TRAINING MANUAL

FOR
THE CARDIOVASCULAR EXAMINATION

TRAINING MANUAL FOR THE CARDIOVASCULAR EXAMINATION

A. Vascular system
A-1. Upper limbs
1. Measure blood pressure in right arm. If hypertension is discovered, measure blood pressure in
left arm. When secondary hypertension is suspected, also measure blood pressure in both
lower limbs.
Blood pressure may be measured with the patient in a sitting or lying position. In each position,
the artery in which the blood pressure is to be measured should be at the level of the heart (at
the level of the fourth intercostal space in the sitting position; at the level of the middle axillary
line in the lying position). The patients arm should be resting on a smooth table or supported
by the examiner, and slightly flexed at the elbow.
Place cuff in correct location 2-3 cm above the antecubital crease
The examiner secures the blood pressure cuff snugly over the upper arm so that one finger can
be admitted under the cuff. The cuff should be positioned 2-3 cm above the antecubital crease
or elbow joint. Put the middle of the cuff over the brachial artery.
Palpate brachial artery
In order to determine the systolic blood pressure adequately and to exclude an error as a result
of an auscultatory gap, blood pressure is first assessed by palpation. In this procedure, the
right brachial or radial artery is palpated while the cuff is inflated above the pressure required to
obliterate the pulse. The examiner can locate the brachial artery which lies slightly medial to the
tendon of the biceps muscle in the antecubital fossae. The systolic pressure is identified by the
reappearance of the brachial pulse while the cuff is deflated.
The mercury column on the manometer dial should be properly calibrated with the pointer at 0
before the cuff is inflated (i.e, all the air should be pressed out of the cuff before it is inflated).
The stethoscope is placed firmly over the brachial artery. The examiner inflates the cuff slowly
but steadily until the brachial artery pulse disappears. Then he continues to inflate cuff 2.6-4.0
kPa (20-30 mmHg) higher, generally to about 21.3 kPa (160 mmHg).
Measure blood pressure over brachial artery twice and record the lower reading
Deflate the cuff slowly at the rate of about 0.26 kPa (2 mmHg) per second. The number where
the examiner hears the first pulse sound is the systolic pressure. The pulse sound will weaken
and then disappear. The number where the pulse sound disappears is the diastolic pressure.
The cuff must be completely emptied with the pointer at 0 before it is reinflated. The same
procedure may be followed for a second measurement of B.P. in the same or opposite arm.
The lower pressure is recorded as the patients blood pressure. After finishing the
measurement, the examiner deflates and rolls up the cuff, leans the manometer over a little so
the mercury column disappears, closes the mercury column switch, puts the balloon in order,
and closes the manometer.
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The normal adult blood pressure varies over a wide range. The normal systolic pressure varies
from 95 to 140 mmHg, generally increasing with age. The normal diastolic range is from 60 to
90 mmHg. Pulse pressure is the difference between the systolic and diastolic pressures. Mean
pressure can be approximated by dividing the pulse pressure by three and adding this value to
the diastolic pressure. The pressure should be determined in both arms, at least during the
initial evaluation. One may have a normal variation of up to 10 mmHg between the two arms.
When it is advisable to measure the blood pressure in the leg, such as when a congenital
narrowing (coarctation) of the aorta or dissecting aortic aneurysm is suspected, the palpation
method should be employed with the patient prone. Apply the cuff to the calf or thigh and
estimate the systolic level by palpating the tibial or dorsalis pedis artery. The systolic pressure
in the leg is normally equal to or higher than that in the arm. It is never critical to measure the
diastolic pressure in the leg.
2. Examine nail beds and hands. Check for cyanosis, clubbing.
Examine the color of nail beds and angle between nail and basic bed of the nail.
3. Check for capillary pulsation when wide pulse pressure is present
Examine capillary pulsation by pressing on nails of lips with a clean glass and looking at the
change of color from pink to white. Capillary pulsation occurs in aortic insufficiency and other
abnormalities associated with wide pulse pressure.
4. Palpate radial (wrist) pulse (at least 30 seconds), check for rate, rhythm.
The examiner places the pad of his index, middle and ring fingers over the radial artery. If
properly done, the examiner should be able to feel the artery pulsating under the examiners
fingertips. The radial pulse may be measured for 30 seconds, then the pulse per minute can be
found by multiplying by two. Attention should also be paid to the rhythm. The examiner should
not use his thumb to palpate any pulse. Check strength of the beat and elasticity of artery.
5. Palpate radial pulses simultaneously for symmetry
6. Check if there is water hammer pulse when wide pulse pressure is present.
It is a bounding pulse and reinforced by elevating the arm above the head. It occurs in aortic
insufficiency and other abnormalities associated with wide pulse pressure.
7. Palpate radial pulses and check for pulsus paradoxus when pericardial effusion is suspected
Pulsus paradoxus is an important sign of cardiac tamponade. It is found with tense pericardial
effusions and less frequently with chronic constrictive tense pericardial effusions and less
frequently with chronic constrictive pericarditis. The term refers to a weakening of the pulse
