Cardiovascular Systems

Examination
DR SEIF JUMA ABAS
MD

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Learning Objectives

• Identify common symptoms and conditions of the

respiratory system
• State the general considerations before starting systemic
examination
• Describe steps in conducting a cardiovascular examination

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 Main Symptoms
1. Dyspnoea
2. Orthopnoea
3. Paroxysmal Nocturnal Dyspnoea
4. Chest Pain
5. Cough/Haemoptysis
6. Oedema
7. Palpitations
8. Syncope
Conducting Cardiovascular System
Examination
General Considerations
• The patient must be properly undressed for examination
• Recommended position is patient propped up at 45º
• The examination room must be quiet to perform adequate
auscultation
• Examine cardiovascular system systematically by following
an “inverted J” technique

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General Considerations
• Observe the patient for general signs of cardiovascular
disease (finger clubbing, cyanosis, oedema, anaemia)
• In cardiac examination, it is recommended to start with
general inspection of the patient, then radial pulses,
measurement of heart rate and blood pressure, examination of
the neck (carotid pulse, jugular venous pulse), palpation of
the anterior chest wall, auscultation of the heart, percussion
and auscultation of the lung bases and finally examination of
the peripheral pulses and auscultation for carotid and arterial
bruits
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Arterial Pulses
• Rate, Rhythm and Volume
oCompress the radial artery with your index and middle fingers
o Note whether the pulse is regular or irregular
o Count the pulse for 30 seconds and multiply by two (2)
oIf the pulse is irregular, count for a full minute (60 seconds).
o While counting the rate feel whether the pulse is of normal,
small (weak/feeble) or large (strong) volume or absent.
o Record the rate, rhythm and volume

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 Interpreting Pulse Examination
Normal Bradycardia Tachycardia

60 to 100 beats per minute Less than 60 beats per minute More than 100 beats per
minute

Regular Regularly Irregular Irregularly Irregular

Evenly spaced beats, may Regular pattern overall with Chaotic, no real pattern, very
vary slightly with respiration "skipped" beats difficult to measure rate
accurately

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 Blood Pressure (BP)

• The room should be quiet and the patient comfortable and at rest
• Position the patient's arm so the anticubital fold is level with the
heart
• Center the bladder of the cuff over the brachial artery
approximately 2 cm above the anticubital fold
• Proper cuff size is essential to obtain an accurate reading
• Be sure the index line falls between the size marks when you
apply the cuff
• Position the patient's arm so it is slightly flexed at the elbow
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 Blood Pressure (BP)
• Palpate the radial pulse and inflate the cuff until the pulse disappears
• This is a rough estimate of the systolic pressure
• Place the Stethoscope over the brachial artery
• Inflate the cuff 20 to 30 mmHg above the estimated systolic pressure
• Release the pressure slowly, no greater than 5 mmHg per second
• The first appearance of the sounds marks systolic pressure
• Continue to lower the pressure until the sounds muffle and disappear. This is
the diastolic pressure
• Record the blood pressure as systolic over diastolic (e.g. 120/70mmHg)

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Interpreting Blood Pressure Examination
Systolic Diastolic Interpretation

140 90 Borderline High

130 85 High Normal
120 80 Normal Blood Pressure

110 75 Low Normal

90 60 Borderline Low
60 40 Too Low Blood
Pressure
50 33 Dangerous low Blood
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Pressure 10
 Look for and Document Findings on the Neck

• Position the patient supine with the head of the table elevated
at 45 degrees.
• The internal jugular vein is deep in the sternocleidomastoid
muscle, while the external jugular vein is lateral to it.
oTraditionally the use of external jugular vein to estimate
JVP is not allowed but the right external jugular vein and
right internal jugular vein give consistent readings of JVP
• Look for a rapid, double (sometimes triple) wave with each
heart beat
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 The Precordium
• Examination of the precordium is based on inspection,
palpation and auscultation
• Note that percussion is not a routine procedure in
examination of the precordium because always the dullness
of the heart will always be felt

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Inspection
• Always examine from the patient's right side
• Inspect the precordial contour e.g. normal, bulging
• Inspect for precordial movement e.g. hyperactivity
• Tangential lighting will make movements more visible

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 Palpations
• Palpate the precordium to locate apex beat (the point of
maximal impulse (PMI or apical pulse). Note the location,
and quality of the impulse (heave)
• Apex is normally located in the 4th or 5th intercostal space
along the left midclavicular
• Also find out whether there is thrill during palpation

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 Percussion
• line.

• Only done when the examiner needs to determine the cardiac

outline
• It is done with the patient lying in supine position
• The examiner starts percussion from the anterior axillary line
towards the sternum.
• The distance of more than 10.5 cm between the left border of the
heart (the point where the percussion note becomes dull) to the
middle of the sternum indicates cardiomegally.
• This sign is not useful in the presence of lung disease.
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 Auscultation

• The diaphragm and bell of the stethoscope permit appreciation of

high and low pitched heart sounds respectively
• The apex, lower left sternal angle, upper left sternal angle and upper
right sternal angle should be auscultated.
• These locations correspond to mitral, tricuspid, pulmonary and
aortic valve respectively
• First sound (s1) corresponds to mitral and tricuspid closure at the
onset of systole
• Second sound (s2) corresponds to aortic and pulmonary valves
closure following ventricular contraction
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Auscultation

• Third and fourth sounds (s3 and s4)

• These low frequency sounds occur in early and late diastole
respectively and they are abnormal sounds
• When present they give characteristic ‘gallop` to cardiac
rhythm
• Both sounds are best heard with the bell of the stethoscope at
the cardiac apex

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Auscultation

• Heart murmurs
o These are caused by turbulent blood flow within the heart and great
vessels
o Occasionally the turbulence is caused by increased blood flow
through a normal valve usually aortic or pulmonary producing an
innocent murmur
o However murmur may indicate valve disease or abnormal connection
between the left and right side of the heart (e.g. septal defect)
• Complete cardiovascular examination by examining the bases of lungs
for fine crepitation and the liver for tenderness
• These findings indicate left and right sided heart failure respectively
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 Key Points

• During cardiovascular examination, patient should be positioned

supine lying at 45degree (45o)
• Examine cardiovascular system systematically by following an
“inverted J” i.e. the pulse, BP, JVP and the Precordium
• Properly taking the pulse and blood pressure can give clue of
diagnosis
• When doing a physical examination a patient should be exposed only
a system examined at a time to maintain privacy and there must be
enough light

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References

• Braunwald, E. & Fauci, A.N. (2008). Harrison’s Principles

of Internal Medicine (17th ed.). Oxford: McGraw Hill.
• Davidson, S. (2006). Principles and Practice of Medicine
(20th ed.). Churchill:Livingstone.
• Kumar, P.J. & Clark, M. (2003). Textbook of Clinical
Medicine. (6th ed.). Churchill:Livingstone
• Swash, M. & Glynn, M. (2007). Hutchison’s Clinical
Methods (24nd ed.). London:Harcourt Publishers Ltd.

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 END

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