ARABIAN GULF UNIVERSITY

PROFESSIONAL SKILLS PROGRAMME

Academic Year 22/23

Clinical Examination of the Cardiovascular

System

A– Cardio-Vascular System
B- Peripheral-Vascular System

Coordinator: Dr. Taysir Garadah

Co-Coordinator: Dr. Khadija Al Assas

Name of Student: ………………………………………….. I.D. No……………….

Tutor Name: ………………………………………………… Group ……………….

Main Reference:
The Cardiovascular System.
Macleod’s Clinical Examination.
13th Edition.
Year 2013
 CONTENTS

COURSE DESCRIPTION .....................................................................................3

ROLE OF STUDENTS .........................................................................................4

LEARNING OBJECTIVES ...................................................................................5

METHODS OF ASSESSMENT ............................................................................6

CARDIOVASCULAR & PERIPHERAL VASCULAR SYSTEMS.......................7

STUDENT ACTIVITIES ..............................................................................................9

LEARNING RESOURCES ........................................................................................ 18

2|Page
 Course Description

This component of Professional Skills Program lasts for 12 weeks

and relies primarily on student-center learning. With the exception of
the first week, we will spend the class time in a series of sessions
covering the basic requirements for physical examination skills for
cardiovascular and respiratory system. You will find the sessions much
more useful if you familiarize yourself with the relevant reading
materials well in advance.

After practicing on simulated patients and gaining a degree of "comfort"

with the skills required for this course, students will be assigned to
sessions in the hospital to perform the required skills with supervision
by the assigned tutor. The tutor will give feedback, check out each
student and sign a checklist. There will be penalties for unexcused
absences.

Educational Philosophy

The best way to learn clinical skills is by practicing and receiving timely
feedback about performance. Students will develop medical expertise by
practicing history and physical examination techniques in supportive
setting employing constructive feedback. Self assessment is an
important step in self-directed learning and will be encouraged in the
course.

3|Page
 Role of Students

1. To attend on time all the learning activities.

2. Students are expected to be professional in dealing with
simulated patients, colleagues and faculty.
3. To be onset in their academic work.
4. Students should maintain an appearance that conveys a
professional image.
5. To show an interest during small group activities, read the
required learning resources before and after each session and
participate in the group discussion.
6. To utilize all available learning resources including video-tapes,
checklists text books and others to understand the learning
objectives.
7. To understand the content of the portfolio and fill all the
required forms.

Penalties for absenteeism: as per the regulation of the college

students will not be allowed to appear for the final exam if reported
to be absent without an acceptable excuse for more that 15% of the
learning sessions.

Penalties for late submission of the assignment: 40% of the

total score will be deducted in case of late submission of the
assignment.

ORGANISATION

Dr. Taysir Garadah System coordinator 39450393

Dr. Khadija Al Assas System Co-coordinator 33100034

4|Page
 LEARNING OBJECTIVES

Goals and Objectives

Goals

By the end of this course, students should be able to:

1. Apply their knowledge of basic science to the task of physical diagnosis.

2. Perform a focused physical exam integrated with a medical history.
3. Critique their physical examination technique and that of their peers, including
effective feedback.

Objectives

General Objectives

1. To enable students to communicate skillfully with patients through

accurate history taking.

2. To conduct a physical examination in a respectful, efficient and skilful

manner.

3. To approach diagnosis with a thorough knowledge of disease

presentation, the ability to extract critical information and use clinical
reasoning processes.
4. To maintain skills for continuing education; to increase competence in
obtaining new information from diverse sources.

5. To identify, define and understand ethical issues in medicine, with

consideration for cultural differences and beliefs, in order to provide health
care in a morally responsible manner.

6. To recognize the importance of management skills that will allow him/her

to employ effective responses to work challenges, stress and economic
constraints.

7. To be skilled in accurate, responsible and respectful communication with

other personnel involved in health care delivery.

5|Page
 METHODS OF ASSESSMENT

Essential of Professional Skills Program is pass or fail. Evaluation and

grading has been designed to reflect the goals of the course, and involves
assessment of skills and attitudes. You will receive regular feedback from
your tutor that will help you to assess your progress in this course.

The students must receive a passing grade from small group sessions and
pass the final exam at the end of each unit to be able to attend the
written exam.

Assessment of students’ competence will be based on the following

categories.

