EXAMINATION OF CARDIOVASCULAR SYSTEM

FIRST IMPRESSION
INHERITED SYNDROMES
DOWN'S SYNDROME (PDA, ASD & VSD)
MARFAN'S SYNDROME (AORTIC DISSECTION, VALVE DISEASE)
TURNER'S SYNDROME (AORTIC COARCTATION & AORTIC STENOSIS)
OTHER SYNDROMES
ANKYLOSING SPONDYLITIS
(AORTIC REGURGITATION)
ACROMEGALY
(HYPERTENSION & CARDIOMEGALY)


DOWNS SYNDROME MARFAN S SYNDROME
TURNER S SYNDROME TURNER S SYNDROME

ACROMEGALY

ACROMEGALY
GENERAL EXAMINATION
BREATHLESSNESS
IN PAIN
FEBRILE
PALLOR
XANTHELESMA

CLEFT EAR LOBES

CENTRAL CYANOSIS
DENTAL CARE
THYROID ENLARGEMENT
CENTRAL CYANOSIS
CLUBBING OF THE FINGERS
SPLINTER HEAMORRHAGES
SPLINTER HAEMORRHAGES
OSLERS NODES
OSLERS NODES

JANEWAYS LESIONS
ANKLE OEDEMA
SACRAL OEDEMA
PULSE
PRESENCE OR ABSENCE
RATE
RHYTHM
CHARACTER
PRESENCE OF BRUITS
BLOOD PRESSURE
PLACE THE CUFF ROUND THE UPPER ARM
BRACHIAL ARTERY IS AT THE SAME LEVEL OF THE HEART
PALPATE BRACHIAL ARTERY
INFLATE THE CUFF UNTIL THE BRACHIAL PULSE NOT FELT
REDUCE THE PRESSURE IN THE CUFF SLOWLY
JUGULAR VENOUS PULSE
THE INTERNAL JUGULAR VEIN PROVIDES INFORMATION ABOUT RIGHT ATRIAL
AND RIGHT VENTRICULAR FUNCTION
THE JVP CAN BE DISCRIMINATED FROM THE CAROTID PULSE BECAUSE:
IT CANNOT BE PALPATED
IT HAS A COMPLEX WAVE FORM IT IS USUALLY SEEN TO FLICKER TWICE
WITHIN EACH CARDIAC CYCLE
IT MOVES ON RESPIRATION, NORMALLY DECREASING ON INSPIRATION AND
RISING ON EXPIRATION
MILD PRESSURE APPLIED TO THE BASE OF THE NECK OBLITERATE ITS
PULSATIONS
MILD PRESSURE APPLIED OVER THE LIVER WILL EXPEL MORE BLOOD INTO THE
RIGHT SIDE OF THE HEART AND ELEVATE THE JVP, A POSITIVE HEPATO!
JUGULAR REFLEX
JUGULAR VENOUS WAVE PATTERN
THE JVP IS DESCRIBED IN TERMS OF:
HEIGHT
CHARACTER
THE HEIGHT OF THE JVP IS EXPRESSED AS THE VERTICAL
DISTANCE FROM THE MANUBRIOSTERNAL ANGLE TO THE MAXIMUM HEIGHT OF
PULSATIONS IN THE INTERNAL JUGULAR VEIN WITH THE PATIENT SEMI!RECUMBENT AT AN
ANGLE OF "# DEGREES$
IT IS NORMALLY LESS THAN 3 CM.
THIS E%UATES TO A RIGHT ATRIAL PRESSURE OF & CM OF WATER AS IN
THIS POSITION, THE MANUBRIOSTERNAL ANGLE IS ABOUT # CM ABOVE THE CENTRE OF
THE RIGHT ATRIUM
CAUSES OF A RAISED JVP
INCREASED RIGHT VENTRICULAR FILLING PRESSURE
OBSTRUCTION OF BLOOD FLOW FROM THE RIGHT ATRIUM TO THE RIGHT VENTRICLE
SUPERIOR VENA CAVAL OBSTRUCTION
POSITIVE INTRATHORACIC PRESSURE
ABNORMAL WAVES
ABNORMALLY LARGE A WAVES INDICATE INCREASED RESISTANCE TO RIGHT
ATRIAL EMPTYING FROM RIGHT VENTRICULAR HYPERTROPHY, AS IN SEVERE
PULMONARY STENOSIS, OR TRICUSPID STENOSIS$
A WAVES ARE ABSENT IN ATRIAL FIBRILLATION, SINCE COORDINATED ATRIAL
CONTRACTION IS NECESSARY TO PRODUCE THEM,
ABNORMAL WAVES
CANNON WAVES ARE VERY LARGE A WAVES THAT OCCUR WHEN THE RIGHT
ATRIUM CONTRACTS AGAINST A CLOSED TRICUSPID VALVE$
THEY OCCUR IRREGULARLY IN COMPLETE HEART BLOCK AND VENTRICULAR
TACHYCARDIA, CONDITIONS THAT ARE CHARACTERISED BY
ATRIOVENTRICULAR DISSOCIATION WITH RANDOM OCCASIONAL
SIMULTANEOUS ATRIAL AND VENTRICULAR CONTRACTIONS$
AN EXAGGERATED X DESCENT INDICATES THAT BLOOD IS BEING EJECTED
FROM A RESTRICTED PERICARDIAL CAVITY, FOR EXAMPLE, BECAUSE OF
CARDIAC TAMPONADE OR CONSTRICTIVE PERICARDITIS WITHOUT
CALCIFICATION$
A SLOW Y DESCENT MAY BE SEEN IN TRICUSPID STENOSIS AND RIGHT ATRIAL
MYXOMA$
EXAMINATION OF THE PRECORDIUM

