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CARDIOVASCULAR SYSTEM ASSESSMENT

INTRODUCTION
A careful and detailed clinical assessment is essential in order to assess the likely cause and severity of
symptoms, arrange appropriate investigations and referral, avoid unnecessary investigations, and to
assess individual risk of cardiovascular disease or cardiomyopathy.

PREPARATION OF PATIENT
Room that is warm & quiet
Examining table positioned so you can stand on the patients right side
Explain the procedure to the patient and obtain consent.
Make the patient in a comfortable position.
Arrange and keep the articles at bedside.
Wash the hand.

ARTICLES REQUIRED
A watch with a second hand
Stethoscope with diaphragm & bell
Centimeter ruler, Penlight
Tape measure
Sphygmomanometer

STEPS
I. History collection
II. Physical examination

I.HISTORY COLLECTION
a. Socio demographic data
Name:
Age:
Sex:
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Occupation:
Address:
Date of admission:
Diagnosis:
Date of physical assessment:
b. Symptoms & history of present illness

Dyspnea
- Assess
onset & duration
acute or sudden ( acute MI, MS, AF)
- Severity / grade
Grade I No limitation of any physical activity but occur on more than ordinary
exertion
Grade II Dyspnea on less than ordinary daily activity
Grade III - Dyspnea on less than ordinary daily activities
Grade IV limitations of all activities (Dyspnea at rest)
- Paroxysmal nocturnal Dyspnea (PND): CARDIAC ASTHMA
Main factors contributing pulmonary venous congestion
- Orthopnea
Indicate presence of severe left heart failures [pulmonary edema]
- Wheeze [seen in left sided cardiac failure due to bronchial mucosal congestion]
Chest pain
Site
Type
- Squeezing
- Burning
- Heaviness
- Constricting

Duration
Aggravating factors
Relieving factors
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Associated symptoms
Palpitation
Onset & duration
- Palpitations which starts & terminates may be due to PVT, AF
- Slow onset of palpitations with gradual termination of an attack may be due to - sinus
- tachycardia, anxiety
Precipitating factors
Reliving factors
Associated symptoms along with palpation
Syncope
- Sudden onset Stokes Adams attack , VT or seizure
- Gradual onset Hyperventilation, hypoglycemia
- Significance of associated symptoms along with an attack of syncope
Intake of insulin hypoglycemia
Intake of anti hypertensives Postural hypotension
Occurrence of chest pain Acute MI, Pulmonary embolism
Occurrence of neurological defect CVA
Cough with expectoration
- Dry, irritating nocturnal cough Pulmonary venous congestion (LHF)
- Pink, frothy sputum Pulmonary congestion & pulmonary edema
- Attack of recurrent bronchitis LHF
- Recurrent respiratory tract infection VSD, PDA
- Hemoptysis - MS, Pulmonary infarction (due CF with MS)
Cyanosis
Cyanosis clinically manifest when the O2 saturation is < 85 %
- Cyanosis: appearing in infancy congenital cardiac anomalies with right to left shunt (TOF)
- Cyanosis appearing after 6 weeks of age -VSD
- Cyanosis in suspected patients of congenital heart disease between the age of 5-20 Years
Reversal of left to right (Eisenmengers reaction)
- Central cyanosis - Skin & mucous membranes: occurring predominantly in tongue ,
lips( cyanotic heart disease , reversal of left to right shunt or LHF)
- Peripheral cyanosis Only on skin
(Arterial / venous obstruction, Raynauds phenomenon)
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Differentiating points Central cyanosis Peripheral cyanosis

Site Skin & mucous membrane Only skin

: tongue, lips
On breathing 100 % O2 Cyanosis reveres if due to lung No effect at all

disease : not if due to right to left

shunts
Warming the limb No effect Cyanosis decreases
Clubbing Usually associated Not associated
Periphery Warm Cold

Pedal edema, right hypochondria pain & decreased urine output

Suggest RVF
Swelling of feet ( Pedal oedema )
RHF
Right hypochondriac pain
This is due to enlarged & congested liver & scratching of its capsules
Decreased urine output
Cardiac failure
GI Symptoms
Anorexia, abdominal fullness, right hypochondria pain - RHF
Acute MI & digitals effect may also present with & vomiting
Fatigability
Chronic heart disease
Exclusive use of diuretics in patients with CCF, use of beta blockers care also cause swore
fatigue
Fever
Presenting symptoms in patients with infective endocarditis , rheumatic fever , or other
systemic infections with cardiac disease .

