Clinical assessment of the cardiovascular system. Featured: Main symptoms and physical exam. References from Bates' guide to physical examination and history taking and Medex app.

1. The Cardiovascular System
Examination
CelestinBilongMbangtangJNR,MG4
Facultyof MedicineandBiomedicalSciences
Universityof YaoundeI
Cameroon

2. OBJECTIVES
L2, L3: Know the steps and features of the cardiovascular
system examination.
M1: Understand and master the facets of the cardiovascular
system examination.
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3. PLAN
INTRODUCTION
COMMON SYMPTOMS
JUGULAR VENOUS PRESSURE
CLINICAL EXAMINATION
(General examination, Inspection, Palpation,
Percussion and Auscultation)
LOWER EXTREMITY VASCULAR EXAM
CONCLUSION
I
II
III
IV
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4. INTRODUCTION
Components of CVS exam, Keys to a successful exam

5. INTRODUCTION (1/2)
Components of CVS exam
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 Includes Vital Signs in particular:
–Blood pressure
–Pulse: rate, rhythm, volume
 Includes Pulmonary Exam
 Includes assessment of distal vasculature (legs, feet, carotids) -
vascular disease (atherosclerosis)
 4 basic components:
–Inspection, Palpation, Percussion & Auscultation

6. INTRODUCTION (2/2)
(Keys to performing a respectful and effective exam)
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 Explain what you’re doing (& why) before doing it.
 Expose minimum amount of skin necessary - “artful” use
of gown & drapes (males & females)
 Examining heart & lungs of female patients:
–Ask patient to remove bra prior (can’t hear well through fabric)
–Expose side of chest to extent needed
–Enlist patient’s assistance: positioning breasts to enable cardiac exam
 Don’t rush, act in a callous fashion, or cause pain
 PLEASE… don’t examine body parts through gown/dress:
–Poor technique
–You’ll miss things

7. I. COMMON SYMPTOMS

8. COMMON SYMPTOMS
 Chest pain
 Palpitations
 Shortness of breath: dyspnea, orthopnea,
paroxysmal nocturnal dyspnea
 Swelling
 Fainting: syncope, presyncope
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9. I.1 Chest Pain (1/4)
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10. I.1 Chest Pain (2/4)
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11. I.1 Chest Pain (3/4)
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12. I.1 Chest Pain (4/4)
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13. I.2 PALPITATIONS (1/2)
 Unpleasant awareness of heart beat
 Patients often use words such as skipping, racing, running,
pounding or stopping of the heart to describe palpitations
 Palpitations do not necessarily mean heart disease
 Anxious and hyperthyroid patients may report palpitations
13

14. I.2 PALPITATIONS (2/2)
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15. I.3 SHORTNESS OF BREATH
 Dyspnea: Uncomfortable awareness of breathing
inappropriate to a given level of exertion.
 Orthopnea: Dyspnea which occurs when the patient is
supine and improves when the patient sits up. Classically
quantified by the number of pillows used to sleep.
 Paroxysmal Nocturnal Dyspnea (PND): Sudden episodes
of dyspnea and orthopnea that awaken the patient 1-2 hours
after sleeping causing him to sit up, stand or go to a window
for air.
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16. I.4 SWELLING (EDEMA)
 Accumulation of excessive fluid in extravascular interstitial
space
 Pitting edema: Cirrhosis, Nephrotic syndrome, Congestive
heart failure, …
 Non pitting edema: Lipidema, Lymphedema, Myxoedema
 Severely generalized edema extending to sacrum and
abdomen = Anasarca
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17. I.5 FAINTING
 Syncope: Transient loss of consciousness due to transient
global cerebral hypoperfusion characterized by rapid
onset, short duration and spontaneous complete recovery.
 Presyncope: Sensation that one is about to pass out
(severe light headedness).
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18. II. CLINICAL EXAMINATION
General examination, Inspection, Palpation, Percussion, Auscultation