during normal inspiration. It is really a misnomer, however, because this is an exaggeration of
the normal (up to 10 mmHg) inspiratory decline in systolic blood pressure. Although pulsus
paradoxus may be detected by palpation, it is more reliably quantitated by using the
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sphygmomanometer. As the pressure in the cuff is slowly reduced, the first Korotkoff sound will
appear only during expiration (upper systolic level). As one lowers the pressure, the sounds
begin to occur in both inspiration and expiration (lower systolic level). A difference of greater
than 10 mmHg between these two points is abnormal. A common non cardiac cause of pulsus
paradoxus is the labored respiration of the patient with obstructive pulmonary disease (asthma,
emphysema).
A-2 Neck
8. Observe and approximately measure the venous pressure in either the internal or external
jugular vein
Check the jugular veins. Both external and internal jugular veins require careful inspection:
external vein for estimation of mean right atrial pressure, and internal vein for wave form as well
as pressure. Ask patient to assume a sitting or 30-45 degree semirecumbent position. If an
engorged external jugular vein can be seen above the clavicle, this indicates increased venous
pressure. This can be measured by adding 5 cm to the vertical distance in centimeters
between the sternal angle and the highest point of oscillation in the internal jugular veins.
Normally the highest point is on more than 3 cm above the sternal angle with the patient semirecumbent. In most positions, whether upright or supine, the sternal angle is roughly 5-7 cm
above the right atrium. Venous pressure varies from 5 to 10 cm of H20. Jugular venous
pressure elevation is an important sign of congestive heart failure, pericardial constriction,
pericardial effusion and superior vena cava syndrome which may result from mechanical
obstruction to venous inflow.
9. Observe neck, check for jugular venous wave form in internal jugular vein when the pressure
of vein is increased
Jugular venous pulses (wave form) are not easy to see normally, but may demonstrate specific
changes in complete atrioventricular block, tricuspid stenosis or regurgitation, and pulmonary
hypertension with right ventricular hypertrophy. This will be studied in Internal Medicine. It is
important to differentiate venous from arterial pulsations. The venous pulse is diffuse and
undulant. Venous pulsations in the neck are lower and more lateral, either under or just behind
the sternocleidomastoid muscle, without a palpable impulse. Arterial pulsations in the neck are
localized and brisk and are usually best seen high and medial to the sternocleidomastoid
muscle. The differential key points are as follows:
1) The level of visible pulsation in the neck vein descends with inspiration, (although the venous
waves may become more prominent during inspiration) because thoracic pressure decreases.
Arterial pulsations do not vary with respiration.
2) Venous waves can usually be obliterated by moderate pressure at the base of the neck.
Arterial pulsations can be obliterated by much more pressure.
3) Arterial pulsations are unaffected by position but the venous pulse usually disappears or
markedly decreases in a setting position.
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4) Venous waves are polyphasic during normal sinus rhythm, including A, C, V positive
deflections and X, Y negative deflections.
Perhaps the simplest method is to use vision and touch, observing the venous pattern while
palpating the opposite carotid pulse.
10. Palpate carotid artery bilaterally
With the pads of his fingers, the examiner exerts gentle pressure on patients carotid arteries in
the lower half of the neck on the inside edge of patients sternocleidomastoid muscle. One
should not palpate both carotids simultaneously as the patient might feel faint if both carotids
are palpated at the same time. In the elderly patient auscultation should occur before palpation
of carotid artery.
11. Auscultate both sides of neck, check for carotid bruit
Generally, use the diaphragmatic chestpiece of the stethoscope to listen for a bruit. Pay special
attention to the carotid artery and the lower half of the neck.
A-3. Abdomen
12. Auscultate abdominal aorta (midline of abdomen)
Place diaphragmatic chestpiece firmly in the midline of abdomen about 5 cm above the
umbilicus, auscultate for any bruits.
13. Auscultate renal arteries (RUQ and LUQ)
Place diaphragmatic chestpiece firmly about 5 cm above the umbilicus and 3-5 cm laterally to
the right and to the left of midline, auscultate for any bruits.
A-4 Lower limbs
14. Palpate femoral artery
Feel the femoral impulse midway between the pubic symphysis and the anterior superior iliac
spine. Palpate both sides for symmetry.
15. Auscultate femoral artery, note if there is pistol-shot sound and Duroziezs sign when aortic
insufficiency is suspected.
If one of the femoral pulses is diminished or absent, auscultation for a bruit is necessary, Place
diaphragmatic chestpiece firmly over the femoral artery and auscultate for any bruits. The
presence of a bruit may indicate obstructive aorto-ilio-femoral disease.
When aortic insufficiency is suspected, put the bell head on the femoral artery to auscultate for
a pistol-shot like Ta-Tasound. Press the distal edge of the bell over the femoral artery to hear
the to and fro bruit called Duroziezs sign. Both of the sounds are associated with increased
pulse pressure. Normally a systolic murmur can be heard in severe anemia only when the
proximal edge of the bell head is pressed over the femoral artery.
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16. Palpate dorsalis pedis pulse

