This document provides details on cardiovascular examination including cardinal symptoms, chest pain characteristics, breathlessness causes, palpitations description, syncope causes, and edema types. It also describes techniques for cardiovascular auscultation including listening locations, sounds, murmur characteristics like timing, intensity location, loudness, quality, pitch, radiation, and changes with maneuvers.

1.  Cardiovascular system examinationCardiovascular system examination

2. Cardinal symptomsCardinal symptoms
 Chest painChest pain
 BreathlessnessBreathlessness
 PalpitationsPalpitations
 SyncopeSyncope
 Easy fatiguabilityEasy fatiguability
 Swelling of legsSwelling of legs

3. Chest painChest pain
 Myocardial ischaemiaMyocardial ischaemia
 PericarditisPericarditis
 Aortic dissectionAortic dissection
 Pulmonary embolismPulmonary embolism
 AnginaAngina
 Oesophageal refluxOesophageal reflux
 Musculoskeletal painMusculoskeletal pain

4. Chest painChest pain
 S – SiteS – Site
 O- OnsetO- Onset
 C- CharacterC- Character
 R- RadiationR- Radiation
 A- associated symptomsA- associated symptoms
 T- Time( Does the npain follow any patterT- Time( Does the npain follow any patter
 E- Exacerbating / relieving factorsE- Exacerbating / relieving factors
 S- SeverityS- Severity

5.  Anginal painAnginal pain
 Pericardial pain: Central chest pain, sharp inPericardial pain: Central chest pain, sharp in
character, aggravated by inspiration, cough orcharacter, aggravated by inspiration, cough or
postural changespostural changes
 Pleuritic chest painPleuritic chest pain
 Aortic dissection: Severe tearing pain in eitherAortic dissection: Severe tearing pain in either
the front or back of the chestthe front or back of the chest

6. BreathlessnessBreathlessness
 Abnormal awareness of breathing occuringAbnormal awareness of breathing occuring
either at rest or at an unexpectedly low level ofeither at rest or at an unexpectedly low level of
exertionexertion
 CausesCauses
 Restricted filling: MS, Cons. Pericarditis,Restricted filling: MS, Cons. Pericarditis,
CardiomyopathiesCardiomyopathies
 Pressure loading: HTN,Aortic stenosisPressure loading: HTN,Aortic stenosis
 Volume loading: MR,ArVolume loading: MR,Ar
 Contractile impairment: CAD, DCMContractile impairment: CAD, DCM

7.  Orthopnoea: On lying there is breathlessnessOrthopnoea: On lying there is breathlessness
 May use extra pillows, Sleep in sitting postureMay use extra pillows, Sleep in sitting posture
 Paroxysmal nocturnal dyspnoea: FrankParoxysmal nocturnal dyspnoea: Frank
pulmonary oedema on lying wakes the patientpulmonary oedema on lying wakes the patient
from sleep with distressing dyspnoea, and fearfrom sleep with distressing dyspnoea, and fear
of imminent death.of imminent death.

9. FatigueFatigue
 Exertional fatigue is an important symptom ofExertional fatigue is an important symptom of
heart failure particulary towards the end of theheart failure particulary towards the end of the
day.day.
 Deconditioning and muscular atrophy andDeconditioning and muscular atrophy and
decreased oxygen supply to exercising muscledecreased oxygen supply to exercising muscle

10. PalpitationPalpitation
 Abnoraml awareness of ones heart beatAbnoraml awareness of ones heart beat
 May be normal during exercise or heightenedMay be normal during exercise or heightened
emotionemotion
 Description of rate and rhythm is essentialDescription of rate and rhythm is essential
 History of “missed”beatsHistory of “missed”beats
 May be due to rhythm or forced contractonofMay be due to rhythm or forced contractonof
the heart.the heart.