Competency Percent of grade

Portfolio 10%
History write-up 20%
OSCE 70%

6|Page
 CARDIOVASCULAR AND PERIPHERAL VASCULAR
SYSTEMS EXAMINATION

General Objectives

1. To recognize common symptoms and history taking techniques relevant to

the system.

2. To identify the surface anatomy of the great vessels and heart.

3. To reorganize the normal radiological anatomy of the Cardiovascular

system.

4. To identify the surface anatomy of the major arteries and veins. To

identify the point of palpation of the peripheral arteries, and the
visualization of the internal jugular veins.

5. To describe blood flow in the venous and arterial vasculature systems

during the phases of the cardiac cycle.

6. To identify the normal arterial pulse waveform; to describe the constituent

variables which determine the characteristics of the arterial waveform; to
identify the normal rate and rhythm of the arterial pulse; to describe
possible causes of abnormalities of rate and rhythm.

7. To demonstrate the correct technique for the evaluation of the peripheral

palpable and auscultatory blood pressure. To demonstrate the technique
for identifying pulsus paradoxus.

8. To identify the components of the normal venous pulse including the

characteristic waves and slopes of the jugular venous pulse. To describe
the appropriate physiological determinants of the normal waves and
slopes of the jugular venous pulse.

9. To identify the normal contour and describe dysmorphic contours of the

precordium. To identify the visible normal impulses of the precordium.

10. To demonstrate palpation of the position of the normal cardiac impulses.

To describe the characteristics of the normal point of maximal impulse. To
demonstrate appropriate patient positioning to help elicit clinical findings
on palpation. To identify the classic landmarks for the position of normal
cardiac impulses. To demonstrate the point of palpation for abnormal
cardiac impulses.
7|Page
11. To demonstrate the classic landmarks for cardiac auscultation. To
demonstrate the procedure for cardiac auscultation, including the
landmarks for auscultation, and proper use of the bell and diaphragm of
the stethoscope for identifying normal and abnormal cardiac sounds. To
describe the relative differences in heart sound according to area. To
describe the physiology and pathophysiology of the cardiac heart sounds.
To describe the pathophysiology of extra heart sounds.

12. To describe the pathophysiology, timing, and auditory findings of cardiac

murmurs. To provide a classification scheme to characterize heart
murmurs. To describe characteristics which may differentiate pathological
from functional murmurs.

13. To demonstrate auscultation for bruits located over peripheral arteries.

14. To demonstrate :

(a) the positioning for assessment of the jugular venous pressure.

(b) maneuvers to differentiate the carotid and jugular venous pulses.

(c) maneuvers to elicit the jugular venous pulse.

(d) additional maneuvers required for the complete assessment of the

jugular venous pressure.

15. To demonstrate :

(a) the clinical characteristics of peripheral venous insufficiency.

(ii) the clinical findings of peripheral arterial insufficiency.

16. To describe the peripheral stigmata of endovascular infection.

17. To develop a classification system for describing the limitation of

functional exertion.

8|Page
STUDENT

ACTIVITIES

9|Page
 Case Report
(to be completed by individual students)

Student Name:

I.D.: Date:
Patient Interview

 Biographical Data:

Name: Place of Birth:

Date of Birth / Age: Marital Status:

Sex: Occupation:

Ethnic Origin: Religion:

Date of History:

 Chief Complaint(s):
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________

 History of Present Illness:

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_______________________________________________________________________
_________________________________________________________________________

10 | P a g e
 Pastmedical and surgical History:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_______________________________________________________________________

 Medications :-----------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------

 Systems Review:
_________________________________________________________________________
Resp
Cardiac:
Renal:
GIT:
Locomotor:
Neurology:

 Psychosocial History:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

 Family History:
Father , mother , brothers,
sisters:-----------------------------------------------------------------------------------------------------

11 | P a g e
--------------------------------------------------------------------------------------------------------------
-------

12 | P a g e
  Pedigree:

 Physical Examination

1. General Assessment:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

2. Vital Signs:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

13 | P a g e
3. Examination of Respiratory system
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

4. Examination of Cardiovascular system

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

14 | P a g e
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

15 | P a g e
 Working diagnoses & explanation:

Select two or more hypotheses to

explain the patient’s presenting Explanation for these choices
complaints and symptoms
1.

2.