Miscellaneous history

Diabetes mellitus - Predisposes to coronary, artery disease & cardiac muscle

abnormalities.
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Hypertension: - Can use LVH, cardiac failure coronary artery disease & aortic valve

disease

Bronchial asthma: Beta blockers should be cautiously administered in patient of bronchial asthma with

hypertension (It may precipitate bronchopasam)

c. PAST HISTORY

Rheumatic fever, RHD ,tuberculosis

Recurrent attacks of lower respiratory infections since childhood its common in adult with left to

right intra cardiac shunts

Detection of murmur at school going age VSD, PDA

Enquire about dental carries, the recent dental extraction or genito urinary instrumentation - with

or without antibiotic to rule out possibility of infective endocarditis

Previous history of angina ,MI,CABG

History of cardiac evaluation and its findings to be detailed

Previous history of DM & HTN

Enquire about cyanotic spells & squatting after exertion

- Common in TOF

d. FAMILY HISTORY

Marriage : Consanguineous , children

Essential HNT, hypertensive cardiac disease in family member

History of coronary artery disease

Rheumatic fever

Sudden cardiac death in family

( Birth history & development history curry important in congenital heart disease had normal /

caessarian delivery, whether mother had any disease during pregnancy, whether the parents had
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consanguine marriage , mother was on any drugs during pregnancy ( eg: Lithium Ebstein anomaly

or vit D- Williams syndrome Development milestones.)

e. PERSONAL HISTORY

Weight loss - Common in patients with CCF

Sleep - Sleep may be distracted due to PND & orthopnea in patients with cardiac failure.

Enquiry about number of pillow used to sleep (nocturnal dyspnea result in loss of sleep in CCF

patients )

Smoking: enquire about the duration & the amount of cigarette smoking (CAD) (pack year

history)

Alcoholism Enquire the duration & the amount of alcohol consumption (Cardiomyopathy,

CCF, )

Urine output: Oliguria in CCF

Menstrual flow Flow may be decreased in female patients with CEF.

Bowel & bladder functions

Socio , economic conditions

Stress type of stress

Exercise pattern / activity pattern:

Health check up: cardiac disease screening.

f. TREATMENT HISTORY

Patient may be taking long acting penicillin Rheumatic fever

Patients of sublingual nitrate - Ischemic heart disease

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Patients with c/o postural hypotension , fatigability & palpitation may be on anti- hypertensive

Regularities in taking prescribed cardiovascular medication

Patients on anti neoplastic drugs cyclophosphamide, doxorubicin May experience LV dysfunction

Self monitoring of heart rate or blood pressure.

History of surgeries angioplasty ,CABG , corrective surgeries for congenital heart diseases.

GENERAL EXAMINATION
Built
- Assess whether the patients is tall / dwarf
Short stature & growth retardation can over in children with sever congenital heart disease
Persons with Turners syndrome , Downs syndrome are short.
Tall stature : Including lower segment > upper segment & arm span > height seen in
Marfans syndrome ( reverse of infantile proportions ) associated with aortic regurgitation ,
dissecting aneurysm of aorta and MVP

Nourishment:
- Extreme degree of emaciation law occur in severe chronic heat failure .
- Obesity Predominently central(coronary artery disease)
Pallor
- Pallor due to ( secondary to CCF, infective ,endocarditis )
Cyanosis
- central cyanosis is seen in the following cardiac condition
cyanosis congenital heart disease
reversal of left to right shunt
pulmonary edema
- peripheral cyanosis occur in
congestive cardiac disease
peripheral vascular disease
Jaundice
Seen in
- CCF with congestive hepato megaly
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- Cardiac cirrhosis
- Pulmonary infarction

Pedal edema
- Pitting edema seen in conjecture cardiac failure, constrictive pericardits , tricuspid valve disease
+1 Pitting Edema = 0 to inch indentation
+2 Pitting Edema = to inch indentation
+3 Pitting Edema = to 1 inch indentation
+4 Pitting Edema = More than 1 inch indentation

Clubbing
Clubbing is caused y prolonged hypoxemia of the extremities. Hypoxemia causes structural
changes in the distal phalanges over time. Nail clubbing is characterized by diffuse, bulbous
enlargement of the finger tips and/or the toe tips. The nails appear shiny and curve downward
with loss of the normal angulations between the nail bed and the distal interphalangeal joint.
Clubbing of the fingers and toes is easily recognized upon inspection. However, do not become
alarmed when clubbing present
- Cardiac causes
Cyanotic Congenital heart disease
Reversal of left to right shunts
Infective endocarditis

