Cardiovascular System Examination

• Presented By –
• Prof.Dr.R.R.Deshpande (M.D
in Ayurvdic Medicine & M.D.
in Ayurvedic Physiology)
• www.ayurvedicfriend.com
• Mobile – 922 68 10 630
• professordeshpande@gmail.
com

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 CVS Examination

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 Before CVS Examination
• Before CVS Examination do –
• 1) Pulse Examination
• 2) Look for clubbing of nails
• 3) Look for Cyanosis
• 4) Check pulsations at peripheral vessels like
Femoral artery, Popliteal artery, Dorsalis Pedis
artery, prominence of neck veins

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 Before CVS Exam -
Do Pulse Examination

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 Before CVS Exam –
Look for clubbing

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 Before CVS Exam – Look for
central Tongue Cyanosis

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 Before CVS Exam –
Look for Leg oedema

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 Before CVS Exam –
Look for Neck veins

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 Systemic Examination of CVS
• 1) Inspection

• 2) Palpation

• 3) Percussion

• 4) Auscultation

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 Inspection of chest
• 1) Shape of precordium
• 2) Apex beat

• 3) Pulsations outside the precordium

• A) Suprasternal
• B) Epigastric
• C) Neck vein

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 Shape of Precordium
• Symmetry of Precordium

• Look whether precordium is retracted or

bulging or normal

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 Apex Beat
• Apex beat is outermost point of cardiac
impulse. It comes in contact with chest wall

• Apex beat should be seen tangentially from

side & below .Up & down movements are
better appreciated ,when we look tangentially

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 Apex beat inspection
tangentially from side

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 Apex beat inspection tangentially from below

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 Apex Beat
• In few conditions Apex beat may not be visible
• Emphysematous chest ,Muscular individual, Apex
beat is situated below sternum ,pendulous breast in
females
• In these conditions to look Apex beat ,give sitting
position to patient ,leaning forward
• Apex beat is observed below left nipple .It should not
be too prominent ,nor too feeble

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Pulsations outside the precordium
• A) Suprasternal pulsations are due to Carotid
Artery
• B) Epigastric pulsations are due to descending
abdominal Aorta – To check epigastric
pulsations ,patient should hold breath during
expiration
• C) Neck veins are prominent in RVH,CCF

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 Inspection for Epigastric pulsation
due to abdominal aorta

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 Palpation of chest
• Apex beat
•
• A) Position
• B) Character

• C) Rate
• D) Rhythm

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 Palpation – Apex beat
• To palpate Apex beat ,we use flat hand ,ulnar
border of palm & tip of fingers

• After locating Apex beat ,mark the point as

cross ,with ball pen

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 Palpation by flat of hand

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Palpation by ulnar border of hand

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 Palpation by tip of fingers

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 Palpation – Apex beat
• Palpate sternum .Palpate 2nd rib on the Left
side .Below 2nd rib is 2nd intercostal space

• Normal Apex beat – Left 5th Intercostal space

,medial to mid clavicular line

• Apex beat can be in 4th Left intercostal space

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 Palpation – Apex beat
• In some patients ,Apex beat may not be
palpable ,because –
• It may be behind rib or person may be
muscular

• In this case give Left lateral position or sitting

position to the patient & try to locate Apex
beat

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 If Apex beat is not seen or palpated in muscular
individual ,palpation in left lateral position

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 Percussion of chest
• 1) Left border of heart
• 2) Right border of heart

• Left border is more important ,because it is

formed by left ventricle
• Right border is formed by right ventricle
• Inferior border is formed by right ventricle

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 Second intercostal space

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 Percussion of Left border of heart
• Start percussion from anterior axillary line at the
level of apex beat .Go from lateral to medial .Mark
Point at which resonant note changes to dull note
• Now go up one intercostal space up & percuss from
lateral to medial & mark point of dullness
• Now again go up one intercostal space up & percuss
from lateral to medial & mark point of dullness
• Joining of these 3 points ,will form left border of
heart

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 Percussion for left border of heart