Palpate both sides for symmetry. This pulse lies between the first and second metatarsal bone
on the dorsal surface of the foot. The pulse is most prominence of the navicular bone which
serves as a reliable landmark for palpation.
B. Heart
B-1. Patient in supine position
Inspection
Observe patient in the supine position, head elevated to 15-30 degrees (or 45 degree if
pathological condition is suspected.)
17. Inspect the general appearance.
Inspect position, breath, skin, face, eyes, mouth, chest configuration, extremities and nails to
evaluate.
18. Observe precordium.
Observe protrusion of the precordium and abnormal pulsations in this area. The character and
location of any visible cardiac impulses should be noted. For example, the location, range and
intensity of apical impulse should be observed. Minor precordial movements can be amplified
by observing during expiratory apnea. Check for other movement in other areas and if present
describe its location, range and intensity.
19. Tangential viewing is necessary
Examiner moves toward the foot of the bed when abnormality is discovered. Observing the
chest surface tangentially is helpful, allowing you to see the pulsations at their maximal
amplitude.
Palpation
Palpation serves: to confirm the observations made during inspection, to detect pulsatile
movements that are not visible, and to reveal thrills in the presence of specific cardiac diseases.
20. Palpate apical (mitral) area with two steps (palm first, then use fingertips). If the apical impulse
cant be felt, palpate with the patient on his left side.
The palm is especially useful for detecting thrill, fingertips are more helpful in detecting and
analyzing pulsations. First the examiner uses his palm or fingertips to palpate the apical
impulse, and then use two fingertips to further localize the impulse. The normal point of
maximum impulse (PMI) is usually in the fourth or fifth intercostal space, should not be felt in
more than one intercostal space, usually occupies less than the first half of systole, and should
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not be felt further to the left than halfway between the midsternal line and anterior axillary line.
Left ventricular hypertrophy produces a sustained, systolic apical impulse that may be
displaced laterally and downward. If the apical impulse cant be felt, palpate with the patient on
his left side.
21. Palpate pulmonary area (2nd ICS LSB)
Examine for any pulsation, thrill, and shock.
22. Palpate aortic area (2nd ICS RSB)
Examine for any pulsation, thrill, and shock.
23. Palpate precordium (3rd, 4th, 5th, ICS, both sides of lower half of the sternum).
Palpate any pulsation or thrill. Right ventricular hypertrophy and dilation produce a movement
that is usually more diffuse and can be felt along the left sternal edge.
Detection of thrills (palpable murmurs), is usually best accomplished using the sensitive area
just proximal to the metacarpophalangeal joints.
If an abnormality is discovered on palpation, there are 2 techniques for timing it:
1) Listen simultaneously to the heart with a stethoscope. When listening at the apex you may
watch the movement of the stethoscope as it usually reflects left ventricular contraction and can
note its relation to the first and second heart sounds. You can also listen at the apex while
watching or feeling impulses elsewhere on the chest.
2) Feel the carotid impulse in the neck with your left 2nd and 3rd fingers as you inspect or palpate
the chest. The carotid impulse is systolic.
The methods of detecting and significance of thrills and shock: Thrills most often accompany
loud harsh or rumbling murmurs such as those of aortic stenosis, patent ductus arteriosus,
ventricular septal defect, and mitral stenosis. In order to time what you observe in relation to the
cardiac cycle, you can use two methods mentioned above. Short, high-frequency vibrations are
known as shocks. They are palpable heart sounds, such as accentuated aortic or pulmonic
valve closure; there are usually due to hypertension.
Auscultation
The content of auscultation includes heart rate, rhythm, heart sound, murmur and friction rubs.
Endpieces of the stethoscope are of two standard types, the diaphragm and the bell. The
diaphragm acts as a filter, eliminating low-pitched sounds. High-pitched sounds, such as the
second heart sound, and high-pitched murmurs are best heard with the diaphragm. With the
bell, the skin becomes the diaphragm, and the natural frequency varies depending on the
amount of pressure exerted. When you try to detect low-pitched sounds and murmurs,
therefore, the bell should be applied as lightly as possible.

