2. GENERAL CVS EXAMINATION (AS
GENERAL EXAMINATION BUT STRESS IN
FOLLOWING):
Look at the patient carefully:
Dyspnoeic or orthopnoeic (may be found in left ventricular failure),
cachexia (in severe heart failure).
Squatting position in Tetralogy of Fallot
Face:
i. Malar flush (in MS).
ii. Marfanoid face.
iii. Corneal arcus and xanthelasma, which may be related to atherosclerosis in ischaemic
heart disease (IHD),
iv. mouth (high arch palate in Marfan’s syndrome).
Anaemia: may be responsible for anaemic heart failure.
Cyanosis: found in tetralogy of Fallot (TOF) and Eisenmenger’s syndrome.
Oedema: pitting oedema is found in congestive cardiac failure (CCF).
3. IN HANDS:
Clubbing.
Cyanosis.
Splinter haemorrhage.
Osler’s node (red, raised, palpable, tender nodule on pulp of finger, toes,
also in thenar or hypothenar area).
Janeway lesion (non-tender, red, maculopapular lesion on palm or pulp of
finger).
Xanthoma: Palmar or tendon (related to atherosclerosis in IHD).
Tobacco stain (found in smokers, responsible for IHD).
9. FINGER CLUBBING
is likely if:
1. the interphalangeal depth ratio is
> 1 (that is, the digit is thicker at
the level of the nail bed than the
level of the distal interphalangeal
joint )
2. the nail fold angle is > 190
degrees
3. Schamroth’s window sign is absent
25. Kussmaul’s sign is a paradoxical rise of
JVP on inspiration that is seen in
pericardial constriction, severe right
ventricular failure and restrictive
cardiomyopathy.
Cannon waves (giant ‘a’ waves) occur
when the right atrium contracts against
a closed tricuspid valve.
1. Irregular cannon waves are seen in
complete heart block and are due to
atrioventricular dissociation.
2. Regular cannon waves occur during
junctional rhythm and with some
ventricular and supraventricular
tachycardias.
27. INSPECTION
1. Precordial bulge : area of the chest overlying the heart (from the 2nd to
6th costal cartilage, from left sternal border to MCL)>> RV enlargement
since early childhood.
2. Dilated veins :SVC obstruction (Filling upwards downwards),milking test
?
3. Scar (name , healing (lry intention : clean linear healing, 2ry intention :
pigmentation , keloid)
A. Median sternotomy scar: open heart surgery e.g. valve replacement , CABG
B. Lateral thoracotomy (inframammary) scar: closed heart surgery e.g. mitral
valvotomy
4. Shape of the chest .
5. Pulsations Apex ,Suprasternal pulsation, 1st aortic area , Pulmonary area
, Left parasternal pulsation , epigastric pulsation.
31. PALPATION
Finger Tips for :
Apex
Pulmonary and aortic area
Finger pads for : apex
Ball of the hand for :
Thrills
Palpable sound
Heel of the hand : for Parasternal
heave
32. APEX
1. Site
2. Extent =area
3. Character
4. Thrill
5. Palpable S1
NB: Pulse deficit ??? HR vs. Pulse rate ?
35. KNOW YOUR STETHOSCOPE!
It is important to understand the uses of both the diaphragm and the bell.
■ The diaphragm is better for picking up the relatively high pitched sounds
of S1 and S2, the murmurs of aortic and mitral regurgitation, and pericardial
friction rubs. Listen throughout the precordium with the diaphragm, pressing
it firmly against the chest.
■ The bell is more sensitive to the low-pitched sounds of S3 and S4 and the
murmur of mitral stenosis. Apply the bell lightly, with just enough pressure
to produce an air seal with its full rim.
Firm pressure on the bell can stretch the underlying skin and make it
function more like the diaphragm. Low-pitched sounds like S3 and S4 may
then disappear— an observation that can help identify them.
39. FIRST HEART
SOUND (S1)
The first heart sound (S1), ‘lub’,
is caused by closure of the mitral
and tricuspid valves at the onset
of ventricular systole.
It is best heard at the apex.
40. SECOND HEART SOUND (S2)
The second heart sound (S2), ‘dub’,
is caused by closure of the
pulmonary and aortic valves at the
end of ventricular systole and is
best heard at the left sternal edge.
It is louder and higher-pitched than
the S1 ‘lub’, and the aortic
component is normally louder than
the pulmonary component.
41. THIRD HEART SOUND (S3)
The third heart sound (S3) is a low-pitched
early diastolic sound best heard with the
bell at the apex. It coincides with rapid
ventricular filling immediately after opening
of the atrioventricular valves and is
therefore heard after the second heart
sound as ‘lub-dub-dum’. It is a normal
physiological finding in children, young
adults and febrile patients, and during
pregnancy, but is usually pathological after
the age of 40 years. The most common
causes are left ventricular failure, when it is
an early sign, and mitral regurgitation, due
to volume loading of the ventricle.
In heart failure, S3 occurs with a
tachycardia, referred to as a ‘gallop’
rhythm, and S1 and S2 are quiet (lub-da-
42. FOURTH HEART SOUND
The fourth heart sound (S4) is less
common. It is soft and low-pitched,
best heard with the bell at the apex. It
occurs just before S1 (da-lub-dub). It
is always pathological and is caused by
forceful atrial contraction against a
non-compliant or stiff ventricle.
An S4 is most often heard with left
ventricular hypertrophy (due to
hypertension, aortic stenosis or
hypertrophic cardiomyopathy).
It cannot occur when there is atrial
fibrillation.
43. An opening snap is commonly heard
in mitral (rarely, tricuspid) stenosis. It
results from sudden opening of a
stenosed valve and occurs early in
diastole, just after the S2. It is best
heard with the diaphragm at the
apex.
Ejection clicks are high-pitched
sounds best heard with the
diaphragm. They occur early in
systole just after the S1, in patients
with congenital pulmonary or aortic
stenosis .
44. MURMUR
In describing murmur, we comment
upon the following:
1. Timing
2. Character
3. Site of maximal intensity
4. Grades and thrill
5. Radiation
6. Maneuvers to increase the murmur