11. SyncopeSyncope
 Transient hypotensionTransient hypotension
 Results in abrupt cerebral hypoperfusionResults in abrupt cerebral hypoperfusion
 Feeling of lightheadednessFeeling of lightheadedness
 Recovery is usually rapidRecovery is usually rapid
 Causes: Postural, vasovagal, valvular obstructionCauses: Postural, vasovagal, valvular obstruction

12. oedemaoedema
 Pitting or non pittingPitting or non pitting
 Diurnal variationDiurnal variation

13.  Left sided heart failure vs right sided failureLeft sided heart failure vs right sided failure
symptomssymptoms

14. Past historyPast history
 Rheumatic feverRheumatic fever
 Thyroid diseasesThyroid diseases
 DiabetesDiabetes
 HypertensionHypertension
 Stroke/ TIAStroke/ TIA

15. Personal historyPersonal history
 SmokingSmoking
 Life styleLife style
 Alcohol abuseAlcohol abuse

16. Family historyFamily history
 Coronary artery diseaseCoronary artery disease
 HypertensionHypertension
 CardiomyopathiesCardiomyopathies

17. Treatment historyTreatment history
 InjectionsInjections
 B- blockersB- blockers
 NSAIDSNSAIDS

18. General examinationGeneral examination
 Pulse:Pulse:
 RateRate
 RhythmRhythm
 CharacterCharacter
 VolumeVolume
 Peripheral pulsesPeripheral pulses
 Radio- radial/ Radio- femoral delaysRadio- radial/ Radio- femoral delays

20. Blood pressureBlood pressure
 Stages: Korotkoffs soundsStages: Korotkoffs sounds
 BP cuff- 12cm widthBP cuff- 12cm width

21.  PallorPallor
 ClubbingClubbing
 CyanosisCyanosis
 OedemaOedema
 LymphadenopathyLymphadenopathy
 JaundiceJaundice

22. oedemaoedema
 Pitting or non pittingPitting or non pitting

23. Jugular venous pressureJugular venous pressure

27. Cardiac examinationCardiac examination
 Inspection:Inspection:
- deformity- deformity
- Sternotomy scar- Sternotomy scar
- Posture of the patient- Posture of the patient
- Breathlessness- Breathlessness
--

29. PalpationPalpation
 Apex beat: Lowest and most lateral point atApex beat: Lowest and most lateral point at
which the cardiac impulse is feltwhich the cardiac impulse is felt
 Normal: 5Normal: 5thth
intercostal space mid clavicular lineintercostal space mid clavicular line
 Displacement from the normal site indicatesDisplacement from the normal site indicates
cardiac enlargement; usually due tocardiac enlargement; usually due to
dilatation(MR,AR)dilatation(MR,AR)
 In hypertrophy the cardiac location may beIn hypertrophy the cardiac location may be
normal(AS)normal(AS)

31. Cardiac AuscultationCardiac Auscultation

32. Cardiac auscultation is mostCardiac auscultation is most
useful part of CVS examinationuseful part of CVS examination
which gives anatomical,which gives anatomical,
physiological and hemodyanamicphysiological and hemodyanamic
information of normal andinformation of normal and
abnormal cardiac function.abnormal cardiac function.

33. InstrumentInstrument
 DiaphragmDiaphragm
 BellBell

35. Auscultatory areasAuscultatory areas

36. Auscultatory eventsAuscultatory events
 SoundsSounds
 S1S1
 S2S2
 S3 or S4S3 or S4
 ClicksClicks
 Systolic murmursSystolic murmurs
 Diastolic murmursDiastolic murmurs
 Pericardial rubPericardial rub

37. Systolic Vs DiastolicSystolic Vs Diastolic
 CarotidsCarotids
 ApexApex

38. S1S1
 Closure of mitral andClosure of mitral and
tricuspid valvetricuspid valve
 Medium pitchMedium pitch
 DiaphragmDiaphragm
 Heard in all areasHeard in all areas

39. S2S2
 Closure of Aortic andClosure of Aortic and
Pulmonary valvesPulmonary valves
 AV and PV donot closeAV and PV donot close
simultaneouslysimultaneously
 2 components of S22 components of S2
 A2 and P2A2 and P2
S1 A2 P2
S1 A2 P2
Inspiration
Expiration

40. S3 and S4S3 and S4

41. ClicksClicks
Just as closure of AV valves andJust as closure of AV valves and
Semi-lunar valves cause S1 and S2,Semi-lunar valves cause S1 and S2,
their opening also may producetheir opening also may produce
sounds called Clicks, but thatsounds called Clicks, but that
happens only when they are diseased.happens only when they are diseased.

