You are on page 1of 66

General physical examination

of cvs

Presenter -Dr.mohit jain

Moderator- dr.sanjay kumar
The Arterial Pulse

With each contraction ,the left ventricle ejects a volume of

blood into the aorta and on into the arterial tree

A pressure wave moves rapidly through the arterial system

where it can be felt as the arterial pulse

It moves at 5m/sec

While the blood column moves at 0.5 m/sec

Tidal wave

Percussion wave
The arterial pulse should be examined in all 4 limbs and both sides
of the neck

1. Radials
2. Brachials
3. Carotids
4. Femorals
5. Popliteals
6. Peripheral arteries of the legs :Dorsalis pedis
Posterior tibial
How to feel the Pulse-
The Radial pulse:

The 3 fingers are used

The palmar surface of the fingers overlies the radial A. and
encircles the wrist and we feel radial artery against the head of
At first the artery is completely occluded, then gradually release
the pressure until maximum feeling of the pulse wave is
Brachial Artery

Rest the patient arm with elbow extended palm up

Use the thumb of the opposite hand

Cup your hand under the patient elbow

Feel the pulse just medial to biceps tendon just above antecubital fossa
The Carotids
The patient lies down with the head of the bed elevated 30 degrees

Carotid pulsations may be visible just medial to sternocleidomastoid

Place the left thumb on the right carotid A. in the lower third of the
neck at the level of the cricoid cartilage, just inside the medial border of
the sternocleidomastoid and press posteriorly
Femoral Pulse

Press deeply below the inguinal ligament and about mid way between
ASIS and SP against femur.
Posterior Tibial

Curve your fingers 1cm behind the medial malleolus of the ankle

Posterior tibial and dorsalis pedis may be not palpable as they are not
palpable in 2% of the normal population

Sublingual nitrate 5mg can be given after checking bp

The arteries may become palpable

Dorsalis Pedis

Feel the dorsum of the foot just lateral to the extensor tendon of the big

If you cannot feel the pulse, explore the dorsum of the foot more
Popliteal Pulse

Patient knee should be flexed at 120 degreesleg relaxed

Place both the thumbs on patella and the finger tips of both hands so
that they meet in the middle line behind the knee and press them deeply
in the popliteal fossa
Comment on the Pulse

1. Rate

2. Rhythm

3. Volume (amplitude)

4. Comparison of the two sides

5. Special character

6. Condition of the arterial wall


Rate of the pulse recorded at radial artery

Normal at rest :60-90 beat / min
* if regular: count in 15 sec x 4
* if fast (tachycardia ) or slow (bradycardia) count in 1 min
*if irregular count at apex
weak beats may not be felt (pulse deficit)
Pulse deficit >6 atrial fibrillation
< pvcs
Is the rhythm regular or irregular?

If irregular irregular regularly irregular

Atrial fibrillation sinus arrthythmia

MFAT pulsus bigeminus

SVT with aberrant conduction pulsus alterens

partial heart block (1st and

- 2nd degree)
Volume (Amplitude)

Hperkinetic /bounding pulse

* High systolic: increased stroke volume

Rigidity of aorta

* Low diastolic :aortic regurgetation

B--Small amplitude (weak pulse)

1- low stroke volume

shock (thready)
severe mitral stenosis

2- Aortic stenosis
C--Variation in amplitude

1-pulsus alternans
2-pulsus paradoxus
Comparison of both sides

Causes of unequal pulse

1. Genetic absence or change in the course of the radial artery
2. Compression of the vessel
3. Atheromatous plaque
4. Embolus
Special character

Factors affecting the form

Upstroke (rise)
Downstroke (fall)
Types of Pulses
Collapsing /Water hammer pulse/pulsus
celer/corrigenn pulse
Rapid upstroke
Rapid down stroke
High amplitude
Short duration

Found in :
Aortic incompetence,ruptured sinus of valsalva,PDA,AP window
Hyperdynamic states: Fever
Anacrotic Pulse (Plateau pulse)

Upstroke is slow with a notch on it

Duration of pulse is prolonged
Amplitude is small
In aortic stenosis
Pulsus Bisferiens

In combined aortic stenosis and regurge

Pulse has 2 peaks:
Upstroke is sharp and rises high to the first peak
Falls and rises again to a second peak

