This document outlines the components of a cardiovascular system (CVS) examination. It discusses examining the vital signs, chest, pulmonary system, and distal vasculature. The CVS exam involves observation, palpation, percussion, and auscultation. Specific areas of the heart are examined using auscultation. Common sounds that may be heard include murmurs, extra heart sounds like S3 and S4, and abnormal heart rhythms. The carotid arteries, jugular veins, and peripheral pulses are also assessed. Signs of vascular disease in the lower extremities and feet are described. The document provides guidance on examining murmurs during respiration and the Valsalva maneuver.

1. EXAMINATION OF CVS
Dr. Shilpa Kantilal Ingle
Sharirkriya Dept.
Govt. Ayurved college , Nanded
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2. COMPONENTS
Includes Vital Signs in particular:
 –Blood pressure
 –Pulse: rate, rhythm, volume
 Includes Pulmonary Exam
 Includes assessment distal vasculature (legs,
feet, carotids)
 4 basic components:
–Observation, Palpation, Percussion &
Auscultation
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3. OBSERVATION
Pay attention to:
 –Chest shape
 –Shortness of breath (@ rest or walking)?
 –Sitting upright? Able to speak?
 –? Visible impulse on chest wall from
vigorously contracting ventricle (rare)
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4. SURFACE ANATOMY
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5. AREAS OF AUSCULTATION
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7. PALPATION
Right Ventricle
 Vigor of contractility
 –Felt with heel of hand
 –Prominence described as
a “lift” or “heave”
 Thrill – rare palpable sensation
associated w/regurgitant or
stenotic murmurs
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8. AUSCULTATION: USING YOUR STETHESCOPE
 Diaphragm-Higher pitched sounds
 Bell-Lower pitched
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9. Courtesy- Wilbur Lew, M.D.
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10. WHAT ARE WE LISTENING FOR?
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11. AUSCULTATION TECHNIQUE
 Start over Aortic area
2nd Right Intercostal Space (ICS) – Use
Angle of Louis as landmark
 Pulmonic area (2nd L ICS)
 Inch down Sternal border
Tricuspid area (4th L ICS)
 Inch towards Mitral area (4th ICS,
midclavicular)
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12. 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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13. EXTRA HEART SOUNDS – S3 & S4
Ventricular sounds, occur during diastole
 –normal in young patient (~ < 30 years)
 –usually LV, rarely RV
S3 follows S2
 –caused by blood from LA colliding w/”left over” blood
in LV
 –assoc w/heart failure.
S4 precedes S1
 –caused during atrial systole
 –when blood squeezed into non-compliant LV
 –assoc w/HTN
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14. S3 & S4-CONTD…
 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) – can also check over RV (4th
ICS, L parasternal)
 •Abnormal beyond age ~30
 •When present, S3 or S4 are referred to as
“gallops”
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15. CAROTID ARTERIES
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16. CAROTID ARTERIES
 •Anatomy
 •Palpation (each side separately!)
–Rhythm
–Fullness
•Auscultation
 –Radiation of murmurs
 –? Intrinsic atherosclerosis – may produce
“shshing” noise known as bruit
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17. JUGULAR VENOUS PRESSURE (JVP)
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18. JUGULAR VENOUS PRESSURE (JVP)
 Straight line with RA
 Manometer - reflecting Central Venous Pressure
(CVP)
 A: ATRIA CONTRACT
 C: CLOSURE OF TRICUSPID VALVE
 V: VOLUME OF ATRIA INCREASES
 Find correct area – helps to first identify SCM &
triangle it forms w/clavicle
 Hepatojugular reflux (gentle pressure over liver
pushes blood back into IJ & makes pulsations more
apparent)
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19. JVP TECHNIQUE (CONT)
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20. JVP WAVEFORM
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21. NORMAL JVP
 The height Observe the patient at 45°, with his head turned
slightly to the left.
 Look for the right internal jugular vein as it passes just
medial to the clavicular head of the sterno cleidomastoid up
behind the angle of the jaw to the earlobes. The JVP is the
vertical height of the pulse above the sternal angle
(measured from the angle of Louis to the upper part of the
JVP pulsation). It is raised if >4cm.
 Pressing on the abdomen normally produces a transient
rise in the JVP. If the rise persists throughout compression,
it is a positive abdominojugular reflux sign.
 This is a sign of right ventricular failure, reflecting inability
to eject the increased venous return
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22. SOME OF THE ABNORMALITIES OF THE JVP
Raised JVP with normal waveform: Fluid overload,
right heart failure.
Fixed raised JVP with absent pulsation: svc
obstruction
Large a wave: Pulmonary hypertension, pulmonary
stenosis.
 Absent a wave: Atrial fibrillation.
 Large v waves: Tricuspid regurgitation—look for
earlobe movement.
 Absent JVP: When lying flat, the jugular vein
should be filled. If there is reduced circulatory
volume (e.g. dehydration, haemorrhage) the JVP may
be absent.
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23. PULSES
 RATE
 Rhythm
 Character
 Volume
e.g.
Bounding pulses are caused by CO2 retention, liver failure, and
sepsis
Small volume pulses occur in aortic stenosis, shock, and
pericardial
Effusion
Collapsing (‘water hammer’) pulses are caused by aortic
incompetence,
AV malformations, and a patent ductus arteriosus
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24. LOWER EXTREMITY VASCULAR EXAM –
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
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25. POPLITEAL PULSE (BEHIND THE KNEE)
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26. VASCULAR DISEASE OF THE LOWER LEG
Components:
–outflow (arterial)
–return (venous, lymphatic)
Clinical Presentations:
Arterial: pain (supply-demand);
wound healing
Venous: Edema; Lymph
(uncommon), obstruction
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27. 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 ? atherosclerosis &/or hypo-
perfusion
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28. Source-
Examination Of The Cardiovascular System
Charlie Goldberg, M.D. Professor of
Medicine, UCSD SOM
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29. RESPIRATION AND VALSALVA MANEUVER
Respiration
Right-sided murmurs generally increase with
inspiration. Left-sided murmurs usually are louder
during expiration.
Valsalva Maneuver
Most murmurs decrease in length and intensity. Two
exceptions are the systolic murmur of HCM, which
usually becomes much louder, and that of MVP, which
becomes longer and often louder. After release of the
Valsalva, right-sided murmurs tend to return to
baseline intensity earlier than left-sided murmurs.
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