 Predisposing / risk factors (mention appropriate approach to preventive

measures, and health education)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

16 | P a g e
 Reflection on Communication Skills

You should complete this form after interviewing the patient with respiratory
disease. This form should be submitted as part of your portfolio in
communication skills.

Name:…………………………………………………. ID. No:……………

1. What did you feel went well in the interview, in term of your
communication skills?

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

2. What did you feel were your shortcomings in the interview, in terms of
your communication skills?

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

17 | P a g e
3. What changes to your communication skills are you going to make next
time you interview a patient?

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

18 | P a g e
 LEARNING
RESOURCES

19 | P a g e
Common Symptoms of Cardiac System

Cardinal Symptoms

 Chest Pain angina [character, site, duration, radiation, precipitating and

relieving factors].
 Shortness of Breath (dyspnea)
 Shortness of Breath at Night, Paroxysmal Nocturnal Dyspnea (PND).
 Palpitation (duration, precipitating & relieving factors, fast or slow).
 Syncope (relation to position, palpitation).
 Ankle swelling.


Other Relevant Correlative Symptoms of Chest Pain and Dyspnea

 Inability to lay flat

 Relation and degree to effort.
 Relation to emotion, cold weather and heavy meal.
 Relation to sexual activity.

20 | P a g e
 Functional Class of Stable Angina (Canadian Classification)

grade 1 angina on heavy, prolonged effort (walking two miles).

grade 2 angina on walking uphill, walking upstairs (2 stories) or
walking more than 100 meters on flat level.
grade 3 angina on walking few meters, less than two blocks (building)
on flat level.
Walking upstairs (one story).
grade 4 angina pain at rest.

Functional Class of Shortness of Breath, dyspnea or other heart failure related symptoms
(New York Heart Association Classification)
Patients with cardiac disease but without resulting in limitation
grade 1
of physical activity
Patients with cardiac disease resulting in slight limitation of
physical activity. They are comfortable at rest. Ordinary
grade 2
physical activity results in fatigue, palpitation, dyspnea, or
anginal pain
Patients with cardiac disease resulting in marked limitation of
physical activity. They are comfortable at rest. Less than
grade 3
ordinary activity causes fatigue, palpitation, dyspnea, or
anginal pain.
Patients with cardiac disease resulting in the inability to carry
on any physical activity without discomfort. Symptoms of heart
grade 4
failure or the anginal syndrome may be present even at rest. If
any physical activity is undertaken, discomfort is increased.

21 | P a g e
The History

 Patient’s data.
 Presenting complaint & duration.
 History of present illness.
 Past medical history.
 Surgical history.
 Drug history.
 System review.
 Family history (father, mother, brothers and sisters).
 Socio-economic history (smoking, alcohol).
 Occupational history.

General Examination
 Appearance, general look, mental status (cheerful/sad)
 Body built (under – over – moderate)
 Discomfort in bed, shortness of breath on rest, using accessory muscle.
 Face (Malar flush).
 Cyanosis (peripheral versus central).
 Eye for Xantholasma & Jaundice + pallor in palpebral conjunctiva.
 Corneal arcus (presenile – senile).
 Venous pulsations in the neck.
 Palmar and tendon Xanthomas.
 Finger for:
- Splinter haemorrhages and nicotine stains.
- Osler node.
- Clubbing.
 Ankle odema.

22 | P a g e
Arterial Pulse
Radial pulse / for - Rate – Beat per minute.
- Rhythm – (Regular or irregular).
- Pulse volume (low, high, good)
- Character: - 1 - Collapsing pulse.
- 2 - Slow rising pulse.
- 3 - Pulsus alternans.
- 4 - Paradoxical pulse.
- Equality on both sides. (Radio-radial
delay)
- Radio-femoral delay
NB

 Character and volume of pulse better demonstrated in carotid artery.

 Rigidity of wall is a common finding in elderly and it is of no clinical value.
 Radio - femoral pulse delay to be checked in patient at age less than 40
years.
 The normal range of heart rate is [ 60 – 100] Beat Per Min.

3 Conclusion: Fast, jerky, blood flow in brachial means there is

collapsing pulse, otherwise no collaps

23 | P a g e
Examination sequence of pulse
 Radial and carotid pulses

1. Place your three middle fingers over the right radial pulse.
2. Use the pads of your fingers to assess the rate, rhythm and volume.
3. Count the pulse for 15 seconds and multiply by four to obtain the
pulse rate in beats per minute (b.p.m.)
4. Now palpate simultaneously both the radial pulses, feel for
diminished volume in any side.
5. To detect a collapsing pulse.

