during inspection any noticed cutaneous sign should be noted.
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9. Cont…
• Inspect the hands for:
• Temperature - described as warm or cool,
clammy or dry
• Skin turgor for hydration
• Janeway lesion
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10. Cont…
• Osler's node
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11. Cont….
• Inspect the head for:
Cheeks for the malar flush of mitral stenosis.
The eyes for corneal arcus and surrounding tissue for xanthalasma.
Conjunctiva pallor a sign of anemia.
The mouth for hygiene.
The mucosa for hydration and pallor or central cyanosis.
The ear lobes for Frank's sign.
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12. Cont…
Then inspect the precordium for:
visible pulsations
apex beat
masses
scars
lesions
signs of trauma and previous surgery (e.g. median sternotomy)
permanent Pace Maker
precordial bulge
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13. Palpation
• RightVentricle
 Vigour of contractility –
Felt with heel of hand –
Prominence described as a “lift” or “heave”
Thrill – rare palpable sensation associated w/regurgitant or stenotic murmurs
(feels like sensation when kink garden hose)
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14. • Left ventricle
Fingers across chest,
under breast (explain 1st to female pts!)
 Point of Maximal 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
Vigour of contraction
Palpable thrill (rare)
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16. Jugular venous pressure
• Sternal angle is 5 cm above right atrium
• Right atrial pressure = height of jvp above sternal angle + 5
• Normal ra pressure: 5-10 cm h2o
• Sitting bolt upright, your dyspneic (short of breath) patient has visible jugular
venous pulsations to the angle of his jaw, which is 12 cm above his sternal angle.
• What is his right atrial pressure? Why might he be short of breath?
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17. Cont….
• A: atria contract
• C: closure of tricuspid valve
• X: Atria begin to fill
• V: volume of atria increases
• Y: tricuspid valve opens, ventricles fill
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19. Cont…
• Right ventricle: anterior
• Left ventricle: left heart border/ apex/ posterior
• Right atrium: right heart border
• Left atrium: posterior
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RA
RV
LV

21. Cont…
• Aortic: right sternal border
• Pulmonic: left upper sternal
• Tricuspid: left fourth intercostal space
• Mitral: apex (5th intercostal space, midclavicular line)
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A
O
PU
TR
MI

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24. • Valves closing: s1, s2
• Blood striking left ventricular wall: s3, s4
• Turbulence: murmurs
• S1
• AV valves closing (mitral and tricuspid)
• Start of systole
• Loudest at apex
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25. • S2
Semilunar valves closing: aortic and pulmonic
A2 before p2
Splits with inspiration at pulmonic area (lusb)
Loudest at base (top of heart)
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26. • S3
Early diastole (soon after s2)
Blood rushes in just after mitral valve opens, striking lv wall (palpable)
At apex only
Congestive heart failure (or healthy young person)
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27. • S4
• Atrial contraction
• Just before s1 (mitral valve closure) – late in diastole
• Blood strikes stiff left ventricle (palpable, at apex)
• Sign of high blood pressure or heart attack (mi)
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28. • Diaphragm-Higher pitched sounds
• Bell- Lower pitched
• Technique
Patient lying @ 30-45 degree incline
 Chest exposed (male) or loosely fitted gown (female)
 need to see area where placing stethescope – stethescope must contact skin
Stethescope w/diaphragm (higher pitched sounds) engaged
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29. Murmurs
• Murmurs: Sound created by turbulent flow across valves:
• Leakage (regurgitation) when valve closed
• Obstruction (stenosis) to flow when normally open
• Systolic Murmurs: – Aortic stenosis, Mitral regurgitation (Pulmonary stenosis,
Tricuspid regurgitation)
• Diastolic Murmurs: – Aortic regurgitation, Mitral stenosis (Pulmonary
regurgitation,Tricuspid stenosis)
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30. Cont…
• Characterized by: position in cycle, quality, intensity, location, radiation
• Intensity Scale:
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
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31. Cont…
• Some murmurs best appreciated in certain positions:
• Mitral: patient on L side;
• Aortic: sitting up and leaning forward
• Example – Mitral Regurgitation: Holosystolic, loudest in mitral area, radiates
towards axilla.
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33. Summary
1.State Introduction
of CVS examination 1.Demonstrate
Inspection of CVS
1.Demonstrate
Palpation of CVS
1.Demonstrate
Percussion of CVS
1.Demonstrate
Auscultation of CVS
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34. References
1. Examination OfThe Cardiovascular System Charlie Goldberg, M.D. Professor of
Medicine, UCSD SOM.
2. Macleod's clinical medicine
3. www.cardiacexam.org
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35. THANKYOU
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