This document provides an overview of how to examine the cardiovascular system through history, examination of vital signs, inspection, palpation, and auscultation. It details how to examine the pulse, blood pressure, jugular venous pulse, apex beat, and heart sounds. It describes normal findings as well as abnormalities that may be found and how to characterize different types of murmurs. The examination is supported by additional tests like ECG, chest x-ray, and echocardiogram.

1. Cardiovascular system
History & Examination

2. Cardinal symptoms
 Chest pain
 DOE, PND, orthopnea
 Palpitation, syncope
 Edema or weight gain
 Claudication
 Cyanosis

3. Relevant other examination
 Vitals- Temperature, PR, BP, RR
 Pallor/cyanosis
 Clubbing
 Edema
 Hepatomegaly and/or splenomegaly
 Crepitations at lung base

4. Cardiac examination
 Pulse
 Blood pressure
 Jugular venous pulse (JVP)
 Inspection
 Palpation
 Auscultation

5. Pulse
Palpable- temporal, CAROTID,
brachial, RADIAL, femoral, popliteal,
posterior tibial, dorsalis pedis

6. Pulse
 Rate- normal 60-100 per minute
 Rhythm- regular or
irregular (atrial
fibrillation, ectopics)
 Volume- rough guide of pulse pressure
 Character
 Radio-femoral delay
R & R- radial, Vol. & Charac.- carotid

7. Character of pulse
 Slow rising- AS
 Collapsing- AR
 Bisferiens- AR & AS
 Pulsus paradoxus- heart sounds heard,
but no radial pulse- seen with
cardiac tamponade or severe asthma
 Pulsus alternans- alternate strong &
weak beats- seen in severe LVF

8. Blood pressure
 Measured by sphygmomanometer
 Patient comfortable
 Manometer at the level of arm
 Cuff length- >40% arm circumference
 Proper cuff width- 2/3rd
of arm- 12.5 cm.
 Korotkoff sounds heard by stethoscope
 Appearance- systolic BP
 Disappearance- diastolic BP
 Pulse pressure- systolic - diastolic

9. Classification of BP
 Normal- 90-119/60-79
 Pre-HT- 120-139/80-89
 Stage 1- 140-159/90-99
 Stage 2- >160/>100
 Systolic- >140/<90
AHA,2003

10. Jugular venous pulse
Internal jugular vein
At an angle of 45 degree
Look tangentially

11. JVP vs. Carotid pulse
 Better seen
 2 upstrokes/beat
 Upper level
 Less forceful
 Easily obliterated
 Changes with
posture/respiration
 HJ reflux +ve
 Better felt
 1 upstroke/beat
 No upper level
 More forceful
 Not obliterated
 No change with
posture/respiration
 No change

12. Jugular venous pulse
 a wave- atrial contraction with TV open,
precedes S1
 c wave- bulging of closed TV in atrium
 x descent- atrial relaxation with TV closed,
precedes S2
 v wave- atrial filling with TV closed
 y descent- atrial emptying with TV open
x, v- systolic; y, a- diastolic

13. Abnormal JVP
 a absent- A-fib.
 a large- TS, PS, PHT
 a cannon- arrythmia- CHB, VT, ectopics
 y & x prominent- constric. pericarditis
 y prominent, x absent- TR
 y slow- TS

14. Inspection
 Proper exposure
 Deformity
 Apex beat
 Scars
 Respiration

15. Palpation- apex beat
 Lowest & outermost point of definite cardiac
pulsation
 Lies just medial to MCL in 5th
ICS
 Size- 1-2.5 cm.
 Caused by left ventricle
 Normally <50% of systole
 Hyperkinetic- <50% systole, forceful, dilated LV,
regurgitant lesion (MR/AR), ±S3
 Sustained- >50% systole, forceful, hypertrophic LV,
stenotic lesion (AS/HOCM) or HT, ±S4

16. Palpation- other
 Parasternal impulse- enlarged LA/RV
 Thrill- palpable murmur (>grade 3)
 Other palpable sounds
 S1- apex, MS
 A2- R 2nd
ICS, systemic HT
 P2- L 2nd
ICS, pulmonary HT
 S3/S4- apex/L parasternal,
dilatation/hypertrophy of ventricle
 Aortic pulsation- chest/epigastrium,
consider aneurysm

17. Auscultation- normal
 Palpate carotid simultaneously
 Areas for auscultation
 Mitral- apex
 Tricuspid- L parasternal
 Aortic- R 2nd
ICS
 Pulmonary- L 2nd
ICS
 Only S1 & S2 are heard
 S1- closure of MV/TV, single, systole begins
 S2- closure of AV/PV, split (normally A2 before P2,
best heard in pulmonary area during inspiration),
systole ends

18. Auscultation areas

19. Auscultation- abnormal
 Altered intensity (soft/loud)
 All soft- emphysema, pericardial effusion
 Soft S1/A2/P2- calcific valve
 Loud S1- non-calcific MS, tachycardia, ASD/Ebstein’s, high cardiac
output states like anemia, exercise, hyperthyroidism
 Loud A2/P2- systemic/pulmonary HT
 Splitting of S2
 Single- AS/PS
 Wide- PS, RBBB
 Fixed- ASD
 Reverse- LBBB (appears on expiration, disappears on inspiration)
 Syst./pulm. HT- wide, narrow or reverse split

20. Auscultation- other sounds
 Systolic-
 Early ejection click- AV/PV
 Mid/late ejection click- MVP
 Diastolic-
 Opening snap- MS
 S3- poor LV compliance- CHF, DCMP
 S4- increased LV resistance- HT, AS, HOCM

21. Auscultation- murmurs
 Due to turbulent blood flow
 Characteristics-
 Timing- systolic/diastolic, early/mid/late/pan
 Location- apex, LLSB, aortic/pulmonary area
 Radiation- AS to carotids, MR to axilla
 Duration/shape
 Grade- 1-6, grade 4 causes palpable thrill
 Pitch- high-regurgitant/low-stenotic
 Quality- blowing high-pitched- regurgitant,
harsh rough rumbling low-pitched-
stenotic
 Variation- with respiration, position, valsalva etc.

22. Auscultation- murmurs
 Systolic-
 Ejection- AS/PS, flow murmurs (non pathological)
 Pan- MR/TR, VSD
 Late- MVP, HOCM
 Diastolic-
 Early- AR/PR
 Mid- MS/TS
 Continuous- PDA

23. Supported by
ECG, CxR, ECHO