CLINICAL EXAMINATION OF CVS

D R S P S R I N I VA S
MD
IMPORTANT SYMPTOMS AND SIGNS OF
CARDIOVASCULAR DISEASE
1 . Chest pain
2 . Dyspnoea
{ orthopnoea - dyspnoea on lying down }
3 . Palpitation
4 . Tachycardia
5 . Oedema
 EXAMINATION OF CVS
This is to be done as mentioned below:
1. General physical examination :
2. Systemic examination:
a. examination of the arterial pulse
b. examination of venous pulse
c. examination of the heart :
This is done under the following headings :
 Inspection
 Palpation
 Percussion : to define cardiac borders
 Auscultation
EXAMINATION OF THE VENOUS PULSE [JVP]
PULSATIONs IN THE NECK
1. Both arterial and venous pulsations may be seen in the neck,
especially in thin persons.
2. However, venous pulsations can be easily occluded by pressure
with a finger above the clavicle.
3. Arterial pulsations can be palpated and are stronger, increase
with heart rate on mild exertion , and cannot be easily occluded.
JUGULAR VENOUS PULSE AND CAROTID PULSE
DIFFERENCES
EXAMINATION OF VENOUS PRESSURE

The venous pressure can usually be estimated by watching the

degree of distension of peripheral veins , especially the neck veins.
For example , in normal, resting, sitting individuals, the neck veins
are not distended .
However, when the right atrial pressure rises , as in congestive heart
failure, the veins become distended.
JUGULAR VENOUS PRESSURE
The internal jugular vein is almost in line with right atrium and is a
better measure . It reflects all atrial pressure changes, thus
providing important information about this pressure, which
represents the central venous pressure .
PROCEDURE
The subject is made to lie on his back, with the upper part of the
body supported at an angle of 45 degree to the horizontal, with
the chin pointing slightly to the left. The neck veins are then
inspected carefully. Normally , slight pulsations in the neck veins
are seen just above the clavicle.
This level is the same as the sternal angle ( angle of Lewis ) whatever be the
position of the thorax. The vertical distance between the right atrium and
the sternal angle indicates the mean hydrostatic pressure, which is normally
2-3 cm of water (1-2 mm Hg).
The veins are then inspected in the upright position . Normally, no pulsations
are visible . In right heart failure , the right atrial pressure increases , and
thus the jugular venous pressure is raised, the veins are full and show
pulsations even in the upright position. This is the raised JVP.
JVP MEASUREMENT DIAGRAM
 EXAMINATION OF THE HEART
1. Inspection
Precordium is the area of the chest wall lying in the front of the heart. The
subject should be examined in the recumbent and sitting position, and in
good light. The following are to be seen :
A. Shape of chest : is noted for any deformity, such as kyphosis ( forward
bending of spine ), scoliosis (sideward bending of spine ), or bulging of
the precordium (enlargement of heart )
B. Inspection for cardiac pulsation and apex beat : the precordium is
inspected from all angles to see if any pulsations are visible – any
pulsation in this region is called cardiac impulse or cardiac pulsation,
which is due to a forward systolic thrust of the apex of the left
ventricle.
APEX BEAT
Definition :
# 1 . It is the lowest and the outermost point of definite cardiac
pulsation.
# 2 . It is usually visible and palpable, and is located 8-10 cm {3 – 4
inches} from the midsternal line , in the left 5th intercostal space.
# 3 . Normally, it is almost always within the midclavicular line ( or
nipple line in the male ).
# 4 . Not always seen and it is normal.
APEX BEAT
The apex beat may not be visible in some normal persons because :
 It may be located behind a rib.
 The chest wall may be thick due to fat or muscle.
 The emphysematous lung may cover part of the heart.
 Pendulous breast .
C. Inspection for other pulsations: it is done in the precordium and
nearby regions.
 Arterial pulsations in the neck may be visible in hyperdynamic
circulation, as in – anxiety , hyperthyroidism , aortic
regurgitation , and hypertension.
 Pulsations to the right or left of the upper sternum may be due to
aortic aneurysm.
 Enlargement of the right ventricle, or enlarged left atrium due to
severe mitral gurgitation may cause pulsations in the left upper
parasternal region.
 Pulsations in the epigastrium are most commonly due to
pulsations of abdominal aorta (increased by emotional
excitement in thin individuals) , or enlargement of the right
ventricle, or due to hepatic pulsations from tricuspid
regurgitation.
 Pulsations in the superficial arteries of thorax may be visible in
coarctation of aorta .
2. Palpation
 Position of the Trachea
 Apex beat
For locating the position of the apex beat by palpation , the flat of
the hand is placed over the heart to feel for the apical impulse.
