Pearls of

Cardiovascular
Examination

Kanchit
Likittanasombat
Ramathibodi Hospital
 The Essence of
Physical Examination

• ฝึ กฝนทักษะ
• อย่ าฉาบฉวย
• นิ่มนวล
• มีสมาธิ
• ช่ างสังเกต
• บรรยากาศเหมาะสม
 Hypertension
is not just
a measurement of BP !!
Correct patient positioning for BP measurement
(After adequate rest)

1. Back supported
2. Legs uncrossed with
feet flat on the floor
or supported with a stool
3. Arm supported with the
BP cuff at heart level
4. No one should be talking
during the measurement
 Physical Assessment of
Hypertensive patients
• BW/ Ht & BMI
• Waist circumference
• Facial appearance
– Cushing
– Acromegaly
•PAD
• Signs of dyslipidemia oars
•Takayasu
takanodisease disease
• Equality of pulses
• Measure BP both arms •Coarctation
coracention
ofaorta
of aorta
• Radiofemoral delay •Coarctation
aortaof aorta
corarantonof
• Fundal exam
 Physical exam in HTN patients

• Neck bruit Atherosclerosis

nanooraeosis

• Apical heave Hypertensive

manas HD
Hypertensive
• S4 gallop
• Left infraclavicular murmur ofnon
coractation
Coarctation a
Aorta
• Abdominal bruit Renal artery stenosis
stenosis
renalarray
• Bimanual palpitation PKD
APKD
• Pedal pulse parTn
PAD, Takayasu
Kayan
• Pedal edema Fluidretention
aura retention,
CKDCKD
 Female 50, with HTN
• BP 166/96 Rt arm, 172/98 Lt arm
• Pulse : Upper limbs 1+, Lower limbs 1+
• Bruit + : both carotid artery Rt >Lt & at the
back along whole spine & abdomen
• Apical heave +
• S4 gallop
DXtakaynov'sds
 Female 50, with HTN
“Takayasu’s disease”

banian
arrey
aorta
deaending

Anterior Posterior
 Female 40 with HTN
• BP 178/88 Rt arm, 182/86 Lt arm
• Apical heave +
• Lt infraclavicular murmur 2/6
• Bruit + at the back along the spine

• What is the other very important physical

sign ?
femoral
Radio
Awe delay
cradomeneuriouremonieuwe
 Female 40 with HTN
Radio-femoral delay in Coarctation of Aorta
 Physical Exam in Pts with HTN

Assessment for………..

- Level of BP

- Target organ damage

of
atherosclerosis

- Associated risk factors

 Male 50, Obese, with
1st diagnosis of HTN (BP 150/90)
given Amlodipine 5mg od
• 1 week later, presented
with fainting spell
particularly on standing

• What happened ???

falseHighop
ois m
nwo arr.mn
osro
Ordinary and Obese arm
 Falsely high BP
20 to Inappropriate cuff size

“ Large cuff for the obese”

Hypertensive Retinopathy

AV nicking
Appropriate Place & Light
 Make sure he is comfortable !!

• 450 Head-up is a must for cardiovascular

examination
Famnwat
awsomealis xnntneleom

enaonxan.name

enlarge
aranonistadon

enetive
xnn
m.mn
y
Lots of Information from Examination of
Hands
 Finger clubbing

Shamroth’s
sign
 Early signs of Finger clubbing
• Loss of angle of Nail bed
• Fluctuation test

normal
Check for Equality of Pulse
สาเหตุ ที่ Pulse ที่แขน 2 ข้างไม่เท่ากัน
• With acute chest pain Aortic dissection

• Without chest pain

– Atheroslerosis
– Takayasu disease
– Coarctatation of the aorta (Preductal type)
( Lt radial pulse)
– Previously used arterial line
 Palpation of Radial pulse
(Rate, Rhythm, Volume & Contour)

ดนู าฬิกา หลับตา เพ่ งจิตไปที่ Pulse

 หลีกเลี่ยงการใช้คาว่า “Pulse full”
ควรใช้คาว่า
“Normal, Small or Large Pulse volume”
or
“Absent pulse”
 Abnormalities of Pulse Rhythm
• Totally irregular pulse
– Rate • Atrial fibrillation
– Rhythm
– Volume

• Regular with • PAC’s

Premature beats

• Regular with Dropped • PVC’s or PAC’s

beats
 Abnormalities of the Pulse Contour

ECG
Normal
Pulsus parvus
et tardus
iuE
omniwame • Aortic stenosis
Ernososas • Aortic regurgitation
Waterhammer

Bisferens • HCM or Mixed AS/AR

moans
Alternans • Advanced Systolic HF
vaneereserman
Paradoxical
• Cardiac tamponade
Collapsing pulse

atomaninin
Listening for Carotid bruit
 Contour of Carotid artery
(eg. Delay carotid upstroke in AS or
Bisferens pulse in HCM)

• Do not apply pressure > 10 seconds

 rector
crook
Female 45 ,No RF, presented with ACS,
underwent PCI of LAD but unable to access
both femoral arteries
• Pulses
– Upper limbs 2+
– Lower limbs 0
• Bruit at Abdomen
& Back
ourvanonce noon
abdominal

• Takayasu’s disease
A proper way to look at JVP
 Tools for measurement of JVP
1. เตียงที่ยกศีรษะสูงได้ 450
2. ไม้ บรรทัด 2 อัน
Measurement of JVP

Sternal angle
 The simple but useful physical sign

The JVP was elevated up to the angle

of the mandible
 Sometimes You can see it even
in the Upright Position !!!!!