A double pulse is felt and seen in the carotid

mustbe belevel
arm circumference exceeds 33
circumference exceeds 33cm,cm,
cuff must
mustbe beused.
brachial artery.
brachial artery.

should Stethoscope
be relaxedand
relaxed andthethe mercury
mercurymust mustbebe
arm must
arm must bebe
supported. Mercury Inflate
Ensureno notight
tight machine pulse.
pulse. Deflate at 2toto
Deflate at 2
clothing constricts
clothing constricts 33mm/s.
arm. systolic
systolic (firstsound)
(first sound)
nearest 22mm mmHg.


Jugular Venous Pulse:

defined as the oscillating top of vertical column of blood in
right IJV that reflects pressure changes in Right Atrium in cardiac
Jugular Venous Pressure:
Vertical height of oscillating column of blood.
Why Internal Jugular Vein?

IJV has a direct course to RA.

IJV is anatomically closer to RA.
IJV has no valves( Valves in EJV prevent transmission of RA pressure)
Vasoconstriction Secondary to hypotension ( in CCF) can make EJV
small and barely visible.
Why Right Internal Jugular Vein?
Right jugular veins extend in an almost straight line to superior vena
cava, thus favouring transmission of the haemodynamic changes from
the right atrium.

The left innominate vein is not in a straight line and may be kinked or
compressed between Aortic Arch and sternum, by a dilated aorta, or by
an aneurysm.
Difference from Carotid Pulse
Venous Pulse Carotid Pulse
More lateral Medial
Wavy, Undulant Forceful, Brisk
Decrease with Inspiration No change
Increase in supine position No change
^with abdominal pressure No change
Double Peaked Single Peak
Obliterated with Pressure Cannot be Obliterated
Better Visible Better palpated
Better viewed from foot
end of bed
Method Of Examination

The patient should lie comfortably during the examination.

Clothing should be removed from the neck and upper thorax.

Patient reclining with head elevated 45

Neck should not be sharply flexed.

Examined effectively by shining a light tangentially across the

There should not be any tight bands around abdomen
Observations Made

the level of venous pressure.

the type of venous wave pattern.

The level of venous pressure

Using a centimeter ruler, measure the vertical distance

between the angle of Louis (manubrio sternal joint) and the
highest level of jugular vein pulsation.

The upper limit of normal is 4 cm above the sternal angle,.

Add 5 cm to measure central venous pressure since right

atrium is 5 cm below the sternal angle.

Normal CVP is < 9 cm H2O

Normal pattern of the jugular venous

The normal JVP reflects phasic pressure changes in the

right atrium and consists of three positive waves and
two negative troughs
Simultaneous palpation of the left carotid artery aids
the examiner in relating the venous pulsations to the
timing of the cardiac cycle.

Venous distension due to RA contraction

Retrograde blood flow into SVC and IJV
Synchronous with S1, Follow P of ECG
Precede Carotid pulse
is due to
The x descent:
X Atrial relaxation
X` Descent of the floor of the right atrium
during right ventricular systole.
Begins during systole and ends before S2

The c wave:
Occurs simultaneously with the carotid pulse
Artifact by Carotid pulsation
Bulging of TV into RA during ICP

Rising right atrial pressure when blood flows into the right
atrium during ventricular systole when the tricuspid valve is
Synchronous with Carotid pulse
Begins in early systole, Peaks after S2 and ends in early diastole

The decline in right atrial pressure when the tricuspid valve

Following the bottom of the y descent and before beginning of
the a wave is a period of relatively slow filling of the ventricle,
the diastases period, a wave termed the h wave.
Identifying Wave Forms

The x descent occurs just prior to the second heart sound (

during systole), while the y descent occurs after the second heart
sound (during diastole).

Normally X descent is more prominent than Y descent. Y descent

is only sometimes seen during diastole. Descents are better seen
than positive waves.

The a wave occurs just before the first sound or carotid pulse and
has a sharp rise and fall.

The v wave occurs just after the arterial pulse and has a slower
undulating pattern.

The c wave is never seen normally.

