1. History Taking & Physical Examination.
CHAN SOVANDY, M.D.
International University, Phnom Penh

2. Outline
• Anatomy and physiology
• Surface projections of the heart and great vessels
• Cardiac chambers, valves, and circulation
• The heart sounds
• Heart murmurs
• Relation of the auscultatory findings to the chest wall
• Techniques of Examination
• The arterial pulse
• Blood pressure
• Jugular venous pressure and pulses
• The heart
• Special techniques
• Pulsus alternans
• Pulsuss paradoxus
• Summary

3. Surface projections of the heart
and great vessels- RV and PA
• RV cover most of
anterior cardiac surface
• RV meets PA at left
border of sternum and
at the 3rd rib level

5. Surface projections of the heart and
great vessels – LV , Aorta, RA and LA
• LV occupies just small portion of
anterior cardiac surface
• LV produces the “apical impulse” –
seen at the 5th interspace, 7 to 9
cm from the midsternal line
• Aorta: right sternal border at the
3rd rib
• RA from R border of the heart, it is
usually not identified on PE
• LA is mostly posterior and cannot
be examined directly

7. Cardiac chambers, Valves, and
Circulation
• AV valves
•TV and MV
• Semilunar (SL) valves
•AoV and PV
• The vibration of those valves when they
are closed generate the normal heart
sounds

9. Heart Sounds
• S1 when AV valves close at the beginning of
ventricular systoles
• S2 when SL valves close at the beginning of
ventricular diastoles
• S3 is heard in children and young adults during
rapid ventricular filling
• S4 is occasionally heard in normal adults during
atrial contraction
• Before LV filling begins, the MV valves open. the
opening of MV usually is silent, but it may be
audible as an opening snap in mitral stenosis

10. Splitting of heart sounds
• Physiologically, the events occurring on
the right side of the heart are slightly later
than those on the left
•TV closes a bit later than the MV, this
generates splitting of S1
•PV closes a bit later than AoV, this
generates splitting of S2
• However, splitting of the heart sounds are
not normally heard.

11. Heart murmurs
• Heart murmurs differ from heart
sounds by their longer duration
• They are due to turbulent blood flow
against the abnormal valves, too
narrow( stenotic) or too wide
(regurgitant)

12. Relation of the auscultatory finding
to the chest wall
• Sounds and murmurs that originate in:
•The MV are usually heard best at cardiac
apex
•The TV are heart best at lower left
sternal border
•The PV are heard best at left sternal
border at the 2nd and 3rd interspace
•The AoV are heard best at tight sternal
border at the 2nd and 3rd interspace

14. Techniques of Examination- The
arterial pulses
• Arterial pulses detects:
• Rate of the heart
• Rhythm of the heart
• Amplitude of the pulse
• Obstruction to blood flow( thrill on palpation and
bruit on auscultatory)
• Commonly used arterial pulses
• Radial pulse
• The carotid pulse
• The brachial pulse

16. Techniques of examination
Rate and rhythm of the heart
• Rate the heart
• Use radial pulse
• If regular- count the number of pulse in 15
seconds×4
• If irregular- count till 60 seconds and also do the
count by auscultating the heart because beats that
occur earlier than others may not be detected
peripherally
• Rhythm of the heart
• Also use radial pulse
• Better use auscultation when the rhythm is
irregular

17. Techniques of examination
amplitude of the pulse
• When radial pulse is rapid and weak (or thread
or small) it suggests hypotension
• When radial pulse is absent, it suggests that
systolic BP is below 80 mm Hg.
• We then proceed to palpate carotid pulse. if
carotid pulse is present, it suggests systolic BP
of at least 60 mm Hg.
• The present of brachial pulse suggests systolic
of at least 70 mm Hg.

20. Techniques of examination Thrill
and Bruit
• When palpating carotid pulse, note for
thrill, if thrill is present for bruit. The
present of thrill or bruit mean the carotid
artery carries an atheroma plaque.
• When palpating carotid pulse, avoid:
• Palpating over the carotid sinus which lies at the
top level of the thyroid cartilage.
• Palpating the 2 carotid arteries at the same time.

22. Techniques of examination Blood
pressure
• Use proper cuff
• The width of the bladder should be 40% of the
circumference of the limb measured
• The length of the bladder should be 80% of the
circumference of the limb measured
• Obese pt may need 15 cm wide cuff or 18 cm thigh cuff.
• The cuff that is too tight makes falsely high BP
• Best to use sphymomanometer of mercury type,
yet aneroid one can be used with regular
calibration.

