PHYSICAL EXAMINATION CARDIOVASCULAR SYSTEM

Mervyn Gotsman M.D.

Department of Cardiology, Hadassah University Hospital, Hebrew University Hadassah Medical School, Jerusalem, Israel

The Wiggers Diagram

PHYSICAL EXAMINATION CARDIOVASCULAR SYSTEM

CARDIOVASCULAR SYSTEM

General examination

General examination Arterial pulse brachial, Jugular Venous Pressure The heart
Inspection Palpation Percussion Auscultation carotids, peripheral

Walking and gait Sitting or lying Orthopnoea Cyanosis (central or peripheral), anaemia, jaundice Fever and embolic signs Right heart failure (JVP, dependent oedema, hepatomegaly, ascites, pleural effusions) Left heart failure (dyspnoea, tachypnoea, orthopnoea, cough, basal crepitations Pulmonary disease Sytemic disease: thyrotoxicosis, thyrotoxicosis, scleroderma, scleroderma, lupus erythematosis, erythematosis, etc

Left Heart Failure

Elevated LVEDP LAP PVP Pulmonary congestion Dyspnoea Orthopnoea Cough Tiredness and lethargy Weight

Right Heart Failure

JVP Hepar Ascites Ankle Edema

PHYSICAL EXAMINATION CARDIOVASCULAR SYSTEM

Arterial pulse
Radial artery

Arterial pulse Jugular Venous Pressure Cardiac Examination:

Inspection Palpation Percussion Auscultation

Arterial pulse
Radial artery

120 80

Arterial pulse
Carotid artery

Heart rate: ( 6060-100 ). Rhythm: Regular

Amplitude/Contour:

Hypokinetic ( weak ) - Hypovolemia

120 80

Irregular: Irregular: Sinus arrhythmia Occasional - Premature beats - Dropped beats Totally - irregular

Heart failure Aortic stenosis Fever, anemia, hyperthyroidism AR, bradycardia, atherosclerosis

Hyperkinetic increased stroke volume

120 80

Arterial pulse: Carotid artery

Bisferiens - HOCUM Collapsing AR Parvus et tardus - AS Alternans - Heart failure Bigeminal - Premature beats Paradoxical - Pericardial tamponade Dicrotic Cardiomyopathy Filiform - shock
Amplitude/Contour:

Pulsus parvus et tardus

The phono-carotid pulse tracing:

Phono

Carotid pulse tracing

Long systolic ejection murmur Paradoxical split of the 2nd heart sound Pulsus parvus et tardus

- Constrictive pericarditis

PHYSICAL EXAMINATION CARDIOVASCULAR SYSTEM

Jugular Venous Pressure 45o angle

Arterial pulse Jugular Venous Pressure The heart

Inspection Palpation Percussion Auscultation

Jugular Venous Pressure

Jugular Venous Pressure

Patient at 30 degrees and oblique lighting Differentiation from arterial pressure Two waves ( if not in A fib) Changes with position Obliterated with pressure Decreases with respiration

Jugular Venous Pressure

Reflects
Right atrial pressure Blood volume Tricuspid valve Diastolic events in the right ventricle

Jugular Venous Pressure

Estimate CVP Maximal 3cm from sternal angle + 5cm from atrium (Right atrial pressure) Increased pressure Right sided heart failure Constrictive pericarditis Tricuspid stenosis Obstructed SVC Increased intrathoracic pressure

External jugular vein Internal jugular vein

Venous Pressure

Jugular Venous Pressure

Jugular Venous Pressure

a x
S1 S2

wave

descent
S1 S2

Angle of Lewis Systole Diastole

Jugular Venous Pressure

Amplitude of pulsations

Jugular Venous Pressure

Diagnosis ?

a wave, x descent, v wave, y descent

Absent a wave - atrial fibrillation Giant a wave - tricuspid Stenosis, PHT Cannon a waves - AV dissociation Large v wave - tricuspid regurgitation Slow y descent tricuspid stenosis

Atrial contraction, relaxation, atrial filling, emptying

1 '
A V ' Y'

Jugular Venous Pressure

Diagnosis ?

: 2 '
. . .- . . . - .

Jugular Venous Pressure

Hepatojugular reflux
Sustained rise of JVP Heart failure. Kussmaul Kussmauls sign - Increase with inspiration Constrictive pericarditis Heart failure

PHYSICAL EXAMINATION CARDIOVASCULAR SYSTEM

Arterial pulse Jugular Venous Pressure Cardiac Examination

Inspection Palpation Percussion Auscultation

Cardiac Examination: Inspection

Cardiac Examination: Inspection

Cardiac pulsations PMI Parasternal lift S3, S4 Dyskinesis Aneurysm

PHYSICAL EXAMINATION: CARDIOVASCULAR SYSTEM

Cardiac Examination: Palpation

Arterial pulse Jugular Venous Pressure Cardiac Examination

Inspection Palpation Percussion Auscultation

Areas of palpation

Apical impulse (PMI) Left sternal border Left and right 2nd interspace Epigastric area Thrills

Cardiac Examination: Palpation

Cardiac Examination: Palpation

Apical impulse (PMI)