INSPECTION
SCARS,
THE MIDLINE SCAR OF A STERNOTOMY
THE LEFT LATERAL SCAR OF A MITRAL VALVOTOMY
DEFORMITY
PACEMAKER
VISIBLE APEX BEAT OR OTHER PULSATION
PECTUS EXCAVATUM
PALPATION
APEX BEAT
PARASTERNAL HAEVE
PALPABLE HEART SOUNDS
PLAPABLE MURMURS
APEX BEATS DIFFERENT TYPES
SUSTAINED OR HEAVING APEX BEAT IS CAUSED BY PRESSURE OVERLOAD
AORTIC STENOSIS,
SEVERE HYPERTENSION$
TAPPING APEX BEAT SEEN IN
MITRAL STENOSIS
THRUSTING DISPLACED APEX BEAT IS CAUSED BY VOLUME OVERLOAD: AN ACTIVE LARGE
STROKE VOLUME VENTRICLE
AORTIC REGURGITATION
MITRAL REGURGITATION
LEFT TO RIGHT SHUNTS$
DOUBLE OR TRIPLE IMPULSE OCCUR IN HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY
AN IMPALPABLE APEX BEAT
OBESITY
OVERINFLATED CHEST
PERICARDIAL EFFUSION
DEXTROCARDIA
APEX BEAT
PARASTERNAL HEAVE IS DETECTED BY PLACING THE HEEL OF THE HAND
OVER THE LEFT PARASTERNAL REGION$ IN THE PRESENCE OF A HEAVE THE
HEEL OF THE HAND IS LIFTED OFF THE CHEST WALL WITH EACH SYSTOLE$

