Physical Diagnosis

CARDIOVASCULAR SYSTEM
Dr. Moneen Magdalene Dumas Sarabosing

Detailed Course Outline

PROGRAM OUTCOMES

PERFORMANCE
INDICATOR

COURSE TOPICS
TEACHING LEARNING ACTIVITIES (TLAs)

To be able to recall
Basic Anatomy and
Physiology of the
Cardiovascular System

Formulate a Complete
Written History and
Perform Thorough
Physical Examination on
Cardiovascular System

To be able to
Formulate a Complete
History and Identify
important details
pertaining to
Cardiovascular System

ASSESSMENT METHODS

Brief Review on Basic Anatomy and

Physiology of the Cardiovascular
System

Class Participation and Oral

Examination

Discussion on the risk factors for

cardiovascular diseases to be
included in the History Taking

Written History

To be able to perform a
thorough Physical
examination on
Cardiovascular System

Discuss systematic and proper

techniques of Physical Examination
on Cardiovascular System

Practical Examination

To be able to identify
signs and symptoms in
patients with
cardiovascular
diseases through
History and Physical
Examination

Discuss on Normal and Pathologic

findings of Physical examination of
the Cardiovascular System

Practical Examination

Review of the Cardiovascular

Anatomy

Chambers of the Heart

Review of Cardiac Physiology

Determinants of your Blood Pressure

CO: Volume of blood ejected during 1 minute
: HR x SV
PRELOAD: Load that stretches the heart prior to
contraction
MYOCARDIAL CONTRACTILITY: ability of the
cardiac muscle when given a load
AFTERLOAD: vascular resistance

CVS HISTORY
Frequent complaints:
CHEST PAIN: Angina Pectoris, MI, Dissecting aortic
aneurysm
: intensity, location, radiation, timing, triggering
and relieving factors
Palpitation
Shortness of Breath, Orthopnea
Paroxysmal Nocturnal Dyspnea
Swelling and Edema

CVS Physical Examination

A. Jugular Venous Pressure Examination
B: ANTERIOR CHEST EXAMINATION
C: EXAMINATION OF THE EXTREMITIES

JUGULAR VENOUS PRESSURE

DETERMINATION
JVP :
- Pressure in the right
atrium, or central venous
pressure
- best assessed from
pulsations in the right
internal jugular vein
- IJ vein pulsation is
ussually evident in euvolemic
patients
- In Hypovolemic patients,
lower the head to identify
pulsation of IJV

Steps in Assessing for the Jugular

Venous Pressure
1. Make the patient comfortable. Raise the head slightly on a pillow to relax
the sternomastoid muscles.
2. Raise the head of the bed or examining table to about 30. Turn the
patient's Head slightly away from the side you are inspecting.
3. Use tangential lighting and examine both sides of the neck. Identify the
external jugular vein on each side, then find the internal jugular venous
pulsations.
4. If necessary, raise or lower the head of the bed until you can see the
oscillation point or meniscus of the internal jugular venous pulsations in
the
lower half of the neck.

Steps in Assessing for the Jugular

Venous Pressure
5. Focus on the right internal jugular vein. Look for pulsations in the suprasternal
notch, between the attachments of the sternomastoid muscle on the sternum
and clavicle, or just posterior to the sternomastoid.
6. Identify the highest point of pulsation in the right internal jugular vein. Extend
a
long rectangular object or card horizontally from this point and a centimeter
ruler vertically from the sternal angle, making an exact right angle. Measure
the vertical distance in centimeters above the sternal angle where the
horizontal object crosses the ruler. This distance, measured in centimeters
above the sternal angle or the right atrium, is the JVP.

JUGULAR VENOUS PRESSURE

DETERMINATION
Internal Jugular Pulsations

Carotid Pulsations

Rarely Palpable

Palpable

Soft, rapid, undulating quality,

usually with two elevations and two
troughs per heart beat

A more vigorous thrust with a single

outward component

Pulsations eliminated by light

pressure on the veins just above the
sternal end of the clavicle

Pulsations not eliminated by this

pressure

Level of pulsations changes with

position, dropping as the patient
becomes more upright

Level of the pulsation unchanged by

position

Level of pulsations usually descends

with inspiration

Level of the pulations not affected

by inspiration

JUGULAR VENOUS PRESSURE

DETERMINATION

Normal: 3-4 cm above the sternal

angle or 8-9 cm above the the
right atrium

Increased: Right sided heart

failure, constrictive pericarditis,
tricuspid stenosis, superior vena
cava obstruction

Obstructive lung disease:

Increase during expiration,
collapsed during inspiration

Hepatojugular/ abdominojugular
reflux

done to check a rise in jugular venous pressure in suspected congestive

heart failure.

