CARDIOVASCULAR EXAMINATION

ANDI WAHJONO ADI,MD,FIHA

CARDIOVASCULAR EXAMINATION
• History taking (dyspnea/chestpain/fainting etc)
• Skin (cyanosis,clubbing finger)
• Congenital and acquired facies(marfan syndrome etc)
• Eyes (jaundice,yellowished rim iris etc)
• Edema
• Extremities (spider finger,wrist sign etc)
• Chest and respiration(pectus exacatus and or carinatus, cheyene stokes, etc)

J. Constant, 2003
CLUBBING FINGER

E. Braunwald, 2012
EDEMA
JUGULAR VEIN ANATOMY

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JUGULAR VENOUS PRESSURE

Angle of Louis

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JUGULAR VEIN WAVEFORMS

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J. Constant, 2003
DIFFERENCES JUGULAR VEIN VS CAROTID ARTEY

E. Braunwald, 2012
INSPECTION

• Wall chest
• Voussure cardiac
• Apex beat
• Ventricular heave
PALPATION
• Apex beat
• Thrill
• Ventricular heave

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HEPATOJUGULAR REFLUX

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PERCUSSION

• Lung-liver border
• Right heart border
• Cardiac waist
• Heart silhoutte
AUSCULTATION

• Heart sound
• Extra heart sound
• Murmur
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AUSCULTATION LOCATION

Polaski and tatro,1996

S1 (First Heart Sounds)
• The normal first heart sound (S1) comprises mitral (M1) and tricuspid (T1) valve closure.
• The two components usually are best heard at the lower left sternal border in younger subjects.

S2(Second Heart Sound)

• The second heart sound (S2) comprises aortic (A2) and pulmonic (P2) valve closure.
• Best heard at the second left interspace with the patient in the supine position.
• Increase in the intensity of p2 relative to a2, indicate pulmonary artery hypertension.
• With fixed splitting, the a2-p2 interval indicating ostium secundum asd.

Learn the heart.,2015

HEART SOUNDS

Normal physiologic splitting of the second heart sound because of augmented venous return to the right
heart during inspiration
P.A.McCullough,1999
S3 - Ventricular Gallop
Occurs in early diastole
Occurs during passive LV filling
May be normal at times
Requires a very compliant LV
Can be a sign of systolic CHF

S4 - Atrial Gallop
Occurs in late diastole
Occurs during active LV filling
Almost always abnormal
Requires a non-compliant LV
Can be a sign of diastolic CHF

Learn the heart.,2015

CLINICAL HEART SOUND
OF S1,S2,S3,S4

A. Jeremies,D.L. Brown,2010
MURMUR

Murmurs are described by their timing in the cardiac cycle, intensity, shape, pitch,
location, radiation, and response to dynamic maneuvers.

Learn the heart.,2015

Major causes of cardiac murmurs :
• Blood is forced through a tight area, turbulent blood flow ensues.
• Blood abnormally travels backward through an incompetent valve causing turbulence
when it meets normal, forward blood flow.
• Blood is forced through a congenital anomaly from one chamber to another, as in an
atrial septal defect (asd) or ventricular septal defect (vsd), a murmur is produced
again due to turbulence.
• Increased flow of blood through a normal valve.

Learn the heart.,2015

1.TIMING

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2.GRADING

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3. SHAPE
The shape of a murmur describes the change of intensity throughout the cardiac
cycle. Murmurs are either crescendo, decrescendo, crescendo-decrescendo, or
uniform.

Learn the heart.,2015

3. PITCH
• High pitch i.E. Aortic stenosis.
• Low pitch i.E. Mitral stenosis
• High pitched sounds are heard with the diaphragm of the stethoscope while low pitched
sounds are heard with the bell.
4. LOCATION
A = aortic valve post (right upper sternal border or RUSB)
P = pulmonic valve post (left upper sternal border or LUSB)
T = tricuspid valve post (left lower sternal border or LLSB)
M = mitral valve post (apex) Learn the heart.,2015
E = "erb's point“
5. RADIATION
• While murmurs are usually most intense at one specific listening post, they often
radiate to other listening posts or areas of the body.
• For example, the murmur of aortic stenosis frequently radiates to the carotid
arteries and the murmur of mitral regurgitation radiates to the left axillary region.

Learn the heart.,2015

 EXTRA HEART SOUNDS
• Systolic ejection click 
a systolic ejection click frequently indicates a bicuspid aortic valve. This sound is heard just after the 1st heart
sound (S1).
• Mitral valve prolapse click 
mitral valve prolapse produces a mid-systolic click usually followed by a uniform, high-pitched murmur.
• Opening snap
The increased left atrial opening pressures causes an opening snap (OS) to occur when the mitral valve leaflets
suddenly tense and dome into the left ventricle in early diastole.
• Tumor plop
Early diastolic low pitched sound just after the S2 heart sound.
• Pericardial knock
Present in patients with constrictive pericarditis as the early filling of the left ventricle is limited from the
constrictive process.
Learn the heart.,2015
DYNAMIC AUSCULTATION

A. Jeremies,D.L. Brown,2010
ARTERIAL PULSATION
• Pulsus bisferiens
• Pulsus celer/corrigan/water hammer
• Pulsus alternan
• Pulsus defisit
• Pulsus parvus et tardus
• Pulsus paradoxus
0, absent
1, Decrease
2, normal
3, Bounding

J. Constant, 2003
ANKLE BRACHIAL INDEX
V. Aboyans, 2012
J. Constant, 2003
THANK YOU