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 Mark the point of dull note

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 Left border of heart determined

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 Percussion of Right border of heart
• It is situated behind right sternal border
• We start percussing from right 2nd intercostal
space ,down ,up to Liver dullness
• Then we percuss from lateral to medial
• We will proceed from below upwards ,step by
step .Each time one intercostal space up .
• Joining these points will give right border of
heart
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 Percussion for
right border of heart

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 Right border of heart determined

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 Percussion of chest
• If there is abnormal feel like Thrill ,it should
also be noted

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 Auscultation of chest
• Auscultation of heart sounds & additional
sounds in following areas –

• 1) Mitral area
• 2) Tricuspid area
• 3) Aortic area
• 4) Pulmonary area

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 Auscultation of chest
Sr.No Valve Area
1 Mitral Area Located at Apex

2 Tricuspid Area 4th intercostal space ,just

lateral to sternum

3 Aortic Area 2nd right costal cartilage

4 Pulmonary area 2nd left intercostal space ,just
lateral to sternum

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 Mitral area for Auscultation

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 Tricuspid area for Auscultation

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 Aortic area for Auscultation

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 Pulmonary area for Auscultation

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 Auscultation of chest
• Note that Valves are not located at the area
,mentioned in front of Valve

• All valves are located below the sternum

• These are areas ,where conduction of sound is

better from corresponding valve

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 Auscultation of chest – Mitral Area
• Put diaphragm on Mitral area
• Heart sounds should be auscultated ,always with
simultaneous palpating carotid artery pulsations ,to
distinguish in between first & second heart sounds
• First heart sound coincides with carotid pulsation

• In Mitral area first heart sound is loud with compare

to second heart sound

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 Auscultation at Mitral area

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 Auscultation of chest – Tricuspid Area

• Put diaphragm on Tricuspid area

• Heart sounds should be auscultated ,always with

simultaneous palpating carotid artery pulsations ,to
distinguish in between first & second heart sounds

• First heart sound coincides with carotid pulsation

• In Tricuspid area first heart sound is loud with
compare to second heart sound

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 Auscultation of chest
• First heart sound is due to closing of Atrio
Ventricular valves

• So in Mitral & Tricuspid area ,First Heart

sound is heard better

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 Auscultation of chest – Aortic Area

• Put diaphragm on Aortic area

• Heart sounds should be auscultated ,always with

simultaneous palpating carotid artery pulsations ,to
distinguish in between first & second heart sounds

• First heart sound coincides with carotid pulsation

• In Aortic area second heart sound is loud with
compare to first heart sound

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 Auscultation at Aortic area

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 Auscultation of chest – Pulmonary Area

• Put diaphragm on Pulmonary area

• Heart sounds should be auscultated ,always with

simultaneous palpating carotid artery pulsations ,to
distinguish in between first & second heart sounds

• First heart sound coincides with carotid pulsation

• In Pulmonary area second heart sound is loud with
compare to first heart sound

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 Auscultation of chest
• Second heart sound is due to closing of Aortic
& Pulmonary i.e Semilunar valves

• So in Aortic & Pulmonary areas ,Second

Heart sound is heard better

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 Auscultation
• By Auscultation at these four areas ,we get
rough idea about cardiac cycle

• Gap between first & second heart sound is

Ventricular systole
• Gap between second & first heart sound is
Ventricular Diastole

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 Auscultation
• Also Auscultate abnormal sounds like murmur

• Decide type of murmur ,to understand the

pathology behind it

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 Provisional & Confirm diagnosis
• By Clinical examination ,some times we can
make provisional diagnosis

• In this case clinical findings should be

correlated with Investigations like ECG, Stress
or Treadmill Test ,2 D Echo, Angiography etc

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 Please see also Videos
• Copy ,Paste Link as URL
• CVS Examination -- By Prof.Dr.R.R.deshpande

• https://youtu.be/Js3w5hrbjgg

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 Prof.Dr.R.R.Deshpande
• Sharing of Knowledge

• FOR

• Propagating Ayurved

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