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When you examine a patient with a cardiac problem, you do not concentrate on the heart alone, but on all the parts of the body from
the head to the foot. Other findings, for example, edema, you know it’s cardiac when it is accompanied by other physical findings that
are pertaining to the heart: orthopneic, distended jugular vein, enlarged heart, crackles give you a diagnosis of heart failure.
Preparing a patient for examination: Proper position is required.
VIDEO: After taking the patient’s history, move on to the physical examination. First record the patient’s vital signs, such as the pulse,
blood pressure, height, weight, and temperature, before working down the body from the head to the lower extremities. However,
certain physicians prefer to move the blood pressure measurement until the end of the exam, when the patient is less anxious.
Blood pressure measurement is usually recorded in a sitting position, or the patient first sitting then standing. The rest of the
examination should be carried out with a patient lying on the bed with the upper body inclined at about 45 degrees. He should be
undressed but appropriately covered with a blanket until full access is required. By convention, the patient is always approached from
The different parts of the physical examination do not have to be performed in a fixed order, although the observation of the patient’s
general appearance always forms the starting point.
In preparing a patient for physical examination, the proper position of the patient and the doctor is necessary. The patient is
approached from their right, so you stay on the right side of the patient, so that you will have enough room to move your hands (right
Proper examining table/hospital bed has a provision of trying to move the trunk of the patient: flat on bed, 30, 45, 60, and sitting.
Why on the right? And why is the patient not lying down flat? Semi-recumbent position.
It is better if the patient is a male patient because the full chest can be exposed. There is some limitation in examining a female patient.
Use your eyes, ears, hands in proper examination.
So with this position, your patient is comfortable with breathing, but of course you can ask the patient to lie down flat and see if there
is some discomfort in breathing. The recognition of a cardiac patient is that they have discomfort in breathing, they feel so tired, they
have chest pain.
Look for visible pulsations on the region of the chest, especially in the rigin of the apex of the heart. But not in all cases will you see a
pulsation. It is normal that you don’t see a pulsation esp when the chest id full/thick and rich with subcutaneous tissue. If you see a
visible pulsation, that might be an abnormal finding in itself.
The apical beat signifies the left ventricular impulse. It tells us whether the patient has a cardiomegaly or not when the apical beat is
displaced away from the midclavicular line.
Look at the neck. Is there any visible jugular venous vessel? You are particularly interested whether it is distended or not, because the
vein does no pulsate. If you see something pulsate, that is the carotid artery. You should try to distinguish it from a prominent
sternocleidomastoid muscle which is also there. In a patient who is suffering from chronic obstructive pulmonary disorder, like
pulmonary emphysema, that is a prominent expiratory muscle. Because the hallmark in the diagnosis of patients with COPD is
expiratory obstruction; they find it hard to exhale but they don’t find it hard to inhale.
When does venous return become accelerated? Recumbent. (Flow of blood is towards the heart.) And so if there is no interference to
the venous return, you can see that in the recumbent postion, there is distention of the jugulars, and as you move the patient, the
jugulars collapse. But should there be resistance (increased pressure in pulmonary and resistance at theright side of the heart) there
will be backward transmission into the jugulars.
