UNIT-III:

ASSESSMENT OF
CARDIOVASCULA
R SYSTEM

By: Farzana Kausar Khattak

Lecturer
INS-KMU
HISTORY
• Present illness, chief complaint
• Pain: Onset, course duration, quality precipitating &
alleviating factors
• Fatigue
• Palpitation
• Pain
• Dyspnea
• Cough
• Exercise

04/27/24 Farzana Khattak

 HISTORY
• Syncope
• Dependent Edema.
• Weight gain
• Nocturia
• Hemoptysis
• Cyanosis

04/27/24 Farzana Khattak

 PAST MEDICAL HISTORY
• Co-morbids / known case
• Previous illness
• Hospitalization
• Surgeries
• Use of drugs, recreational drug use, herbs
• Allergies

04/27/24 Farzana Khattak

FAMILY HISTORY
• HTN
• Diabetes
• Stroke
• Kidney disease
• Siblings & parents health

04/27/24 Farzana Khattak

PSYCOSOCIAL HISTORY
• Occupation
• Education
• Stress tolerance
• Coping
• Marital status
• Health habits, drugs, smoking etc.

04/27/24 Farzana Khattak

HEART PHYSICAL
ASSESSMENT
• General
• BP
• Arterial Pulse
• JVD
• Inspection, Palpation, Percussion & Auscultation
• Edema

04/27/24 Farzana Khattak

GENERAL APPEARANCE
• Patient Position
• Facial Expression
• Restless
• Quiet
• Pallor
• Cyanosis
• Level Of Consciousness

04/27/24 Farzana Khattak

CHEST PAIN
• Cardiac
• Vascular
• Pulmonary
• Gastrointestinal
• Neural
• Musculoskeletal
• Emotional

04/27/24 Farzana Khattak

CHEST PAIN ATTRIBUTES
• P - Provocative-palliative Factors
• Q - Quality
• R - Region
• S - Severity
• T - Timing

04/27/24 Farzana Khattak

ANGINA
• P - Exertion Sustained Before Pain (Lag), Emotion, Eating,
Cold, Subsides With Rest, Nitroglycerine
• Q - Deep, Pressure, Squeeze, Heavy, Strangle, Tight
• R - Mild to severe intensity, can radiate to Jaw, arms, neck,
back: Diffuse
• S - Mild to severe
• T - Episodic, “seizes”, Duration is short: 2-3 minutes (>/<10
minutes)

04/27/24 Farzana Khattak

ACUTE MI
• Steady, deep pain
• Lasts 20 minutes or longer
• May not be relieved by nitroglycerine
• Feeling chest contriction, crushing
• Nausea, vomiting, diaphoresis
• May occur at rest, with exertion or stress

04/27/24 Farzana Khattak

PERICARDITIS
• Deep constant or pleuritic pain
• Pericardial friction, may be related to resp.
• Increases with cough
• Sharp, stabbing
• Fever or recent infection
• Shallow breathing, sitting up, leaning forward relieves

04/27/24 Farzana Khattak

PALPITATIONS:
ARRHYTHMIAS
• Palpitation is an abnormality of heartbeat that ranges from
often unnoticed skipped beats or accelerated heart rate to
very noticeable changes.
• May not indicate serious disease.
• Cardiac
• Thyrotoxicosis (hyperthyroidism)
• Hypoglycemia
• Fever
• Anemia
• Anxiety
• Other Factors: Caffeine, Tobacco, Drugs

04/27/24 Farzana Khattak

SYNCOPE
• Fainting, Dizziness, Blackout
• Cardiac
• Metabolic
• Psychiatric
• Neurologic
• Orthostatic Hypertension

04/27/24 Farzana Khattak

 FATIGUE (MOST COMMON)
• Decreased cardiac output
• CHF
• Mitral valvular disease
• Anxiety & depression
• Anemia or chronic diseases

04/27/24 Farzana Khattak

DEPENDENT EDEMA
• CHF
• Worse as day progresses
• SOB
EDEMA GRADING
• +1 = 2mm
• +2 = 4mm
• +3 = 6 mm
• +4 = 8 mm

04/27/24 Farzana Khattak

 GENERAL
EXAMINATION
GUIDELINES

04/27/24 Farzana Khattak

THE PATIENT
Should have their shirt(s) off, or wear an
examination gown
Females nine years old and older should wear a
gown with the opening in the front
Should be calm and quiet

POSITION OF PATIENT
• Supine, with the head elevated 30°
• Left lateral decubitus
• Sitting, leaning forward, after full exhalation

04/27/24 Farzana Khattak

 THE STETHOSCOPE
• Should have a separate bell and diaphragm
• Bell allows in all sounds
• Diaphragm lets in middle and high frequency sounds
• Bell should be used relatively lightly (avoid diaphragm
effect)

04/27/24 Farzana Khattak

THE ENVIRONMENT
 Should be quiet (patient, family, clinic attendants, exam
room, surrounding areas)

 Should be well lighted.