42. MurmursMurmurs
Musical sounds created by turbulentMusical sounds created by turbulent
flow across an abnormal valve orflow across an abnormal valve or
abnormal flow across a normal valveabnormal flow across a normal valve

44. Describing murmursDescribing murmurs
 Which part of cardiac cycle?Which part of cardiac cycle?
 Site of maximum intensity?Site of maximum intensity?
 Loudness grade?Loudness grade?
 Quality?Quality?
 Pitch?Pitch?
 Any specific radiation?Any specific radiation?
 Change with specific maneuver?Change with specific maneuver?

45. Types of murmursTypes of murmurs
 SystolicSystolic- begin and end in systole- begin and end in systole
 DiastolicDiastolic- begin and end in diadtole- begin and end in diadtole
 ContinuousContinuous- begin in systole and spill over- begin in systole and spill over
into diastole across S2into diastole across S2

46. Systolic murmursSystolic murmurs
 PansystolicPansystolic
 Mid-systolic or ejectionMid-systolic or ejection
systolicsystolic
 Late systolicLate systolic
S1 A2 P2
S1 A2 P2
S1 A2 P2

47. Pansystolic murmursPansystolic murmurs
 Mitral regurgitationMitral regurgitation
 Tricuspid regurgitationTricuspid regurgitation
 Ventricular SeptalVentricular Septal
defectdefect
S1 A2 P2

48. Ejection systolic murmursEjection systolic murmurs
 Aortic stenosisAortic stenosis
 Pulmonic stenosisPulmonic stenosis
 Flow murmursFlow murmurs
S1 A2 P2

49. Late systolic murmursLate systolic murmurs
 Mitral valve prolapseMitral valve prolapse
S1 A2 P2

50. Diastolic murmursDiastolic murmurs
 Early diastolicEarly diastolic
 Mid diastolicMid diastolic
 Late diastolic/Late diastolic/
PresystolicPresystolic
S1 A2 P2
S1 A2 os
S1 A2 P2

51. Early diastolic murmursEarly diastolic murmurs
 ARAR
 PRPR
S1 A2 P2
S1 A2 P2

52. Mid diastolic murmursMid diastolic murmurs
 Mitral stenosisMitral stenosis
 Tricuspid stenosisTricuspid stenosis
 Increased flow across MVIncreased flow across MV
 VSDVSD
 PDAPDA
 MRMR
S1 A2 os
S1 A2

53. Late diastolic/ PresystolicLate diastolic/ Presystolic
 Mitral stenosisMitral stenosis
S1 A2 P2

54. Continuous murmursContinuous murmurs
 PDAPDA
 AV fistulaAV fistula

55. Describing murmursDescribing murmurs
 Which part of cardiac cycle?Which part of cardiac cycle?
 Site of maximum intensity?Site of maximum intensity?
 Loudness grade?Loudness grade?
 Quality?Quality?
 Pitch?Pitch?
 Any specific radiation?Any specific radiation?
 Change with specific maneuver?Change with specific maneuver?

56. Site of max intensity?Site of max intensity?
 Mitral valve- apical areaMitral valve- apical area
 Tricuspid valve- lower Lt sternal edgeTricuspid valve- lower Lt sternal edge
 Aortic valve – 2Aortic valve – 2ndnd
right ICSright ICS
 Pulmonary Valve- 2Pulmonary Valve- 2ndnd
left ICSleft ICS

57. Describing murmursDescribing murmurs
 Which part of cardiac cycle?Which part of cardiac cycle?
 Site of maximum intensity?Site of maximum intensity?
 Loudness grade?Loudness grade?
 Quality?Quality?
 Pitch?Pitch?
 Any specific radiation?Any specific radiation?
 Change with specific maneuver?Change with specific maneuver?