The JVP was elevated up to the angle

of the mandible in upright position
What does elevated JVP mean?

JVP = RA pressure
 Raised JVP

Elevated RA pressure

The most theoretical cause is …………..

Tricuspid stenosis
cranes
Very rare in clinical practice
 Raised JVP

Elevated RA pressure

The most common cause

Physical signs
in clinical practice is ……

Increased RV pressure Lt parasternal heave

followed by RVH & RVE

Pulmonary artery HTN Loud (+ palpable) P2

Which wave is the most prominence ?

• Prominent “a” wave

• This patient has

Hypertrophic
cardiomyopathy
• (HCM)
 Which wave is the most prominence ?

• Prominent “a” wave

• Another patient
with Hypertrophic
cardiomyopathy
 Pulmonary Artery HTN (Loud P2)
pressurec meme
increased
Lt sided Heart disease Lung disease

• IHD with poor LV function

• Valvular HD
• Hypertensive HD
• Thyrotoxic HD
• Congenital HD
• Myocarditis
• etc
 Pulmonary Artery Hypertension due to
Lung Disease
• Chronic lung disease
– COPD
– Interstitial lung disease
• Sleep disorder
– OSA
– Hypoventilation
• Pulmonary embolism
• Collagen-vascular
disease
• Hematologic disease
– Hemoglobinopathies
• HIV
• Porto-pulmonary HT
• Drugs
– Anorexic/Contraceptive
• Others
• Primary pulmonary HT
 Raised JVP
Elevated RA pressure Pericardial Constriction

Acute MI with
In rare case
Isolated RV infarct
Increased RV pressure
Ebstein’s anomaly

No Pulmonary artery HTN Arrhythmogenic RV dysplasia

( ARVD)
(Normal P2)
Isolated TR
(eg. Traumatic TR)
 Abdominojugular Reflux (AJR)

Technique
• Press firmly over RUQ 10-60 secs(pressure of 20 to 35 mmHg
• Observe JVP
 Positive AJR
JVP > 3 cm & sustained >15 sec

• a reflection of a right ventricle that cannot

accommodate augmented venous return
– Impaired RV preload
– RV compliance
– RV systolic function
– RV afterload
 AJR is not specific to any one disorder
• RV failure
• RV infarction
• Severe TR
• Fluid overload
• Restrictive cardiomyopathy
• Constrictive pericarditis
• Also positive in LV failure, but only when
pulmonary capillary wedge pressure > 15 mmHg
One diagnosis not seen with AJR is Cardiac tamponade
Palpation : Be gentle & careful
 อยากให้หลีกเลี่ยงการใช้ 2 คานี้
XXXXXXXXX
• Active precordium • Point of maximal
impulse (PMI)

PMI

Apical impulse
omgaerialimpulse
Normal Apical Heaving or
Impulse Sustained Apex
Heaving or Sustained Apex
“Pressure Overload to LV”

• > 2/3 of Systole

• DDx
–Hypertensive HD
–Severe AS
–HCM
Normal Apical Hyperdynamic
Impulse Impulse
amino
osseous roamed
 Hyperdynamic Impulse
“Volume Overload to LV”

• AR
• MR
• PDA
• Hyperdynamic
circulation
 Normal Apical Diffused Apical
impulse impulse

Apical Ø > 2 cm
Apical Ø < 2 cm
Poor LV systolic function
 Diffused
Apical Impulse

• Poor LV function
or
• LV aneurysm
 Double Apical Impulse
“Hypertrophic Cardiomyopathy”
Double Apical
Impulse in
HCM
 Abnormal Apical Impulse

• Heaving apex or Sustained apex

• Hyperdynamic • Diffused apex

• Double apical impulse

• Tapping apex : Mitral stenosis

Listen carefully
ใช้ฝ่ามือคลาหา Apex ใช้นิ้วชี้ identify Apex

ใช้ bell ฟัง Gallop rhythm, DRM (MS) ใช้ diaphragm ฟังในท่าหายใจออก
Erb’s point
DBM (AR)

sa news
 การฟังด้านหลัง นอกจาก Breath sound แล้ว
อย่าลืมฟัง Arterial bruit ตามแนว spine ด้วย
(Takayasu or Coarctation of the aorta)
Q.1 The following signs indicate
severe mitral stenosis EXCEPT

A. Soft S1
B. Loud P2
C. Short S2-OS interval Msc omit
rhythm
a
D. Presystolic accentuation
E. Long rumbling diastolic murmur
Q.1 The following signs indicate severe
mitral stenosis EXCEPT

