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COMMONLY ASKED QUESTIONS:

➢ Examine the CVS.
➢ Examine the precordium.
➢ Auscultate here - (examiner may point a particular
part.)
➢ Palpate the pulse. What are your findings? (There may
be no pulse or irregular, small- or high-volume pulse,
bradycardia, tachycardia and pulse delay.)
➢ Palpate the pulse and auscultate the precordium.
Describe your findings. [There may be low-volume,
slow-rising pulse. On auscultation, ejection systolic
murmur (ESM) may be present due to aortic stenosis
(AS).]

 COMMONLY ASKED QUESTIONS:

➢Palpate the precordium. What are your findings? (There
may be tapping or shifting of the apex beat, heaving or
thrusting in nature, thrill, palpable p2, left parasternal
lift.)

➢What are the diseases that can be diagnosed by

palpation?

➢Auscultate the precordium. What are your findings?

(Present systematically, starting from the heart sounds,
murmur and any extra finding.)

COMMONLY ASKED DISEASES ARE MOST LIKELY:

▪Mitral stenosis [(MS) pure].
▪Mitral regurgitation (MR).
▪MS with pulmonary hypertension (PH).
▪MS with MR (mixed mitral valve disease).
▪As or aortic regurgitation (AR).
▪As with AR (mixed aortic valve disease).
▪Congenial heart disease [ASD,VSD,PDA and
dextrocardia].

 EXAMINATION ROUTINE:
Proceed as follows:
1. Look at the patient carefully.
➢Dyspnoeic or orthopnoeic (LVF), cachexia (in severe
heart failure).
2. Face:
➢Malar flush (in MS).
➢Marfanoid face.
➢Corneal arcus and xanthelasma related to
atherosclerosis in IHD, Argyll Robertson Pupil (related to
AR), mouth (high arch palate in Marfan Syndrome).

 EXAMINATION ROUTINE:
1. Anemia
2. Cyanosis (TOF) and Eisenmenger Syndrome].
3. Edema (leg and sacrum in CCF).
4. In hands:
➢ Clubbing.
➢ Koilonychia.
➢ Cyanosis.
➢ Splinter hemorrhage.
➢ Osler node (red, raised, palpable, tender nodule on the pulp of
finger or toes; also, in thenar or hypothenar area).
➢ Janeway lesion (nontender, red, maculopapular lesion on palm or
pulp finger).
➢ Xanthoma: Palmar or tendon (atherosclerosis in IHD).
➢ Tobacco stain (smoker, IHD).

 PERIPHERAL ARTERIAL EXAMINATION LINK

https://youtu.be/i4mv8LJQPNo

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 EXAMINATION OF PULSE
The usual instructions are:
– Examine the pulse.
– Examine the pulse and relevant.
– Examine the pulse and auscultate the heart.
Usually any of the following findings will be present:
– Irregular pulse (AF and ectopics).
– High-volume pulse or Water Hammer Pulse.
– Bradycardia (complete heart block).
– Unequal radial pulse.
– Absent pulse.
– Radiofemoral delay and radio radial delay or inequality.

 CAUSES OF ABSENT RADIAL PULSE

▪Anatomical aberration.
▪Blockage by embolism or narrowing.
▪Takayasu syndrome.
▪Iatrogenic (Blalock Taussig shunt in TOF and AV fistula
for hemodialysis).
▪Dissecting aneurysm.
▪Coarctation or aorta (before the origin of left subclavian
artery). Brachial artery catheter with poor technique or
tied during surgery.

 PULSE:
1) Rate.
2) Rhythm.
3) Volume (must see collapsing pulse).
4) Character.
5) Condition of the vessel wall.
6) Radio-femoral delay and radio-radial
delay or inequality.

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IMPORTANT DISCUSSIONS: PULSE-

1. RATE:

➢Tachycardia: When the pulse rate is >100/min.

➢Bradycardia: When the pulse rate is <60/min.
CAUSES OF TACHYCARDIA:
1) Sinus tachycardia due to any cause.
2) Supraventricular tachycardia.
3) Atrial fibrillation (AF) and atrial flutter.
4) Ventricular tachycardia.

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 CAUSES OF SINUS TACHYCARDIA:

1. PHYSIOLOGICAL (Anxiety, Emotion, Exercise And
Pregnancy).
2. PATHOLOGICAL:
i. Hyperdynamic Circulation [Fever, Anemia, Thyrotoxicosis,
Arteriovenous Fistula And Beriberi].
ii. CCF.
iii. Myocarditis.
iv. Chronic Constrictive Pericarditis.
v. Shock (Except Vasovagal Attack).
vi. Acute Anterior MI (Except Inferior MI).
vii. Sick Sinus Syndrome.
viii. Pulmonary Embolism.
ix. Drugs (Salbutamol, Atropine And Other Sympathomimetics).