 Ask the patient if they have shoulder pain

 Palpate the radial pulse with your hand wrapped around the wrist

 Raise the arm above the head briskly

 Feel for a tapping impulse through the muscle bulk of the arm as blood
empties from the arm very quickly in diastole, resulting in the palpable
sensation
6. Palpate both radial and femoral artery for assessment of femoral
delay pulse.
7. Palpate the carotid pulse with the patient lying on a bed or couch in
case you induce a reflex bradycardia.
8. Never compress both carotid arteries simultaneously.
9. Use your left thumb for the right carotid pulse and vice versa.
10. Place the tip of your thumb between the larynx and the anterior
border of the sterno-cleidomastoid muscle.

24 | P a g e
Blood Pressure Assessment
Rule of thumb for BP measurements:
On Blood Pressure check, attention needs to be paid to the following points:
1. Patient should be in supine position.
2. Patient’s arm to be positioned at same level of the heart.
3. Cuff size should be optimal 30-35 cm length and 12 cm width (cover 70% of
arm and to be one inch above anti-cubital fold.
4. Bladder tubes should be parallel to brachial artery.
5. Bladder deflation rate should be slow at 3 mmHg / sec.
6. With stethoscope over brachial artery, the first sound to be heard is the
systolic pressure.
7. Diastolic pressure is the level at which the sounds disappear completely
(or just muffled if sounds persist).
8. It is preferable that the blood pressure should be taken in both arms on
the first encounter.

Blood Pressure Classification in Adults according to 7th JANC

Category Systolic Diastolic
Normal <130 <80
High Normal (Pre Hypertension) 130-139 85-89
Phase I (Mild Hypertension) 140-159 90-99
Phase II (Moderate Hypertension) 160-179 100-109
Severe Hypertension 180-209 110-119
Crisis Hypertension >210 >120

25 | P a g e
Examination sequence of the blood pressure

 Rest the patient for five minutes

 In ambulant patient, measurements are normally made with the patient
seated. Either arm can be used.
 Support the patient’s arm comfortably at about heart level.
 Apply the cuff to the upper arm with the center of the bladder over the brachial
artery.
 Palpate the brachial artery.
 Inflate the cuff until the pulse is impalpable. Note the pressure on the
manometer. This is a rough estimate of the systolic pressure.
 Now inflate the cuff another 10 mmHg and listen through the stethoscope over
the brachial artery.
 Deflate the cuff slowly until regular sounds are first heard. Note the reading to
the nearest 2 mmHg. This is the systolic pressure.
 Continue to deflate the cuff slowly until the sounds disappear.
 Record the pressure at which the sound completely disappears as the
diastolic pressure. Occasionally muffled sounds persist and do not disappear,
in which case the point of the muffling is the best to the diastolic pressure.

26 | P a g e
Jugular Venous Pressure (JVP)

Jugular vein:
 JVP wave to be looked for at the internal Jugular vein (an imaginary line
between ear lobule to the point between the two heads of sterno-
cleidomastoid.
Jugular wave:
 Normal venous wave usually has two peaks, “a” for atrial contraction in
diastole and “v” Ventricular peak for venous filling in systole.
Difference of venous versus arterial pulsation:

Difference Between Jugular and Carotid Pulse

Jugular
Runs between the two heads of the
sternocleidomastoid
Double pulsation per hearbeat
Rapid inward movement
Impalpable
Obliteration of pulsation by applying
pressure at the root of the neck
Height varies with change of patient
position
Height is reduced by inspiration,
more prominent on expiration
Becomes more prominent with
hepato-jugular reflux
Carotid
Runs deeper and more medial to
sternocleidomastoid
One pulsation per heartbeat
Rapid outward movement
Palpable
Pulsation unaffected by pressure at
the root of the neck
Height independent of change in
position
Unchanged by respiratory cycle
Unchanged by hepato-jugular reflux

N.B

External Jugular vein should not be assessed for JV pressure as venous

wave does not reflect the right atrial pressure

27 | P a g e
 Measurement of the jugular venous pressure:

Estimate the vertical height of venous pulse wave above the sternal notch in
cm, and then add 5 cm (as the sternal notch is 5 cm above the right atrium
while the patient is laying at a 45 degree angle.) The central venous
pressure measured in cm/H2O.
Examination sequence of JVP

 Position the patient reclining supine at 45° in good light.