23. What is Blood Pressure?
Blood pressure is a measure of the pressure of the blood
Against the walls of the arteries ,it is dependant upon the action
of the heart ,the elasticity of the artery walls and the volume
and thickness of the blood .the blood pressure reading are a
radio of the maximum or systolic
pressure (as the heart pushes the blood out to the body )
written over the minimum or diastolic pressure (as the heart
begins to fill with blood )
Systolic pressure
Diastolic pressure

24. Techniques of examination Blood
pressure (cont’d)
• No smoking or caffeine 30 min prior
• Rest 5 min prior, relax in a quiet room
• Arm free of clothing and of AV fistula for hemodialysis
• Pt can be supine, sitting, or standing
• Brachial artery at the level of the heart (junction of 4th interspace with the
artery.
• Locate brachial artery
• Place lower border of BP cuff at 2 to 3 cm above antecubital creases with its
bladder on top of brachial artery.
• Blow up the cuff until brachial pulse disappears, then about 30 mm Hg high.
• Place the bell of stetoscope on brachial artery at the antecubetal creases
• Deflate the cuff slowly 2 to 3 mmHg/second
• The first pulse heart is SBP and the last pulse heard is DBP
• Should take BP both arms, if high BP found => should measure legs BP and its
pulse (to rule out coarctation of aorta, which gives BP in the legs than in the
arms and pulses in the legs smaller than in those in the arms )

27. What is Hypertension?
Hypertension is the result of persistent high arterial blood
pressure which may cause damage to the vessels and
arteries of the heart ,brain ,kidneys ,and eyes. The entire
circulatory system is affected since it become increasingly
more difficult for the blood to travel from the heart to the
major organs. Multiple blood pressure readings are taken
to
establish an average and analyzed by a physician to
determine hypertension

28. Techniques of examination Jugular
venous pulses and pressure
• Examination of the jugular veins pulsation helps to
estimate:
• The jugular venous pressure (JVP), and
• The pressure in the RA (or the central venous pressure:
CVP)
• The JVP is an indicator of the CVP. The pressure in the
internal jugular veins is a better indicator than the right
one for the CVP, however, it is hard to examine as it lies
deeps into the SC muscle
• To look for pulsation of the internal JV, shinning the light
and look for the pulsation of the surrounding soft tissue
near the external jugular vein and along the SC muscle.
Press over it to rule out carotid artery pulsation.

29. Techniques of examination Jugular
venous pulses and pressure (cont’d)
• JVP does not depend on position. In position A,
we cannot assess JVP as the jugular vein is full
and lies under the chin, so we need to change
position to B or C.
• Roughly, sternal angle is about 5 cm from the
RA
• Normally, JVP is about 3 to 4 cm above the
sternal angle. Pressure above that means high
CVP (i.e. the RA has a high pressure, which is
seen in right sided heart failure)

32. Indication for Placement of a
central Venous Catheter
-Measurement of central venous pressure
-Rapid infusion of fluids
-Insertion of a transvenous pacemaker
-Parenteral alimentation
-Long term chemotherapy
-High risk for venous air embolism (place catheter
at junction of the superior cava and right atrium)

33. CVP BP Diagnosis Fluid
low low/normal fluid lack increase
high normal fluid overlord stop
high low cardiac failure restrict
p.s. CVP :normal :5-10cm of water

34. Techniques of examination The
heart
• General approach
• Inspection and palpation
• Percussion
• Auscultation

35. Techniques of examination The
heart: general approach
• The examination stands on the right of the pt
• Sequences of examination
– Supine with head elevated 300
• Inspect and palpate the precordium: the 2th interspace, the
RV and the LV including the apical impulse
• listen at the tricuspid area with the bell
• Listen at all the auscultatory areas with the diaphragm
– Left lateral decubitus
• Listen at the apex with the bell of the stetoscope
– Sitting, leaning forward, after full exhalation
• Listen along the left sternal border and at the apex

37. Techniques of examination The
heart: inspection and palpation
• Use tangential light for inspection and use several fingertips,
then 1 fingertip for palpation
• look at feel for location of the apical impulse (area of the LV)
• Apex of the heart normally is at the 5th interspace with
the midclavicular line
• Apex that is displaced to the left means enlarged LV or
enlarged heart
• Look and feel for left sternal border impulses at the 3th to 5th
interspace of enlarge RV
• Look and feel at epigastric area for impulse of enlarged RV
especially in obese or muscular pt. Index finger under the rib
cage and up toward the left shoulder while the pt breaths in.
• Feel for thrill in case there is murmur of intensity greater than
3/6.

41. Techniques of examination The
heart: percussion
• Percussion helps to detect whether there is an
enlarged heart when inspection and palpation
fail to detect due to:
• Obesity
• Muscular chest
• Large pericardial effusion
• Markedly dilated failing hypokinetic apical impulse
• During percussion, starting well to the left on
the chest, note for dullness area of the heart.

