Cardiovascular Examination

CARDIOVASCULAR EXAMINATION
Abdiwahab Hashi Ahmed

Component of CVS Examination
• GENERAL APPEARACE
• VITAL SIGN
• VEINS
• ARTERIES
• PRECORDIUM
• A methodical approach is recommended,
starting:
– With inspection of the patient and proceeding to
examination of the radial pulse,
– Measurement of heart rate and blood pressure,
– Examination of the neck (carotid pulse, jugular
venous pulse),
– Palpation of the anterior chest wall,
– Auscultation of the heart,
– Percussion and auscultation of the lung bases,
and,
– Finally, examination of the peripheral pulses and
Jugular Venous Pressure(JVP)
• The JVP is the elevation at which the highest
oscillation point, or meniscus, of the jugular
venous pulsations is usually evident in euvolemic
patients
• JVP reflects pressure in the right atrium, or
central venous pressure also blood volume,
status of tricuspid valve and diastolic event in RV
• Best assessed from pulsations in the right
internal jugular vein.
• Estimate CVP maximal 3cm from sternal angle
+ 5cm from atrium (Right atrial pressure)
• 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
Measuring JVP
JVP
CAUSES OF DISTENTED JVP
• CHF-especially right failure
• Cor pulmonale
• Pulmonary embolism
• Constrictive pericarditis
• Superior vena cava obstruction
• Tricuspid valve disease
The Carotid Pulse
• After you measure the JVP, move on to
assessment of the carotid pulse.
• The carotid pulse provides valuable information
about cardiac function and is especially useful for
detecting stenosis or insufficiency of the aortic
valve.
• Take the time to assess the quality of the carotid
upstroke, its amplitude and contour, and
presence or absence of any overlying thrills or
bruits.
How to assess carotid pulse
Examination of Heart/ Precordium
• Inspection
• Palpation
• Auscultation
• Percussion ???
Precordium - Inspection
• Active or quiet precordum
• Location of apical impulse
• Scars
• Chest deformity
– Pectus excavatum
– Pectus carinatum
• Pacemaker box
palpation
• The apex beat is defined as the lowest and most
lateral point at which the cardiac impulse can be
palpated.
• Its location inferior or lateral to the fifth intercostal
space or the midclavicular line, respectively , usually
indicates cardiac enlargement
• Location
• Character
– Heaving
– Thrusting
– Double
– Tapping
– Paradoxical
Palpation of the precordium
The Apical Impulse or Point of Maximal
Impulse (PMI)
• The apical impulse represents the brief early
pulsation of the left ventricle as it moves anteriorly
during contraction and touches the chest wall Note
that in most examinations the apical impulse is the
point of maximal impulse, or PMI; however, some
pathologic conditions may produce a pulsation that
is more prominent than the apex beat, such as an
enlarged right ventricle, a dilated pulmonary
artery, or an aneurysm of the aorta.
• If you cannot identify the apical impulse with the
patient supine, ask the patient to roll partly onto
the left side—this is the left lateral decubitus
position.
• Palpate again using the palmar surfaces of several
fingers
• If you cannot find the apical impulse, ask the
patient to exhale fully and stop breathing for a few
seconds.
• When examining a woman, it may be helpful to
displace the left breast upward or laterally as
necessary; alternatively, ask her to do this for you
Abnormalities of PMI
• AORTIC STENOSIS
• VSD : ventricular septal defect
• PDA: patent ductus arteriosus
• The apical impulse may be displaced upward
and to the left by pregnancy or a high left
diaphragm.
• Lateral displacement from cardiac enlargement
in congestive heart failure, cardiomyopathy,
ischemic heart disease.
• Displacement in deformities of the thorax and
mediastinal shift
• Thrills (palpable murmurs)
– Systolic
– Diastolic
• Palpable P2 (pulmonary hypertension)
• Para sternal heave- RVH

