This document outlines the steps for examining the cardiovascular system, including inspection, palpation, auscultation, and percussion of the heart, neck, lungs, abdomen, and limbs. Key steps include assessing pulse and blood pressure, listening to heart sounds and murmurs at different auscultation sites, and differentiating between systolic and diastolic murmurs that may indicate conditions like aortic stenosis, mitral stenosis, or aortic regurgitation. The goal is to perform a thorough routine exam of the cardiovascular system and identify any abnormalities.

1. Chest and heart examination
By Dr Wedad Bardisi

2. Framework for routine examination of the
cardiovascular system.
1. Watch the patient face for feature of anxiety,
distress, breathlessness…
2. Assess hand wormth, nails for clubbing or splinter
haemorrhages.
3. Palpate the radial pulse and assess the rate
&rhythm.
4. Locate &palpate the brachial pulse and assess the
character.
5. Measure the blood pressure.

3. Frame work for routine examination of the
cardiovascular system
6. With the patient lying supine at 45°, assess the
jugular venous pressure and the jugular venous
pulse form.
7. Palpate the carotid pulse and assess its character.
8. With the patient‘s chest exposed, inspect the
pericardium and assess the breathing pattern and
presence of any abnormal pulsation.
9. Palpate the pericardium, locate the apex beat and
assess its character, any abnormal vibration or
thrills

6. Cardiac auscultation
10. Listen with the stethoscope and assess heart sound
and murmurs.
 Systolic murmur is not always pathological.
 Diastolic murmurs are difficult to hear.
 Ask the patient to roll on left side to detect the
diastolic murmur of mitral stenosis at the apex.
 Ask the patient to sit and lean forward and hold his
breathing after expiration to detect the diastolic
murmur of aortic regugitation at lower left sternal
border.

8. Ask the patient to roll on left side to detect the diastolic
murmur of mitral stenosis at the apex.

9. Frame work for routine examination of the
cardiovascular system
11. Percuss and auscultate the chest both front and
back looking for pleural effusions.
12. Lay the patient flat and palpate the abdomen,
feeling in particular for the liver and any dilatation
of the abdominal aorta.
13. Assess the femoral pulses and the popliteal and foot
pulses. Look for ankle or sacral edema.

10. The best site for cardiac auscultation and the
cause of murmur
• Upper right sternal border: Aortic stenosis.
• Upper left sternal border: Pulmonary valve murmur.
• Lower left sternal border: Tricuspid regugitation
• Aortic regugitation
• Apex mitral or aortic valve
• Axilla: Radiating mitral regurgitation
• Below left clavicle: radiating pulmonary valve
murmur.

12. Cardiac Auscultation
Tricuspid regugitatiion,
Aorticregugitation ,
mitral or
aorticvalve

13. Differentials of diastolic murmur
• Always pathological.
• Difficult to hear it.
• Diastolic murmur of aortic regurgitation:
 Best hear at lower left sternal border.
 Radiate to the apex.
 Ask pt to sit and lean forward and hold his breath(expiration)
 Associted with wide pulse pressure (e.g. 170/60).
 Tapping apex beat.
 Opening snap.

14. • Diastolic murmur of mitral stenosis
Best hear at apex when pt rolled on left side.
Murmur does not radiate.

15. Cardiac Auscultation
pathology Murmur
Tricuspid regurgitation Pansystolic murmur
Ventricular septal defect
Mitral regurgitation
Aortic stenosis
Pulmonary stenosis Ejection systolic murmur
Normal Heart valve
Mitral stenosis Diastolic murmur
Aortic regurgitation

16. Differentials of systolic murmur
 Ejection systolic:
• Innocent systolic murmur.
• Aortic stenosis.
• Pulmonary stenosis.
• Hypertrophic cardiomyopathy.
• Flow murmur.
• Atrial septal defect
• Fever
• Athlete‘s heart

17. Pansystolic murmur
• Tricuspid regurgitation.
• Mitral regugitation.
• Ventricular septal defect.

18. • Pulmonary stenosis: below left clavicle.
• Aortic stenosis: upper right sternal border.
• Aortic regurgitation: lower left sternal border.
• VSD, pulmonary valve murmur: upper left sternal
border.
• Mitral regurgitation : axilla
• Mitral regurgitation , stenosis & aortic stenosis: Apex

19. Heart sounds

21. Cardiac auscultation
aortic valve disease
• Aortic stenosis:
• ejection systolic murmur radiate to the neck.
• Aortic regurgitation:
• early diastolic murmur.
• Ask pt to sit and lean forward and hold his breath
(expiration).
• Radiate to apex
• Wide pulse pressure e.g. (170/60)

22. Cardiac auscultation
mitral valve disease
• Mitral regurgitation:
• pansystolic murmur
• Apex radiate to the axilla.
• Mitral stenosis:
• Tapping apex beat.
• Opening snap.
• Mid diastolic murmur.
• Apex when pt. rolled on left side.
• Murmur doesnot radiate

23. Cardiac auscultation
pulmonary valve disease
• Pulmonary stenosis:
• ejection systolic murmur radiate to the left clavicle
• Right ventricular heave.
• VSD: pansystolic murmur
• Radiate all over the pericardium