Position patient on the bed so that the highest level of pulsation is

readily seen in the lower half of the neck

Place the palm of the hand on the center of the abdomen and slowly
press inward, exerting firm & sustained pressure for 30-60 secs.

Watch for a sustained increase in JVP which is >3 cm rise for at least 15
secs after resumption of spontaneous respiration

( seen in RV heart failure/CHF)

JUGULAR VENOUS PRESSURE

DETERMINATION

Carotid Artery Pulsation

Position the patient lying down with head elevated at 30. Located at the lower third of
the neck inside the medial border of the sternomastoid muscle.
Inspection: Inspect for pulsation
: Decreased pulsation: Decreased Stroke volume, atherosclerosis

and occlusion

Palpation: Palpate for the carotid artery pulsation (systolic ) at the lower
third of the neck medial to the SCM at the level of the cricoid cartilage on
both sides.
: Do not simultaneously palpate the carotids, this may result in
bradycardia and syncope due to the presence of hypersensitive carotid
: Small thready and Weak pulses- cardiogenic shock
: Delayed carotid upstroke - aortic stenosis
: Paradoxical Pulse respiratory variation
Auscultation: Check for carotid bruit on both sides.
: Bruit is a murmur sound in a blood vessel

sinus

Anterior Chest examination: The

Heart

Patient Position

Examination

Supine, with the head elevated

30

Inspect and palpate the precordium: the 2nd

right and left interspaces; the right ventricle; and
the left ventricle, including the apical impulse
(diameter, location, amplitude, duration).
Palpate the apical impulse if not previously
detected. Listen at the apex with the bell of the
stethoscope.

SEQUENCE OF CARDIAC
EXAMINATION

Left lateral decubitus

Accentuated Findings

Low-pitched extra sounds such as

an S3, opening snap, diastolic
rumble of mitral stenosis

Supine, with the head elevated

30

Listen at the 2nd right and left

interspaces, along the left sternal
border, across to the apex with
the diaphragm.
Listen at the right sternal border
for tricuspid murmurs and sounds
with the bell.

Sitting, leaning forward, after full Listen along the left sternal border and at the
exhalation
apex with the diaphragm.

Soft decrescendo diastolic murmur

of aortic insufficiency

Inspection
Patient in supine position with head of bed elevated at 30
Gross chest deformities (pectus excavatum? carinatum? bulgings or
prominences over the precordium? )
Epigastric pulsation may be visible (from abdominal aorta in thin patients)
Hypertrophied RV / overactive RV can also give epigastric pulsation
Pulsations the only normal pulsation seen in the chest is the apex beat
Apex beat or PMI: Location : 5th LICS, 7-9 cm from MSL
Size : less than 2 cm in diameter.
Can be normally invisible

Palpation
1. Apex Beat

- try supine position first, if not palpable may do partial left

lateral decubitus position or ask pt to fully exhale and

hold
breath while palpating.
Search first with palmar surfaces of several fingers, once you have found the
apex beat use fingertips for finer assessment and the with 1 finger.
Conditions that will result in undetectable apical impulse:
obesity, very muscular chest wall, emphysema
Condition of the heart that displaces Apical Impulse:
Dextrocardia, Situs inversus

Apex beat characteristic

a. Location at 5th L ICS, 7-9 cm from MSL (media to MCL)
If located lateral to the MCL, suggest cardiac enlargement or displacement
b. Diameter 1-2 cm ( > 2 cm > LV enlargement)
c. Ampitude small in amplitude and feels like a gentle tap
Increase amplitude is seen in hyperkinetic states (hyperthyroidism), LV
pressure overload (aortic stenosis/anemia) or LV volume overload (mitral
regurgitation)
d. Duration auscultate at the same time palpating for the
apex beat.
Normal duration is brief and occupies the first 2/3 of systole; does not
reach the S2
A sustained contraction that reaches the S2 > LV enlargement.
A sustained low contraction indicates DCM

