Cardio-

Vascular
Examination
 Start with general examination to CVS then go for
pericardium examination

Step 1

A. Self introduction to the patien

B. Patien Position

Patient should be seated on 15˚

The head should be supported allowing relaxation of the mcs in the neck

All the upper chest up to the epigastrium should be exposed

Step 2 General Examination

General Inspection ABCD

Appearance Does the patient look well / ill ?

Body Built Overweight / Underweight / Cachetic ?

Abcormal Pale / Jaunndice / cyanosis ?

Color

Distress Dyspmic – tachypnic – in pain – anxious ?

Face
Anemia Pale Conjunctiva

• Anemia can precipitate heart failure

•Prosthetic valve hemologis
WHY ? •Infective ecdocatitis cause anemia

Jaundice Yellow discoloration of the sclera

• CCF : can cause liver congestion

WHY ? • Prosthetic valve : hemolysis

Xanthelasma Yellow, raised lesion around the eye

Indicative of high serum cholesterol

Corneal Arcus Yellow ring seen overlying the iris

• Significant in patient < 40 year can be normal in older patient

• Indicate hyperlipidemia

Malar Flush Mitral Facies

Rosy cheeks suggestive of mitral stenosis

Cyanosis Seen as blue-ish dislocation of the lips ant tongue

Dental Hygiene A common source of organism causing endocarditis

Neck
Carotid Pulse

• Auscultate : first for bruit

• Palpate : by thumb / palpate gently / never asses both carotids simultaneusly

JVP

The jugular veins connect to SVC & the right atrium without any valves → so
any change in pressure in right atrium will transmit a pressure wave up these
veins

The internal jugular veins (IJV) is used

Why ? b/c the (EVJ) External Jugular Vein has tartuais course, means that
impulse are not treansmitted easily

The center of the right atrium lies ± 5 cm below the sternal angle which use as
reference part

The normal JVP is ± 8 cm of blood ( therefore 3 cm above the sternal angle)

 • Patient lying back at 45˚, neck exposed
• Neck muscles relaxed, ask patient to turn head
Steps to the left
• Look for pulsation, measure the vertical distance
from the top of the pulsation to the sternal angle
•Add 5 cm to the result = JVP
It can be difficult sometomes to distinguish th ejugular venous pulse from the
carotid pulse

Jugular Pulsation Carotid Pulsation

2 Peaks / cycle 1 peak / cycle
ImPalPeble Palpeble
Remember
Obliterated by Pressure Hard to obliterate
5P
Moves with resPiration Little movement at respiration
↑ at hePatojugular reflux No change

JVP Waves

α → atrial contraction
C → triCuspid pulge during ventrical contraction
X → atrial relaxation
V → atrial villing ( filling ) against closed tricuspid
Y → opening tricuspid
 Abnormal Findings

• Right ventricel failure - Large “v” wave : - T.R

↑ JVP : • T.S
•T.R - Sharp “y” descend :
• SVC obstruction constrictive pericarditis
• PE
• fluid overload - Sharp “x” descend :
cardiac temponade
Absent “a” wave → AF

• P.s -Kussmaul sign :

Large “a” wave → • P. HTN • ↑ JVP during inspiration
•T.s • Constrictive pericarditis
•Complete • Pericardial effusion
• Complete heart
Canon “a” wave →block
•V tech
 Hands → Cold in ccf

Warm / sweaty → thoracotoxicosis ↑ T3 →

Termperature causing heart failure

Precipitate heart failure

Cause AF → arrythmia
State of nails

• Blue discoloration → if perpheral blood flew is poor

• Splinter hemorrhage ( small streak – like bleeds in the nail
bed)
- seen in infective endocarditis

Finger Clubbing
• infective endocarditis
Cardiac causes • cyanotic congenital heart failure

Aster’s Nodes : Red, tender nodules in the finger pulps

- seen in Infective endarditis
Janeway Lession: non tender, erythematous macule seen on the palm
- in Infective endarditis

Check for tremor : fine tremor → tyrotoxicosis

Entire skin surface → for ptechiae and ecchimosis

Lower Limbs
• if its unilateral / bilateral
Pedal Edema • is it pitting / non- pitting
• How high its extends : ankle / leg / thigh
•If the edema extend : beyond the thigh → its inp. To examin
the external genitalia “ in men”