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 CAUSES OF BRADYCARDIA:
1) Sinus bradycardia due to any cause.
2) Second-degree heart block.
3) Complete heart block.
4) Nodal rhythm.
CAUSES OF SINUS BRADYCARDIA:
i. Physiological (due to increased vagal tone):
Athlet, during sleep.
ii. Pathological:
▪Acute inferior MI.
▪Myxedema/ Hypothyroidism.

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SINUS BRADYCARDIA: CONT.

▪Hypothermia. Raised Intracranial Tension (Due to

inhibitory effect on sympathetic outflow).
▪ Obstructive Jaundice (Due to deposition of bilirubin in
conducting system).
▪Drugs (Digoxin, Beta-blockers, Amiodarone And
Verapamil).

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2. RHYTHM:
A. Regularly irregular:
i. Sinus arrhythmia (pulse rate increases on
each inspiration, decreases on each
expiration). It is abolished by exercise.
ii. Occasional ectopics. Second-degree heart
block (Mobitz Type 1, Wenckebach Type).

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RHYTHM: CONT.
B. IRREGULARLY IRREGULAR (irregular in
rhythm and volume):
i. Atrial fibrillation.
ii. Multiple ectopics.
iii. Atrial flutter with variable block.
iv. Paroxysmal atrial tachycardia with
variable block.

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 3. VOLUME OF PULSE:
A. CAUSES OF HIGH-VOLUME PULSE:
i. AR.
ii. Hyperdynamic circulation due to any cause.
iii. PDA.
iv. Hypertension.
B. CAUSES OF LOW-VOLUME PULSE:
i. Shock.
ii. AS.
iii. MS.
iv. Chronic constrictive pericarditis.
v. Pericardial effusion.
vi. PH.

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 4. CHARACTER OF PULSE:

▪ Anacrotic pulse: Slow-raising, small-volume

pulse (AS).

▪ Bisferiens pulse: Double peak of pulse, which

is felt better in carotid (AS & AR).

▪ Water hammer pulse(AR).

▪ Pulsus alternans: (LVF).
▪ Jerky pulse is seen in carotid artery (HCM).

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CHARACTER OF PULSE CONT:

VI. PULSUS PARADOXUS: When volume of pulse reduces on
inspiration and increases on expiration, it is called
pulsus paradoxus (also systolic BP falls during
inspiration, normally <10 mm Hg). It is the exaggeration
of normal phenomenon (normally present in children).
Abnormal, if >10 mm Hg.
CAUSES OF PULSUS PARADOXUS:
– Pericardial Effusion (Cardiac Tamponade).
– Chronic Constrictive Pericarditis.
– Acute Severe Asthma And COPD.
– Massive Pulmonary Embolism.

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 CHARACTER OF PULSE: CONT

VII. COLLAPSING PULSE: There is a rapid
upstroke and descent of pulse, seen by
raising the arm above the head.
Causes:
a) AR (the commonest cause).
b) Hyperdynamic circulation due any cause.
c) PDA.
d) Rupture Of Sinus Of Valsalva. Large
Arteriovenous Communication.

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 CAUSES OF UNEQUAL RADIAL PULSE (Radio-

radial delay):
➢Atherosclerosis (usually elderly).
➢Congenital anomaly or aberrant radial artery.
Coarctation or aorta (before the origin of left subclavian
artery).
➢Dissecting aneurysm.
➢Takayasu Disease.
➢Occlusion of subclavian artery (by ribs and neoplasm).
➢Aneurysm of aortic arch.
➢Iatrogenic (Blalock-Taussig shunt in TOF).

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 JVP:
JUGULAR VENOUS PULSE OR
JUGULAR VENOUS
PRESSURE

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DEFINITION OF JVP:

The jugular venous pressure (JVP) reflects

pressure in the right atrium (central venous
pressure); the venous pressure is estimated
to be the vertical distance between the top
of the blood column (highest point of
oscillation) and the right atrium.