Auscultation of the precordium
• The diaphragm and bell of the stethoscope permit
appreciation of high- and low-pitched
auscultatory events, respectively.
• The apex, lower left sternal edge, upper left
sternal edge and upper right sternal edge should
be auscultated in turn.
• These locations correspond respectively to the
mitral, tricuspid, pulmonary and aortic areas, and
loosely identify sites at which sounds and
murmurs arising from the four valves are best
heard.
FIRST SOUND (S1)
• This corresponds to mitral and tricuspid valve
closure at the onset of systole.
• It is accentuated in mitral stenosis because
prolonged diastolic filling through the narrowed
valve ensures that the thickened leaflets are
widely separated at the onset of systole.
• S1 (lub), marks the beginning of systole (end of
diastole).
– Related to the closure of the mitral and tricuspid
valves.
– Loudest at the apex.
SECOND SOUND (S2)
• This corresponds to aortic and pulmonary valve
closure following ventricular ejection.
• S2 is single during expiration.
• Inspiration, however, causes physiological splitting
into aortic followed by pulmonary components
because increased venous return to the right side
of the heart delays pulmonary valve closure.
• The 2nd heart sound, S2 (dub), marks the end of systole
(beginning of diastole).
– Related to the closure of the aortic and pulmonic valves.
– Loudest at the base.
Techniques of auscultation
Auscultation of the Heart: What to listen
1. The Normal Heart Sounds: 1st and 2nd Heart

sounds
2. Added Heart Sounds

3rd and 4th heart sounds, opening snap, ejection
click, percardial knock and friction rub
3. The murmurs
Heart murmurs
• Heart murmurs are the noises you hear due to
turbulent blood flow caused by defective
heart valves.
Characterize murmurs
1. Timing
2. Loudness Intensity
3. Area of maximum intensity and radiation
4. Pitch
5. Quality ( character )
6. Relation to respiration and other maneuvers
1.Timing
1.1 Systolic murmur

– Mid-systolic murmur: Aortic /pulmonic
stenoisi
– pansystolic mulrmur: Mitral/Tricuslpid
regrigitation
ventricular septal defect
1.2 Diastolic murmur
• Early diastolic murmur: AR, PR
• Mid diastolic murmur: MS, TS
2. Loudness of Murmur: reflects degree of turbulence
• Grade 1 :just audible with a good stethoscope in a

quiet room
• Grade 2 quiet but readily audible with a stethoscope
• Grade 3 easily heard with a stethoscope
• Grade 4 a loud, obvious murmur with a palpable
thrill
• Grade 5 very loud, heard with the edge of the chest
piece of stethoscope
• Grade 6 Loudest murmur, heard with stethoscope off
chest
3. Area of maximum Intensity and Radiation
Aortic stenosis:
– heard with same loudness at 2ICS and apex.
Radiates to right carotid artery
Mitral regurgitation
– Maximum intensity at apex
– Radiates to left axilla or back if the anterior leaflet
is affected
• Aortic regurgitation
– Best heard at the Erb’s point ( 3rd LICS parasternal)
3.Radiation and intensity
• Aortic stenosis
– Heard with same loudness at 2ICS and apex
– Radiates to the right carotid aa
• Mitral regurgitation
– Maximum intensity at aped
– Radiates to the left axilla or back
• Aortic regurgitation
– Best heard at erb’s point (3rd Lics parasternal)
4. Pitch
High pitched murmur: Increased velocity
Low pitched murmur: decreased velocity
High, medium, low pitched murmur
5. Quality of murmur
Rough/Harsh: produced from an obstruction to
flow ex: Aoritc/pulmonary stenosis
Soft/blowing: regurgitated flow ex: AR/MR
Rumbling: mitral stenosis
Grading of murmurs
 1/6 – very soft, only heard after listening for a
while
 2/6 – soft, but detectable immediately
 3/6 – clearly audible, but no palpable thrill
 4/6 – clearly audible, palpable thrill
 5/6 – audible with a stethoscope only partially
touching chest
 6/6 – can be heard without stethoscope
touching chest
The greatest events
aren't the loudest,
but the most quiet
hours
THANK
U!!! 34

Cardiovascular Examination

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CARDIOVASCULAR EXAMINATION

Abdiwahab Hashi Ahmed

• Para sternal heave- RVH

1. The Normal Heart Sounds: 1st and 2nd Heart

2. Added Heart Sounds

1.1 Systolic murmur

• Grade 1 :just audible with a good stethoscope in a

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