04/27/24 Farzana Khattak

 EXAMINATION
• Inspection
• Palpation
• Percussion?
• Auscultation = S1, S2 at PMI (Point of Maxium
Impulse-Apex Beat)
• Aortic
• Pulmonic
• Tricuspid
• Mitral

04/27/24 Farzana Khattak

INSPECTION
 Can be insensitive.
 Mainly check apical impulse, carotid pulse.

 Assess carotid arteries.

 Inspection below and just medial to the angle of the jaw.

 Asymmetry can indicate Right Ventricular Enlargement.

 Increased anterior posterior chest diameter indicates

chronic air trapping/hyperinflation.
 Kyphoscoliosis can have cardiopulmonary effect.

04/27/24 Farzana Khattak

PALPATION
 Sometimes overlooked and not always helpful
 Use the most sensitive portion of the hand

 Lay the heel of R hand at left sternal border with fingertips

pointing to left axilla
 Palpate mitral, pulmonary, Rt & Lt ventricular areas, apical
impulse and thrills, carotid pulse

04/27/24 Farzana Khattak

04/27/24 Farzana Khattak
PALPATION

04/27/24 Farzana Khattak

PERCUSSION
• Percussion of the heart is not commonly done since chest X
ray study is a more accurate measure of heart enlargement.
• Usually not performed for cardiac borders, but for lung
fields.
• The sound will change from resonance (over the lungs) to
dullness (over the heart).
• Should be done in the upright position (even infants can be
held upright).

04/27/24 Farzana Khattak

AUSCULTATION
WHERE TO LISTEN:

Apex/5LICS (mitral area)

Left lower sternal border/4LICS (tricuspid and secondary
aortic area)
Right middle sternal border/2RICS (aortic area)

Left middle sternal border/2LICS (pulmonary area)

04/27/24 Farzana Khattak

• Aortic: 2nd right intercostal space.
• Pulmonary: 2nd left intercostal space.
• Tricuspid: 4th intercostal space, at lower left
sternal border.
• Mitral: 5th left intercostal space, 1 cm medial
to midclavicular line.

04/27/24 Farzana Khattak

04/27/24 Farzana Khattak
 HOW TO LISTEN
All heart sounds are generally low pitched “low frequency” and
difficult for the human ear to hear.
You may start auscultation from base to apex or from apex to
the base.
Assess:
1. Rate and rhythm of the beat.
2. Concentrates initially on sound "1", noting its intensity and
variations.
3. Then listen to Sound "2" for same characteristics.
4. Finally listen for extra sounds and for murmurs

04/27/24 Farzana Khattak

 LUB-S1
 Sound "1": caused by the closure of the atrioventricular
(tricuspid and mitral) valves. “Systole begins with Sound "1" &
extends to Sound "2“.
 High pitched, can be listened with diaphragm

 Best heard at the apex and Left Lower Sternal Border

 Tends to be more low-pitched and long as compared to S2

04/27/24 Farzana Khattak

DECREASED S1
 Slowed ventricular ejection rate/volume
 Mitral insufficiency

 Increased chest wall thickness

 Shock

 Aortic insufficiency

 First degree AV block

04/27/24 Farzana Khattak

INCREASED S1
• Increased cardiac output

• Increased A-V valve flow velocity (acquired mitral

stenosis, but not congenital MS)

04/27/24 Farzana Khattak

 DUB-S2
• Results from closing of the aortic & pulmonary valves.
• Sound 2 louder than Sound 1 at the base of heart, and is
quieter than Sound 1 at the apex.
• Divided into A2 and P2 (aortic and pulmonary closure
sounds) Normally split due to different impedance of
systemic and pulmonary vascular bed.
• Best heard at 2LICS
 Higher pitched than S1-better heard with diaphragm

04/27/24 Farzana Khattak

S2 SPLITTING (NORMAL)
 Normally split due to different impedance of systemic and
pulmonary vascular bed.