 Ensure that the neck muscles are relaxed by resting the back of the head
on a pillow and instructing the patient to turn his head to the left..
 Look across the neck from the right side of the patient.
 Identify the internal jugular pulsations (if necessary use the abdomino-
jugular reflux).
 Estimate the vertical height in centimeters between the top of the venous
pulsation and the sternal angle to give the venous pressure.
 If necessary, readjust the position of the patient until the waveform is
clearly visible.
 Identify the timing and form of the pulsation and note any abnormality.

28 | P a g e
The Precordium
Inspect precordium for:
- Dilated veins.
- Scar.
- Pulsation (at apex, Right and Left 2nd intercostal space and sternal
notch).
- Any bone deformity.

Palpate for:
- para sternal heave.
- palpable sounds (II sound).
- Systolic thrill over Aortic and Mitral area.
- Palpate apex beat for (position and character).
Examination sequence of precordium

 Inspect the precordium with the patient sitting at 45° angle with shoulders
horizontal. Look for surgical scars, visible pulsations and chest deformity.
 Lay your whole hand flat over the precordium to obtain a general
impression of cardiac activity.
 Locate the apex beat by laying your fingers on the chest parallel to the rib
spaces; if you cannot feel it, ask the patient to roll onto the left side (this
will displace apex by 0.5 – 1 cm. lateral)
 Assess the character of the apex beat and its position:
(thrusting, forceful, heave, and tapping).
 Feel for the right ventricle using the heel of your hand applied firmly to the
left parasternal position. Ask the patient to hold his breath in expiration.
 Palpate for thrills at the apex and both sides of the sternum.
 Absent apex beat may indicate:
( dextrocardia, obesity, emphysema, or behind the rib).

29 | P a g e
Listening to the Heart Sounds (Auscultation)

Key points for auscultation:

 Use the diaphragm of stethoscope for high pitch sounds and the bell for low
pitch sounds.
 Be aware of the four clinical auscultation areas for the four anatomical
valves and the radiation areas of each.

 On auscultation you have to identify:

- First and second heart sounds (and splitting of 2nd sound)
- Extra sounds (third and fourth sounds).
- Any added sounds such as ejection click or opening snap.
- Pericardial friction rub.
- Any murmur (systole or diastole).
NB

Time systole by palpating the pulse wave in the carotid artery (systolic
murmur coincides with the palpable pulse in carotid artery).

30 | P a g e
On assessing murmur comment on the following:

1. Timing (systole or diastole) using the carotid pulse.

2. Timing on (early, mid or late) systole or diastole.
3. Character of murmur, pitch (low or high), and character (blowing, harsh,
rumbling, whistling).
4. Volume or (amplitude) of murmur, loud or soft.
5. Relation to expiration and inspiration. Murmurs originating in right side of
the heart accentuate on inspiration (e.g. tricuspid regurgitation). The left
side murmurs accentuate on expiration (e.g. murmur of aortic regurgitation).
6. Relation to position (leaning forward for murmur of aortic regurgitation and
to the left lateral position for the murmur of mitral stenosis.
7. Maximum intensity of murmur and radiation.

Interpretation of Murmurs:

Murmurs and Extra Sounds

Systolic Click
Systolic Ejection Pansystolic Late Systolic

Innocent/Physiologic Mitral/Tricusp Regurgitation Mitral Valve Prolapse

Aortic/Pulmonic Stenosis    

Opening Snap
Early Diastolic Mid Diastolic Diastolic Rumble

Aortic Regurgitation Mitral/Tricusp Stenosis Mitral Stenosis

Murmur Grades
Grade Volume Thrill
1/6 very faint, only heard with optimal conditions no
2/6 loud enough to be obvious no
3/6 louder than grade 2 no
4/6 louder than grade 3 yes31 | P a g e
5/6 heard with the stethoscope partially off the chest yes
6/6 heard with the stethoscope completely off the yes
chest
  Explain that you wish to examine the chest and ask the patient to remove his
clothing above the waist.
 With the patient lying at approximately 45° to the horizontal, listen to the heart
with the diaphragm side of a stethoscope using a “Z” pattern over the chest.
First at the right second intercostal space close to the sternum, along the left
sternal border in each intercostal space from the second through the fifth,
and finishing at the apex(mitral area).
 It is also permissible to start from the apex and follow the pattern in reverse.
 Follow the same pattern and listen using the bell side of the stethoscope.
 Make sure to note the timing of the murmurs in relation to the cardiac cycle
using the carotid pulse
 Listen for the first heart sounds over the mitral and tricuspid areas and for the
second heart sounds (intensity and splitting) over the pulmonary and aortic
areas
 At each site identify the first and second heart sounds and assess their
intensity; note any splitting of the second heart sound.
 Concentrate in turn on systole (the interval between S1 and S2). Listen for
added sounds
Examination and then for
sequence ofmurmurs.
heart auscultation:
 Roll the patient on to the left side. Listen at the apex using light pressure with
the bell, to detect the mid-diastolic and presystolic murmurs of mitral
stenosis.
 Sit the patient up and forwards, and ask the patient to breathe out fully and
then hold his breath.
 Listen over the right second intercostal space and over the left sternal edge
with the diaphragm for the murmur of aortic incompetence.
 Note the character and intensity of any murmur heard.
 A murmur should be described by where it is (location and radiation),
when it occurs (timing in the cardiac cycle using the carotid), how it
sounds (intensity grade 1-6, pitch, quality, shape) and things which 32 | P a g e
alter it (respiration, exercise, hand grip, squatting, valsalva, etc).
 Clinical Approach for Cardiac Systolic Murmurs

Clinical diagnosis Character Special Features

- Left Ventricle Hypertrophy
(Mid) Aortic Stenosis Musical, - Radiate to right neck
Ejection Harsh, - Slow rising pulse
Systolic or Blowing - 2nd sound faint or not
crescendo / Rasping audible
decrescendo Pulmonary Stenosis Blowing - Radiate to left neck

33 | P a g e
 - Left Ventricle Hypertrophy
Mitral Regurgitation Harsh - Radiate to axilla
Pan Systolic - Third heart sound
- Accentuates on inspiration
Tricuspid Reg. Harsh - Localized to low sternal
- Thrill, Biventricular
Ventricular Septal Blowing Hypertrophy
Defect (VSD) - Localized to left 3rd inter
costal space
Mitral valve prolapse Blowing - Mid systolic click
Late Hypertrophic
Systolic Cardiomyopathy Blowing - Double apex beat
- Severe anaemia
- Fever
Ejection - Pregnancy Soft - Mostly at apex
Murmur - Atrial Septal defect Blowing
- Severe aortic
regurgitation
- No radiation
Benign Functional Soft - No Thrill
(innocent) - Not diastolic
- Vary with position
- Vary with stethoscope pressure
- No sign of heart disease

Clinical Approach for Diastolic Murmurs

3-Character
Site at Left 3rd
1-Timing 2-Clinical Diagnosis 4-Special Features
I/C space

Soft - Collapsing pulse.

Aortic Regurgitation
Blowing - Intensity at end of
Early (high pitch)
expiration while
leaning forward

34 | P a g e
 Pulmonary regurgitation - The murmur
Soft
due to dilation of accentuates on
Blowing
pulmonary artery in expiration
pulmonary Hypertension

Soft
Atrial Septal Defect - S11 with fixed splitting
Blowing

- Opening Snap
- Low pitch - Loud first sound
- Localized to apex - Accentuates at left
Mid Mitral Stenosis - Rumbling Murmur lateral position
- Accentuates on expiration

- Combined aortic Machinery or continuous

stenosis & regurgitation Localized at the murmur
- Mixed aortic and 2 I/C space
nd

Mitral Valve Disease

(Systolic &
- Patient ductus
Diastolic) Localized at the Machinery
arteriosus rd
3 left ICC space