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R L

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THE DIFFERENCES BETWEEN VENOUS OR ARTERIAL
PULSE IN NECK.
VENOUS ARTERIAL
1. IT IS WAVY (TWO PEAKS WITH CARDIAC NOT WAVY
CYCLE)
2. IT HAS AN UPPER LIMIT NO DEFINITE UPPER LIMIT

3. UPPER LIMIT FALLS WITH INSPIRATION NOT SO

4. VARIES WITH POSTURE INDEPENDENT OF POSTURE

5. IT IS BETTER SEEN THAN PALPATION IT IS BETTER FELT THAN SEEN

6. UPPER LIMIT IS INCREASES BY PRESSING THE NOT SO

ABDOMEN (HEPATOJUGULAR REFLEX)
7.JUST FELT OR LIGHTLY FELT THRUSTING

8.IT IS OBLITERATED BY LIGHT PRESSURE AT CANNOT BE OBLITERATED

THE ROOT OF THE NECK AND THEN FILLED
FROM ABOVE

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 CAUSES OF RAISED JVP:
1) CCF (Right heart failure).
2) Pericardial effusion.
3) Chronic constrictive pericarditis.
4) Fluid overload - e.g., renal disease.
5) Pulmonary embolism.
6) Pulmonary hypertension
7) TR and PS.
8) SVC obstruction (nonpulsatile).
9) Others: Occasionally in pregnancy, exercise,
anxiety and anemia.

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 PROMINENT ‘A’ WAVE:

• PH.
• Pulmonary Embolism.
• TR and TS.
• PS.
GIANT ‘A’ WAVE:
Atria contracts against closed TV
• Complete Heart Block(‘a’ wave is intermittent).
• Junctional Rhythm (regular cannon wave).
• Ventricular Tachycardia (‘a’ wave is intermittent)

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 JVP: CONT.
GIANT ‘V’ WAVE:
Tall, sinuous, oscillating up to ear lobule.
Example: TR.
GIANT X DESCENT:
Chronic constrictive pericarditis and Cardiac
tamponade.
SLOW Y DESCENT:
TS.

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 KUSSMAUL SIGN:
It means raised JVP during inspiration due to
reduction of right ventricular output. It is best seen
with the patient at 90 degree with normal
breathing (normally, JVP falls during inspiration).
Causes:
– Pericardial effusion (usually, cardiac tamponade).
– Chronic constrictive pericarditis.
– Right ventricular infarction.

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 CVS EXAMINATION LINK

https://youtu.be/XU_xeUMJ3Zc

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 PRECORDIUM EXAMINATION:
INSPECTION:
❖Deformity of chest (kyphosis, scoliosis, lordosis, pectus
excavatum or carinatum).

❖Visible cardiac impulse (visible apex beat).

❖Other impulses (epigastric, suprasternal or any other
impulse).

❖Scar mark in the midline (valve replacement/ CABG/

valvotomy in MS).

❖Pacemaker or ICD.

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 ❖CAUSES OF EPIGASTRIC PULSATION:

➢Normally palpable (lean and thin person).
➢RVH.
➢Aneurysm of abdominal aorta (expansile pulsation).
➢Mass overlying aorta (carcinoma of stomach).
➢Pulsatile liver (in TR).
❖SUPRASTERNAL PULSE:
➢Aneurysm of aorta and atherosclerosis.
❖PULSATION AROUND SCAPULA:
➢Coarctation of aorta (due to anastomotic vessels).

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 PALPATION:
1. APEX BEAT:
▪ Site (localize the intercostal space. Do not forget
Dextrocardia).
▪ Distance from midline.
▪ Nature (normal, tapping, heaving, thrusting and
diffuse).
2. THRILL:
▪ Site (apical or basal or other intercostal space).
▪ Nature (systolic or diastolic): Feel carotid pulse at the
same time. If coincides with carotid pulse, it is systolic
and if it does not coincide (comes after or before), it is
diastolic.

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 PALPATION:1. APEX BEAT

❖HEAVING:
Forceful, sustained, lifting the examining finger (pressure
overloaded). Example: LVH and AS.
❖THRUSTING:
Forceful, less sustained, lifting the examining finger
(volume overloaded).
• Example: left ventricular dilatation (MR & AR).
❖TAPPING APEX:
Neither sustained nor forceful, not lifting the finger. It is
the palpable first heart sound. Example: MS (rarely TS).

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 ❖ DOUBLE APEX BEAT:

▪ Ventricular aneurysm.
▪ HCM.
❖ CAUSES OF IMPALPABLE APEX BEAT:
▪ Thick chest wall (obesity).
▪ If the apex is behind the rib.
▪ Emphysema.
▪ Pericardial effusion.
▪ Dextrocardia (apex is on the right side).
❖ CAUSES OF DIFFUSE APEX BEAT:
▪ Anterior MI
▪ Left ventricular aneurysm.

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 3. LEFT PARASTERNAL HEAVE:

Place the flat of right palm in left parasternal and
feel by giving gentle sustained pressure (RVH).
4. Palpable P2 (if present, indicates PH).
5. Epigastric pulsation.

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 2. LEFT PARASTERNAL HEAVE:

❖ CAUSE:
▪RVH
➢PH,
➢COR PULMONALE,
➢PS AND PR &
➢TR.