Peripheral • posterior tibial

Pulsation • a. Dorsalis pedis

• Shiny, pale, skin

Ischemic • Cold limb
changes • Loss of hair
• Absent peripheral pulse
• if severe : ischemic ulceration / gangrene

• Peripheral blood
Vital Sign • Blood pressure
• Temperature
• Respiratory rate
 Peripheral Pulse
1. HR
Pulse wave depends on
2. Stroke volume
3. Left vent. Outflow obstruction
4. Arterial elasticity
5. Peripheral resistance

Pulse should be expressed

In : beats per minutes = bpm

Normal healthy adult pulse should be = 60-100 bpm

( a rate < 60 bpm → called bradicardia
> 100 bpm → called tachycardia )

N.C.C of tachycardia : sinus tachycardia

N.C.C of bradicardia : drugs / athlete

 • Regular
Rhytm • Regularity irregular -> due to
1. ectopic beat at regular internal
2. 2nd degree A.V. block
• Irregularity regular -> dit atrial fibrillation (AF)

Notes
• In AF → ther rate depends on the number of
beat conducted by AV – node
If untreated can reach 200 bpm
• because of the variabillity of the ventricullar
filling the pulse volume varies “same cycle not felt
at radial pulse “ that explaind the pulse deficit

Pulse deficit = H.R by auscultation – Radial pulse

rate
Character / waveform

Slow rising pulse : Aortic Stenosis

Colapsing Pulse = Waterhammer

Which feels as its suddenly hits your finger and falls away just quickly
“You can feel it at brachial artery cohen rising the arm above the patient
heart”
DD : - Aortic Regurtitation
- thyrotoxicosis
- anemia

Pulsus Biferiens • waveform at 2 peaks

• dit A.R + A.S co exist

• Alternating strong & weak

Pulsus Alterans pulsation
• Occure in severe LVF
 • Pulse is weaker during inspiration (↓ systolic BP >
Pulsus Paradoksus 15 mmHg during inspiration )
• d/t : cardiac tamponade
constrictive pericarditive
Acute severe asthma

Jerky Pulse • Hypertropic cardiomyopathy

Pulsus Pervus = ↓ volume pulse

• Heart failure
• Peripheral vascular
disease
•Hypovolemia
•A.S.
Other Test of Arterial Pulsation

Radio- Radial delay

→ you should deel both radial pulses simautenously

→ you delay in the pulsation on one side may indicater pathalogy such
as an aneurysm at the aortic arc or subclavian artery stenosis

Radio- Femoral delay

→ Any delay in the pulsation reaching the femoral artery may indicate pathalogy
such as coarcation
 Blood Pressure
• Using sphygnomonometer
• Normal BP < 140 / 90

• Rest the patient fot at lease 5 minutes

• Patient seated or lying down → arm supported at about the heart lever / no
tight cloting
• Choose the cuff size suitable for the patient → bladder length should cover
80% of arm circumference
• Palpatory method : palpate the radial artery and inflate till the pulse
impalpable → this gives a rough estimation of systolic BP
• Auscultation method : Re-inflate above the pressure reading by ± 30 mmHg →
then listen ( by stethoscope at brachial arthery → tapping sound “systolic”
continue till sound diseappear “diastolic”
• Measure BP in both arms → take the higher number
 Korotkoff Sounds

Sound produced b/w systole → diastole because the artery collapse completely
( during inflation of the cuff ) and re-open ( during deflation )
the sound is snapping or knocking sound with each beart-beat ( 5 phase)

Phase 1 → 1st appereance of sound ( systole)

Phase 4 → Muffled sounds
Phase 5 → Disappearance of sound ( dyastole)

Common Problem

1. BP Diffrent in each arm

If > 10 mmHg difference → subclavian artery dix
- Recond the highest → guide the management

2. Wrong cuff size

in obese patient if we use small cuff → this will
overestimate BP ( use larger cuff or thight cuff)
3. Auscaltory gap : 80 % or elderly HTN have Korotkoff sound
appear at systolic and diseapear for internal b/w systolic →
dyastolic
If the last sound missed →
If the first sound missed →
diastolic falsely will be
systolic falsely will be low
high