Abnormalities of jugular venous pulse

A. Low jugular venous pressure

1. Hypovolaemia.
B. Elevated jugular venous pressure
1. Intravascular volume overload conditions
Right ventricular infarction
Left heart failure
Myocardial infarction.
Valvular Heart Disease

2. Constrictive pericarditis.
3. Pericardial effusion with tamponade
Elevated a wave
Increased Resistance to RV Filling.

Tricuspid stenosis
R Heart Failure
Cannon a wave
(atria contract against
a closed tricuspid
Complete heart block
Ventricular pacing
Junctional rhythm
Absent a wave

1. Atrial fibrillation
Elevated v wave

1. Tricuspid regurgitation.
2. Right ventricular failure.
3. Restrictive cardiomyopathy.
4. Cor Pulmonale
Tricuspid regurgitation

Absent X Decsent
CV/ Regurgitant Wave
Has a rounded contour
and a sustained peak
Followed by a rapid deep Y
Amplitude of V increases
with inspiration.
Cause subtle motion of ear
lobe with each heart beat
a wave equal to v wave
Prominent X descent
followed by a large V
M Configuration
Indicates a large L-R shunt
With PAH A wave
becomes more
If L JVP > R JVP indicates
associated PAPVC
Prominent x descent
1. Cardiac tamponade.
2. Constrictive Pericarditis
4. Restrictive Cardiomyopathy
5. Atrial septal defect

Blunted x descent
1. Tricuspid regurgitation.
2. Right atrial ischaemia
Prominent y descent
1. Constrictive pericarditis.
2. Tricuspid regurgitation.
3. Atrial septal defect.

Absent y descent
1. Cardiac tamponade.
2. Right ventricular infarction
3. Restrictive Cardiomyopathy

Slow y descent
1. Tricuspid stenosis.
2. Right atrial myxoma.
Constrictive pericarditis.

M shaped contour
Prominent X and Y descent (FRIEDREICH`SIGN)
Y descent is prominent as ventricular filling is
unimpeded during early diastole.
This is interrupted by a rapid raise in pressure as the
filling is impeded by constricting Pericardium
The Ventriclar pressure curve exhibit Square Root sign
Abdomino-jugular reflux
Is positive when JVP increase after 10 sec of abdominal
pressure followed by a rapid drop in pressure of 4 cm on
release of compression.

Most common cause of a positive test is RHF

Positive test in: Borderline elevation of JVP
Silent TR
Latent RHF

False positive: Fluid overload

False Negative: SVC/IVC obstruction
Budd Chiari syndrome

Positive Test imply SVC and IVC are patent

Kussmaul sign

Failure of decline in JVP occur during inspiration.

Constrictive Pericarditis
Severe RHF
Restrictive Cardiomyopathy
Tricuspid Stenosis

Thickening of the tissues at the base of the finger and toe nails such
that the normal angle between the nail & the digit is filled in.

VEGF is the key entity, platelet derived growth factor stimulated by

hypoxia and produced in diverse malignancies.
VEGF induces vascular hyperplasia, edema, and fibroblast or
osteoblast proliferation at peripheral levels in nails

thoracic & non-thoracic

THORACIC causes: bronchitis, empyema, lung abscess, cystic
fibrosis, Lung Ca, Esophageal Ca,
mesothelioma, Bac. Endocarditis.
Interstitial lung disease: asbestosis, fibrosing
Vascular causes: AV malformations, Cyanotic
heart disease.

Non-thoracic causes: Hepatic cirrhosis, Ulcerative colitis,

Crohns disease.
Grades of clubbing

Grade 1: Nail bed fluctuation

Grade 2: Obliteration of Lovibond angle
Grade 3: Parrot beaking
Grade 4: Hypertrophic osteo-arthropathy(HOA)

Loss of normal angle between nail and nail bed.

Inc. Nail bed fluctuation
Inc. nail bed curvature in the later stages
Inc. bulk of soft tissue over the terminal phalanges
Parrot beak app.

Drumstick appearance
Hypertrophic Osteo-arthropathy

Earlier known as hypertrophic pulmonary osteo-arthropathy(HPOA)

Syndrome of clubbing of the digits, periostitis of the long bones and
Primary: occurs w/o any underlying cause and is familial
Secondary: pulmonary, cardiac, hepatic, intestinal disease.