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Physical Examination of

Cardiovascular
Dr.Ira Andaningsih SpJP
Cardiovascular Block 2008
Learning Objective

1. Examine the important surface topographic
landmarks of the heart (inspection, palpation,
percussion and auscultation).
2. Assessment of the blood pressure and its variation
about the cardiovascular disease (orthotastic
hypotension, coarct aorta, cardiac tamponade).
3. Assessment of the arterial pulse (a. radialis, a.
brachialis, aorta abdominalis, a. femoralis, a. poplitea,
a. carotis, a. dorsalis pedis).

Learning Objective
4. Assessment of the JVP and hepatojugular
reflux.
5. Assessment of the peripheral edema (tibial).
6. Students should be able to identify the
normal heart sound (S1, S2).
7. Students should be able to identify the
abnormal heart sound (S1, S2, S3, S4, systolic
clicks, diastolic opening snaps, murmurs).

Procedure
1. Inspection
2. Measurement of blood pressure
3. Arterial pulsation examination
4. JVP examination and hepatojugular reflux
5. Edema examination
6. Percussion
7. Palpation
8. Auscultation

General Inspection
Clues for cardiac diagnosis:
Is the patient in acute distress?
What is the patients breathing like?
Are accesory muscles being used?
Are the patient pale?
Is the patient cyanosis?
Inspection
Inspect the head and face
Inspect the skin
Inspect the eyes
Inspect the mouth
Inspect the neck
Inspect the chest configuration
Inspect the nails and extremities

Head and face
- An earlobe crease in a relatively young
person (CAD)
- A cyanotic lips, and slight jaundice due
to hepatic congestion(RHD)
- Bobbing of the head coincident with
each heart beat (severe aortic
regurgitation)

Earlobe Creases
Head and face
Down syndrome is associated with congenital
heart disease.
Another diseases are associated with heart
disease is : Marfans syndrome, Systemic
Lupus Erythematosus, Cushing syndrome
have characteristic that can be present in
general appearance.
High arched palate (MVP)
Palatal ptechiae (infective endocarditis)

Skin
Cyanosis (central/peripheral?)
Pallor
Temperature: warmer(severe anemia,
thyrotoxicosis),coolness and pain
(claudicatio,occlusion)
Xanthomata(tendon,eruptive)
Rash(erythema marginatum)
Ptechiae (infective endocarditis)

Xanthomata
Xanthomata
Eyes
1. Xanthelasma ( CAD)
2. Embolic retinal occlusions (rheumatic heart
disease, atheroslerosis of the aorta or arch
vessels).
3. Papilledema ( malignant hypertension, cor
pulmonale with severe hypoxia,patients with
cyanosis and polycythemia).
4. Arcus senilis (CAD)
5. Hypertelorism(Pulmonary Stenosis,supravalvar
aortic stenosis
Xanthelasma
Arcus Senilis
Papilledema
Neck and chest configuration
Webbing of the neck(Turners syndrome
/coarctatio aorta or Noonans syndrome/
pulmonary stenosis)
Distended Jugular veins (CHF)
Visible cardiac motion ?
Pectus Excavatum (Marfans syndr,MVP)
Pectus carinatum (Marfans syndr)


Pectus Excavatum
Pectus Carinatum
Chest Configuration
Extremities

Nicotine staining of the fingers(CHD)
Oslers nodes(infective endocarditis)
Splinter hemorrhages(infective
endocarditis)
Abnormalities finger/toe:extra
phalanges/toe (ASD)

Splinter Hemorrhages
Extremities
Long,slender fingers(Marfans
syndrome/Aortic regurgitation).
Quinckes sign:systolic flushing of the
nailbeds, which can be readily detected
by pressing a flashlight against the
terminal digits( Aortic regurgitation).
Extremities
Clubbing of the fingers and toes(central
cyanosis/congenital).It may also appear
within a few weeks of the development of
infective endocarditis.
Edema of the extremities (CHF)
Edema in only one leg(obstructive venous or
lymphatic disease than to heart failure)
Pain and cool in the extremities with
cyanotic(arterial occlusion).