PARASTERNAL HAEVE
PARASTERNAL HEAVE IS CAUSED BY :
RIGHT VENTRICULAR ENLARGEMENT
SEVERE LEFT ATRIAL ENLARGEMENT WHICH PUSHES THE RIGHT VENTRICLE
FORWARDS
THRILL
THESE ARE PALPABLE MURMURS
THEY ALWAYS INDICATE AN ORGANIC DEFECT
THE AREA WHERE THE THRILL IS FELT STRONGEST GIVES CLUES AS TO THE
AETIOLOGY OF THE THRILL
THRILLS MAY BE
SYSTOLIC OR DIASTOLIC:
BEST FELT SITE SUGGEST THE OETIOLOGY
SYSTOLIC:
APEX MITRAL INCOMPETENCE
AT 'RD OR "TH INTERSPACE VSD
AT BASE ON RIGHT AORTIC STENOSIS
AT BASE ON THE LEFT PULMONARY STENOSIS
BELOW LEFT CLAVICLE ! PDA
DIASTOLIC:
APEX MITRAL STENOSIS
ACCURATE AND SENSITIVE AUSCULTATION OF THE PRAECORDIUM RE%UIRES EXPERIENCE
LOCATION OF HEART VALVES
AUSCULTATION SHOULD BEGIN IN THE MITRAL REGION:
USE THE BELL INITIALLY TO DETECT THE LOW FRE%UENCY SOUNDS OF MITRAL STENOSIS
OR A THIRD HEART SOUND
USE THE DIAPHRAGM TO DETECT THE HIGHER FRE%UENCY SOUNDS OF
MITRAL INCOMPETENCE OR A FOURTH HEART SOUND
USING THE BELL AND DIAPHRAGM, LISTEN IN THE FOLLOWING LOCATIONS
TRICUSPID AREA
PULMONARY AREA
AORTIC AREA
NEVER FORGET TO AUSCULTATE OVER THE MITRAL AREA IN LEFT LATERAL POSITION IN
EXPIRATION WITH THE BELL TO FIND MID DIASTOLIC MURMUR IN MITRAL STENOSIS

NEVER FORGET TO AUSCULTATE OVER THE LOWER LEFT STERNAL EDGE IN EXPIRATION ,
IN SEATED AND BENT FORWARD POSITION, WITH THE DIAPHRAM TO FIND EARLY
DIASTOLIC MURMUR IN AORTIC INCOMPETENCE
HEART SOUNDS
THERE ARE TWO MAJOR GROUPS OF HEART SOUNDS
THEY ARE CLASSIFIED ACCORDING TO THEIR MECHANISM,
VALVULAR
VENTRICULAR FILLING
VALVE SOUNDS
THESE INCLUDE:
FIRST HEART SOUND
SECOND HEART SOUND
EJECTION SOUNDS
OPENING SNAPS
THE FIRST HEART SOUND IS CAUSED BY THE CLOSING OF THE MITRAL VALVE
AND THE CLOSING OF THE TRICUSPID VALVE
IT IS HEARD LOUDEST AT THE APEX$
POSSIBLE CAUSES OF A SOFT FIRST HEART SOUND INCLUDE
MITRAL REGURGITATION
LOW BLOOD PRESSURE,
RHEUMATIC CARDITIS
SEVERE HEART FAILURE
LEFT BUNDLE BRANCH BLOCK
LOUD FIRST SOUNDS