While auscultating, you should follow the following sequence: Pulmonic area, Aortic area, mitral
area, Tricuspid area, OR mitral area, Pulmonic area, Aortic area, Tricuspid area, because mitral
valve diseases are more common.
24. Using diaphragmatic chestpiece, auscultate apex at least 1 minute. If atrial fibrillation is
suspected, auscultate at apex and simultaneously palpate radial pulse. Note any pulse deficit.
Use diaphragmatic chestpiece to listen at apex, for the heart beat and rhythm, for at least 1
minute. Normally the rate ranges from 60-100 per minute, and the apical beat corresponds to
the radial pulse. The rhythm is regular and may change slightly with respiration, becoming
faster during inspiration and slower during expiration. This is called respiratory sinus arrhythmia.
Rate lower than 60 is called bradycardia. Rate higher than 100 is called tachycardia.
Many arrhythmias can be detected by careful auscultation and examination of the radial pulse
simultaneously at the bedside. Pay attention to pulse deficit. Some of the common arrhythmias
and their associated physical findings are listed in the Table 1 below. Pay attention to the
characteristics of sinus arrhythmia, premature beats, paroxysmal tachycardia, atrial fibrilation, etc.
TABLE 1. Characters of Common Arrhythmias
Common
Arterial Pulse
Cardiac
Arrhythmias
Examination
Premature contraction
lrregular
Loud S1, Premature cardiac cycle
With or without subsequent pause
Paroxysmal supraventricular Rapid, often diminished bouncing precordium with rate of
tachycardia
150-240 per minute
Atrial fibrillation
Irregular pulses deficit Variable intensity S1
It is important that identify the first and second sounds which divide the cardiac cycle into
systolic and diastolic phased, and listen to them separately. Place the diaphragm over the
pulmonary area. Normally there are two sounds: S1 and S2, S1 is lower pitched, softer and
longer than S2. With normal rhythm the interval between S1 and S2 is shorter than between S2
and the next S1.
Sometimes it may be difficult to identify S1 and S2, especially if they are abnormal. The
following three techniques may be of value:
1) It is easy to correlate the sounds with the apex impulse, which is systolic in timing. The S1
should just precede these phenomena because of the time required for the mechanical
transmission of the pulse wave.
2) The sounds can be confirmed by simultaneously feeling the carotid pulse, which is systolic in
timing. The pulse corresponds to S1.
3) You can familiarize yourself with the S2 at the pulmonic area, which is invariably the louder
sound, and then move the stethoscope inch by inch downward toward the apex, keeping the
S2 sound and rhythm clearly in your mind.
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Pay attention to the changes of intensity, nature and splitting of the heart sounds.
In some conditions, S1 may be intensified, i.e., this includes high fever, tachycardia, and
hyperthyroidism. In other conditions, S2 may be intensified, i.e., this includes systemic
hypertension and pulmonary hypertension.
The splitting of the heart sounds may indicate cardiac abnormalities but can also occur in
people with otherwise health hearts. Splitting of the second sound : In some individuals, there is
a slight difference in closure of the two valves. This results in the slight separation of the S2
called splitting of the second. The splitting is more prominent during inspiration. Splitting of the
first sound : S1 may also be split because the mitral valve closes slightly before the tricuspid.
If an extra heart sound is discovered in systole or diastole, note its timing, intensity and pitch.
Gallop: In people with an accentuated S3, there is a triple sound like a horse running, and, it is
called a gallop. It is often associated with tachycardia.
Opening snap: In patients with mitral stenosis there may be a higher pitched, short crackling
sound, immediately after S2, which is more predominant slightly to the right of the mitral area.
This is called the opening snap of the mitral valve. It occurs early in ventricular diastole prior to
the rapid filling phase.
If a heart murmur is discovered, auscultate it carefully. To detect murmurs, concentrate on the
interval between the heart sounds in each area. Differentiate systolic form diastolic murmurs. In
each area, use both diaphragm and bell.
Heart murmurs are of longer duration than heart sounds. They originate within the heart itself or
in its great vessels and are usually caused by one of several mechanisms, including: valve
stenosis, valve regurgitation, increased flow, shunting, great vessel dilation and rupture of a
valve or chordae.
Pay attention to timing, location, duration, quality, conduction, intensity, pitch and the
relationship with position of the body, respiration and exercise, etc.
*Timing: systolic, diastolic, continuous,
*Location: point of maximum intensity. Described in terms of anatomical landmarks: apex, left
sternal border, interspace and centimeters from the midsternal, midclavicular or one of the
axillary lines.
*Duration: Table2