Once the cardiac pulsation is felt, the ulnar border of the hand and
then the tip of the index finger is used to locate and confirm the
point of apex beat already defined by inspection.
The apex beat should then be marked by a marker pen.
Position of apex beat :
The apex beat is located 8-10 cm from the midsternal line, in the left
5th intercostal space. To locate the 5th space, the sternal angle
(angle of Lewis ) –the junction between manubrium sterni and
body of sternum –is first located.
The second costal cartilage articulates with sternum at this level; the
2nd intercostal space is below the 2nd rib. The 5th space can now
easily be counted downward and located .
If the apex beat is not palpable, then patient is turned over to the
left side, or sits up and bends forward. However, despite all
efforts the apex beat may not be palpable .
NOTE –
One should always make it a habit, especially if the apex beat is not
palpable in its usual place, to palpate the chest on both sides,
with hands placed on either side, so as not to miss dextrocardia.
CHARACTER-
In normal persons, the apex beat gently raises the palpating finger.
The strength of this thrust increases after exercise, in
nervousness, in hyperthyroidism , or in left ventricular
hypertrophy.
IMPORTANCE OF APEX BEAT
Apex beat shifts in or forceful in -
1. Enlargement of heart
2. Pull or push of the mediastinum
3. Left Ventricular Hypertrophy
4. Mitral stenosis
THRILLS
When the vibrations from the heart or greater vessels are
transmitted to the palpating hand , they are called
thrills .
It is an palpable murmur and is produced when blood
passes through a narrowed valve or in abnormal flow
in congenital defects making a sound which when
heard through a stethoscope [MURMUR].
PARASTERNAL HEAVE
It is indicative of right ventricular hypertrophy elicited by
palpating with the ulnar border of our hand/paper/pen
, just left to the sternum where in we can feel/see the
lift of pen/paper.
It is an adjuvant to the other conditions as thrills & apex
beat displacement and is not present individually
3. PERCUSSION
This is to demarcate the borders of the heart
1. The upper border of the liver is demarcated by starting
the percussion downward along the midclavicular line
till the resonance changes to dullness.
2. Then starting in the mid-axillary line , 2/3 spaces above
the liver dullness , percussion is carried out toward the
right sternal margin.
3. Normally , right border of the heart , which is formed by
the right atrium , lies behind the sternum.
4. Left border of the heart –
The position of the apex beat is first located , then
percussion is done in the 5th 4th & 3rd intercostal spaces
starting in the left mid-axillary line and going towards
the heart till the notes change from resonance to
dullness.
5. Each point where the dullness appears is marked and
joined
6. The area of cardiac dullness increases in pleural
effusion , while decreased in emphysema.
4. AUSCULTATION
 AUSCULTATION [LISTENING]
You have to auscultate all the four areas of the heart, which are
named according to the valves from which the sounds arise . They are
1. MITRAL area – corresponds to the apex beat (left 5th intercostal
space)
2. TRICUSPID area – this area lies just to the left of the lower end of
the sternum.
3. AORTIC area – lies to the right of the sternum in the 2nd intercostal
space.
4. PULMONARY area – lies to the left of the sternum in the 2nd
intercostal space.
AREAS
AUSCULTATION AREAS
Please note that the corresponding valves of the heart do not
lie under these areas only the sounds produced by these
valves are heard best over these areas.
Over , all these areas of auscultation both the 1st and 2nd heart
sounds are heard clearly , though the 1st sound is heard
better in mitral and tricuspid areas while the 2nd sound is
heard better in aortic and pulmonary areas .
DIFFERENCES BETWEEN 1ST AND 2ND HEART
SOUNDS
1st heart sound 2nd heart sound
1.Because of 1.Because of
closure of A-V closure of
valves semilunar valves
2.Duration is 0.14s 2.Duration is 0.11s
3.Is of Lower 3.Is of higher
frequency frequency
DEVIATIONS OF NORMAL HEART SOUNDS ARE
IN -
1. Intensity
2. Split – lub dub
3. Gallop rhythm or triple rhythm – heard when heart
rate is above 100 per minute as seen in left
ventricular failure
4. Adventitious or extra sounds – these occur along with
or replace the heart sound called as murmurs .
Pericardial friction or Rub seen in pericarditis.
MURMURS
These may be systolic or diastolic having a different
sounds of either blowing or swishing in type of quality .
They should be identified as –
• Time of occurrence
• Region of maximum intensity
• Characteristics are noted
Valvular defects (change in size / deformities ) are the
usual causes for the murmurs & when these are palpated
{felt} , then they are called as thrills.
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