A LOUD FIRST HEART SOUND OCCURS WHEN THE LEAFLETS ARE WIDE OPEN AT THE
END OF VENTRICULAR DIASTOLE AND SHUT FORCEFULLY AT THE BEGINNING OF
VENTRICULAR SYSTOLE$
CAUSES OF FIRST HEART SOUND
ATRIAL FIBRILLATION
SHORT DIASTOLE ( TACHYCARDIA
ATRIAL PREMATURE BEAT
MITRAL STENOSIS WHERE HIGH LEFT ATRIAL PRESSURE DELAYS MITRAL VALVE
CLOSURE
IF THE BLOOD FLOW FROM ATRIA TO VENTRICLES VARIES FROM ONE BEAT TO THE
NEXT, THEN THE INTENSITY OF THE FIRST HEART SOUND WILL CHANGE ACCORDINGLY
CAUSES INCLUDE
VARYING DURATION OF DIASTOLE
COMPLETE ATRIOVENTRICULAR BLOCK
A SOFT, OR ABSENT, A) IS HEARD IN:
POORLY MOBILE CUSPS (
CALCIFICATION AS OCCURS IN SOME FORMS OF AORTIC STENOSIS
DILATATION OF THE AORTIC ROOT ! SYPHILITIC AORTITIS
A SOFT, OR ABSENT, P2 IS HEARD IN:
PULMONARY STENOSIS
LOUD SECOND HEART SOUNDS CAN BE LOUD A2 OR A LOUD P2.
LOUD A) OCCURS IN SYSTEMIC HYPERTENSION WHERE THERE IS A DILATED
PROXIMAL AORTA
A LOUD P) IS HEARD IN PULMONARY HYPERTENSION
SPLITTING OF SECOND HEART SOUND
A) AND P) SEPARATE ON INSPIRATION
(P) FOLLOWING A))
THIS IS BECAUSE OF THE INCREASED RIGHT VENTRICULAR STROKE VOLUME
THAT OCCURS AS THE RESULT OF INCREASED VENOUS RETURN
THE SECOND HEART SOUND IS WIDELY SPLIT IF THERE IS AN EARLY A) OR IF THE P)
IS DELAYED$
EARLY A2 CAN OCCUR IN
MITRAL REGURGITATION
VENTRICULAR SEPTAL DEFECT
DELAYED P2
POSSIBLE CAUSES INCLUDE:
RIGHT BUNDLE BRANCH BLOCK
PULMONARY STENOSIS
ATRIAL SEPTAL DEFECT
FIXED SPLITTING
SPLITTING OF SEOND HEART SOUND IN BOTH INSPIRATION AND EXPIRATION
REVERSED SPLITTING
IN THIS CONDITION, P) OCCURS BEFORE A)
ON EXPIRATION, A) IS DELAYED SUCH THAT IT OCCURS AFTER P)
INSPIRATION CAUSES P) TO BE DELAYED AND THE SPLIT IS DIMINISHED$
POSSIBLE CAUSES OF A DELAYED A2
LEFT BUNDLE BRANCH BLOCK
SYSTOLIC HYPERTENSION
SEVERE AORTIC STENOSIS OR HOCM
PATENT DUCTUS ARTERIOSUS
LEFT HEART FAILURE
EJECTION CLICKS
THESE ARE CAUSED BY THE OPENING OF THE AORTIC AND PULMONARY
VALVES$
THESE SOUNDS ARE HIGH PITCHED AND OFTEN DESCRIBED AS CLICKY$
THEY OCCUR IN EARLY SYSTOLE AND ARE BEST HEARD WITH A RIGID
DIAPHRAGM CHEST PIECE$
OPENING SNAPS
IN CERTAIN PATHOLOGICAL STATES THE AV VALVES OPEN MORE RAPIDLY
THAN NORMAL, THIS RESULTS IN AN AUDIBLE OPENING SNAP$
A MITRAL OPENING SNAP MAY BE CAUSED BY:
MITRAL STENOSIS WITH A MOBILE VALVE
RAPID MITRAL FLOW CAUSES A SOFT SNAP IN LEFT TO RIGHT SHUNTS SUCH AS
VSD OR PDA$
SEVERE MITRAL REGURGITATION
A TRICUSPID OPENING SNAP IS RARE AND MAY BE CAUSED BY:
RHEUMATIC STENOSIS
ATRIAL SEPTAL DEFECT WITH INCREASED TRICUSPID FLOW
FILLING SOUNDS
THESE SOUNDS ARE OF MUCH LOWER FRE%UENCY THAN THE VALVE SOUNDS
AND MAY BE DIFFICULT TO HEAR$
