PHYSICAL EXAMINATION

OF
CARDIOVASCULAR SYSTEM
Adhytya Pratama A.

Physical Examination

General
Hands
Pulse
Blood pressure
Face
Neck
Jugular venous
pressure

Precordium
Inspection
Palpation
Percussion
Auscultation

Back
Abdomen
Lower limbs

Blood Pressure
Measurement

Blood Pressure
Measurement

Rest the patient for 5 minutes.

Use either arm unless one arm is known to record
a higher pressure.
With the patient seated or lying down, support his
arm comfortably at about heart level, ensuring
that no tight clothing constricts the upper arm.
You can measure over thin clothing, as it makes
no difference to the result.
The usual sphygmomanometer cuff has a bladder
width of 12.5 cm and length of 3-35 cm. Apply
the cuff to the upper arm, with the centre of the
bladder over the brachial artery.

Palpate the brachial pulse.

Inflate the cuff until the pulse is impalpable.
Note the pressure on the manometer; this is a
rough estimate of systolic pressure.
Inflate the cuff another 30 mmHg and listen
through the diaphragm of the stethoscope
placed over the brachial artery.
Deflate the cuff slowly (2-3 mmHg/s) until you
hear a regular tapping sound (phase 1
Korotkoff sounds). Record the reading to the
nearest 2mmHg. This is the systolic pressure.

Continue to deflate the cuff slowly until the

sounds disappear.
Record the pressure at which the sounds
completely disappear as the diastolic
pressure

ANATOMY

Anterior Surface of the Heart

ANATOMY

The Sectional
Anatomy of
the Heart

CARDIAC
CYCLE

Pressure

Ventricle Volume

Heart Sounds
Electrical Activity

PHYSICAL EXAMINATION

The jugular venous pressure

The arterial pulse
The S1 and S2
Extra sounds both in systole and diastole
Cardiac murmurs

JUGULAR VENOUS PRESSURE

STEPS FOR ASSESSING JVP :

Raise the head slightly on a pillow
Raise the head of the bed to 30o
Use tangential lighting to identify EJV then IJV
Raise or lower the head of the bed to see
oscillation point
Identify the highest point of pulsation

JUGULAR VENOUS PRESSURE

JUGULAR VENOUS PRESSURE

JUGULAR VENOUS PRESSURE

Normal pressure (30o) R+2 cmH20

ARTERIAL PULSE

Radial artery, brachial artery, dorsalis pedis

artery, femoral artery, carotid artery
Assess : volume, frequency, and regularity

ARTERIAL PULSE

Normal pulse

Anacrotic pulse (pulsus parvus et tardus)

AS

ARTERIAL PULSE

Pulsus bisferiens AR+AS

Pulsus alternans congestive heart failure

ARTERIAL PULSE

Waterhammer pulse AR

ARTERIAL PULSE

EXAMINATION OF THE
HEART

INSPECTION AND PALPATION

EXAMINATION OF THE
HEART

INSPECTION AND PALPATION

EXAMINATION OF THE
HEART

INSPECTION AND PALPATION

EXAMINATION OF THE
HEART

PERCUSSION
Estimation of cardiac size
Cardiac dullness

Percussion

Percussionofthechestforcardiacborder
5thintercostalspaceattheleftanterioraxillaryline
Normalfindingswouldberesonancebecauseyouwillbe

overlungtissue

Next,percussthemidclavicularlineandtheleft

sternalborder

Shouldchangetodullasyoupercussovertheheart

Figure17.21Percussingthechest.