4. Patient aim at wrong level

- patient elbow should be at level of the heart
- 7 cm change in arm elevation → ± 5 mmHg change in both
systolic and diastolic BP

5. Postural Change:
- When a healthy person stand : - Pulse ↑ 11 bpm
- Systolic BP ↓ ( 3-4 mmHg)
- Diastolic BP ↑ ( 5-6 mmHg)
then BP stabilize after 1-2 minutes
- Check BP after 2 min from patient standing a drop ≥ 20
mmHg → Postural Hypotension
 Some IMP Differntial Diagnosis
Causes of Postural
Hypotension
1. Dehydration / hypovolemia
2. Drugs ( diuretics,
vasodilatation)
3. Disease of Addiction
4. Diabetes Melitus (
Autonomic Neuropathy)
Peripheral Cyanosis
Seen in nails, never in tongue
1. Cold Exposure
2. Hypovolemia / shock
3. Raymondi Phenomenon
4. Arterial Occlusion
Central Cyanosis
4D
Occurs when deoxy Hb > 5 g/dL
(or > 50 g/L)
SaO2 <90% PaO2 ≤60 mmHg
In anemia-hypovolemia → rare to have
central cyanosis because they need
severe hypoxia to be detected
In polycythemia → cyanosed easily
Seen in (lips-tongue)
Causes:
1. Cyanotic CHD / Eisenmengensi Syndrom
2. Severe Respiratory Disease ( ex,
pneumonia_
3. Acute pulmonary edema
4. Pulmonary Embolism
5. Asphyxia
6. Methemoglobinemia
 ↑ Volume Pulse Splinter Hemorrhage
1. Exercise 1. Infective Endocarditis
2. Pregnancy 2. Trauma
3. Aortic regurgitation 3. Vasculitis
4. Fever 4. Rhaumatoid artrithis
5. Thyrotixicosis 5. Sepsis
6. Anemia
7. Peripheral AV-shunt Sinus Tachycardia
8. Payets disease of
the bones
1. Anxiety
2. Pain
↓ Volume Pulse
3. Exercise
1. Heart failure 4. Anemia
2. Peripheral vascular dix 5. Thyrotoxicosis
3. Hypovolemia 6. Caffeine : tar
4. Aortic stenosis 7. Drugs : β –agonist
vasodilators
Sinus Bradycardia Clubbing : loss of the angle between nail and
nail bed
Grades:
1. Sleep Gr 1 : flactuation / softening of nail bed
2. Drugs : β-blocker / Gr 2 : loss of angle
digoxin/ verapamile/ Gr 3 : drum stick = parrot beak appearance
diltiazem Gr 4 : hand 0steo-arthropathy
3. Hypothiroidism
4. Obstructive jaundice Causes
5. Hypothermia 1. Congenital / Familial (5-10%)
6. ↑ intracranial pressure 2. Thoracoc causes (70%) : lung cancer
7. Athlete chronic supurative condition (bronchiectasis,
CF, llung abcess, empyema), P. fibrosis,
mesothelioma, fibroma
3. CVS
- cyanotic CHD
- Infective endocarditis
- atrial myxoma
4. GIT
- Liver cirrhosis
- IBD
- celiac disease
5. Thyrotoxicoxis ( Thyroid acropathy)
The Pericordium Examination
In the exam ( time : to minutes)
You should following:
 Self introducing to patient/ patient position
 Inspection
 Palpation........... : Apex beat
Parasternal heave
Thrill
P2
 Auscultation of the mitral area while :
- Palpating the carotid
- Using special manuver ( lying on left side expiration–inspiration)
 Auscaltion of aortic area while :
- palpating the carotid
- using special manuver ( sitting position expiration-inspiration
 Ausculation of bicuspid and pulmonary area
 Presentatin of physical finding
 Detection & interpretation of pysical finding
 Step : patient should be lying at 45⁰ with chest expose

Inspection : 5 S
Chest Deformity :
Symmetry Pectus Carinatum ( Pigeon chest)
Pectus excavatum ( Funnel chest)
Barrel chest
Sternotomy scar ( CABG- valve replacement)
Left submammary scar ( mitral valvotomy-vavloplasty)
Scar Infra-clavicular (it side) (pacemaker-defibrilator)

Any scar should expressed in follow:

Site – length – type of healing “1⁰ - 2⁰ intension” – any
complication – “keloid- hypertrophied scar”

Bruises → v. IMP if patient on warfarin

Skin rash
Herpes zooster →presented with chest pain

Superficial veins SVC obstruction

Mitral area
Superficial pulsation It sternal border
Epigastric area
 Palpation

Apex beat ( lowermast – amter mast palpable beat)

 Use your right hand flat area the precordium to obtain general impression of
cardiac impulse
 Localize apex beat
 Determine the character
 If not palpable → put the patien on left lateral position and palpate again, if
still notl palpable → palpater right sife ( for dextro-cardia)

Lt. Parasternal heave

 Use the heet of your right hand firmly to the left parasternal area and feel for
right ventricular heave ( indicate right ventricular dilatation

Thrill : “ Palpable murmur → in all valve area ( if + ve → grade 4 murmur or more )

 Aucultation of Mitral Area
• Palpate the carotid ( for timing)
• Put the diaphragm of the stethoscope in the mitral area and
auscultate for S1 –S2 ( S1 with the pulse)
• Note any abnormality (soft – load – muffled)
• Auscultate for any murmer → comment if its systolic/ diastolic –
duration – location – character ( hars-blowing-mumbling) –
intensity – location – radiation.
• If you hear a murmur at mitral area, ask the patient to hold his
breath on expiration & note any change of the intensity → then
auscultate the axilla for radiation
• Now auscultate using the belt of stethoscope on mitral area for :
added sound S3-S4
• Then ask the patient to turn on lt. Lateral position and hold his
breath on sxpiration → looking fot the murmur of mitral stenosis
 Auscultate Tricuspid Area
• Using the Diaphragm of stetoschope on tricuspid area while
palpating the carotid for timing → ask the patient to hold his
breath on inspiration
• If you hear a murmur comment as before, and auscultate the
epigastric area for radiation

Auscultate Pulmonam Area

• Using the diaphragm
• Notice any abnormality of S2
• Ask patient to take a deep inspiration and
hold
 Auscultate Aortic Area
• Using the diaphragm
• Notice any murmur → ask patient to hold his breath on expiration →
auscultate the neck and ask patient to hold his breath “ for radiation of A.S
murmur”
• Then, ask the patient to sit and bend forward and hold his breath
expiration → this manuver to detect the murmur of (A.R.) it’s best heard
over the 2nd aortic area (it 3rd ICS parasternal edge)

Don’t forget to cover the patient and thank him / her

Look at the examiner and present your finding ni organized, consistent

manner
Normal case “ no finding” → comments as
following
• By inspection : there is no deformity, no scar, no
skin rash, no superficial veins, no visible pulsation
• By palpation : apex beat in it 5th ICS,
midclavicular line normal in character, no
parasternal heave, no thrill
• By auscultation S1- S2 normal, no added sound,
no murmur
 Interpretation of Physical Finding

1. Normal in thin people

DD of Epigastric Pulsation
2. Abnormal aortic aneurysm
3. Pulsatic liver in T.R.
4. Right ventricular enlargment

Apex beat

Normal site : 5th ICS midclavicular line

DD of Impalpable Apex beat : Abnormal Character
1. Obesity 1. Tapping : Indicate load S1 (M.S.)
2. Under the rib 2. Forceful sustained ( pressure
3. Pericardial effusion overload) : systemic HTN, aortic
4. Pleural effusion stenosis
5. Hyper inflated chest 3. Forceful non-sustained (volume
6. Dextrocardia overload) : Aortic regurge, Mitral
regurge
Normal character : gentle , non- 4. Double apex beat : HOCM
sustained 5. Diffuse apex beat : dilatad
cardiomyoplasty
Site of Cardiac Dullnes S1
At 3rd – 4th – 5 th ICS, medial -Mufflied in : MR, TR
to the mid clavicular line - Load in : M.S.