- Combined Mitral valve

apex Machinery
disease

Clinical Drill I
Examine this patient with sudden onset of central chest pain:
- Feel pulse for tachy or bradycardia (Ischaemia)
- Palpate for equality of pulses (aortic dissection)
- Pulsus paradoxus in pericardial tamponade.
- Check BP in both hands (aortic dissection).
- Look for JVP in heart failure or pulmonary embolism or pericardial
tamponade.
- Palpate apex beat for mediastinal shift (pneumothorax).
- Palpate the epigastrium for epigastric tenderness and pulsation (of abdominal
aorta).
35 | P a g e
- Auscultate for S3 gallop (heart failure)
- Systolic murmur at apex (Ischaemia).
- Pericardial Rub in (pericarditis).
Clinical Drill II
Examine this patient who had sudden loss of consciousness:
- Assess the level of consciousness (response to verbal
commands and eye opening).
- Inspect for cyanosis or pallor (consider post epilepsy cyanosis,
and pallor in fainting).
- Feel the pulse for bradycardia (stokes Adam’s attack),
tachycardia and irregularity e.g. sudden onset of atrial fibrillation.
- Measure the blood pressure for Hypotension (septicaemia,
acute myocardial infarction) (S.B.P. > 90mmHg).
- Check blood pressure at erect (sitting) and supine position for
postural
Clinical Drill II -fallcontinued
of S.B.P. > 20mmHg.
- Check temperature, raised in Meningitis and subarachnoid
haemorrhage.
- Listen to structural heart disease (valve disease, ventricular
septal defect post myocardial infarction, cardiac tamponade).
- Listen to carotid bruits (embolic CVA).
- Examine for focal neurological signs (post epileptic).
Peripheral Vascular Disease

A) Arterial Disease
 Common Symptoms:
 Limb Symptoms:
Stage I - asymptomatic ischaemia but ankle to brachial
systolic pressure ratio or index < 0.8.

36 | P a g e
 Stage II – Intermittent claudication (pain at calf, thigh or
buttock on walking constant distance.
Stage III – pain at rest.
Stage IV – tissue loss (ulcer and gangrene).
 History:
 Can you walk without leg pain?
 Can you do your own shopping?
 How much you can walk without pain?
 Physical Examination of (lower limbs):
 Look for:
- Hair loss
- Scar
- Temperature
- Pallor
- Cyanosis
- Swelling
- Pigmentation
- Ulcer (margin, floor, color, depth)
 Palpate both 1- femoral artery in both legs
2- popliteal artery in both legs
3- posterior tibial artery in both legs
4- dorsalis pedis artery in both legs
 Record pulse in both legs as follows:

artery R L
normal + Femoral + +
reduced + Popliteal + +
absent - Posterior tibial + +
aneurysmal ++ Dorsalis - -
pedis

37 | P a g e
Buerger’s test for leg ischemia:
With patient supine, raise the leg at 45° for 2-3 min, then ask patient to sit
up and observe for pallor on elevation followed by Hyperemia on standing
indicates peripheral arterial disease. The angle at which the affected leg
becomes pale is called Buergers angle. Normal return of color occurs
immediately. A delay in return of color followed by reactive hyperemia is
indicative of peripheral arterial insufficiency.

Allen test:

For patency of deep and superficial blood supply in hand.

 Elevate the hand to drain all blood.
 Compress both radial and ulnar arteries.
 Lower the hand and release the ulnar artery.
 Watch for return of colour to the hand.
 If this does not occur, there is no connection between the deep and
emoral pulse
superficial palm of arches.

38 | P a g e
 Femoral Pulse:
 With the patient supine, firmly press down and towards the patient’s head in
the middle of groin crease using two or three extended fingers. It can be
difficult to feel in the obese.
 Listen for bruits using the diaphragm of your stethoscope.
 Check for radio-femoral delay.
Popliteal pulse
 Patients should lie on a firm comfortable surface so they can relax their
muscles.
 Flex the patient’s knee to 30°.
 With your thumbs in front of the knee and your fingers behind, press firmly
in the midline over the popliteal artery. It is sometimes difficult to feel.
 By sliding your fingers 2-3 cm below the knee crease it may be possible to
compress the artery against the back of the tibia as it passes under the
soleal arch making it easier to feel.
 If the popliteal artery is especially easy to feel, consider the possibility of an
aneurysm and request an ultrasound scan.
Posterior tibial pulse
 Feel 2 cm below and 2 cm behind the medial malleolus, using the pads of
your index and middle fingers.
39 | P a g e
 Dorsalis pedis pulse
 Feel in the middle of the dorsum of the foot just lateral to the tendon of
extensor hallucis longus.
Examination Sequence
 Start at the head of the patient and work down the body using the
sequence and principles of inspection, palpation and auscultation for each
area.
The arms
 Examine the radial, brachial and carotid pulses.
 Measure the blood pressure in both arms. Many patients with peripheral
arterial disease have asymptomatic subclavian artery disease. A difference
of up to 10 mmHg in systolic pressure between the two arms is normal. If
the discrepancy is greater than this, then the higher value is the true central
pressure.
The abdomen
 Look for obvious pulsations.
 Palpate and listen over the abdominal aorta. If the aorta is easily palpable,
consider the possibility of an abdominal aortic aneurysm, which is present in
5% of men > 65 years.