THEY ARE BEST HEARD WITH THE BELL GENTLY APPLIED TO THE CHEST AND
ARE DESCRIBED AS A DULL THUD BECOMING PALPABLE WHEN LOUD$
VENTRICULAR FILLING SOUNDS INCLUDE:
RAPID FILLING (THIRD)
ATRIAL (FOURTH)
THIRD HEART SOUND
THIS HEART SOUND IS CAUSED BY RAPID VENTRICULAR FILLING IN EARLY
DIASTOLE$
THE THIRD SOUND IS NORMALLY AUDIBLE IN CHILDREN, WITH THE INTENSITY
DIMINISHING WITH AGE$
THE THIRD HEART SOUND BECOMES INAUDIBLE (BUT RECORDABLE) IN
NORMAL SUBJECTS IN MIDDLE AGE WITH INCREASING VENTRICULAR
STIFFNESS$
FOURTH HEART SOUND
THE FOURTH HEART SOUND IS DUE TO ATRIAL CONTRACTION INDUCING
VENTRICULAR FILLING TOWARDS THE END OF DIASTOLE$
THEY ARE NEVER AUDIBLE IN NORMAL SUBJECTS$
A FOURTH HEART SOUND IS THE RESULT OF POWERFUL ATRIAL CONTRACTION
FILLING AN ABNORMALLY STIFF VENTRICLE$
LEFT ATRIAL HEART SOUND IS MAXIMAL AT THE APEX, WITH POSSIBLE CAUSES
INCLUDING:
LEFT VENTRICULAR HYPERTROPHY
FIBROTIC LEFT VENTRICLE
HYPERTROPHIC CARDIOMYOPATHY
RIGHT ATRIAL HEART SOUND IS MAXIMAL AT THE LOWER LEFT STERNAL EDGE
AND ON INSPIRATION.
THIS MAY OCCUR IN
RIGHT VENTRICULAR HYPERTROPHY
MURMURS
HEART MURMURS ARE CAUSED BY TURBULENT BLOOD FLOW THROUGH VALVES OR
VENTRICULAR OUTFLOW TRACTS
CHARACTERISTICS OF HEART MURMURS
TIMING
DURATION
CHARACTER AND PITCH
INTENSITY
LOCATION
RADIATION
MURMURS ARE RECORDED IN SIX GRADATIONS:
*+, MURMUR IS JUST AUDIBLE BY AN EXPERT IN OPTIMAL CONDITIONS
)+, IS %UIET
'+, IS MODERATELY LOUD
"+, IS MARKEDLY LOUD , ACCOMPANIED BY A THRILL
#+, IS VERY LOUD WITH A THRILL
,+, IS AUDIBLE WITHOUT A STETHOSCOPE
WITH REFERENCE TO VALVULAR LESIONS
SYSTOLIC MURMURS IMPLY INCOMPETENCE OF ATRIOVENTRICULAR VALVE
OR STENOSIS+SCLEROSIS OF SEMILUNAR VALVE$
DIASTOLIC MURMURS IMPLY STENOSIS OF ATRIOVENTRICULAR VALVE OR
INCOMPETENCE OF SEMILUNAR VALVE
LEFT VENTRICULAR EJECTION MURMURS ARE MAXIMAL AT THE AORTIC
AREA, LOWER LEFT STERNAL EDGE AND APEX.
POSSIBLE CAUSES INCLUDE:
AORTIC STENOSIS
HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY
AORTIC CUSP SCLEROSIS
EJECTION SYSTOLIC MURMUR MAXIMAL OVER THE AORTIC AREA:
AORTIC STENOSIS
AORTIC SCLEROSIS
COARCTATION OF THE AORTA
HYPERTROPHIC CARDIOMYOPATHY
EJECTION SYSTOLIC MURMUR MAXIMAL OVER THE PULMONARY AREA:
INNOCENT
PULMONARY STENOSIS
PULMONARY HYPERTENSION
ATRIAL SEPTAL DEFECT
PANSYSTOLIC MURMURS
PANSYSTOLIC MURMURS OCCUR THROUGHOUT SYSTOLE CAUSED BY:
MITRAL REGURGITATION
VENTRICULAR SEPTAL DEFECT
TRICUSPID REGURGITATION
DIASTOLIC MURMURS
EARLY DIASTOLIC MURMURS
MID!DIASTOLIC MURMURS
EARLY DIASTOLIC MURMURS
AORTIC REGURGITATION ! MAXIMAL AT THE "TH INTERSPACE BELOW THE
AORTIC VALVE$ MAXIMAL IF THE PATIENT LEANS FORWARDS$ RADIATES TO