04/27/24 Farzana Khattak

EXTRA HEART SOUNDS
S3 (GALLOP)
Usually physiologic
Low pitched sound, occurs with rapid filling of ventricles in
early diastole causes vibrations of ventricular walls , and this
known as sound "3" .
•Sound "3" best heard at the apex with bell of stethoscope.
Best heard with patient supine or in left lateral decubitus

Increased by exercise, abdominal pressure, or lifting legs

LV S3 heard at apex and RV S3 heard at LLSB

04/27/24 Farzana Khattak

S4 (GALLOP)
 Nearly always pathologic
 Can be normal in elderly or athletes

 Low pitched sound in late diastole

 Sound "4": occur after Sound "3" (late diastolic filling), occur
from vibrations of ventricular wall or vibrations of the
valves.
 Better heard at the apex in the supine or left lateral
decubitus position
 Occurs separate from S3

04/27/24 Farzana Khattak

S4 ASSOCIATIONS
 Congestive cardiac failure(CCF)
 Severe systemic HTN

 Pulmonary HTN

 Myocarditis

04/27/24 Farzana Khattak

EJECTION / SYSTOLIC
CLICK
 Usuallypathologic
 Snappy, high pitched sound usually in early systole

 Due to vibrations in the artery distal to a stenotic valve

04/27/24 Farzana Khattak

WHOOP (SOMETIMES
CALLED A HONK)
 Loud, variable intensity, musical sound heard at the apex in
late systole
 Classically associated w/ and MR(Mitral Valve Regargitation)

 Seen with VSD’s closing, w/ an aneurysm,

 Some whoops evolve to become systolic murmurs

04/27/24 Farzana Khattak

FRICTION RUB
 Creaking sound heard with pericardial inflammation.
 The sound of a pericardial rub resembles the sound of
squeaky leather and is often described as grating, scratching,
or rasping.
 Changes with position, louder with inspiration.

04/27/24 Farzana Khattak

MURMUR
 Sounds made by turbulence in the heart or blood stream
 Can be benign (innocent, flow, functional) or pathologic

 Murmurs are the leading cause for referral for further

evaluation
 Don’t let murmurs distract you from the rest of the exam!!

04/27/24 Farzana Khattak

CARDIAC EXAM AND
MURMUR GENERAL
DESCRIPTORS

 Various combinations used for all normal and abnormal

heart sounds

04/27/24 Farzana Khattak

GENERAL DESCRIPTORS
 Timing within the phase
 Shape

 Character/quality

 Location of maximum intensity on the precordium

 Radiation of murmur

 Intensity

04/27/24 Farzana Khattak

 TIMING OF THE MURMUR
RELATIVE TO THE
CARDIAC CYCLE
Most benign murmurs are early to mid systolic.
• Diastolic murmurs almost always indicate pathology.
• A systolic murmur is present between S1 and S2
• A diastolic murmur is present between S2 and S1
• A continuous murmur is present in systole and diastole

04/27/24 Farzana Khattak

 LOCATION
Most important identifying characteristics of a murmur.
• This is determined by the site where the murmur
originates. Find the location by exploring the area where
you hear the murmur
• For example, a murmur best heard in the 2nd right
interspace usually originates at or near the aortic valve.

04/27/24 Farzana Khattak

RADIATION
• This reflects not only the site of origin but also the intensity
of the murmur and the direction of blood flow.
• For example A loud murmur of aortic stenosis often radiates
into the neck (in the direction of arterial flow).

04/27/24 Farzana Khattak

 INTENSITY
• Intensity is synonymous with the loudness or amplitude of a
sound wave.
• Grade 1: very soft and heard with difficulty
• Grade 2: soft but readily heard with stethoscope
• Grade 3: moderately loud, no thrill.
• Grade 4: Loud with thrill (palpable vibration of the chest wall).
Louder than the first and second heart sounds.
• Grade 5: Thrill, very loud, but not audible without a
stethoscope
• Grade 6: Thrill, audible without a stethoscope

04/27/24 Farzana Khattak

 QUALITY
This is described in terms such as blowing, harsh, rumbling, and
musical.

PITCH
•The frequency of a murmur depends on the pressure gradient
across a valve or narrowing.
•Low-pitched murmurs are heard best with a bell, and high-
pitched murmurs are heard best with a diaphragm.

04/27/24 Farzana Khattak

OTHER ASSESSMENTS
JUGULAR VEIN PRESSURE
Assess JVD which reflects increased filling volume and
pressure on (R) side of heart
 JVD associated with (R) HF,
•(Normal is 4cm)
PULSE DEFICIT
•The difference between apical HR and peripheral pulse
associated with heart blocks
PULSE PRESSURE
The difference between systolic & diastolic pressure
04/27/24 Farzana Khattak
04/27/24 Farzana Khattak
 AGE RELATED CHANGES
• Decreased myocardial contractility
• Thickening of endocardium & valves
• Coronary arteries rigid & thickened
• Decreased elasticity of vessel walls
• Decreased internal diameter of vessels

04/27/24 Farzana Khattak

 DOCUMENTATION
• No visible pulsation on anterior chest.

• PMI palpable at left 5th ICS.

• Heart Auscultation: rate 68 beats/ min, regular rhythm,

S1and S2 identified.

• No extra heat sounds, murmur or rubs.

April 27, 2024 Unit-III (Cardiac Assessment) || By: Noor 54

04/27/24 Farzana Khattak