A. Soft S1
B. Loud S1
C. Short S2-OS interval
D. Presystolic accentuation
E. Long rumbling diastolic murmur
 Mitral Stenosis
S1 S1
MS with S2 OS S2
sinus
rhythm
Presystolic accentuation
(LA contraction)
S1 S1
MS S2 OS S2
with AF
 Mitral Stenosis
• Exclusively Rheumatic in origin
Mitral regurgitation
Causes of Mitral regurgitation
• Mitral valve prolapse • Papillary muscle
(MVP) dysfunction
• Rheumatic HD • Chordal rupture
(Always with MS)
• Functional MR (due to
• Calcified mitral LV dilatation)
annulus
• Previous IE
 MVP & Click & Murmur

standing noon
moon

• Anything that LV volume eg. venous return,

tachycardia, myocardial contractility or afterload
cause MV leaflets to prolapse earlier in systole &
systolic click & murmur will move towards S1 &
the murmur will become longer
 MVP & Radiation of MR

Lt sternal Axilla
border

murmurataeex anterior.name
maintetoieassonairoades toaxilin
 Signs of Chronic Severe MR
• Hyperdynamic & displaced apical impulse
• S1
• Wide splitting of S2 due to early closure of the AV
• The duration of the murmur
• S3 due to LV dysfunction
• Loud P2 due to Pulm HTN

• Intensity of murmur : not correlated with severity of MR

• Intensity may be in severe MR caused by LV dysfunction,
acute MI, or periprosthetic valve regurgitation
Aortic stenosis
Signs of Severe AS

• Pulsus Parvus et Tardus

(weak & delayed)
• Delayed carotid upstroke
• Apical heave or Sustained apex
• Absent A2
• Late peaking murmur
 Causes of Valvular AS

• Congenital – bicuspid AV
• Acquired
– Rheumatic
– Degenerative (age related)
– Calcific AS associated with Paget’s Disease,
CKD, rheumatoid arthritis
 Aortic Stenosis
Loud & Late peaking

S1 S2 S1 S2
Mild-Moderate Severe
Aortic regurgitation
 Aortic Regurgitation

S1 S2 S1
Diastolic
Blowing
Murmur

AR + AS
mixed
 Severity of Aortic Regurgitation
Peripheral signs + Length of murmur
S1 S2 S1
Moderate AR

S1 S2 S1

Severe AR
tooth a on
Exception : DBM will become shorter in Severe AR
with Poor LV function
 Differential causes of AR
Valve Disease Aortic Root disease

• RHD cMs • Hypertension

• IE • Aortic dissection
• Bicuspid aortic • Collagen disease
valve – Marfan syndrome
• Valvulitis – Pseudoxanthoma
– SLE elasticum
– RA • Syphilitic aortitis
 Diastolic
Blowing
murmur

1. ถ้ าได้ ยนิ DBM ที่ RUSB ชัดกว่ า LUSB suggest

ว่ า น่ าจะเป็ น AR จาก Root disease มากกว่ า
2. DBM at LUSB with signs of RV failure & pulm
HTN suggestive of Pulmonic regurgitation
(Graham Steell murmur) notAf
 Famale 38, with DOE
• BP 128/88 Rt arm, 124/86 Lt arm
• Apical heave +
• To & fro murmur gr 2/6 at AVA
• Very loud neck bruit bilaterally
• What is the diagnosis?

• Mixed AS/AR
• Very loud neck bruit bilaterally ??
Female 38 with DOE
“Supravalvular AS”
 Hint!!
If the murmur is louder at the
Neck than at the AVA
Consider valued
Charlie
• Neck bruit form carotid disease area
• Supravalvular AS
 Murmur of HCM
1 2

LVOT Obstruction Systolic anterior motion

of the Anterior Mitral
leaflet with MR
Dynamic Auscultation in HCM & MVP

situ
in was
Effects of Valsalva & Standing
Valsalva • Standing from
squatting position
Intrathoracic • sudden pooling of
pressure blood in the legs

Venous return & LV filling

LVOT obstruction

Murmur intensity
 Q.3 Which of the following factors
has prognostic significance in
patients with Systolic heart failure ?

A. S4 gallop elevatexp
sogallop
B. Crepitations earprognosiscar
C. Elevated JVP
D. Sinus tachycardia
E. Cardiomegaly on CXR
 Q.3 Which of the following factors
has prognostic significance in
patients with Systolic heart failure ?

A. S4 gallop
B. Crepitations
C. Elevated JVP
D. Sinus tachycardia
E. Cardiomegaly on CXR
 Prognostic Importance of
Elevated JVP & S3 gallop in HF patients
n=2569, FU 32 months

N Engl J Med 2001;345:574-581

Have we lost the need for
Physical touch ??
The end
Dynamic Auscultation : HCM & AS
MVP
 The Valsalva maneuver
• diminishes nearly all systolic murmurs
with the exception hypertrophic
cardiomyopathy (HOCM)
Valsalva on MR
Squatting & MR