58. LoudnessLoudness
 Grade-1 heard after intense effort in a quietGrade-1 heard after intense effort in a quiet
roomroom
 Grade 2 easily heardGrade 2 easily heard
 Grade 3 loud murmur with no thrillGrade 3 loud murmur with no thrill
 Grade 4 loud murmur with thrillGrade 4 loud murmur with thrill
 Grade 5 murmur heard with rim touchingGrade 5 murmur heard with rim touching
 Grade 6 murmur heard with St off the chestGrade 6 murmur heard with St off the chest

59. Describing murmursDescribing murmurs
 Which part of cardiac cycle?Which part of cardiac cycle?
 Site of maximum intensity?Site of maximum intensity?
 Loudness grade?Loudness grade?
 Quality?Quality?
 Pitch?Pitch?
 Any specific radiation?Any specific radiation?
 Change with specific maneuver?Change with specific maneuver?

60. Quality?Quality?
 RumblingRumbling MS, TSMS, TS
 BlowingBlowing MR, TR,ARMR, TR,AR
 Machinery murmurMachinery murmur PDAPDA

61. Describing murmursDescribing murmurs
 Which part of cardiac cycle?Which part of cardiac cycle?
 Site of maximum intensity?Site of maximum intensity?
 Loudness grade?Loudness grade?
 Quality?Quality?
 Pitch?Pitch?
 Any specific radiation?Any specific radiation?
 Change with specific maneuver?Change with specific maneuver?

62. Pitch?Pitch?
 High pitchHigh pitch MR, TR, ARMR, TR, AR
 Low pitchLow pitch MS, TSMS, TS
 Harsh (mixed)Harsh (mixed) VSD, ASVSD, AS

63. Describing murmursDescribing murmurs
 Which part of cardiac cycle?Which part of cardiac cycle?
 Site of maximum intensity?Site of maximum intensity?
 Loudness grade?Loudness grade?
 Quality?Quality?
 Pitch?Pitch?
 Any specific radiation?Any specific radiation?
 Change with specific maneuver?Change with specific maneuver?

64. Radiation?Radiation?
 MRMR axilla, Interscapular areaaxilla, Interscapular area
 ARAR LLSELLSE
 ASAS CarotidsCarotids
 MSMS
 TSTS donot radiatedonot radiate
 TRTR

65. Describing murmursDescribing murmurs
 Which part of cardiac cycle?Which part of cardiac cycle?
 Site of maximum intensity?Site of maximum intensity?
 Loudness grade?Loudness grade?
 Quality?Quality?
 Pitch?Pitch?
 Any specific radiation?Any specific radiation?
 Change with specific maneuver?Change with specific maneuver?

66. Dyanamic auscultationDyanamic auscultation
 Respiratory variationRespiratory variation
 PosturePosture
 Valsalva maneuverValsalva maneuver
 Handgrip exerciseHandgrip exercise
 AmylnitriteAmylnitrite

67. Respiratory variationRespiratory variation
 How to see?How to see?
 Why does it change murmurs?Why does it change murmurs?
 Implication?Implication?
 Right sided murmurs increase with inspirationRight sided murmurs increase with inspiration
 Left side murmurs increase with expirationLeft side murmurs increase with expiration

68. PosturePosture
 Certain murmurs are best appreciated inCertain murmurs are best appreciated in
specific postures.specific postures.
 MS in left lateralMS in left lateral
 AR in sitting postureAR in sitting posture

69. DrugsDrugs
 AmylnitriteAmylnitrite
 How does it act?How does it act?
 What is the effect?What is the effect?

70. Pericardial rubPericardial rub
 Leathery qualityLeathery quality
 3 components3 components
 Sitting and leaning forwardsSitting and leaning forwards

71. Thank youThank you