S2

 Mufflied in : A.S , PS, AR, PR

 Load in : pulmonary HTN, systemis HTN
 Splitting of S2:
- normal splitting : occurs during inspiration because ↓ intrathoracic
pr → ↑ V. R → ↑ R.V filling → ↑R.V ejection time → delay closure of
pulmonary valve
- wide splitting : d/t delay R.V emptying (PS- RBBB)
its an exagerated normal splitting
- Fixed splitting : ASD
(it →R + shunt →↑ RA & RV volume →regardless of breath)
- Paradoxical Splitting
- d/t delayed Aortic valve closure ( AS-LBBB)
Area of Auscaltation & Murmur
Mitral Area (N)
(it. 5th ICS midclavicularis
line)
-Pansystolic mumur (M.R)
- Diastolic Murmur (M.S)
Tricuspid area (T)
(4th ICS- lt sternal border)
-Pansystolic murmur (TR) –
(VSD)
- Diastolic Murmur ( TS)
(ASD)→(d/t ↑ flow area
tricuspid valve)
Pulmonary Area (P)
- Systolic ejection Murmur
( P.S)
Aortic area ( A)
- Systolic murmur (AS) (
flow murmur) ( aortic
sclerosis)
Left Sternal border “3rd
ICS” (2nd aortic area) (*)
-Diastolic Murmur (AR)
- Systolic Murmur
(hypertropic
cardiomyopaty)
Common murmur in the exam

Mitral Regurgitation
• Inspection : as before
• Palpation :
- apex beat can be displaced to the left because of lt
ventricular dilatation “I can’t determine”
- thrill can be felt near mitral area ( if the murmur is
grade 4 or more)
• Ausculation : S1 : soft S2 : normal ±S3
there’s pansystolic murmur, best heard aver the
mitral area, radiating to the axilla, blowing in
character, increasing at expiration, grade 3
 Mitral Stenosis
• Inspection : as before
• Palpation :
- apex beat “lt 5th ICS mid clavicular line” I can’t
determine the character, there’s lt parasternal heave
“because of right ventricular dilatation”, thrill over
bicuspid area if grade 4
• Auscultation : S1 → load S2 : normal no added sound
• there’s late diastollic murmur heard aover the mitral
area, when the patient on lt lateral position, no
radiation rumbling in character, increasing with
expiration grade “3”
 Aortic Stenosis
• H.C.C age related calcification
• Inspection : as before
• Palpation : apex beat ( normal site), “I can’t
determine the character”, no parasternal
heave, thrill if grade 4 murmur
• Auscultation : S1 : normal S2 : soft ±S4
ejection systolic murmur heard on 1st aortic
area radiating to the neck, increased with
expiration grade “3”
 Aortic Regurgitation
• Inspection : as before
• Palpation : apex beat can be displaced to the left
(because lt ventricular dilatation) “I can’t
determine the character”, no parasternal heave, ±
thrill.
• Auscultation : S1 : normal S2 : soft
diastolic blowing murmur, best heard over 2nd
aortic area when patient seated and bend
sonvard ? ↑ at expiration, grade 3 no radiation
 Tricuspid Regurgitation
• Inspection : as before / ± epigastric pulsation
• Palpation : apex beat ( normal site ), normal
character, ± lt parasternal heave ( d/t right
ventricular dilatation) ± thrill “over tricuspid area
if grade 4 murmur)
• Auscultation : S1 : soft S2 : normal ±S3
there’s pansystolic murmur, best heard over the
tricuspid area radiating to epigastric area, ↑ with
inspiration, blawing in character, grade “3”
 Patient with Prostetic Valve
• By examination
• Inspection : sternotemy scar
• Auscultation : you will hear a metallic click. You shiuld
determine whether the click is S1 or S2 via timing with
carotid pulse
• Common valves be replaced are
- Mitral Valve ( metallic S1 click, loadest in mitral area,
normal S2)
- Aortic Valve ( metallic S2 click, normal S1, loadest at aortic
area
Note : ejection systolic murmur may present and it’s not
indicative of valve malfunction
 Types of Valves

Mechanical Valves Homografts

Xenografts - Cadaveric valves
-ball-cage (Stan-Edwards)
- Made from porcine - Useful in young patient
- Tilting disc ( Bjork-Shiley)
valves of pericardium in replacement of
- Double tilting (St. Jude)
infected valves

-Very durable
They are less durable
- ↑ risk of
and may require
thromboembolism
replacement at 8-10
- Require lifelong
years
anticoagulant
Complication of prosthetic Valves

Systemic embolism/ infective endocarditis / hemolysis / structural

valve failure/ arrythmias