Clubbing Finger
Measurement of Blood
Pressure
The principles:
Direct (intra arterial catheter)
Indirect (Sphigmomanometer)
Korotkoff sounds 1-5.
Determinant BP by palpation
Determinant BP by auscultation
Assess BP by Palpation
Assess BP by Auscultation
Blood pressure

Rule out orthostatic hypotension
Rule out Supravalvar Aortic Stenosis
Rule out Coarctation of Aorta
Rule out Cardiac Tamponade

Rule out Orthostatic
Hypotension
1. Patient recumbent for at least 5 minute,
measure the baseline BP and pulse
2. Patient standing and measure the BP and pulse
3. Orthostatic hypotension if:
Systolic BP drop 20 mm Hg or more with
development of symptom such as dizzyness or
syncope(in most patients,also increase HR)

Rule out Supravalvular Aortic
Stenosis
If BP in the right arm high, measure BP in
the left arm (auscultatory )
Supravalvar Aortic Stenosis if:
Hypertension in the right arm and
Hypotension in the left arm
Rule out Coarctation of the
Aorta
If the BP is elevated in the arm, measure BP in the
lower extremities.
Patient lie down on the abdomen ,the cuff is
placed around the posterior aspect of the midthigh
The stethoscope is placed over the popliteal fossa
If wide cuff not available,place the reg.cuff in the
distal border maleoli and stethoscope is placed
over posterior tibial or dorsalis pedis artery.
Coarc Aorta if BP in the leg is lower than in the
arm
Rule out Cardiac Tamponade
Paradoxical pulse (pulsus paradoxus)
Patient breathe as normal as possible
Inflate cuff until no sounds are heard.
Gradually deflate until soundsare heard in
expiration only.Note this pressure.
Continue deflate slowly untilsounds are
heard during inspiration.Note this pressure
AbN if difference 10 mmHg,N if 5 mmHg
Arterial Pulsation Examination
Determinant the cardiac rate
Determinant the cardiac rhythm
Palpation Carotid artery
Palpation Radialis/Brachialis pulse
Palpation Abdominal Aorta pulse
Palpation Femoralis/Popliteal pulse
Palpation Posterior Tibial/Dors.Pedis pulse

Determinant Cardiac Rate
Assessed by the radial pulse.
The examiner stand in the front of the patient
Grasp both radial arteries with the 2
nd
,3
rd
and 4
th

fingers.
Count the pulse for 30 seconds x 2.
If patient in irregular rhythm(AF) presents,patient
has pulse deficit. Only assessment by auscultation
on the heart can count the cardiac rate.
Technique evaluating Radial
Pulse
Determinant cardiac rhythm
The ECG is the best method for diagnosing
cardiac rhythm.
Regular rhythm: regular on palpation
Regularly irregular:irregularity in a definite
pattern(premature beats, bigeminy)
Irregularly irregular:has no pattern (Atrial
Fibrillation).
Palpation Carotid Artery
Patient in the supine position,examiner in the right
side
Auscultate carotid artery for bruits first.
If bruits presents do not palpate the artery,if the
cholesterol plaque is present it can produce an
embolus
Place 2
nd
and 3
rd
fingers on the thyroid cartilage
and slip them laterally between trachea and
m.sternocleidomastoid

Technique Auscultation
Carotid Artery
Technique Evaluating Carotid
Artery Pulse
Technique Evaluating Carotid
Artery Pulse
Palpation Carotid Artery
Palpation should be performed low in the
neck to avoid pressure on carotid sinus (can
cause drop in BP and HR)
Each carotid artery is evaluated separately.
Never press on both carotid artery in the
same time.
Palpation Carotid Artery
Normal :Smooth, upstroke stepper more rapid
than downstroke
Diminished : Small, weak pulse (anacrotic)
Increased:Large,strong,hiperkinetic
(waterhammer)
Double peaked pulse :Prominent percussion
and dicrotic wave (bisferiens)
The Arterial Pulse
Palpation Brachialis pulse

The examiner use the thumbs to palpate.
Can be felt medially under the tendon of the
biceps muscle.
Examiner standing in front of the patient
simultaneously can be felt both brachial
arteries.