HEART SOUNDS

AUSCULTATION

S1 mitral and tricuspid valve

S2 aortic and pulmonal valve

S3 the rush of blood during early diastole

S4 atrial contraction

HEART SOUNDS

AUSCULTATION

24

HEART SOUNDS

AUSCULTATION

HEART SOUNDS

Variations of the S1

Tachycardia, mitral stenosis

MR,
CHF

Complete heart block, AF

RBBB, PVC

HEART SOUNDS

Variations of the S2
Increased A2 systemic hypertension, dilated
aortic root
Increased P2 pulmonary hypertension, dilated
pulmonary artery, ASD
Decreased A2 AS

Decreased P2 increased AP diameter of the

chest, PS

HEART SOUNDS

Extra Heart Sounds in Systole

Aortic ejection sound : dilated aorta,
aortic valve disease (congenital stenosis)
Pulmonic ejection sound : dilated pulm.
artery, PS

Mitral Valve Prolapse (MVP)

HEART SOUNDS

Extra Heart Sounds in Diastole

Mitral Stenosis (MS)

Physiologic : children, pregnancy

Pathologic : decreased myocardial
contractility, myocardial failure, MR,
TR

Left-sided S4 : HHD, CAD, AS,

cardiomyopathy
Right-sided S4 : PH, PS

M
R
U
M

S
R
U

Table17.3DistinguishingHeartMurmurs

Table17.3(continued)DistinguishingHeartMurmurs

HEART SOUNDS (MURMURS)

Midsystolic Murmurs
No evidence of CV disease. Found in : children,
young adults, or even elders

Temporary increase in blood flow : anemia, fever,

pregnancy, hyperthyroidism

Location : 2nd 3rd left ICS. Radiation : toward the left shoulder
& neck. Intensity : soft loud (thrill). Pitch : medium. Quality :
often harsh

HEART SOUNDS (MURMURS)

Location : 2nd right ICS. Radiation : often to the neck & LSB,
even apex. Intensity : soft loud (thrill). Pitch : medium, maybe
higher. Quality : often harsh. Aids : sitting & leaning forward

Location : 3rd 4th left ICS. Radiation : down to the LSB to the
apex or base, not to the neck. Intensity : variable. Pitch :
medium. Quality : harsh. Aids : squatting, straining down

HEART SOUNDS (MURMURS)

Pansystolic Murmurs
Location : apex. Radiation : to left axilla, less often to the LSB.
Intensity : soft loud (apical thrill). Pitch : medium high.
Quality : blowing. Aids : do not become louder in inspiration

Location : lower LSB. Radiation : to the right of the sternum,

xiphoid area, left MCL, not into the axilla. Intensity : variable.
Pitch : medium. Quality : blowing. Aids : inspiration

Location : 3rd,4th, 5th left ICS. Radiation : often wide. Intensity :

often very loud with thrill. Pitch : high. Quality : often harsh.

HEART SOUNDS (MURMURS)

Diastolic Murmurs
Location : 2nd 4th left ICS. Radiation : if loud, to the
apex, perhaps to the RSB. Intensity : grade 1 3.
Pitch : high. Quality : blowing (maybe mistaken for
breath sounds). Aids : heard best with sitting, leaning
forward, with breath held in exhalation.

Location : limited to the apex. Radiation : little - none.

Intensity : grade 1 4. Pitch : low. Aids :placing the
bell exactly on the apical impulse, left lateral position,
mild exercise, exhalation

HEART SOUNDS (MURMURS)

Heart Sounds With Both Systolic and Diastolic

Components
Timing : (1) atrial systole, (2) vent. systole,
(3) vent. diastole.
Location : variable, 3rd ICS to the left of the
sternum.
Radiation : little.
Intensity : variable.
Pitch : high.
Quality : scratchy, scraping.
Aids : heard best with leaning forward,
exhales, and holds breath.

HEART SOUNDS (MURMURS)

Heart Sounds With Both Systolic and Diastolic

Components
Timing : continuous murmur in both systole
and diastole, often with a silent
interval late in diastole
Location : 2nd left ICS.
Radiation : toward the left clavicle.
Intensity : usually loud with thrill.
Pitch : medium.
Quality : harsh, machinery-like.

HEART SOUNDS (MURMURS)

Heart Sounds With Both Systolic and Diastolic

Components
Timing : continuous murmur without a silent
interval.
Location : above the medial third of the
clavicles, especially on the right.
Radiation : 1st and 2nd ICS.
Intensity : soft moderate.
Pitch : low.
Quality : humming, roaring.

THANK YOU