THE BACK$
PULMONARY REGURGITATION ! MAXIMAL ABOUT THE THIRD LEFT SPACE.
MID DIASTOLIC MURMURS
MITRAL STENOSIS ! MAXIMAL AT THE APEX WITH THE PATIENT INCLINED TO
THE LEFT$ THE MURMUR BEGINS AFTER THE OPENING SNAP$ THE MURMUR IS
LONG IF SEVERE AND SHORT IF MILD$
TRICUSPID STENOSIS ! MAXIMAL AT THE LOWER LEFT STERNAL EDGE$ THE
MURMUR IS INCREASED BY INSPIRATION$
A MURMUR MIMICKING MITRAL STENOSIS MAY OCCUR WHEN THERE IS
GREATLY INCREASED FLOW ACROSS THE MITRAL VALVE.
THIS MAY OCCUR IN
MITRAL REGURGITATION,
VENTRICULAR SEPTAL DEFECT
PATENT DUCTUS ARTERIOSUS
CONTINUOUS MURMUR
THESE OCCUR WHEN THERE IS A COMMUNICATION IN THE CIRCULATION WITH
A CONTINUOUS PRESSURE GRADIENT THROUGHOUT THE CARDIAC CYCLE$
CONTINUOUS MURMURS ARE OFTEN MAXIMAL IN LATE SYSTOLE
CAUSES OF A CONTINUOUS MURMUR INCLUDE:
PATENT DUCTUS ARTERIOSUS
AORTIC SINUS OF VALSALVA ANEURYSM RUPTURING INTO THE RIGHT HEART
PULMONARY ARTERIOVENOUS COMMUNICATIONS
BRONCHIAL ARTERY ANASTOMOSIS IN PULMONARY ATRESIA
ARTIFICIAL DUCTS
PROSTHETIC VALVE
VENOUS HUM
INNOCENT MURMURS
MANY BABIES AND CHILDREN HAVE HEART MURMURS IN THE ABSENCE OF
ANY STRUCTURAL ABNORMALITY
IF A MURMUR HAS ANY OF THE FOLLOWING CHARACTERISTICS THEN IT
PROBABLY IS NOT INNOCENT:
PANSYSTOLIC
DIASTOLIC
LOUD OR LONG
ASSOCIATED WITH A THRILL OR CARDIAC SYMPTOMS
SOME HINTS CONCERNING LISTENING FOR MURMURS:
TIME THE CARDIAC CYCLE BY PALPATING ONE OF THE PATIENT'S CAROTID
ARTERIES
THE BELL IS GOOD FOR HEARING LOW!PITCHED SOUNDS E$G$ MITRAL
STENOSIS$ IT SHOULD BE APPLIED VERY GENTLY TO THE SKIN
THE DIAPHRAGM IS GOOD FOR LISTENING TO HIGH PITCHED MUMURS E$G$
AORTIC REGURGITATION
LEFT HEART MURMURS ARE LOUDER IN EXPIRATION
RIGHT HEART MURMURS ARE LOUDER IN INSPIRATION
EXERCISE MAKES A MITRAL STENOTIC MURMUR LOUDER
IN GENERAL, FEATURES OF MITRAL STENOSIS
SMALL PULSE, WHICH MAY BE IRREGULARLY IRREGULAR
JUGULAR VENOUS PRESSURE IS ONLY RAISED IF THERE IS HEART FAILURE
RIGHT VENTRICULAR HYPERTROPHY, TAPPING APEX BEAT
LOUD S*, LOUD P) IF PULMONARY HYPERTENSION
OPENING SNAP
MID!DIASTOLIC MURMUR HEARD AT THE APEX ONLY
PRE!SYSTOLIC ACCENTUATION MURMUR IF NO ATRIAL FIBRILLATION

MITRAL STENOSIS
THE MORE SEVERE THE STENOSIS, THE LARGER THE LEFT ATRIUM, THE WORSE THE
DYSPNOEA, THE CLOSER THE OPENING SNAP IS TO THE SECOND HEART SOUND, AND THE
LONGER THE MURMUR.
SIGNS OF MITRAL INCOMPETENCE:
PULSE, WHICH MAY BE FIBRILLATING
JVP RAISED ONLY IF HEART FAILURE
RIGHT AND LEFT VENTRICULAR HYPERTROPHY$
SOFT S* LOUD P) IF THERE IS PULMONARY HYPERTENSION
HIGH FRE%UENCY PAN SYSTOLIC MURMUR BEST HEARD IN THE APEX AND
RADIATING TO THE AXILLA$