1. CVS Examination Dr.Amr Khayat, MBBS
Member of Saudi General Surgery Society
Member of Saudi Society for Vascular Surgery
Member of Saudi Association for Plastic Surgery

2. CVS Examination General The praecordium General appearance The hands
The face
The neck
The praecordium
Inspection
Palpation
Auscultation

3. The Praecordium Inspection Palpation Auscultation Deformities
Apex beat
Visible pulsations
Scars
Palpation
Parasternal heave
Palpable thrills
Auscultation
Heart sounds
Added sounds
Cardiac murmurs

4. 1- General Appearance Look for: (ABCDE) Respiratory distress Cachexia
Dysmorphic features

5. Patient Position in CVS Examination

6. 2- The Hand Look For : Clubbing Cyanosis Splinter hemorrhage
Osler nodes (tender)
Janway lesions (not tender)
Muscle Wasting.

7. 2- The Hand Radial pulse: Condition of the vessel wall Blood pressure
Rate
Rhythm: [regular, irregular (irregularly irregular, regularly irregular)]
Character and volume (collapsing, alternans)
Radio-radial delay
Radiofemoral delay
Condition of the vessel wall
Blood pressure

8. 3- The Face Eye’s : Pallor , Jaundice, Xanthelasma.
Mitral features (rosy cheeks, bluish tinge).
Central cyanosis in the tongue

9. 4- The Neck
Palpate the carotid artery medial to sternomastoid muscle for character (bisferience, collapsing, alternans, jerky)
Inspect the height of the JVP by inspecting the internal jugular vein

10. 4- The Neck Jugular pulse can be distinguished from arterial pulse by:
It is a complex wave (flicker twice)
Jugular is visible but not palpable
JVP decreases with inspiration
It is filled from above after removing pressure applied to the base of the neck.

12. 5- The Precordium By INSPECTION: Scars
Skeletal abnormalities (pectus excavatum, kyphoscoliosis)
Visiable Apex beat
Other visible pulsations

13. 5- The Precordium By PALPATION: Apex beat: Parasternal impulse:
Site (the most lateral and most inferior; normally in the 5th left intercostals space in the mid clavicular line)
Displaced or not
Character (heaving, double impulse, tapping)
Parasternal impulse:
By the heel of the hand rested just to the left of the sternum.
Palpable murmurs (thrills):
Start at the apex then the left sternal edge then the base of the heart.

14. 5- The Precordium By AUSCULTATION:
Start in the mitral area with the bell to hear low pitch sounds like in mitral stenosis then use the diaphragm.
Then move to the tricuspid area (5th Lt. intercostal)
Then to pulmonary area (2nd Lt. intercostal)
Then to aortic area (2nd Rt. intercostal)
On auscultation listen to:
Heart sounds (S1, S2)
Abnormalities in heart sounds (loud, soft, increased splitting, fixed splitting, reversed splitting)
Additional sounds (S3, S4)
Heart murmurs

16. What to look for in murmurs
Site
Intensity ( 6 grades )
Time (systole , diastole)
Duration (early , pan , late)
Radiation (axilla , carotid)
Pitch (High, Low)
Special character

18. 6- The Back
Percussion and auscultation of the lung bases looking for signs of pulmonary edema like:
Crepitation
Dull percussion , decrease air entry (pleural effusion )
In the back look for sacral edema as well

19. 7- The Abdomen
Look for
Ascitis
Hepatomegaly

20. 8- The Lower Limbs Palpate the: Then look for lower limb edema.
Femoral artery (below inguinal ligament 1/3 of the way up from the pubic tubercle)
Popliteal artery (behind the knees)
Post. tibial (below medial malleolus half the way between the calcaneus and medial malleolus)
Dorsalis pedis (between the 1st and 2nd metatarsal bone lateral to flexor hallosis longus)
Then look for lower limb edema.

22. THANK YOU

23. 1. A 45 year old man comes into your office complaining of heart palpitations. You listen at his heart apex with the diaphragm of the stethoscope and hear a mid systolic click (an extra beat in between the 1st and 2nd heart sound). What is the likely diagnosis?
A-Mitral stenosis B-Aortic regurgitation C-Mitral valve prolapse D-Mitral regurgitation

24. 2. A 50 year old woman comes into your office citing exercise intolerance. You listen to her heart at the lower left sternal border with the bell of the stethoscope and hear an S3 sound (an extra, low frequency heart beat occurring after the 2nd heart sound). What is the likely diagnosis?
A-Patent ductus arteriosis B-Aortic stenosis C-Congestive heart failure D-Mitral stenosis

25. 3.If a patient has atrial fibrillation (the atria no longer respond to heart pace-making cells) an S4 heart sound (an extra, low frequency beat occurring before the first heart sound) will not exist.
A-True B-False

26. 4. A 10 year old boy comes into your office with no symptoms or complaints. When listening with the bell of the stethoscope at the apex, you hear an S3 heart sound. What is the diagnosis?
A-Chronic heart failure B-Pulmonic Stenosis C-Tricuspid Stenosis D-Normal heart sound

27. 5. A 40 year old man comes into your office complaining of exercise intolerance. You listen to his heart at the 3rd left intercostal space with the diaphragm and hear a murmur that is saw-like in quality that begins after S1 (first heart sound) and ends before S2 (2nd heart sound) during systole (while the heart is contracting). What is a likely diagnosis?
A-Aortic regurgitation B-Tricuspid stenosis C-Mitral stenosis D-Aortic Stenosis