TABLE2. Duration of Murmurs

Short Duration
Systolic early, late
Diastolic early, late

Long Duration
Pansystolic
Pandiastolic
Continuous

Medium Duration
Mid-systolic
Mid-diastolic

*Quality: blowing, rumbling, harsh or musical.

*Conduction: to determine its distribution and radiation. For example, murmurs in the aortic area
may radiate to the neck or down the left sternal border to the apex; those in the mitral area may
radiate to the axilla.
*Intensity: grade 1 to 6
Grade 1- very faint, heard only after listener has tuned in.
Grade 2 quiet but heard immediately upon placing the stethoscope on the chest
Grade 3 moderately loud, not associated with a thrill
Grade 4 loud, may be associated with a thrill
Grade 5 very loud, may be heard with stethoscope partly off the chest, associated with a thrill
Grade 6 may be heard with stethoscope off the chest, associated with a thrill.
*Pitch: high, medium, or low.
25. Auscultate pulmonary area (2nd ICS LSB)
Carefully auscultate for splitting of the second sound and murmurs. Note the changes in the
splitting related to respiration. Differentiate among narrow, wide, paradoxical or fixed splitting
related to pulmonary and pulmonary valvular diseases.
26. Auscultate aortic area (2nd ICS RSB)
Carefully auscultate changes in heart sounds and murmurs related to aortic, aortic valvular,
disease, etc.
27. Auscultate tricuspid area (4th, 5th, ICS both sides of lower half of sternum)
Pay attention to changes in heart sounds and murmurs related to tricuspid valvular, right
ventricular disease, etc,
B-2 Place patient in left lateral decubitus position
28. Palpate apical area
Ask the patient to roll partially onto the lift side. The apical impulse is always more powerful with
the patient on his left side, which usually displaces the apex 2-3 cm to the left and brings it
closer to the chest wall. For purposes of auscultation and analysis of the configuration of the

