The document summarizes key aspects of performing a bedside cardiovascular examination. It discusses examining a patient's history for common cardiovascular symptoms. It then outlines how to examine the arterial pulse, measure blood pressure, and examine jugular venous pulse waves and pressure. The document also provides details on inspecting the chest, palpating the precordium, auscultating heart sounds and murmurs, and performing dynamic auscultation with maneuvers.

1. MEDICAL WORKSHOP:
BEDSIDE CARDIOLOGICAL
EXAMINATION
Chairperson : Dr. P. k. Biswas
Speaker : Dr. Shalini Halder

2. THE HISTORY
The cardinal symptoms of CVS involvement are –
 Dyspnea
 Chest pain
 Palpitation
 Fatigue
 Syncope

3. ARTERIAL PULSE
 Pulse is a Greek word meaning “move to and fro”.
 Defined as a wave produced by cardiac systole traversing in the peripheral direction in the arterial
tree at a rate(5m/s) faster than the column of blood(.5m/s).
 Characteristics of pulse wave pattern –
 In the peripheral arteries –
 Anacrotic notch disappears
 Incisura in descending limb is replaced by dicrotic notch followed by dicrotic wave

4. Examination of the arterial pulse and its evaluation
 All the major arterial pulses should be bilaterally examined for –
o Rate
o Rhythm
o Character
o Volume
o Condition of the arterial wall
o Radio-radial and radio-femoral delay
 Besides palpation, auscultation of major arteries should be performed to look
for audible bruit.

5. Measurement of Blood Pressure
 SBP – Maximum pressure exerted during systole. Normal SBP <120 mm Hg.
 DBP – Minimum pressure exerted during diastole. Normal DBP <80 mm Hg.
 PP – Difference between SBP and DBP. Normal average PP is 40 mm Hg.
 MBP – Average blood pressure throughout the cardiac cycle.
 Sum of DBP and 1/3 of PP
 Same for each organ and determines the regional blood flow through an organ
 Normally ranges berween 95 – 100 mm Hg, with an average of 96 mm Hg

6. Sphygmomanometric measurements
 Palpatory method without sphygmomanometer –
An approximation of SBP may be done by the amount of brachial artery compression required
to obliterate the ipsilateral radial pulse, as like :
 When relatively mild compression obliterates the radial pulse SBP <120 mm Hg
 When considerable compression required SBP may be >160 mm Hg
 Palpatory method with sphygmomanometer
 Auscultatory method –
This method requires proper understanding of the KOROTKOFF sounds in different phases with
adequate cuff size, proper technique and equipment.
 In order to determine BP in basal condition, patient should avoid caffeine, exercise
and smoking for at least 30 mins and should be seated for at least 5 mins quietly and comfortably.

7. Jugular Venous Pulse Waves and Pressure
 The bedside examination of JVP is done –
• To assess the waveform
• To assess approximately the mean RA pressure
 Normal jugular venous wave pattern –
1. a wave : The first positive presystolic wave, occurs due to right atrial contraction
2. x descent : The systolic collapse, follows the a wave, occurs due to atrial relaxation
during atrial diastole
3. c wave : produced by – i) impact of carotid artery which is adjacent to the IJV, and ii)
upward bulging of the closed TV into the RA during RV isovolumic contraction.

8. Jugular Venous Pulse Waves and Pressure(contd.)
4. v wave : results from rise in RA pressure due to continued filling during ventricular
systole.
5. y descent : results from RA emptying during early diastole.

9. Cardiovascular System Examination
Inspection –
1. Examination of the chest –
I. Shape of the chest - In normal adults, it is bilaterally symmetrical
and elliptical in cross-section with transverse
diameter>anteroposterior diameter and has a subcostal angle of
about 90 Degree.
It may be distorted in various disorders –
 Pectus Excavatum
 Pectus Carinatum
 Straight back syndrome

10. Cardiovascular System Examination(contd.)
ll. Cutaneous lesions –
a) Erythema marginatum seen over the trunk and proximal extremities in patients with ARF.
b) Spider nevi seen in the distribution of SVC in hepatic cirrhosis, Osler-Weber-Rendu syndrome
and pregnancy.
lll. Breast abnormalities –
a) Male gynecomastia as an adverse effect of digitalis, Klinefelter syndrome
b) Female hypomastia is a part of asthenic habitus in mitral valve prolapse
c) Widely spaced nipples associated with BROAD SHIELD CHEST are typical of Noonan
syndrome and Turner syndrome.