43. Techniques of examination The
heart: auscultation
• Location
• Learn to accustom yourself in doing heart
auscultation
• Start from right 2th interspace close to the
sternum and then left sternal border in each
interspace from 2th through the 5th , and finally at
the apex.
• Murmur that is heard at a location, though often is
a result of a valve abnormality at that location, it
may sometimes heard at other places (see the
below picture)

46. Techniques of examination The
heart: auscultation (cont’d)
• Use of stetoscope
• Use diaphragm of your stetoscope for high-pitch
sounds such as S1, S2, the murmur of AR and MR,
and pericardial friction rub. Press the diaphragm
firmly and enough to create and air seal with its
full rim.
• Use bell for low-pitch sounds such as S3, S4, and
murmur of MS. Do not press the bell too hard,
otherwise it will function as a diaphragm and the
low-pitch sounds that you want to listen for will
disappear .

49. Techniques of examination The
heart: auscultation (cont’d)
• What to listen for
– S1
• Due to AV valves closure
• Occurs at the same time as the carotid pulse
• Louder than S2
• Usually loudest at the apex or the 4th left interspace
– S2
• Due to semilunar valves closure
– Splitting of S1 and S2
• Splitting S1 ( MV close long before TV ): M1T1
• Splitting S2 ( AoV close long before PV ): A2P2
– A loud P2 suggest delayed PV closure in pulmonary HTN

50. Techniques of examination The
heart: auscultation (cont’d)
• What to listen for
– Pericardial friction rub
• Sound produced by the inflammed and rough pericardiums
rub against each other during early phase of pericarditis
– Extra sounds in systole
• Early systolic ejection sounds
– Shortly after S1
– Coincident with the opening of AoV and PV
– Indicate AS if heard at aortic area, or pulmonary stenosis and
pulmonary HTN if heard at pulmonic area.
• Systolic clicks
– Heard during mid-to late systole
– Originate from the abnormal motion of the MV such as in MV
prolapse

51. Techniques of examination The
hear: auscultation (cont’d)
• What to listen for
– Extra sounds in diastole
• Opening snap
– Due to the opening of MV that is thick and stenotic (i.e. in
mitral stenosis )
– Best heard at lower left stermal border
• S3 (ventricular) gallop
– Normal in children, it is heard during the rapid ventricular
filling phase
– In adult, it indicates too rapid and high ventricular filling, an
early sign of CHF
• S4 (atrial) gallop
– Occur late in ventricular diastole (or at atrial contraction) from
an increased resistance to ventricular filling from ventricular
stiffness as seen in HTN, AS, and hypertrophic cardiomyopathy.

52. Techniques of examination The
heart: auscultation (cont’d)
• What to listen for
– Heart murmurs
• Sound produced by the turbulence of blood that flows
through narrowed valves (stenosis), or flows backward
(regurgitation0, or flows through abnormal passages (shunts
as seen in VSD).
– When heart murmurs are heard, try to:
• Time them
– Systolic murmur, e.g. MR
– Diastolic murmur, e.g. MS
– Holosystolic, e.g. MR, TR VSD
– Continuous, e.g. PDA
• Determine area best heard and its radiation, e.g. a systolic
murmur that is best heard at aortic area and also heard
along the neck suggest AS
• Determine its intensity (1/6 to 6/6)

53. Determine the intensity of heart
murmur – grade 1/6 to 6/6
• Grade 1/6
– Very faint, heard only after listener has tuned in
• Grade 2/6
– Quiet, but heard immediately after placing the stethoscope
• Grade 3/6
– Moderately loud
• Grade 4/6
– Loud murmur with a palpable thrill
• Grade 5/6
– Very loud, may be heard when the stethoscope is partly off the
chest
• Grade 6/6
– May be heard when stethoscope entirely off the chest.

54. Special techniques
• Pulses alternans
– One strong pulse alternates with one week pulse (pulse with
alternating amplitudes)
– Felt best on radial or femoral pulse
– The presence of pulse alternans indicates left-sided heart failure
• Pulses paradoxus
– Normally, during expiration, blood pools back to the heart and make
SBP 3 to 4 mm Hg greater than SBP during inspiration.
– When the different is greater than 10 mm Hg, this is called pulse
paradoxicus and is seen in cardiac tamponade or constrictive
pericarditis
– Technique
• Inflate BP cuff till no pulse and 30 mm Hg more
• Deflate BP cuff very slowly and note SBP at expiration (first heart sound
heart at expiration)
• Continue to deflate and note SBP when heart sound is heard both at
expiration and at inspiration
• Take the SBP expiration – SBP inspiration

55. Summary
• Explain the pt what you are going to do
• Position your pt, may be more than one
• Start from top and move down
• By order: inspection palpation, percussion,
and auscultation