functional assessment and physical examination of the cardiovascular system

1. Dr. Srimanta Kumar Haldar
Guide:- Poulomi Das.

2. INTRODUCTION
• History taking :
 Any presenting complaints
Previous history of any cardiological disorders
and its treatment
• Physical examination :
 General observation
 Pulse and blood pressure measurement
 Examination of neck, precordium
 Examination of hands, face, eyes, lung bases, abdomen and
legs.
 Examination of peripheral vascular system

3. Common symptoms related to
cardiological disorders
• Chest pain:
It may be due to : Angina Pectoris, Myocardial Infarction, Pericarditic pain,
Aortic pain or non- cardiac causes like costochondritis etc.
• Dyspnoea (breathlessness):
It is an awareness of increased drive to breathe.
Orthopnoea
Paroxysmal nocturnal dyspnoea

4. • Palpitation:
It is an unexpected awareness of the heart beating in the chest.
• Syncope:
It is transient loss of consciousness and postural tone due to reduced
cerebral blood flow, is associated with spontaneous recovery.
• Oedema:
It is clinically apparent increase in the
interstitial fluid volume.

5. Physical examination
• General observation:
Cyanosis
Breathlessness
Sweating
Bodymass
(obesity, weight
loss)
• Examination of hands for
clubbing, splinter haemorrhages,
osler’s node, janeway lesion.

6. • Examination of face for pallor,
central cyanosis, xanthelesma,
corneal arcus
• Examination of eyes
(opthalmoscopy) for hypertensive
retinopathy, Roth spots ( flame
shaped retinal haemorrhages with a
cotton wool centre, seen in infective
endocarditis

7. Arterial Pulse
As the ventricles eject blood into the arteries,
a pressure wave is transmitted and can be felt
in the superficial arteries passing over bone.
This pressure wave is called pulse.
• While taking pulse, the information is
characterised according to
Rate
Rhythm
Volume
Character
• Common arterial pulses examined are radial,
brachial, carotid, femoral, popliteal, posterior
tibial, dorsalis pedis pulse .

8. • The wrist is held in semi-flexed & semi-
pronated position.
• Place pad of index finger, middle finger & ring
finger on the radial artery against the lower
end of radius.
• To detect a collapsing pulse, feel the pulse
with the base of your fingers , then raise the
patient’s hand above his head.
• Palpate both radial pulse simultaneously to
assess radio-radial delay.
• Palpate femoral & radial pulse simultaneously
to assess radio-femoral delay.
Radial Pulse

9. • Brachial artery lies medial to the biceps
tendon. Palpate with your index and
middle fingers.
Brachial Pulse

10. Carotid pulse
• Ask the patient to be in semi
recumbent position.
• Gently place the tip of your
index and middle fingers
between the larynx and
anterior border of
sternocleidomastoid muscle.
• Press your fingers gently to
avoid stimulation of baro-
receptors. Never assess both
carotid pulses simultaneously.
• Listen for bruits over the
carotid arteries using the
diaphragm of the stethoscope.

11. Femoral Pulse
•Ask the patient to lie down.
•With your fingers extended,
place the pad of your index
finger and middle finger over
the femoral artery.
•Listen for bruits over both
femoral arteries.

12. Popliteal pulse
• Ask the patient to lie on a firm
comfortable surface and to relax
• Flex the knee to 30 degrees.
• With your thumb in front of the
knees and your fingers behind, press
firmly in the midline over the
popliteal artery.
• Slide your fingers 2- 3 cm below the
knee crease and try to compress the
artery against the back of the tibia as
it passes under the soleal arch.

13. • Feel 2 cm below and
2 cm behind the
medial malleolus,
using the pads of your
index, middle and ring
fingers.
Posterior tibial pulse

14. Dorsalis pedis pulse
• Using the pads of your index,
middle and ring fingers, feel in the
middle of the dorsum of the foot
just lateral to the tendon of extensor
hallucis longus..

15. Types of arterial pulses
• Normal pulse wave
 Normal pulse wave is called catacrotic
pulse.
 The ascending limb (Anacrotic limb) is
produced by rapid rise of pressure during
ventricular systole.
The dicrotic notch is produced
immediately before closure of aortic valve.
It is due to sharp fall in pressure due to
back flow of blood in aorta towards the
ventricle when the latter start relaxing.
Dicrotic wave is the reflected wave after
the closure of aortic valve.
The arterial pulse wave is recorded from
radial artery by Dudgen’s sphygmograph.

