Physical examination of cardiovascular system

1. Examination of
Cardiovascular

2. Outline
 Anatomy and Physiology
 History
 General examination
 Examination of vessels and Blood pressure
 Pulse
 Blood pressure
 Jugular venous pressure
 Pericardial examination
 Inspection
 Palpation
 Auscultation and
 Percussion

3. Anatomy

4. Anatomy cont’

5. Anatomy Cont’

7.  Animation of cardiac cycle

8. History
 Chest pain
 Fatigue (end of the day)
 dyspnea
 Orthopnea & PND
 Palpitations
 Syncope
 Body swelling

9. History cont’
 Other illnesses :
 Thyroid, connective tissue, neoplastic disorders, Rheumatic fever in
childhood , HTN, DM & dyslipidemia, Smoking, Alcohol (arrhythmias,
CMP)
 Family Hx - CAD, HTN, HCMP
 Family Hx of sudden death - single most important indicator of risk in
HCMP
 Drug Hx :
 β-Blockers & some CCB(diltiazem, verapamil), bradycardias,TCA & β-
agoniststachyarrhythmias, Vasodilators  hypotension syncopal
attack ,Doxorubicin & related compounds toxic cardiomyopathy

10. History
CHEST PAIN
 cardiac origin -Myocardial ischemia, pericarditis, aortic dissection
Myocardial ischemia(angina)
 Retrosternal pain which may radiate into the arms, the throat or the jaw
 Has a constricting/squeezing character, is provoked by exertion & relieved
rapidly by rest or nitroglycerin

11. History cont’
Pericarditis
 Central chest pain, sharp in character & aggravated by deep inspiration,
cough or postural changes, radiates to trapezius muscle
Aortic dissection
 Severe tearing pain in either the front or the back of the chest, abrupt
onset

12. History cont’
SYNCOPE
 Transient, self-limited loss of consciousness due to acute global
impairment of blood flow to the brain.
 Rapid onset , brief duration, & recovery spontaneous & complete
 DDX - seizures, hypoxemia, hypoglycemia, overdose…
 Prodrome (presyncope) is common, although syncope may occur
without prodrome
 dizziness, lightheadedness or faintness, weakness, fatigue, visual
& auditory disturbances
 Causes : neurally mediated syncope (reflex syncope), orthostatic
hypotension, cardiac syncope

13. Examination
 Inspection (Observation)
 Examination of the arteries & veins:
o BP, Radial pulse (HR, rhythm, volume)
o Examination of the neck (Carotid pulse, ± distended neck veins JVP)
o Examination of the peripheral pulses & auscultation for carotid &
femoral arterial bruits
o ± Varicose veins
 Palpation
 Auscultation- heart sounds, murmurs, friction rubb
 Percussion & auscultation of the lung bases (supportive for Dx)

14. Examination
 Inspection
 General appearance
 Look for Sign of cyanosis
 Look for Sign of Anemia
 Look for Clubbing of finger or toe

15. Examination cont’
CYANOSIS
 Blue discoloration of the skin & mucous membranes caused by reduced O2 in the superficial blood vessels
 Can be Central or peripheral cyanosis
 Peripheral cyanosis
o May result when cutaneous vasoconstriction slows the blood flow & ↑ oxygen extraction in the
perpheripheral tissue in the capillary bed.
o Usually in the upper and lower extremities where the blood flow is less rapid.
o Physiological during cold exposure
o HF - ↓COP produces reflex cutaneous vasoconstriction

16. Examination cont’
 Central cyanosis
o Result from the reduced arterial oxygen saturation caused by cardiac or
pulmonary disease
o level of deoxygenated hemoglobin in the arteries is below 5 g/dL with oxygen
saturation below 85%
o Conditions associated with central cyanosis includes;
 Septal defects, PDA,TOF
 Plumonary conditions like severe pneumonia, Massive PE

17. Examination cont’

18. Examination cont’
Clubbing
 Caused by hypervascularity & the opening of anastomotic channels in the nail bed. Rarely, it
may be congenital
 Fingers & toes
 Clubbing is not a cardiac specific sign
 pulmonary 75 – 80 %
 Cardiac 10 – 15 %
 Hepatic and GI 5 – 10 %

19. Examination cont’
 Grade I –softened nail beds or nail bed fluctuation
 Grade II – obliteration of lovibond angle
 Grade III –parrot peaking
 Grade IV – drum stick like finger tips

20. Causes of clubbing
Cardiopulmonary disorders
 Severe chronic cyanosis
 Cyanotic congenital heart disease
 Chronic fibrosing alveolitis
 Chronic suppuration in the lungs
 bronchiectasis
 empyema
 lung abscess
 Bronchial Ca
 Subacute bacterial endocarditis (SBE)
Chronic abdominal disorders
 Crohn's disease
 Ulcerative colitis
 Cirrhosis of the liver
Schamroth's window test

22.  Other cutanoues manifestation
 Splinter hemorrhages in the nail-bed (very non-specific finding)
 Osler's nodes (tender erythematous nodules in the pulps of the fingers)
 Janeway lesions (painless erythematous lesions on the palms)
 Roth's spots (erythematous lesions in the optic fundi)

