CARDIAC PHYSICAL EXAMINATION

Alvin Tonang, MD, FIHA

Kuliah FK UNIMUS
Blok 8
2022
Five Finger of Cardiology (Medicine)
The Patient-Physician Relationship
• Physician need to approach patients not as “cases” or “diseases”
but as individuals whose problems are too often transcend their
physical complaints.

• The ideal patient-physician relationship is based on thorough

knowledge of the patient, on mutual thrust, and on the ability to
communicate.

• This lecture contains additional points besides general physical

examination that has been or will be studied as a general
practitioner
Comprehensive History
• Chief complaints
• Present illness
• Past history
• Social and personal history
• Economic
• Lifestyle
• Family history
Cardinal Symptoms of Heart Disease
• Dyspnea or Easy fatique
• Chest pain / discomfort
• Palpitation
• Edema
• Syncope
• (+) Cyanosis
Present Illness
The principal symptoms should be in terms of :
1. Location
2. Quality
3. Quantity of severity
4. Timing
5. Mode of onset
6. Factors that have aggravated or relieved these symptoms
7. Associated manifestations
Pulse
• There are several location to
palpate a pulse

• Do you know there are types of

pulses?

• The abnormalities of arterial

pulse can help us in diagnosis
Blood Pressure
• Arterial Blood Pressure
• Direct - Invasive
• Indirect Measure

• Dr. Nikolai Korotkoff (1905)

• Describe how to measure arterial pressure

• Systolic and Diastolic Pressure

Factors Affecting
• Systolic Pressure
• Volume and velocity of LV ejection
• The peripheral arteriolar resistance
• The distensibility of arterial wall
• The viscosity of the blood
• The EDV (LVEDV)
• Diastolic Pressure
• Blood viscosity
• Distensibility
• Peripheral resistance to flow
• Length of cardiac cycle
Jugular Venous Pressure
• “The vertical distance
between top of venous
column to sternal angle is
a measure of the venous
pressure.”

• “Sternal Angle is approx. 5

cm from apex RA”

• JVP = R + x cm
• R = sternal angle

• Normally, JVP should not

be more than 7-9 cm*
(Normal <8)
Delp, Manning. Major Physical Diagnosis 8th ed (1975)
Jules Constant, Bedside Cardiology 2nd Ed (2003)
CAROTID PULSES
PALPATION
 Jugular venous pulse waveform
Tricuspid Atrial filling
Atrial valve closure
contraction

Atrial
relaxation Rapid ventricular
filling
Abnormal-Jugular Reflux
• Firm pressure is supplied to the periumbilical region for 10-30 seconds with
the patient breathing quietly
• In normal subjects → JVR ↑ less than 3cm H2O and only transiently
Inspection of Chest
Heart Projection Left atrial appendage

Right atrium

Left ventricle

Right ventricle

Apical impulse
Ictus Cordis
Palpate With Your Hand
 BERBAGAI TIPE DENYUTAN APEKS

Berbaring telentang,
Tentukan lokasi apeks,
Lalu tentukan kualitas denyut

MERABA APEKS JANTUNG

Stethoscope
Place for Auscultation
Listen and Imagine
Heart Sound
• S1
• MT-AP
• Beginning of systole
• S2
• AP-MT
• Beginning of diastole
• Physiologic splitting
• S3
• Gallop ventricular
• Early diastolic phase
• Stiff Ventricle (might be physiologic)
• S4
• Gallop atrial (atrial kick)
• Late diastolic phase
• Pathologic
• Summation gallop (S3 with S4)
• Quadruple gallop (derap kuda)
 SUARA TAMBAHAN PADA AUSKULTASI JANTUNG

BISING
• LOKASI
• FASE
• PUNKTUM MAKSIMUM
• PENJALARAN
• INTENSITAS (1-6)
• KUALITAS

Sambil mendengarkan denyut jantung, raba pula denyut nadi

untuk menentukan bunyi pada sistolik / diastolik
Intensity of Murmurs
The 6 categories are defined as follows :
Grade 1 - very faint, heard only after the
listener has “tuned in”; may not be
heard in all positions
Grade 2 - quiet but heard immediately upon
placing the stethoscope on the chest
Grade 3 - moderately loud
Grade 4 - loud
Grade 5 - very loud, may be heard with a
stethoscope partly off the chest
Grade 6 - may be heard with the stethoscope
entirely off the chest
Systolic Murmurs
Diastolic Murmurs
Cont’ Murmur vs To-Fro Murmur
Quality of Murmurs
Don’t Forget to Look at Extremities
Varicose Vein
Acute Limb Ischemic
• Peripheral Arterial Disease
• Leading to ALI
• Buerger’s Disease
• Thromboangitis obliterans
• Raynaud’s Phenomenon
Not making a physical examination because
of physical distancing is not an excuse.