19. II.1 GENERAL EXAMINATION (1/3)
 Ask history of cardiovascular symptoms (mentioned
earlier)
 Examine face, hands and feet
 Look for signs of any syndromes
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20. II.1 GENERAL EXAMINATION (2/3)
Face, Hands and Feet
Face Hands Feet
Examine for the
presence/absence of:
 Pallor (palpebral and
bulbar conjunctiva)
 Jaundice (sclera)
 Malar flush on face*
 Dental caries/staining
 Central cyanosis of
tongue
 Pallor of lips and oral
mucosa
 High arched palate
Examine for the
presence/absence of:
 Clubbing
 Peripheral cyanosis
 Splinter hemorrhages
 Osler’s nodes
 Janeway lesions
 Absent radii
 Absent thumb
Examine for the
presence/absence of:
 Swelling
 Discoloration
 Ulcers
 Symmetry
*associated with mitral stenosis
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21. II.1 GENERAL EXAMINATION (3/3)
Signs of some syndromes
Rheumatic fever
 Erythema
marginatum
 Subcutaneous
nodules
 Joint pain, swellings
Infective Endocarditis
 Roth’s spots in retina
 Clubbing
 Splinter hemorrhages
 Osler’s nodes
 Janeway lesions
Down’s syndrome*
 Stunted growth
 Short neck
 Slanted eyes
 Protruding tongue
 High arched palate
Turner’s syndrome*
 Short stature
 Webbed neck
 Broad chest
 Widely spaced
nipples
Marfan syndrome*
 Scoliosis
 Thoracic lordosis
 Pectus excavatum
 Pectus carinatum
*associated with ASD, VSD, PDA
and tetralogy of Fallot
*associated with aortic valve
stenosis, coarctation of aorta,
bicuspid aortic valve
*associated with prolapse of mitral or
aortic valve, aortic aneurysm
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22. II.2 INSPECTION
 Scars: Thoracotomy, Lobectomy, Diaphragmatic hernia repair
 Chest wall deformities: pectus excavatum (funnel shaped chest), pectus
carinatum (pigeon shaped chest), precordial bulge (right ventricular
hypertrophy)
 Spine: Kyphosis, scoliosis, ankylosing spondylitis
 Visible pulsations:
1. Epigastric pulsations: RV hypertrophy, Aortic regurgitation, aortic
aneurysm.
2. Apical pulsations: LV & RV hypertrophy.
3. Carotid pulsations: Aortic regurgitation, coarctation of aorta,
hyperdynamic states.
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23. II.3 PALPATION (1/3)
 Apical impulse/Point of maximal impulse: early pulsation of the
left ventricle as it moves anteriorly during contraction and
meets the chest wall. Best evaluated in left lateral decubitus.
 Heaves: palpable impulse that lifts the hand in a sustained and
forceful pulsation. Palpate at 2nd right and left interspaces
along the sternal border. Use palm/finger pads.
 Thrills: Palpable murmur felt as vibrations in the fingers. Use
ball of the hand.
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24. II.3 PALPATION (2/3)
24Apical impulse

25. II.3 PALPATION (3/3)
25Apical impulse
Absent: Dextrocardia, Dilated cardiomyopathy Double: HOCM, left ven
Heaving: left ventricular pressure overload Hypodynamic: Pleural effusion, pericardial effusion,
Tapping: Mitral stenosis COPD
Hyperdynamic: AR, MR, VSD, PDA Diffuse: left ventricular aneurysm

26. II.4 PERCUSSION (1/2)
 Percussion is done to outline the heart borders. Percussing
heart borders aids in identifying cardiomegaly and pericardial
effusion.
 Left heart border:
1. Patient should be in recumbent position.
2. Start at left 5th ICS in the midaxillary line and palpate medially towards
the sternum.
3. The point at which percussion notes become dull from resonant
represents the left heart border.
4. Move to 4th ICS and repeat percussion.
5. Dullness lateral to apex beat signifies pericardial effusion.
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27. II.4 PERCUSSION (2/2)
 Right heart border:
1. First percuss for upper border of the liver along the right midclavicular
line.
2. Percuss one space above upper border of the liver starting from the
right midclavicular line and move medially towards to the sternum.
3. Normally, no dullness is found.
4. Dullness is seen in case of: right atrial enlargement, pericardial
effusion, aneurysm of ascending aorta.
 Base of heart:
1. Percuss 2nd right and left ICS moving medially from midclavicular line.
2. Normally no dullness is found.
3. Dullness in 2nd left ICS: pericardial effusion, pulmonary HTN, ASD,
VSD, space occupying lesion in mediastinum.
4. Dullness in 2nd right ICS: aortic aneurysm, pericardial effusion.
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28. II.5 AUSCULTATION (1/10)
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Using your stethoscope

29. II.5 AUSCULTATION (2/10)
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What are we listening for?
 Normal valve closure creates sound.
 Closure of atrioventricular valves creates S1.
 Closure of semilunar valves creates S2 with physiologic
splitting (successive closure of aortic and pulmonary valves)
during inspiration.
 Sounds created by turbulent flow through valves = murmurs
1. Leakage when normally closed = regurgitation
2. Obstruction when normally opened = stenosis

30. II.5 AUSCULTATION (3/10)
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Technique of auscultation
 Patient inclined at 300-450.
 Chest exposed.
 DON’T examine through dress.
 4 main auscultatory foci in the adult:
1. Aortic: 2nd ICS to the right (parasternal line) (NB: The only auscultatory
focus which is to the right)
2. Pulmonic: 2nd ICS to the left (parasternal line)
3. Tricuspid: 2nd ICS to the left (sternal border)
4. Mitral: 5th ICS to the left (midclavicular line)