24. Roth's spots

25. Examination cont’
 Edema
 Cardinal feature of CHF
 Pitting - tibia, lateral malleoli, sacrum
 Caused by salt & water retention by the kidney
 Most prominent around the ankles in the ambulant pt & over the sacrum
in the bedridden pt (gravity effect)
 Advanced HF- anasarca (generalized edema)

27. Examination cont’
 Arterial Pulse
 Rate
 Rhytm
 Characther
 Symmetry

28. Examination BP
 Instrument
 Sphygmomanometer, stetoscope
 Anaeroid and mercury, digital type
 Blood pressure has two component
 Systolic
 Diastolic pressure
 Normal <140/90 mmHg
 Korotkoff sounds

30. Examination BP cont’
 Width of the inflatable bladder of the cuff should be about 40% of upper arm
circumference (about 12–14 cm in the average adult)
 Length of inflatable bladder should be about 80% of upper arm circumference (almost long
enough to encircle the arm)
 Ideally, ask the patient to avoid smoking or drinking caffeinated beverages for 30 minutes before
the blood pressure is taken and to rest for at least 5 minutes.
 Check to make sure the examining room is quiet and comfortably warm.
 Make sure the arm selected is free of clothing or any problem on the hand

31. Examination BP
 Position the arm at the level of heart
 If the patient is seated, rest the arm on a table a little above the patient’s waist; if
standing, try to support the patient’s arm at the midchest level.

32. Examination BP

33. Examiantion JVP
 Fluctuations in Rt atrial pressure during the cardiac cycle generate a pulse that is transmitted
backwards into the jugular veins
 Best examined while the pt reclines at 45°
 If the Rt atrial pressure is very low - smaller reclining angle
 Alternatively, manual pressure over the upper abdomen may be used to produce a transient
↑in venous return to the heart which elevates the jugular venous pulse (hepatojugular
reflux)

34. Examination JVP
 NV :
o 4cm vertically above the sternal angle
o 9cm above the Rt atrium
o 6mmHg
 Elevation of the JVP  elevation of the RA pressure unless the superior
vena cava is obstructed
 During inspiration the pressure within the chest falls & there is a fall in
the JVP
 In constrictive pericarditis & tamponade, inspiration produces a
paradoxical rise (Kussmaul's sign) in JVP because the ↑ venous return
cannot be accommodated within the constricted Rt side of the heart

35. Examination JVP
 Inspection
o Venous pulse - double undulation, sharper inward movement
o Carotid pulse - easily visible medially & higher in the neck, generally in the
submandibular region, single, sharp outward movement
 The amplitude of the venous pulse can be manipulated by changing the
venous pressure :
o ↓ by raising the head & trunk above the level of the Rt atrium (e.g., sitting
or standing)
o ↑by enhancing the venous return to the Rt side of the heart by raising the
legs or compressing the abdomen(RUQ) (Hepatojugular reflux) for at
least 10s
o positive response is defined by a sustained rise of >3 cm in JVP
for at least 15 sec after release of the hand

36. Examination JVP

37. Examination JVP
 Steps
 Position patient 30/45
 Tangential light
 Identify internal jugular venousepulsation(right)
 Extend a long rectangular object or card horizontally from this point and a
centimeter ruler vertically from the sternal angle, making an exact right angle.
 Measure the vertical distance in centimeters

38. Examination JVP

39. Examination JVP

40. Examination Precordium
 Inspection
 Palpation
 Auscultation

41. Examination Insepction
 Scars
 Chest deformity
 Pectus excavatum
 Pectus carinatum
 Apical beat

42. Examination Palpation
 Apical beat
 Location
 Character
 Heaving
 Thrill
 Double
 Tapping
 Paradoxical
 Left parasternal heave
 Thrills (palpable murmurs)
 Systolic
 Diastolic
 Palpable P2 (pulmonary hypertension)
 Video 2

43. Examination Auscultation
 Bell – low pitched sounds
 Diaphragm – high pitched sounds
 Mitral  Tricuspid  Pulmonary  Aortic areas
 S1 (first heart sound)
 S2 – Splitting (A2, P2)
 S3 – can be physiologic
 Video

44. Examiantion Murmur
 Timing of murmur
 Systolic
 Diastolic
 Continuous
 Site of maximal intensity (location)
 Intensity (Loudness)
 Grades I-VI
 Pitch
 Radiation
 Duration
 manoeuvres
 Respiration
 Left-sided  on exp.
 Right-sided  on insp.
 Valsalva
 Squatting

45. Examination Murmur
 Systolic
 Pansystolic
 Mitral regurgitation
 Tricuspid regurgitation
 Ventricular septal defect
 Ejection systolic
 Aortic stenosis
 Pulmonary stenosis
 Atrial septal defect
 Late systolic
 Mitral valve prolapse
 Video
 Diastolic
 Early diastolic
 Aortic regurgitation
 Pulmonary regurgitation
 Mid-diastolic
 Mitral stenosis
 Tricuspid stenosis
 Atrial myxoma
 Continuous
 Patent ductus arteriosus
 Arteriovenous fistula
 Pericardial friction rub

46. Examiantion Murmurs

47. Thank you