Lymphadenopathy

Conditions associated with generalized Lymphadenopathy may affect CVS Eg: SLE, lymphoma

B .EXTERNAL MARKERS OF CARDIAC DISEASE

Face
- Mitral facies molar flush & pinkish purple patches over the cheek Associated with mitral stenosis
with decreased cardiac output & systemic vasoconstriction
- High arched palate Marfans syndrome
Ear
Presence of crease in pinna of the ear Associated with increased incidence of coronary artery
disease .
Eyes: Exophthalmos Associated with thyroid heart disease
Blue sclera osteogenesis imperfecta with AR
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Skin & mucous membrane

- cyanosis , jaundice
Extremities
- Arachnodactyly with long extremities Marfans syndrome
- Short statured female, medial deviations of extended fore arm - Turners syndrome ( associated
with co arctation of aorta
Vital signs
- Pulse rate rhythm, volume
- B.P
- Respiratory date
- Temperature

C.EXAMINATION OF THE PRECORDIUM

Inspection
1. Pre cordial shape
a. Bulge (prominence )
- suggest cardiac enlargement before the occurrence of puberty
b. Pectus excavatum ( sternal depression ) may be associated with systolic murmur .
2. Apical impulse
- position left 5th intercostals space, 1cm medial to the left mid-clavicular line
3. Pulsation over the precordium : look for the following pulsation
a. left parasternal region
left parasternal heave & (sustained output left)
- produced usually by the right ventricular enlargement or hypertrophy (pulmonary hypertension ,
pulmonary stenosis )
- Patients is made supine & palpate during expiration , best left by the proximal part of the palm or
finger tips kept over the left lower parasternal area
Left parasternal left ( less sustained pulsation )
- Right ventricular volume over load without hypertrophy eg: ASD, TR
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b. left 2nd space

- occurs in conditions producing dilatation of pulmonary artery
c. Right 2nd space
- occur due to ascending aorta aneurysm , massively enlarged right atrium
d. Epigastric region
- causes :- Right Ventricular pulsation
- prominent aortic pulsation
e. Supra sternal region
- causes : unfolding of aorta aneurysm of arch of aorta
hyperkinetic states
4. Scar mark
- Midline scar over the sternum Indicate previous open cardiac surgery
- left infra mammary scar closed mitral valvotomy
5. Spine
- look for kyphoscoliosis
- severe kyphoscoliosis may lead to hypoxia and pulmonary hypertension

Palpation
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a. Apical impulse
b. Pulsation
c. Thrills
- Thrills vibratory sensations
- Thrills are best palpated with head of metacarpal bones
- Thrills suggest presence of a murmur
- Thrills are common with obstructive lesion with narrow orifice
- Diastolic thrills MS
- Continuous thrill PDA
d. Palpable sounds
- loud 1st sound MS
- Palpable 2nd heart sound palpable P2-2nd left intercostals space sever PAH
- Palpate A2 Palpable aortic component of 2 nd heart sound found in patient with system systemic
HTN

Percussion

a. Percussion of cardiac borders

1. Right cardiac border
- locate the upper border of liver by percussing downwards the mid clavicular line from the right 2 nd
intercostals space ( Right 5th intercostals space location of upper border of liver )
- Percuss the intercostals space above the liver dullness in mid-clavicular line moving towards the right
sternal border
- Observe for the change of percussion note ( from the normal lung resonance to dull note )
- Cardiac causes of dull notes outside the right sternal border cardiomegaly , pericardial effusion
2. Right 2nd intercostals space
- Normally resonant
- Dull percussion note Aneurismal dilatation of root of aorta
3. left cardiac border
- Find apical impulse
- start percussion outside the apex in the 5 th intercostal space moving medially towards the left sternal
boarder (apex)
Percussion note changes to dullness when one reaches the left cardiac border(apex)
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- Repeat the percussion in the same way in the upper intercostal space above the apex till the change of
note to delineate the left cardiac border ( 3rd & 4th spaces )
- normally in the adult male, ``the left cardiac boarder is within 10 cm from the mid sternal line in the
left 5th intercostal space
- In the 3rd intercostal space if the left cardiac boarder is 4 cm from the mid sternal line ,it suggest
cardiomegally
Conditions with displacement of the left cardiac- border outside the normal position
Cardiomegaly : left cardiac border will be corresponding to apex
Pericardial effusion: left cardiac border will be outside the apex (cardiac dullnes outside the apex
4. Percussion of left 2nd intercostal space
- normally resonant
- cardiac conditions producing dullness in the left 2 nd space are enlarged pulmonary artery & pericardial
effusion
AUSCULTATION