Right Ventricular Heave/Lift

Right Ventricular Heave/lift place the tips of your curved fingers at the
left
sternal border in the 3rd, 4th and 5th ICS. Hold them flat
or
obliquely on the body surface
Normally, a brief systolic tap of low amplitude and duration is felt
especially for thin individuals which represents systolic impulse of RV
RV impulse with increase amplitude and duration occurs in RV pressure
overload (pulmonic stenosis or pulmonary HTN)

Thrills
Thrills most often accompany loud, harsh or rumbling murmurs (AS, PDA,
VSD, MS)
Use the base of the fingers or ulnar side of the hand
Apical thrills best felt with pt lying on left side and on breathold
Aortic and pulmonic thrills best felt on held expiration and pt leaning
forward

Pulmonic and Aortic Area

Pulmonic left 2nd intercostal space

Aortic Right 2nd intercostal space

Palpable P2

Increase pressure in
pulmonary artery (Pulmonary
Hypertension)

Palpable A2

Systemic hypertension
Dilated or Aneurysmal Aorta

Percussion - to delineate the right

and left cardiac borders.
Left Cardiac Border: delineate the left cardiac border by percussing the
3rd, 4th and 5th starting over the resonant areas near the axilla going
medially. Mark the skin where change from resonant to dullness occurs.
Does not exceed 4 cm (3rd ICS), 7cm (4th ICS) and 9 cm ( 5th ICS) from MSL.

Right Cardiac Border: Percuss the 3rd, 4th and 5th R ICS (normally there
should be no dullness beyond the right edge of the sternum from 3 rd -5th ICS
and should be reported as such)

AUSCULTATION
Auscultatory
areas/Locations :
2nd R ICS aortic valve
2nd L ICS Pulmonic Valve
Left sternal border from 2nd to
5th ICS Tricuspid valve
Apex ( 5th LICS, 7-9 cm from
MSL ) Mitral valve

AUSCULTATION
Note: Locations are not absolute for each heart valve sound. Murmurs of more than
1 origin may occur in a given area.

Sequence: either start to auscultate from the base of the heart to the apex or vice versa.
Use of stethoscope: use the diaphragm of the stethoscope to listen for high pitched sounds
like S1, S2, murmurs of aortic regurgitation (AR) or mitral regurgitation (MR) and pericardial
friction rubs. The bell of the stethoscope is more sensitive to low-pitched sounds like S3, S4
and mitral murmurs
Patient position: auscultate with patient in supine position
Left lateral decubitus position brings the left ventricle close to chest wall
Accentuates left-sided S3, S4, mitral murmurs
Ask pt to sit up, lean forward, exhale completely and hold the breath
This accentuates murmur of aortic regurgitation (AR)

Heart Sounds

S1: Mitral Valve Closure

S1 louder than S2 at the apex
S1 is due to closure of mitral valve (mainly) and tricuspid valve
S1 can be split but not always detected since the louder mitral valve may
mask the softer tricuspid valve
Where to ausculate for split S1 Left lower sternal border
Splitting of S1 does not vary with respiration

S2: Aortic and Pulmonic Valve

Opening
S2 is louder than S1 at the base of the heart ( 2 nd R & L ICS)
S2 is due to closure of aortic and pulmonic valves (A2+P2)
During expiration A2 and P2 fused to produce a single S2
During inspiration A2 and P2 separate slightly S2 Splits into 2 audible
components.
Where to auscultate for split S2 ? 2nd/3rd L ICS near sternu
Maneuvers to perform if split S2 persist during expiration
(maneuvers to fuse the split S2):
a.) ask pt to sit up from a supine position
b.) ask pt to strain down ( Valsava maneuver)
> normal S2 splitting if the above maneuvers will fuse the split S2

Causes of persistent split S2

1. Delayed closure of pulmonic valve seen in:
Right bundle branch block
Pulmonic stenosis
Atrial septal defect
Right ventricular failure
2. Early closure of aortic valve
Mitral regurgitation