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apical impulse, this is a useful maneuver, but assessment as to location and duration of the
apical impulse should be made with the patient supine.
29. Auscultate apical area
Carefully listen at apex with the patient on his left side.
1) The third heart sound (S3) may be heard at the apex. It occurs after S2 and mimics S2, but is
softer. It is low pitched and is often difficult to detect. Auscultation of the cardiac apex in the
left lateral decubitus position with light application of the bell of the stethoscope is imperative
for detection of this sound. It can be heard easily in mitral area. In children and young
adults, it is often heard and doesnt indicate heart disease.
2) Diastolic rumbling murmur may be heard or increased at the apex with the patient in the left
lateral decubitus position.
B-3 Patient in sitting position
30. Palpate the same areas of the precordium as when patient was supine
Check for a pericardial friction rub. Pericardial friction rub is a to-and-fro grating sensation,
which is usually present during the systolic and diastolic phases of the cardiac cycle, especially
with the patient sitting erect and learning forward. It is best palpated in the left third and fourth
ICS at the sternal border. It is caused by a fibrinous pericarditis.
31. Auscultate each area of precordium use diaphragm. When atrial myxoma is suspected, use
bell
1) If you suspect an aortic murmur, especially the murmur of aortic regurgitation, ask the patient
to sit up, lean forward, exhale completely and hold his breath in expiration, with the
diaphragm of your stethoscope pressed on the chest, listen at the aortic area and down the
left sternal border to the apex, pausing periodically so the patient may breathe. The murmur
of obstructive hypertrophic cardiomyopathy may increase with the patient in the sitting
position.
2) Pericardial friction rub of pericardium is a to-and-from rubbing or grating sound, heard in
both phases of the cardiac cycle and unaffected by respiration, It is increased when the
patient is sitting upright or leaning forward, and when the examiner presses the diaphragm of
the stethoscope firmly against the patients chest wall.
3) If atrial myxoma is suspected and a rumbling diastolic murmur is not heard clearly, auscultate
the apical area with bell contacting the chest wall lightly and patient in a sitting position. This
will cause the murmur to increase and be easily heard.

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CHECKLIST FOR THE CARDIOVASCULAR EXAMINATION

A. Vessel
A-1. Upper limbs
1. Measure blood pressure in right arm. If hypertension is discovered, measure blood pressure in
left arm. When secondary hypertension is suspected, also measure blood pressure in both lower
limbs.
2. Examine nail beds and hands. Check for cyanosis, clubbing.
3. Check for capillary pulsation when wide pulse pressure is present
4. Palpate radial (wrist) pulse (at least 30 seconds), check for rate, rhythm.
5. Palpate radial pulses simultaneously for symmetry
6. Check if there is water hammer pulse when wide pulse pressure is present.
7. Palpate radial pulses and check for pulsus paradoxus when pericardial effusion is suspected
A-2. Neck
8. Observe and approximately measure the venous pressure in either the internal or external jugular vein
9. Observe neck, check for jugular venous wave form in internal jugular vein when the pressure of
vein is increased
10. Palpate carotid artery bilaterally
11. Auscultate both sides of neck. Check for carotid bruit
A-3. Abdomen
12. Auscultate abdominal aorta (midline of abdomen)
13. Auscultate renal arteries (RUQ and LUQ)
A-4. Lower limbs
14. Palpate femoral artery
15. Auscultate femoral artery, note if there is pistol-shot sound and Duroziezs sign when aortic
insufficiency is suspected.
16. Palpate dorsalis pedis pulse
B. Heart
B-1. Patient in supine position
Inspection
17. Inspect the general appearance.
18. Observe precordium.
19. Tangential lighting is necessary.
Palpation
20. Palpate apical (mitral) area with two steps (palms first, then use fingertips). If the apical impulse
cant be felt, palpate with the patient in his left side
21. Palpate pulmonary area (2nd ICS LSB)
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22. Palpate aortic area (2nd ICS RSB)

23. Palpate precordium (3rd, 4th, 5th ICS, both sides of lower half of the sternum).
Auscultation
24. Using diaphragmatic chestpiece, auscultate apex at least 1 minute, If atrial fibrillation is
suspected, auscultate at apex and simultaneously palpate radial pulse. Note any pulse deficit.
25. Auscultate pulmonary area (2nd ICS LSB)
26. Auscultate aortic area (2nd ICS RSB)
27. Auscultate tricuspid area (4th, 5th, ICS both sides of lower half of sternum)
B-2. Place patient in left lateral decubitus position
28. Palpate apical area
29. Auscultate apical area
B-3 Patient in sitting position
30. Palpate the same areas of the precordium as when patient was supine
31. Auscultate each area of precordium use diaphragm. When atrial myxoma is suspected, use
bell

ICM2_Update_2557
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