Auscultatory areas :
Mitral area - Corresponds to the apex
Tricuspid area left of the lower part of the sternum (4th &5th intecostal space)
Aortic area - Right of the sternum (in the 2nd intercostal space )
Pulmonary area left of the sternum (2nd intercostal space )
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Heart sounds
1. 1st heart sounds
- produced by the closure of mitral & tricuspid valve
- s1 indicates the onset of ventricular systole
Louds S1 Soft (muffled ) S1
Tachycardia Cardiac failure
MS Brady cardiac
TS Mitral regurgitation
Hyperkinetic state
Indicate pliable anterior leaflet of mitral
valve
2nd heart sounds
- produced by the closure of aortic & pulmonary valve
- 2 component (A2) & (P2)
- A2 occur earlier than P2
- Physiological splitting is seen in children & young adults
- Splitting increases with inspiration
Loud S2 Soft (Muffled ) S2
A2 A2
Systemic HTN Severe as
Aortic root dilatation P2
P2 Severe PS
Pulmonary artery HTN Fallots tetrology

3RD Heart Sound

- produced due to rapid filling of the ventricle during early diastole leading to sudden limitation of
expansion of the ventricular causing vibrations
- S3 is Physiological in healthy young adults , athletes pregnancy fever .
- Low frequency sound heard better with bell of the stethoscope
- S3 occurring after the age of 40 is always abnormal
- Causes of abnormal S3 cardiac failure , MR, dilated Cardiomyopathy

4th heart sound

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- 4th heart sound is produced in conditions with decreased ventricular compliance there will be
decreased atrial contraction producing ventricular distension causing the sound during presystolic
phase .
- Low frequency sounds & are better heard with the bell of the stethoscope
- Causes of 4th heart sound conditions associated with LVH &RVH
Murmurs
- murmurs are due to vibrations produced by the turbulent flow at the region of the valve, near the
valve
And abnormal communication within the heart
may be systolic
diastolic
continuous

-systolic murmurs ausculated in aortic, pulmonary stenosis , MR, TR, VSD

- Diastolic murmurs are heard after the 2nd heart sound and before the subsequent 1st heart sound
- Diastolic murmurs are auscultator in aortic regurgitation, pulmonary regurgitation, MS, TS
- Continuous murmurs begins in the systole ( after the first heart sound) & continues without
interruption through the 2nd heart sound. Eg: PDA, AV fistula, coronary AV fistula
Auscultation of neck
- Abnormal sound auscultated over arteries bruits
- Low pitched & more easily heard with bell of stethoscope
- Bruit ausculated in MR, PS, Carotid artery stenosis .Bruit is audible in hemodialysis patient
transmitted from their AV fistula
C. EXAMINATION OF

Pulse Rate
Rhythm
Volume
Character
Condition of vessel wall

a. Rate -60-100 / men

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b. Rhythm - Regular sinus

Abnormal rhythm
Regularly irregular
o Pulsus bigeminus
o Pulse trigeminus
o PAT
Irregularly irregular
o Atrial fibrillation
o Paroxysmal Atrial tachycardia / flutter
o
- Regularly irregular
Pulse bigeminus
Premature ventricular contraction occurring after each normal beat eg: Digitalis toxicity

c. Volume :
Volume alterations
- High volume pulse (bounding ) Eg: Fever, anemia , AR, MR
- Low volume pulse Eg: state of shock, CCF, Aortic stenosis
Sl .No Volume alteration Description Condition associated
1 Anacrotic pulse Slow raising pulse, peaking late in Sever AS
systole will have a
On the upstroke of carotid pulse
2 Dicrotic Pulse with 2 peaks , one in systole & - dilated cardiomyopathy
other one in diastole & sever CCF, cardiac
tampone, hypovolemic
shock
3 Bisferiens Pulse with 2 peaks (in systole ) -In moderate AS with
separated by a dip (mil systolic ) severe AR
-In severe AR

