1. Cardiovascular examination introduction
Dr. Rasheed Ibdah
For me, the only things of interest are those linked to the heart”

2. GENERAL EXAMINATION GUIDELINES

3. The patient:
Should have their shirt(s) off, or wear an examination gown
Females nine years old and older should wear a gown with the opening in the front
Should be calm and quiet

4. The stethoscope: Should be your own!!!
Should have a separate bell and diaphragm

5. The environment:
Should be quiet (patient, family, clinic attendants, exam room, surrounding areas)
May briefly disconnect ventilator or occlude suction devices

6. Physical Examination General Hands Pulse Blood pressure Face Neck
Jugular venous pressure
Precordium
Inspection
Palpation
Percussion
Auscultation
Back
Abdomen
Lower limbs
Other

7. Examination - General Position patient at 45 degrees Respiratory rate
Cachexia
Marfan’s syndrome
Down’s syndrome

8. Examination - Hands Clubbing
Splinter haemorrhages (infective endocarditis)
Osler’s nodes (tender)
Janeway lesions (non-tender)
Xanthomata (Hyperlipidaemia)

9. Splinter Haemorrhages
Clubbing

10. Examination – Face and Neck
Jaundice
Xanthelasmata
Corneal arcus
Malar flush (mitral stenosis)
High arched palate (Marfan’s syndrome)
Dental caries (infective endocarditis)
Central cyanosis
Carotid pulse character
Slow rising (AS)
Bisferiens (AS + AR)
Collapsing (AR)
Alternans (LVF)
Jerky (HOCM)
Carotid bruit

11. Precordium - Inspection
Scars
Median sternotomy
CABG
Valve replacement
Lateral thoracotomy
Infraclavicular (pacemaker)
Pectus excavatum
Pacemaker box
Apex beat
Sternotomy scar
Pectus excavatum

12. Precordium - Palpation
Apex beat
Location
Character
Heaving
Thrusting
Double
Tapping
Paradoxical
Left parasternal heave
Thrills (palpable murmurs)
Systolic
Diastolic
Palpable P2 (pulmonary hypertension)
Pacemaker box

13. Precordium – Auscultation Murmurs
Pitch
Radiation
Dynamic manoeuvres
Respiration
Left-sided  on exp.
Right-sided  on insp.
Valsalva
Squatting
Timing of murmur
Systolic
Diastolic
Continuous
Site of maximal intensity
Loudness
Grades I-VI
Thrill

14. Where to listen: Apex/5LICS (mitral area)
Left lower sternal border/4LICS (tricuspid and secondary aortic area)
Right middle sternal border/2RICS (aortic area)
Left middle sternal border/2LICS (pulmonary area)

15. AO PU TR MI

16. How to listen:
Listen systematically: S1, S2, systolic sounds, systolic murmurs, diastolic sounds, diastolic murmurs

17. Normal heart sounds
LUB
DUP

18. Heart Murmurs Diastolic Systolic Continuous Pericardial friction rub
Early diastolic
Aortic regurgitation
Pulmonary regurgitation
Mid-diastolic
Mitral stenosis
Tricuspid stenosis
Atrial myxoma
Continuous
Patent ductus arteriosus
Arteriovenous fistula
Pericardial friction rub
Systolic
Pansystolic
Mitral regurgitation
Tricuspid regurgitation
Ventricular septal defect
Ejection systolic
Aortic stenosis
Pulmonary stenosis
HOCM
Atrial septal defect
Late systolic
Mitral valve prolapse

19. S1 AV VALVES CLOSING (MITRAL AND TRICUSPID) START OF SYSTOLE
LOUDEST AT APEX

20. S2 SEMILUNAR VALVES CLOSING: AORTIC AND PULMONIC A2 BEFORE P2
SPLITS WITH INSPIRATION AT PULMONIC AREA (LUSB)
LOUDEST AT BASE (TOP OF HEART)

21. S1 vs S2: Differentiate S1 from S2 by palpating carotid pulse:
S1 comes before and S2 comes after carotid upstroke

22. Extra heart sounds

23. S3 (gallop): Usually physiologic
Low pitched sound, occurs with rapid filling of ventricles in early diastole
Due to sudden intrinsic limitation of longitudinal expansion of ventricular wall
Makes Ken-tuck-y rhythm on auscultation

24. S3 (cont.):
Best heard with patient supine or in left lateral decubitus
Increased by exercise, abdominal pressure, or lifting legs
LV S3 heard at apex and RV S3 heard at LLSB

25. S4 (gallop): Nearly always pathologic
Can be normal in elderly or athletes
Low pitched sound in late diastole
Due to elevated LVEDP (poor compliance) causing vibrations in stiff ventricular myocardium as it fills
Makes “Ten-nes-see” rhythm

26. S4 (cont.):
Better heard at the apex or LLSB in the supine or left lateral decubitus position
Occurs separate from S3 or as summation gallop (single intense diastolic sound) with S3

27. S4 Associations: CHF!!! HCM severe systemic HTN pulmonary HTN
Ebstein’s anomaly
myocarditis

28. Friction rub: Creaking sound heard with pericardial inflammation
Classically has 3 components; can have fewer than 3 components
Changes with position, louder with inspiration

29. Examination - Pulse Radial artery Rate (normal = 60-100)
Bradycardia (<60)
Tachycardia (>100)
Rhythm
Regular
Irregular
Radiofemoral delay (coarctation of the aorta)
Character and volume assessed from carotid artery
Collapsing pulse (aortic regurgitation)
Pulsus alternans (left ventricular failure)
Pulse deficit (atrial fibrillation)

30. Rate: Bradycardic (conditioning, heart block, digoxin toxicity) Normal
Tachycardic (CHF, excitement, fever, anemia, arrhythmia)

31. Rhythm:
Regular
Irregular (can be sinus arrhythmia with respiratory variation or PAC/PVC’s)
Regularly irregular
Irregularly irregular (arrhythmia)

32. Volume:
Bounding/water hammer (pulse pressure >30 mmHg in infant, >50 mmHg in child)
Full
Normal
Thready
low output states: shock, severe CHF, large VSD or PDA
L sided obstruction: AS, aortic atresia, HLHS
Absent

33. Character:
Normal
Alternans
Bisferiens
Paradoxus

34. Jugular venous pulse WHAT: VISIBLE PRESSURE CHANGES IN RIGHT ATRIUM
WHERE: UNDER STERNOCLEIDOMASTOID MUSCLE
WHY: DIAGNOSE HEART FAILURE, FLUID OVERLOAD, AV BLOCK

36. JUGULAR VENOUS PULSE x y c a v