16. • Dicrotic pulse
It is seen in conditions with low peripheral
resistance as in fever. Here the dicrotic notch
is very prominent.
• Bounding pulse/ water hammer pulse
This type of pulse rises suddenly followed by
a quick fall.
Quick rise is due to increased stroke volume,
and the quick fall is due to quick passage of
blood from aorta to ventricle.
Seen in aortic incompetence.

17. • Tardus pulse/ plateau pulse
 The plateau is due to prolonged ejection through the
stenosed aortic opening. Dicrotic notch is not prominent.
 It is seen in aortic stenosis.
• Pulsus alternans
 It shows alternating strong and weak pulse. It is due to
alternation of stroke volume in successive beats in case of left
ventricular systolic impairment.
 In left ventricular dysfunction, the ejection fraction will
decrease significantly, causing reduction in stroke volume,
hence causing an increase in end-diastolic volume. As a
result, during the next cycle of systolic phase, the myocardial
muscle will be stretched more than usual and as a result
there will be an increase in myocardial contraction, related to
the Frank–Starling physiology of the heart. This results, in
turn, in a stronger systolic pulse .

18. In this type of pulse, the pulse volume
becomes noticeably larger during expiration
and smaller during inspiration.
It is seen in pericardial effusion, constrictive
pericarditis, cardiac tamponade.
Pulsus paradoxus

19. Pulsus bigeminous
• It is caused by a premature ventricular
contraction that follows each regular beat.
So, the beat occur in pair followed by a
pause.
• It is seen in HOCM( Hypertrophic
Obstructive Cardio Myopathy ), digitalis
toxicity.

20. Pulsus bisferience
• It has 2 systolic peaks.
• It is seen in aortic regurgitation (
with or without accompanying
aortic stenosis) and hypertrophic
cardiomyopathy.
• The 1st systolic peak (“percussion
wave”) is due to left ventricular
systole.
• The 2nd systolic peak (“tidal
wave”) produced due to
continued ventricular ejection
and by reflected waves from
periphery.

21. Blood pressure measurement
• Blood pressure is a measure of the force
that the circulating blood exerts against the
arterial wall.
• The systolic BP is the maximum pressure
that occurs during ventricular contraction
• Diastolic BP is the lowest value that is
maintained during diastole by the elasticity
and compliance of vessel wall.
• BP is usually measured non-invasively using
a sphygmomanometer cuff. In certain
situations, it is measured invasively using
indwelling intra arterial catheter connected
to a pressure sensor.
• It is measured in mmHg and recorded as
systolic pressure / diastolic pressure,
together with where and how the reading
was taken, e.g. BP= 120/80 mmHg, right
arm, supine.

22. • Rest the patient for 5 minutes.
• Use either arm unless one arm is known to record a
higher pressure. If that is the case, use this arm.
• With the patient seated or lying down, support his
arm comfortably at about the heart level, ensuring
that no tight clothing constricts the upper arm.
• Use the sphygmomanometer cuff of appropriate
size.
• Palpate the brachial pulse
• Inflate the cuff until the pulse is impalpable. Note
the pressure. This is a rough estimate of SBP.
• Inflate the cuff another 30 mmHg and listen through
the diaphragm of the stethoscope placed over the
brachial artery.
• Deflate the cuff slowly (2-3 mmHg/s) untill u hear a
regular tapping sound(phase 1 korotkoff sound).
This is the SBP
• Continue to deflate the cuff untill the sound
disappears. Record the pressure as the DBP.
Procedure

23. Jugular venous pressure( JVP )
and waveform
• The Jugular Venous Pressure reflects the central venous
pressure or right atrial pressure, and indirectly the right
ventricular function
• The central venous pressure is normally < 7 mmHg/
9cmH2O. The sternal angle is approximately 5 cm above the
right atrium, so the JVP should be no more than 4 cm above
this angle when the patient lies at 45°.

24. • Examination sequence:
 Position the patient so that he is reclining supine
comfortably untill the waveform is clearly visible
( start at 45°)
 Rest the patient’s head on a pillow to ensure that
the neck muscles are relaxed
 Look across the neck from right side of the
patient
 Identify the jugular vein pulsation
 If you are not certain, use the abdomino jugular
reflux ( gently press over the abdomen for 10
secs. This increases venous return to right side of
heart temporarily and the JVP normally rises.)
 The JVP is the vertical height in centimetres
between top of the venous pulsation and
sternal angle, whether they are sitting at 45° or
not)
 Identify the timing and form of the pulsation and
note any abnormality.