4 Collapsing Rapid upstroke followed up - severe AR, PDA

(Corrigans / water precipitous fall of pulse (made
hammer) prominent by raising the patients
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5 Pulse paradoxes
6 Parvus et tardus
arm)
Felt as decrease in pulse volume - cardiac tamponade
during normal inspiration due to - constrictive
accentuate full in inspiratory systolic pericarditis, severe air
pressure follow obstruction
Low volume pulse with slow - aortic stenosis
peaking

7 Pulse alternant Alternating large & small beats due Sever LVF
to alternating strong & weak
contractions

Grading of pulse :
Grade 0 Absent
1+ -feeble /low
2+-normal
3+- high /bounding
Condition of vessel wall
Palpate the radial artery with 3 fingers compress the artery with the proximal finger & empty
the useful by squeezing deistically with finger & roll the vessel over the head of the radius with the
middle finger to feel the wall of the empty vessel. In atherosclerosis, the artery can be palpated rolled
with the fingers.
Blood pressure
Cuff for adults
Width -12cm
Length -25 cm
MAP DBP+1/3 X Pulse pressure
Normal BP
Systolic - 100-140
Diastolic 60-90
Juglar venous pulse and pressure (JVP)- Represent the pressure changes within the right atrium
Differentiating features between JVP & carotid pulse.
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Parameters JVP Carotid pulse

Effect of posture Varies with posture Does not change

Effect of respiration Changes with respiration Does not change

Wave form Present & better visible Single upstroke better felt

Forms of pulsation Predominantly inwards Predominant outwards

Effect of finger pressure Abolishes pulsation No change . cannot be

at the root of neck obliterated

a. :- Due to Atrial systole

c :- Movement of tricuspid valve in to right atrium during ventricular systole
v:- Due to venous drilling of right atrium when the tricuspid valve is closed
x descent : Due to Atrial relaxation & due to downward movement of tricuspid valve during early
right ventricular systole
y descent : due to tricuspid valve opening with right Atrial pressure decrease
JVP -3-4 cm
JVP> 4cm from sternal angle at 45 patient position is said to be raised
CVP= 4cm +5 cm (Depth of center of right Atrium from the sternal angle ) = 9cm
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Heapatojuglar reflex- patient in 45 degree inclination . The examiner standing on the right side of the
patient should apply firm pressure over the mid abdomen for 20 seconds . Patient should be asked to
breathe normally (not to strain . In normal individual JVP rise is not more than 4 cm it is not sustained .
In RH sustained elevation of more than 4 cm is noted .
Peripheral signs of endocarditis
-Fever
- Pallor
- Clubbing
- Peripheral hemorrhages
- Splinter hemorrhages ( At the nail bed of fingers & toes )
- Oslers nodes tender subcutaneous nodules at pulp of fingers
- Jane way lesion Hemorrhagic or reddish macular lesion over palms & soles septic embolisation
- Roth spots pale centered oval hemorrhagic spots in the retina

Peripheral signs of rheumatic fever

Arthritis Major joints sudden, warm tender
Erythema marginatum Red muscular lesions with central pallor , non itching & round margins
found on trunk & proximal extremities
Subcutaneous nodules - nodule size 0.5-2 cm, none tender & firm
Found over the extensor surfaces of knee, elbow & occipyut
c. EXAMINATION OF PERIPHERAL VASCULAR SYSTEM

Venous System
History of
Limb pain (claudication) swelling
Associated with the mild degree of fever
Colour changes, ulcers of extremity
Occupations associated with long term standing
CCF
Extreme obesity
Pregnancy
Assess
Edema of limbs
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Colour Changes
Temperature, capillary refill
Tenderness
Homans sign
Moses sign, Trendelenburgs test
Dilatated veins, asymmetric calf swelling
Arterial System
History of :Limb pain and its relation with activity and rest
Distance walked & its relation with pain. Site of pain ( calf ), relieving factors
Effect of cold exposure and pain
Color changes, paresthesia
Assess Temperature of extremity
Clubbing, skin colour, pigmentation, ulcers capillary refill , hair distribution , nails,
pulse .
Tenderness

REFERENCE
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1. Tally J Nicholas and OConner Simon, clinical examination A systematic guide to

physical diagnosis. 5th edition, Elsevier publishers Australia 2006, page no 32-57
2. Cardiovascular History and Examination, available from,
http://www.patient.co.uk/doctor/Cardiovascular-History-and-Examination.htm
3.