Extra Heart Sounds during systole ejection sounds, systolic clicks of

mitral valve prolapse
Extra Heart Sounds during diastole S3, S4, opening snap
S3 is due to rapid ventricular filling as blood flows early in diastole from LA
to LV
Opening snap is due to the opening of a stenotic mitral valve

Heart Murmur

Systolic murmurs may indicate heart disease but often occur with a normal
heart ; systolic murmurs occur in between S1& S2
Diastolic murmurs usually indicate heart disease
Diastolic murmurs occurs in between S2 & S1

Murmurs if heard are characterized

according to:
Intensity 6 point scale for grading murmur intensity
Grade 1 very faint, heard only after the clinician has really
tuned in
Grade 2 quiet but heard immediately upon placing stet to chest
wall
Grade 3 - moderately loud
Grade 4 loud
Grade 5 very loud, heard with stet partly off the chest wall
Grade 6 heard with stet entirely off the chest wall

Timing systolic if in between S1 & S2

- diastolic if in between S2 & S1
Systolic murmur midsystolic murmurs ( AS or PS) or
pansystolic/holosystolic murmur (regurgitant flow across an AV valve MR,
TR, VSD)
Diastolic murmur early diastolic murmur (regurgitant flow across
incompetent AV or PV, middiastolic and late diastolic murmur/presystolic
(due to turbulent flow across AV valve ex. MS)

Quality blowing, harsh rumbling or musical

Pitch high, medium or low pitch
Location which ICS is the murmur heard?
Radiation transmission from the point of maximal intensity
- determined by the intensity of murmur and direction of blood flow
Ex. Murmur of AS often radiates to the neck (direction of
arterial flow)
Effect of Respiration murmurs from right side of the heart tend to
change more with respiration than do left-sided murmurs
Ex. a harsh, medium pitched, grade 3/6 midsystolic
murmur
at the 2nd R ICS with radiation to the neck, no
variation
with respiration.

Special Techniques
Maneuver

Standing; Strain
Phase of
Valsalva

Squatting;
Release of
Valsalva

Cardiovascular
Effect

Decreased left
ventricular
volume from
venous return to
heart
Decreased
vascular tone:
arterial blood
pressure

Murmurs
Increased left
ventricular
volume from
venous return to
heart
Increased
vascular tone:
arterial blood
pressure;
peripheral vascular
resistance

Mitral Valve
Prolapse

prolapse of
mitral valve

Click moves earlier

in systole and
murmur lengthens

Hypertrophic
Cardiomyopathy

outflow
obstruction

intensity of
murmur

Aortic Stenosis

blood volume
ejected into aorta

intensity of
murmur

Effect on Systolic Sounds and

prolapse of
mitral valve

Delay of click and

murmur shortens

outflow
obstruction

intensity of
murmur

blood volume
ejected into aorta

intensity of
murmur

Pulsus Alternans
- In pulsus alternans, the rhythm of the pulse remains regular, but the force of the
arterial pulse alternates because of alternating strong and weak ventricular
contractions
- is usually best felt by applying light pressure on the radial or femoral arteries
- Use a blood pressure cuff to confirm your finding
- After raising the cuff pressure, lower it slowly to the systolic levelthe initial
Korotkoff sounds are the strong beats. As you lower the cuff, you will hear the
softer sounds of the alternating weak beats.
- Pulsus alternans almost always indicates severe left-sided heart failure

Paradoxical Pulse
- If you have noted that the pulse varies in amplitude with respiration or if you
suspect
pericardial tamponade (because of increased jugular venous pressure, a rapid and
diminished pulse, and dyspnea, for example), use a blood-pressure cuff to check
for
a paradoxical pulse. This is a greater than normal drop in systolic pressure during
inspiration. As the patient breathes, quietly if possible, lower the cuff pressure
slowly to the systolic level. Note the pressure level at which the first sounds can
be
heard. Then drop the pressure very slowly until sounds can be heard throughout
the respiratory cycle. Again note the pressure level. The difference between
these
two levels is normally no greater than 3 or 4 mm Hg.
- A difference between these levels of more than 10 mm Hg indicates a
paradoxical pulse and suggests pericardial tamponade, possible constrictive