Korotkoff sound – low-pitched sound; use the BELL of the stethoscope (diaphragm is for high-pitched sounds)
Other sounds where the bell is used: S3 and S4 gallop sounds, diastolic rumbling murmur of mitral and tricuspid stenosis, Korotkoff
PHASE I - clear TAPPING sound (SBP)
PHASE II - onset of swishing sound or SOFT murmur (louder than 1)
PHASE III- LOUD slapping sound (loudest)
PHASE IV - sudden MUFFLING of sound
PHASE V - DISAPPEARANCE of sound / phase of silence (DBP)
Pulse pressure: Difference between systolic and diastolic pressure
ICS Pulmonic area/valve Aortic area/valve
ICS Erb’s point – central point
ICS Left parasternal (tricuspid area)
ICS Left midclavicular (mitral area)
APEX BEAT: gentle tap; turn patient to left lateral decubitus
S1: mitral and tricuspid valve closure
S2: aortic and pulmonic valve closure
Splitting at deep breathing: auscultate at 2
LICS; sitting and leaning forward (bring the valve nearer the chest wall)
Sustained isometric exercise causes a pressor response that may be more pronounced in patients with heart disease. The effects are
depicted as an increase in the left ventricular volume and in increase in the height and width of the systolic excursions of the arterial
pulse. In this normal subject, the magnitude of both the percussion and tidal waves increases with sustained handgrip as the
impedance increases. With mitral or aortic regurgitation, this increase in impedance can augment murmur intensity. Third and fourth
heart sounds may also increase in intensity.
Valsalva strain raises thoracic pressure which impedes venous return, leading to a progressive decrease in cardiac volume. Arterial
systolic pressure, pulse pressure, and systolic duration decline as cardiac output and afterload fall because of decreased preload and
depletion of intra-arterial volume. Reflex mediated increases in sympathetic tone increase the heart rate and arterial resistance.
With Valsalva release, venous return sequentially restores the right and left heart filling and output. An overshoot of arterial pressure
results from residual vasoconstriction, which increases the arterial systolic pressure, pulse pressure, and systolic pulse duration. This
overshoot triggers a vagotonic baroreceptor response that reduces the heart rate. The residual arterial constriction progressively
increases the magnitude of the late systolic tidal wave as cardiac output is restored during release, and then declines during recovery
as constriction ebbs.
Most heart murmurs are diminished in intensity during the Valsalva strain. Right heart murmurs return first, followed by left heart
murmurs, during release. The systolic murmurs of hypertrophic cardiomyopathy and mitral prolapse may increase during Valsalva
strain and diminish with release because they result from distortion and malfunction of the mitral valve in the small ventricular cavity.
Effect of Posture on Click and Murmur
Mitral valve prolapse is a common condition due to a myxomatous degeneration of one of the leaflets of the mitral valve.
In mitral prolapse, the redundant valve is too large to fit properly in the left ventricle. The submitral apparatus (chordae and papillary
muscle) cannot maintain the valve in a competent position within the ventricle as cavity size is reduced during systole, leading to
billowing or prolapse of the inflated leaflet(s) and often loss of apposition and competence.
These recordings were made as our subject alternately stood up and squatted, altering the dimensions of the left ventricle. The yellow
calipers indicate the variable distance between the annular and papillary muscle attachments of the posterior leaflet with changes in
ventricular volume. Standing reduces ventricular filling and leads to prolapse in early systole, and an earlier onset of mitral
regurgitation. Squatting acutely increases venous return and thus the size of the left ventricle, delaying prolapse until late systole.
Normal Left and Right Heart Pressures with Respiration
The pressures in the right heart track with the negative inspiratory pressure in the thorax, drawing more blood into their chambers.
The pulmonary arterial dicrotic notch, indicated by the yellow bar, is delayed by the increase in lung compliance that promotes forward
flow in the pulmonary bed. The right atrial (RA) pressure has 2 positive impulses, the presystolic a-wave and the late systolic v-wave.
Each wave is followed by a decline toward zero, the x-and y-descents respectively. These waves are nearly identical to the jugular
venous pulse that can be observed at the bedside. Note that the v-wave peak coincides with the pulmonic second sound.
Effect of dP/dt on Intensity
The rate of left ventricular pressure rise, or dP/dt, directly affects first sound intensity. The first sound is loud in mitral stenosis, in part
because the leaflets are thickened, but more importantly because valve closure is delayed into systole by the elevated left atrial
pressure. The ventricle reaches a high dP/dt at the time of closure, and with increasing left atrial pressure, the ventricle achieves
increasingly more momentum at the time of closure. An opening snap can also be heard following the second sound.