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 PURCUSSION:
Usually not done; may be helpful to diagnose pericardial
effusion (area of cardiac dullness is increased) and
emphysema (cardiac dullness is oblitered).

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 AUSCULTATION:
1. See first and second heart sounds in all areas. At the same
time, palpate right carotid pulse simultaneously with
thumb. First heart sound coincides with carotid pulse, the
second sound does not (comes after).
2. Murmur:
– Site (apical, parasternal, aortic or pulmonary area).
– Nature: Systolic (pansystolic or ejection systolic), diastolic (mid-
diastolic or early diastolic) by feeling carotid pulse at the same
time (systolic coincides with carotid pulse, and diastolic does not
coincide).
– Radiation (PSM to left axilla and ESM to neck).
– Relation with respiration (right sided murmur increases on
inspiration and left sided murmur increases on expiration).
– Grading of murmur (2/6 or 4/6).

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AUSCULTATION: CONT.

3. Added sounds (pericardial rub and opening snap).

4. Auscultate the back of chest for crepitations
(pulmonary edema).
5. Ask for permission to palpate the liver (enlarged
tender liver in CCF, pulsatile liver in TR) and spleen
(splenomegaly in SBE).

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 HEART SOUNDS:
1. FIRST HEART SOUND:
– Loud in MS, TS (occasionally in anxiety & exercise).
– Soft or absent in MR, myocarditis and cardiomyopathy.
2. SECOND HEART SOUND: Splitting is better heard in
pulmonary area, in inspiration due to prolonged
right ventricular systole.
CAUSES OF WIDE SPLITTING OF SECOND SOUND:
– PS.
– RBBB.
– ASD.
– Wide and fixed splitting: ASD.

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 REVERSE SPLITTING OF S2 (A2 IS DELAYED):

– Left Bundle Branch Block (LBBB).
– AS.
– HYPERTENSION.
LOUD SECOND HEART SOUND:
– Systemic hypertension.
– PH.
SOFT SECOND SOUND:
– Calcified or severe AS.
– Severe PS.
– AR.

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 3. THIRD HEART SOUND:

Low-pitched, distant sound due to ventricular filling,
and comes after second sound. It is better heard at
the apex with bell of stethoscope. Example:
– Physiological: In young, in athlete, during pregnancy
and in fever.

– Pathological: LVF, MR, Anemia, Cardiomyopathy, AR,

Chronic constrictive pericarditis. (Third sound is called
pericardial knock).

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 4. FOURTH HEART SOUND:

Low-pitched sound due to atrial contraction,
precedes first heart sound, better heard at the apex.
Causes: Ventricular failure and ventricular
hypertrophy
▪ Due to left heart: Hypertension, AS, IHD and HCM.
▪ Due to right heart: PS and PH.
TRIPLE RHYTHM:
First and second heart sounds, with either third or
fourth, it is called triple rhythm.
GALLOP RHYTHM
Triple rhythm is associated with tachycardia (>100)
-Gallop rhythm. It is called ‘Gallop’ as the cadence of
sound resembles a galloping horse.

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54
 MURMUR:
❖SYSTOLIC.
❖DIASTOLIC.
❖CONTINUOUS.
SYSTOLIC MURMUR
1. Pansystolic murmur:
➢MR.
➢TR.
➢VSD.
➢AORTOPULMONARY SHUNT.

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 2. Ejection systolic murmur (harsh and high pitched):

• AS.
• PS.
• HCM.
• ASD (due to increased flow through pulmonary valve).

3. Late systolic:
MVP and Papillary muscle dysfunction.

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 DIASTOLIC MURMUR:
1. EDM (Early diastolic murmur) (soft, high pitched,
blowing): Causes:
➢AR.
➢PR (Graham Steell murmur in left second, third, and
fourth space).
2. MDM (Mid diastolic murmur):
➢MS.
➢TS.
➢Left Atrial Myxoma.
➢Austin Flint Murmur in AR.
➢Carey Coombs Murmur (Due To Mitral Valvulitis In
Acute Rheumatic Fever, RF).
➢ASD (Due To Increased Flow Through Tricuspid Valve).

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 CONTINUOUS MURMUR:
➢PDA.
➢AV fistula (coronary, pulmonary or systemic).
➢Aortopulmonary fistula (congenial/B-T shunt).
➢Venous hum.
➢Rupture of Sinus of Valsalva to right ventricle or
atrium.

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 GRADING OF MURMUR:

– Grade 1/6: Very soft murmur, just audible.

– Grade 2/6: Soft.
– Grade 3/6: Moderately loud.
– Grade 4/6: Loud (thrill present).
– Grade 5/6: Very loud (thrill present).
– Grade 6/6: Very much loud, heard without
placing the stethoscope over the chest (thrill
present).
Thrill is present in grades 4-6.

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