25. The waveform
Waveform
component
Phase of cardiac
cycle
Mechanical event
a wave End-diastole Atrial contraction
c wave Early systole Isovolumetric ventricular contraction,
tricuspid motion
toward the right atrium
v wave Late systole Systolic filling of the atrium
x descent Mid-systole Atrial relaxation, descent of the
base, systolic collapse
y descent Early diastole Early ventricular filling, diastolic
collapse

26. JVP waveform abnormalities
Condition Abnormalities
Atrial fibrillation Absent ‘a’ waves
Tricuspid stenosis Giant ‘a’ waves
Atrio ventrivular
dissociation
Cannon ‘a’ waves
Tricuspid regurgitation Giant ‘v’ waves
Pericardial constriction Tall ‘a’ and ‘v’ waves
Steep ‘x’ and ‘y’ descents
Cardiac tamponade Dominant ‘x’ descent
Attenuated ‘y’ descent
Heart failure Elevation, sustained
abdominojugular reflux

27. Examination of the precordium and
the heart sounds
Inspection & palpation:
• Explain that you wish to examine the chest and ask the patient
to remove all clothing above the waist. Keep a female patient’s
chest covered with a sheet as far as possible.
• Inspect the precordium with the patient sitting at a 45° angle
with shoulders horizontal. Look for surgical scars, visible
pulsations and chest deformity.
• Place your right hand flat over the precordium to obtain a
general impression of the cardiac impulse .
• Locate the apex beat by lying your fingers on the chest parallel
to the rib spaces; if you cannot feel it, ask the patient to roll on
to his left side .
• Assess the character of the apex beat and note its position.
• Apply the heel of your right hand firmly to the left parasternal
area and feel for a right ventricle heave. Ask the patient to hold his
breath in expiration .
• Palpate for thrills at the apex and both sides of the sternum
using the flat of your fingers

28. The stethoscope
• The stethoscope is an acoustic medical device for auscultation,
or listening to the internal sounds of an animal or human body.
• The stethoscope was invented in France in 1816 by René
Laennec. It consisted of a wooden tube and was monaural.
• Types of stethoscope:
 Acoustic
 Elctronic stethoscope
• Parts of a stethoscope:
 Earpiece
 Tubing
 Bell: used for listening to low
pitched sounds like normal heart
sounds, yhe diastolic murmur of
mitral stenosis.
 Diaphragm: used for auscultating
high pitched sounds like
pericardial rub, early diastolic
murmur of aortic regurgitation.

29. • Make sure the room is quiet when you auscultate.
Your stethoscope should fit comfortably with the
earpieces angled slightly forward. The tubing should
be ~25 cm long and thick enough to reduce
external sound.
• Listen with your stethoscope diaphragm at the:
 apex
 lower left sternal border
 upper right and left sternal borders.
• Listen with your stethoscope bell at the:
 apex
 lower left sternal border.
Auscultation

30. • Listen over the carotid arteries (ejection systolic
murmur of aortic stenosis) and in the left axilla
(pansystolic murmur of mitral regurgitation).
• At each site identify the S1 and S2 sounds. Assess
their character and intensity; note any splitting of
the S2. Palpate the carotid pulse to time any
murmur. The S1 barely precedes theupstroke of
the carotid pulsation, while the S2 is clearly out of
phase with it.
• Concentrate in turn on systole (the interval
between S1 and S2) and diastole (the interval
between S2 and S1). Listen for added sounds
and then for murmurs. Soft diastolic murmurs
are sometimes described as the ‘absence of
silence

31. • Roll the patient on to his left side. Listen at the apex using light pressure
with the bell, to detect the mid-diastolic and presystolic murmur of mitral
stenosis .
• Ask the patient to sit up and lean forwards, then to breathe out fully and
hold his breath . Listen over the right second intercostal space and over the
left sternal edge with the diaphragm for the murmur of aortic regurgitation.
• Note the character and intensity of any murmur heard.
• Develop a routine for auscultation so that you do not overlook subtle
abnormalities. Identify and describe the following:
 the first and second heart sounds (S1 and S2)
 extra heart sounds (S3 and S4)
 additional sounds, e.g. clicks and snaps
 pericardial rubs
 murmurs in systole and/or diastole.