11. Cardiovascular System Examination(contd.)
IV. Distended vessels –
a) Veins : over anterior chest wall
 With caudal flow – obstruction of SVC
 With cranial flow – obstruction of IVC
b) Arteries : collateral vessels seen in interscapular, infrascapular and posterior
intercostal spaces in patients with COARCTATION OF AORTA called suzman sign.
They are palpable when the patient stands and bends forward with arms
hanging down by the sides

12. Inspection(contd.)
2. Examination of Precordium –
I. Precordial prominence with bulging of intercostal space not involving
the ribs – suggestive of PERICARDIAL EFFUSION.
II. Precordial prominence involving both intercostal spaces and ribs –
long standing cardiomegaly(usually develops before
puberty)usually due to RV hypertrophy.
III. Precordial bulging of non CVS origin – mediastinal new growths,
kypho-scoliosis, bronchogenic carcinoma.
IV. Visible pulsations(if any)

13. Palpation of The Precordium
1. Examination of the chest for confirmation of shape and distended vessels – Shape of
the chest noted during inspection is confirmed by taking measurements including
anteroposterior and transverse diameter.
2. Palpation for precordial tenderness –
Tenderness of costochondral junction – in TIETZE syndrome, which is important
to rule out MI in patient with chest pain.
May be associated with acute pancreatitis, acute myocarditis.
3. Palpation of the cardiovascular pulsations, sounds, thrills and rubs

14. Palpation of The Precordium(contd.)
Palpation for the cardiovascular pulsations is done at –
 Cardiac apex
 Left parasternal area – palpated for i) character(grade) of left parasternal
lift, and ii)palpable low frequency sounds(RV S3, RV S4 )
• The outer most and lower most
point of maximum impulse
• Palpated for size,character,extent
and thrills.
• Located 4th or 5th Intercostal space
at or inside MCL,<_ 10cm from
mid-sternal line.
• Confined to 1 intercostal space,
<3cm in diameter,lasts for <50% of
systole.
Grading of PSL As per Subjective & Objective method
Grade 1/3(mild) • Disappears with mild counter pressure
• Ill sustained,<1/3rd of systole
Grade 2/3(moderate) • Disappears/diminishes with moderate counter pressure
• 50% of systole but not throughout the systole
Grade 3/3 (severe) • Moderate counter pressure doesn’t diminish the PSL
• Throughout the systole

15. Palpation of The Precordium(contd.)
 Left lower sternal area(tricuspid area)
I. Palpable low-frequency heart sounds : RV S3, RV S4
II. Palpable high-frequency heart sounds : opening snap of organic
TS.
III. thrills : systolic thrill of severe TR, diastolic thrill of organic TS.
 Aortic and Pulmonary area
I. Palpable high frequency heart sounds
II. Thrills : systolic and diastolic thrill are looked for.

16. Palpation of The Precordium(contd.)
 Sternoclavicular areas :
continuous/ systolic thrill may be palpable(Blalock-Taussig
shunt, PDA)
 Epigastrium :
• The subxiphoid region allows the palpation of RV
• Pulsations may be due to aortic or hepatic in origin.
 Ectopic areas

17. Cardiovascular Auscultation
The topographical areas of cardiac auscultation are –
 Aortic area
 Pulmonary area
 Tricuspid area
 Mitral area
In addition, auscultation should be regularly be carried out at:
 The axillae
 The back
 Anterior chest on opposite side
 Over the carotids
 Above and below the clavicles
 Over the peripheral arterial sites

18. Cardiovascular Auscultation(contd.)
 Dynamic auscultation –
The impact of respiration on the heart sounds and murmurs should
be assessed routinely.
In selected cases, isovolumetric exercises, Valsalva maneuver, Muller
manuever and pharmacological manuevers(Amyl Nitrate inhalation)should
be employed.
 The heart sounds –
They are characterized by intensity, pitch and quality.
 S1 – signals the onset of ventricular contraction
 S2 – signals the onset of ventricular diastole. Has 2 components: A2(first component),
P2(second component)
 S3 – low frequency, mid-diastolic sound.occurs during rapid ventricular phase.
 S4 – low frequency, late diastolic sound, occurs during atrial contraction.

19. Cardiovascular Auscultation(contd.)
 Added sounds –
 Openig snap – high frequency clicky sound generated in early diastole due to thickening and
deformity of the leaflets of AV valve. It implies thickened but mobile AV leaflets, high atrial
pressure or high velocity flow across the AV valves.
 Tumour plop – high frequency early diastolic sound heard in atrial myxoma
 Systolic ejection sounds – high frequency early systolic sound
 Pericardial knock – low frequency early diastolic rapid filling sound characteristic of
CONSTRICTIVE PERICARDITIS.
 Extracardiac sounds –
 Pericardial rub(movement of parietal and visceral pericardium against each
other)
 Pacemaker sounds
 Mediastinal crunch

20. The Heart Murmurs
Defined as audible signals/vibrations of varying intensity, frequency, configuration
and duration detectable with the aid of stethoscope.
 Characteristics of murmur –
1. Timing :
- systolic
- diastolic
- continuous
2. Location
3. Duration :
- short
- long
- holo
4. Intensity - grading
5. Pitch
6. Configuration
7. Transmission
8. Dynamic auscultation
Grade Character
1/6 Faintest mumur, can be heard only with special effort and
under optimal conditions
2/6 Soft of faint murmur
3/6 Moderately loud murmur without thrill
4/6 Very loud murmur with thrill
5/6 Extremely loud murmur, can be heard by edge of sthethoscope
but not if it is removed. Associated with thrill
6/6 Execptionally loud murmur, can be heard with stetho, without
contact on the chest wall, accompanied by thrill.

21. The Heart Murmurs(contd.)
 Type of bedside manuevers in dynamic auscultation –
a) physical –
respiration, postural changes, isometric handgrip, Valsalva and muller manuever
a) Pharmacological –
by use of vasoactive agents such as amyl nitrate, methoxamine and
phenylephrine.

22. Thank you