28. 6. The diastolic murmur of tricuspid stenosis (narrowing and hardening of the tricuspid valve cusps) can only be heard with the diaphragm of the stethoscope.
A-True B-False

29. 7. A 70 year old man comes into your office complaining of heart palpitations. You listen to his heart at the lower left sternal border with the bell of the stethoscope and hear a rumbling murmur that occurs only during diastole (while the ventricles are filling). What is the likely diagnosis?
A-Mitral stenosis B-Tricuspid stenosis C-Aortic stenosis D-Tricuspid regurgitation

30. 8. A 55 year old woman comes into your office complaining of exercise intolerance. You listen to her heart at the 2nd right intercostal space with the diaphragm of the stethoscope and hear a diastolic murmur of blowing quality. What is the likely diagnosis?
A-Aortic stenosis B-Aortic regurgitation C-Mitral regurgitation D-Tricuspid regurgitation

31. 9. A 67 year old man enters your office with no complaints
9. A 67 year old man enters your office with no complaints. You listen to his heart at the apex and hear an opening snap when listening with the diaphragm and a rumbling diastolic murmur when listening with the bell. What is the likely diagnosis?
A-Pulmonic stenosis B-Tricuspid stenosis C-Mitral stenosis D-Aortic stenosis

32. 10. Now for a whopper: A 60 year old woman enters your office with no symptoms to complain of. You listen to her heart at the 2nd left intercostal space and hear a mid-systolic murmur accompanied with wide fixed splitting of the S2 heart sound (Usually the 2nd heart sound is split and widens with inspiration at the 2nd left intercostal space). What is the diagnosis?
A-Pulmonic regurgitation B-Mitral regurgitation C-Tricuspid regurgitation D-Atrial septal defect

33. 1. A 45 year old man comes into your office complaining of heart palpitations. You listen at his heart apex with the diaphragm of the stethoscope and hear a mid systolic click (an extra beat in between the 1st and 2nd heart sound). What is the likely diagnosis?
A-Mitral stenosis B-Aortic regurgitation C-Mitral valve prolapse D-Mitral regurgitation

34. 2. A 50 year old woman comes into your office citing exercise intolerance. You listen to her heart at the lower left sternal border with the bell of the stethoscope and hear an S3 sound (an extra, low frequency heart beat occurring after the 2nd heart sound). What is the likely diagnosis?
A-Patent ductus arteriosis B-Aortic stenosis C-Congestive heart failure D-Mitral stenosis

35. 3.If a patient has atrial fibrillation (the atria no longer respond to heart pace-making cells) an S4 heart sound (an extra, low frequency beat occurring before the first heart sound) will not exist.
A-True B-False

36. 4. A 10 year old boy comes into your office with no symptoms or complaints. When listening with the bell of the stethoscope at the apex, you hear an S3 heart sound. What is the diagnosis?
A-Chronic heart failure B-Pulmonic Stenosis C-Tricuspid Stenosis D-Normal heart sound

37. 5. A 40 year old man comes into your office complaining of exercise intolerance. You listen to his heart at the 3rd left intercostal space with the diaphragm and hear a murmur that is saw-like in quality that begins after S1 (first heart sound) and ends before S2 (2nd heart sound) during systole (while the heart is contracting). What is a likely diagnosis?
A-Aortic regurgitation B-Tricuspid stenosis C-Mitral stenosis D-Aortic Stenosis

38. 6. The diastolic murmur of tricuspid stenosis (narrowing and hardening of the tricuspid valve cusps) can only be heard with the diaphragm of the stethoscope.
A-True B-False

39. 7. A 70 year old man comes into your office complaining of heart palpitations. You listen to his heart at the lower left sternal border with the bell of the stethoscope and hear a rumbling murmur that occurs only during diastole (while the ventricles are filling). What is the likely diagnosis?
A-Mitral stenosis B-Tricuspid stenosis C-Aortic stenosis D-Tricuspid regurgitation

40. 8. A 55 year old woman comes into your office complaining of exercise intolerance. You listen to her heart at the 2nd right intercostal space with the diaphragm of the stethoscope and hear a diastolic murmur of blowing quality. What is the likely diagnosis?
A-Aortic stenosis B-Aortic regurgitation C-Mitral regurgitation D-Tricuspid regurgitation

41. 9. A 67 year old man enters your office with no complaints
9. A 67 year old man enters your office with no complaints. You listen to his heart at the apex and hear an opening snap when listening with the diaphragm and a rumbling diastolic murmur when listening with the bell. What is the likely diagnosis?
A-Pulmonic stenosis B-Tricuspid stenosis C-Mitral stenosis D-Aortic stenosis

42. 10. Now for a whopper: A 60 year old woman enters your office with no symptoms to complain of. You listen to her heart at the 2nd left intercostal space and hear a mid-systolic murmur accompanied with wide fixed splitting of the S2 heart sound (Usually the 2nd heart sound is split and widens with inspiration at the 2nd left intercostal space). What is the diagnosis?
A-Pulmonic regurgitation B-Mitral regurgitation C-Tricuspid regurgitation D-Atrial septal defect

43. Good Luck