The legs
 Inspect the legs and feet for changes of ischaemia including temperature
and color changes.
 Look for scars from previous vascular or non-vascular surgery and the
position, margin, depth and color of any ulceration.
 Specifically look between the toes and at the heels for ischaemic changes.
Raynaud’s phenomenon:

o Is digital ischaemia induced by cold weather or embolism

has three phases:
- Pallor due to digital artery spasm.
- Cyanosis due to static venous blood.
40 | P a g e
- Redness due to reactive Hyperaemia
Drill Number 3
Examine this patient with acute pain and discoloration of his right
foot?

 Feel radial pulse e.g. Atrial Fibrillation

 Measure blood pressure in both arms – unequal in aortic dissection.
 Listen to the heart: early diastolic murmur may indicate aortic dissection.
 Feel the abdomen for aortic aneurysm.
 Auscultate the abdomen for bruit of aortic dissection.
 Look for feet discoloration (Mottling suggest acute ischaemia).
 Palpate femoral and popliteal arterial for aneurysm.
 Squeeze the calves for tenderness of muscle infarction.
 Compare warmth of both feet and compare with hand.
 Palpate dorsalis pedis and posterior tibial pulses in both feet.
 Ask patient to wiggle (twist) his toes and test for fine touch sensation.

Venous Disease

Venous disease is more common in the legs than the arms.

 Clinical presentation may be:
A- deep venous thrombosis.
B- Varicose veins.
C- Superficial thrombosis.
D- Chronic venous insufficiency and ulceration.
 Common symptoms of venous disease:
- Pain.
- Swelling.
- Discoloration.

41 | P a g e
 - Ulceration.

Features of Deep Venous Thrombosis of the lower limb

Clinical Feature Non Occlusive Occlusive Thrombosis

Pain Absent Present

Tenderness Absent Present

Swelling Absent Present

Temperature Normal Increase

Superficial Vein Normal Distended

Pulmonary Embolism High Risk Low Risk

Examination Sequence of Venous System

 Examine the legs with the patient standing and then lying supine.
 Expose the patient’s limbs and inspect the skin for colour changes, limb
swelling and superficial venous dilation and tortuosity.
 Feel for any differences in temperature.
 Elevate the limb about 15° above the horizontal and note the rate of venous
emptying.
 If appropriate, perform the Trendelenburg test to detect saphenofemoral
junction incompetence.
Trendelenburg Test (assess competence of saphenofemoral junction)
 Ask patient to sit on the edge of examination couch.
 Elevate the limb as far as comfortable for the patient.
42 | P a g e
  Empty the superficial veins by (milking the leg).
 With the leg elevated press with your thumb over saphenofemoral junction
(2-3 cm below and 2-3 cm lateral to pubic tubercle) or use a high tourniquet.
 Ask patient to stand and maintain pressure over saphenofemoral junction.
 If incompetence is present at junction the varicose vein will not fill until the
pressure is removed.

Clinical Features of Acute Limb Ischaemia

 Pallor
 Pain on squeezing muscles
 Paraesthesia
 Paralysis
 Perishing cold

Signs suggesting vascular disease

Sign Implication
Hand/arms - tobacco stain - Smoking
- purple discoloration of finger tips - Embolism
- pits and healed scars in finger pulp - Raynaud’s Syndrome

43 | P a g e
 - calcinosis and fold capillary loss - Scleroderma
- wasting of small muscles of - Thoracic outlet syndrome
hand
Face & Neck - Corneal arcus - Hyperlipidemia
- Xantholesma - Hyperlipidemia
- Horner Syndrome - Mass in left apex of lung
- Hoarseness of voice - Laryngeal nerve palsy
- Bovine cough - Laryngeal nerve palsy
- Prominent veins in the neck & - Subclavian vein
shoulder occlusion
Abdomen - Epigastric pulsations - Aortic aneurysm

- Mottling of the abdominal skin - Rupture abdominal

aortic aneurysm
- evidence of weight loss - Visceral ischeamia

44 | P a g e