32. Sites for auscultation
site sound
Cardiac apex First heart sound
Third and fourth heart sounds
Mid-diastolic murmur of mitral
Stenosis
Lower left sternal border Early diastolic murmurs of
aortic and tricuspid
regurgitation
Upper left sternal border Second heart sound
Opening snap of mitral stenosis
Pulmonary valve murmurs
Pansystolic murmur of
ventricular septal defect
Upper right sternal border Systolic ejection (outflow)
murmurs, e.g. aortic stenosis,
hypertrophic cardiomyopathy
Left axilla Radiation of the pansystolic
murmur of mitral regurgitation

33. Heart sounds
• First heart sound
• Caused by closure of mitral and tricuspid valves at the onset of ventricular systole.
• Best heard at apex.
• Increased intensity in mitral stenosis due to increased left atrial pressure.
• Decreased intensity in low cardiac output conditions.
• Second heart sound
• Caused by closure of aortic and pulmonary valves
• Best heard at the left sternal edge
• Physiological splitting occurs in inspiration.
• Decreased intensity heard in low cardiac output,
calcified aortic stenosis, aortic incompetence
• Increased intensity heard in systemic hypertension (aortic component)
and pulmonary hypertension (pulmonary component)
• Splitting:
– widened in inspiration, RBBB, pulmonary stenosis,
ventricular septal defect
– Fixed in Atrial septal defect(ASD)
– Reverse in aortic stenosis, LBBB, HOCM

34. • Third heart sound
• It is a low pitched early diastolic sound.
• It coincides with rapid ventricular filling immediately after opening
of the atrioventricular valves and is therefore heard after the second
as 'lub-dub-dum'.
• Physiological in fever, pregnancy, young children.
• Pathological after the age of 40 yrs, Left ventricular
failure, mitral regurgitation.
• Fourth heart sound
• It is a soft, low pitched sound, best heard at the apex. It is caused
due to forceful atrial contraction against non-competent ventricle.
• Always pathological.
• Heard in left ventricular hypertrophy.
• Both s3 and s4 cause a “triple” or “gallop” rhythm.

35. Additional sounds
• Opening snap
• heard in mitral stenosis
• Caused due to sudden opening of stenosed valve,
early in diastole just after second heart sound.
• Best heard at apex.
• Ejection click
• Occur in early systole after first heart sound.
• Heard in Aortic stenosis or pulmonary stenosis
• Mid systolic click
• Heard in mitral valve prolapse
• It is high pitched and best heard at apex
• Results from the abrupt halting of prolapsing
mitral valve leaflets' into the atrium by chordae.

36. Auscultation of murmurs
• While doing the auscultation of cardiac murmurs we have to
describe them under the following points:
Timing: determine whether the murmur is systolic or
diastolic
Duration of murmur.
Character and pitch.
Intensity
Location
Radiation

38. Examination of the venous system
Expose the patient’s legs and examine them with the patient
standing and then lying supine.
• Inspect the skin for colour changes, swelling and superficial
venous dilatation and tortuosity.
• Feel for any temperature difference.
• Press with your fingertip above the ankle medially for a few
seconds (gently, as this can be painful; do not do this near an
ulcer) and then see if your finger has left a pit (pitting oedema).
• If the leg is grossly swollen, press at a higher level to establish
how far oedema extends.
• If you find oedema, check the JVP . If the JVP is raised, this
suggests cardiac disease or pulmonary hypertension as a cause.
• Elevate the limb to about 15° above the horizontal and note
the rate of venous emptying.
• If appropriate, perform the Trendelenburg test to detect
saphenofemoral junction reflux.

39. The Trendelenburg Test
• Ask the patient to sit on the edge of the examination
couch.
• Elevate the limb as far as is comfortable for the patient
and empty the superficial veins by ‘milking’ the leg
towards the groin.
• With the patient’s leg still elevated, press with your
thumb over the sapheno-femoral junction (2–3 cm
below and 2–3 cm lateral to the pubic tubercle). A high
thigh tourniquet can be used instead.
• Ask the patient to stand while you maintain pressure
over the saphenofemoral junction.
• If saphenofemoral junction reflux is present, the
patient’s varicose veins will not fill until your digital
pressure, or the tourniquet, is removed