31. II.5 AUSCULTATION (4/10)
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BAD TECHNIQUE: DON’T EXAMINE THROUGH DRESS

32. II.5 AUSCULTATION (5/10)
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MAIN AUSCULTATORY FIELDS

33. II.5 AUSCULTATION (6/10)
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GOOD TECHNIQUE: REMOVE THE DRESS

34. II.5 AUSCULTATION (7/10)
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 S1 coincides with carotid pulse (on palpation).
 Systolic murmurs coincide with carotid pulse (on palpation).
 S1 best heard in mitral and tricuspid fields.
 S2 best heard in aortic and pulmonic fields.
 S3& S4 are normal in young patients.
 When present in adults, they are called “gallops”

35. II.5 AUSCULTATION (8/10)
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In each area, ask yourself:
 Do I hear S1 and S2? Which is louder and relative intensities?
 Is there physiological splitting of S2 on inspiration?
 Is the interval between S1 and S2 regular? (Normally S1-S2
interval (systole) is shorter than S2-S1 interval (diastole)?
 Do I hear something before S1 (an S4) or after S2 (an S3)?
 Do I hear a murmur? In systole? In diastole?
If present, note: Intensity, character, duration and radiation

36. II.5 AUSCULTATION (9/10)
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Murmurs
 Some heard in special positions e.g mitral (patient on L side),
aortic (patient sitting up, leaning forward, ask him/her to
breathe out and stop breath momentarily)
 Systolic murmurs: aortic stenosis, mitral regurgitation
(pulmonary stenosis. Tricuspid regurgitation)
 Diastolic murmurs: mitral stenosis, aortic regurgitation
(pulmonary regurgitation, tricuspid stenosis)

37. AUSCULTATION (10/10)
37
Gradation of murmurs

38. III. JUGULAR VENOUS PRESSURE
Technique, Hepatojugular reflex, Kussmaul’s sign, Causes of elevated JVP, Causes of fall in JVP

39. JUGULAR VENOUS PRESSURE (1/6)
 JVP is examined in internal jugular vein as it is straighter, has no valves
and indicates right atrial pressure changes.
 JVP is an indirect measurement of central venous pressure (pressure in
right atrium).
 Vertical distance above midpoint of right atrium to upper limit of visible
internal jugular pulsations.
 Patient reclined at 450 ;Tangential source of light should be applied.
 Look for multiphasic pulsations: “a”, “c”, “v” waves
 Normal JVP is 3-4 cm H2O (5 cm distance between RA and sternal angle)
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Technique

40. JUGULAR VENOUS PRESSURE (2/6)
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Technique

41. JUGULAR VENOUS PRESSURE (3/6)
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Hepatojugular reflex
 Ask the patient not to hold his breath.
 Apply firm and persistent pressure over the liver for 15
seconds.
 Normally there is transient rise in JVP for 3-5 seconds
after which it falls
 Sustained increase in venous pressure until compression
is released indicates right heart failure.

42. JUGULAR VENOUS PRESSURE (4/6)
42
Kussmaul’s sign
 Paradoxical rise in JVP during inspiration
 Normally, there is fall in JVP during inspiration

43. JUGULAR VENOUS PRESSURE (5/6)
43
Causes of elevated JVP
 Right heart failure
 Superior vena cava obstruction
 Pericardial effusion
 COPD/cor pulmonale
 Constrictive percarditis
 Fluid overload

44. JUGULAR VENOUS PRESSURE (6/6)
44
Causes of fall in JVP
 Shock
 Hypovolemia

45. IV. LOWER EXTREMITY VASCULAR EXAM
Technique, Hepatojugular reflex, Kussmaul’s sign, Causes of elevated JVP, Causes of fall in JVP

46. LOWER EXTREMITY VASCULAR EXAM
 General lower extremity observation: asymmetry, muscle
atrophy, joint (knee, ankle) abnormalities.
 Assess femoral area (palpation for nodes, pulse);
auscultation over fem artery.
 Knees – color, swelling; popliteal pulse
 Assess ankles/feet (color, temperature (warm = inflammation;
cool = atherosclerosis, hypoperfusion), pulses, edema,
capillary refilling)
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47. CONCLUSION
Take note, References

48. CONCLUSION
 Repetition
 Dedication
 Practice
 Don’t rush
 NB: Don’t auscultate through dress
48
Take note

49. CONCLUSION
 MedEx – Clinical Examination
app, Bharath Reddy
 Examination Of The Cardiovascular System
Charlie Goldberg, M.D.
Professor of Medicine, UCSD SOM
 Bates Guide to Physical
examination and History taking,
12th edition, Lynn S. Bickley
References 49

50. Thank you