Apical impulse (PMI)

Cardiac Examination: Palpation

Cardiac Examination - Palpation

Right Right
Left parasternal lift
ASD Pulmonary incompetence Tricuspid incompetence - seesee-saw motion Pulmonary hypertension Pulmonary stenosis Mitral incompetence

ventricular volume load

ventricular pressure load

Apical impulse (PMI)

Left atrial lift

Cardiac Examination: Palpation

Cardiac Examination: Palpation

Left 2nd interspace - Pulmonic: PHT Right 2nd interspace - Aortic: HTN Epigastric area -

Right ventricle in hyperinflated lungs Thrills - Murmurs grade 4+

Left sternal border - Right ventricle

The normal apex-cardiogram

The normal apex cardiogram:

Apexcardiogram in aortic stenosis

Prominent outward presystolic motion Prolonged sustained outward motion fills all of systole
a

Normal outward motion fills the first third of systole Small presystolic outward motion Rapid filling wave

RFW

Apexcardiogram in aortic stenosis

4 '

Prominent outward presystolic motion Prolonged sustained outward motion fills all of systole

. . . . . . . .

Arterial pulse Jugular Venous Pressure Cardiac Examination

Inspection Palpation Percussion Auscultation

PHYSICAL EXAMINATION CARDIOVASCULAR SYSTEM

Cardiac Examination: Auscultation

Areas of auscultation
Apex Left Sternal Border Aortic Pulmonic

Cardiac Examination: Auscultation

Cardiac Examination: Auscultation

Areas of auscultation: Apex

Areas of auscultation: Left Sternal Border

Cardiac Examination: Auscultation

Cardiac Examination: Auscultation

Diaphragm ( high
Position

pitched ) - S1, S2, AR, MR, clicks, friction rubs Bell ( low pitched ) - S3, S4, MS.

Stethoscope

Areas of auscultation: Aortic, Pulmonic

Left decubitus - S3, S4, mitral sounds ( MS ) Lean forward and exhale - Aortic (AR)

Cardiac Examination: Auscultation

Cardiac Examination: Auscultation

Lean forward and exhale

Left decubitus

The Wiggers Diagram

Cardiac Examination: Auscultation

First heart sound (S1):

Closure of Mitral and Tricuspid valves
S1
x y MT

S2

S1

S2

Systole

Diastole

MT

Cardiac Examination: Auscultation

First heart sound (S1) Intensity
LV dp/dt P-R interval
Short PR loud Long PR - soft

Cardiac Examination: Auscultation

Second

heart sound (S2):

S1 A2 P2 S1 A2 P2

Accentuated: Accentuated:

Closure of Aortic and Pulmonic valves

Expiration Systole Diastole Inspiration

Diminished Splitting

Short PR interval high cardiac output states MS 1st degreeAVB, degreeAVB, MR. RBBB VPB VPBs.

Normal

Cardiac Examination: Auscultation

Cardiac Examination: Auscultation

Second

heart sound (S2):

S1 A2 P2 S1 A2 P2

Closure of Aortic and Pulmonic valves

Expiration Systole Diastole Inspiration

Second

heart sound (S2):

S1 P2 A2 S1 A2 P2

Closure of Aortic and Pulmonic valves

Expiration Systole Diastole Inspiration

Normal but wide

Reversed splitting

Cardiac Examination: Auscultation

Second heart sound (S2-A2, P2) SingleSingle- common ventricle or truncus, truncus, valve atresia Fixed splitting - ASD Splitting is due to differences in LV and RV systolic duration RVET>LVET Wider splitting Paradoxical splitting
Longer RVET - overloading Shorter LVET - underloading Longer LVET -overloading Shorter RVET -underloading

Cardiac Examination: Auscultation

Third heart sound ( S3 )

Sudden expansion of the ventricle by rapid ventricular filling Often palpable Physiological in young people and during exercise Pathological in volume overload and heart failure S1 S2 S3 S1 S2 S3

Systole

Diastole

10

Cardiac Examination: Auscultation Fourth heart sound ( S4 ) Sudden expansion of the ventricle

(right or left) by atrial contraction Physiological in athletes, older people. Pathological due to decreased compliance (right or left ventricle)
S1 S2 S4 S1 S2

Cardiac Examination: Auscultation

Physiological in athletes, older people Pathological due to decreased compliance
(thick wall or poor relaxation Pressure overload - HTN, AS Ischemia, Cardiomyopathies Right sided S4: pressure overload ( PS, PHT ) Accentuated by exercise

Fourth heart sound ( S4 )

Systole

Diastole

Cardiac Examination: Auscultation

Cardiac Examination: Auscultation Ejection sound : Left or right

through the valve

Ejection sound
Aortic Pulmonary

Extra systolic sounds:

Midsystolic click Mitral Valve Prolapse Opening snap Mitral Stenosis

Valve stenosis Increased blood flow

Extra diastolic sounds:

Arterial hypertension Dilatation of the artery

Cardiac Examination: Auscultation

Ejection sound: Aortic Stenosis

Ej S1 S2 S1 S2

Extra systolic sounds:

Cardiac Examination: Auscultation

Ejection sound: Aortic Stenosis

Ej S1 S2 S1 S2

Extra systolic sounds:

Systole

Diastole

Systole

Diastole

11

Cardiac Examination: Auscultation

Ejection sound: Aortic Stenosis

Ej S1 S2 S1 S2

Extra systolic sounds:

Cardiac Examination: Auscultation

Midsystolic click:
S1 Cl S2

Extra systolic sounds:

Mitral Valve Prolapse

S1

S2

Systole

Diastole

Systole

Diastole

Opening snap: Mitral or tricuspid stenosis Severe stenosis shorter 22-os interval
S1 S2 OS S1 S2

Cardiac Examination: Auscultation Extra diastolic sounds:

Cardiac Examination: Auscultation

Murmurs:

Systole

Diastole

Timing - Systolic - ( mid, pan ) Diastolic - ( early, mid, late ). Shape - crescendo, decrescendo, plateau. Location Radiation - Axilla, Axilla, Back,Suprasternal notch Intensity ( 1 - 6 ). Pitch Quality - blowing, harsh, rumbling, musical Changes with physiological interventions exercise, standing, squatting, Valsalva

Cardiac Examination: Auscultation Murmurs:

Ejection:
S1

Left and right ventricular outflow tract stenosis (subvalvular , (subvalvular, valvular, valvular, ring, supravalvular) supravalvular)
S2 S1 S2

Cardiac Examination: Auscultation Murmurs:

Ejection:
S1

Left and right ventricular outflow tract stenosis (subvalvular , (subvalvular, valvular, valvular, ring, supravalvular) supravalvular)
S2 S1 S2

Systole

Diastole

Systole

Diastole

12

Aortic stenosis - murmur

Aortic stenosis

The normal apex-cardiogram

The normal apex cardiogram:

Apexcardiogram in aortic stenosis

Prominent outward presystolic motion Prolonged sustained outward motion fills all of systole
a

Normal outward motion fills the first third of systole Small presystolic outward motion Rapid filling wave

RFW

Apexcardiogram in aortic stenosis

Prominent outward presystolic motion Prolonged sustained outward motion fills all of systole

Pulmonary stenosis

13

Right ventricular outflow tract stenosis

Hypertrophic myopathy

Interventricular septum

Abnormal mitral valve chordae

HOCUM

Mitral incompetence

Large a wave

Double pulse

Systolic ejection murmur

Double apex

Response of murmur

Cardiac Examination: Auscultation Murmurs:

Cardiac Examination: Auscultation Severe MR

Pansystolic: Pansystolic:
S1

Mitral, Tricuspid Regurgitation, Ventricular septal defect

S2 S1 S2 S1

A 2 P2 S 3

S1

S2

Systole

Diastole

Systole

Diastole

14

: 5 '
: - . - . - . - . -

Cardiac Examination: Auscultation Murmurs:

MidMid-diastolic+presystolic Mid

Mitral, tricuspid stenosis

diastolic flow murmurs

S1 S2 S1 S2

Systole

Diastole

Cardiac Examination: Auscultation

Mitral stenosis 1. Opening snap 2. MidMid-diastolic murmrur 3. Presystolic accentuation 4. Loud first heart sound
S1 S2 OS S1

Mitral stenosis
Ring
S2

Cusps Chordae Papillary muscles

Systole

Diastole

A P2 A2 2 P2 S S1 1 S S2 2 A P2 A2 2 P2 S S1 1 S S2 2 A P2 A2 2 P2 S S1 1 S S2 2 A P2 A2 2 P2 OS OS MDM MDM PSM PSM

S S1 1

Auscultatory Signs
Mild Stenosis

OS OS

S S1 1

S S1 1

Severe Stenosis

S S1 1

S S2 2 A P2 A2 2 P2 OS OS MDM MDM

S S1 1

Calcific Valve

S S1 1

S S2 2

S S1 1

Atrial Fibrillation

15

: 6 '
? - - . . , . . . . ) ( .

Mitral stenosis
Ring Cusps Chordae Papillary muscles

Cardiac Examination: Auscultation Murmurs:

Early diastolic

Cardiac Examination: Auscultation Murmurs:

Aortic insufficiency mild, severe Pulmonary insufficiency

S1 S2 S1 S2

Early diastolic

Aortic insufficiency Pulmonary insufficiency

S1 S2 S1 S2

Systole

Diastole

Systole

Diastole

Cardiac Examination: Auscultation Murmurs:

Cardiac Examination: Auscultation

Special physiological maneuvers: Squatting -

Early diastolic

Aortic insufficiency Pulmonary insufficiency

S1 S2 S1 S2

Valsalva,

venous return , vascular resistance - LV volume Murmurs of MVP , HOCM , AS

Standing

Inspiration
Systole Diastole

The opposite effect

increase in right sided flow and event decrease in left sided flow and events

16

Cardiac Examination: Auscultation Murmurs:

Continuous

Patent ductus arteriosus Aortopulmonary window ArterioArterio-venous fistula Ruptured sinus of Valsalva
S1 S2 S1 S2

Systole

Diastole

17