Technique Palpation
Brachialis Pulse
Palpation Abdominal Aorta
Performed by palpating deeply but gently
into the mid abdomen.
Presence of mass with laterally pulsatile
suggest abdominal aneurysm.
In thin individual normal pulsatile can be
palpated.

Technique Auscultation
Abdominal Aorta
Palpation Femoral Pulse
Patient in the supine position and examiner in the
right side.
The lateral corners of the pubic hair triangle are
observed and palpated.
Both femoral artery may be compared
simultaneously.
If one of the artery is diminished or absent
auscultation for bruits is necessary.
If presence indicate obstructive aortoiliofemoral
disease.
Technique Palpation Femoral
Pulse
Palpation Popliteal Pulse
Often difficult to assess.
Each artery is evaluated separately.
Patient in supine position
Examiner hold the leg in a mild degree of flexion
and places the thumbs on the patella and presses
the remaining fingers of both hands in the fossa
poplitea medial to lateral biceps femoris tendon
Firm pressure is usually required to feel pulsation
Technique Palpation Popliteal
Pulse
Palpation Dorsalis Pedis
Pulse

Is best felt by dorsoflexion of the foot.
Easily palpated in the grove between the
extensor digitoum longus and hallucis
longus tendon.
May be felt simultaneously
Technique Palpation Dorsalis
Pedis Pulse
Technique Palpation Posterior
Tibial Pulse
Grading of Pulses

0 Absent
1 Diminished
2 Normal
3 Increased
4 Bounding
Jugular Venous Pulse
Provide information about the wave forms
and the right atrial pressure.
Pulsation internal jugular vein are beneath
the sternocleidomastoid muscle.
Only the right internal jugular vein is
evaluated because its straighter than left.
External jugular vein is easier to visualize
but less accurate and should be not used.
Jugular Wave Forms
Patient lie flat without pillow so that the neck will
not be flexed.
The patients trunk at approximately 25 to the
horizontal.
The higher the venous pressure,the greater
elevation will be required.The lower the venous
pressure, the lower the elevation needed.
Patients head turned slightly to the right and
slightly down to relax the right sternocl.mastoid.
With small flashlight shine the light to the neck.
Technique Evaluating Jugular
Wave Forms
Jugular Wave Pressure
Examination
The standard reference is manubriosterno angle/
angulus ludovici
Determine the height of venous distension by
noting the top of the wave forms in the int
jug.venous pulsation.
Imaginary horizontal line from this height to the
sternal angle
Measure the distance
The angle of elevation of the head of the bed is
also estimated.

Neck Vein Distention
JVP
At 45elevation,Jug.pulse is 7 cm above the sternal
angle.
At 45,upper limit of normal 4-5 cm above the
sternal angle.
At 30,upper limit of normal 6 cm.
At supine position,normal if equal or lower than
the sternal angle.
At 90 when neck vein distended up to the jaw
margin that the RA pressure is high(>15 mmHg)

Hepato Jugular Reflux
Examination
Abdominal Compression
Assessing high jugular venous pressure.
Pressure over the liver can grossly assess RV
function.
Patient in supine position,mouth open and
breathing normally
Places the right hand over the liver (right upper
quadran),apply a firm,progressive prssure.
Compression is maintained for 10 seconds.


Hepato Jugular Reflux
Normal response: transient increase in
distension during the first few cardiac
cycles,followed by a fall to baseline level.
RV failure : remained distended during the
compression and falls rapidly(at least 4 cm)
on sudden release.
If test incorrect (patients mouth closed),a
valsava maneuver will result inaccurate.
Edema Examination
Fingers are pressed into dependent area for
2-3 seconds.
If pitting edema is present,the fingers will
sink into the tissue and when removed,the
impression of the fingers will remain.
Usually quantified from 1+ to 4+
If 4+ is usually to the sacrum(bedridden
patient)
Technique Evaluating Pitting
Edema
Technique Evaluating Pitting
Edema
Pitting Edema over the
Sacrum
Landsmark of the Chest
Landsmark of the chest
Technique Percussion
Technique Percussion
Percussion of the heart
Performed at the 3
rd
,4
th
,and 5
th
intercostal
space from the left anterior axillary line to
the right anterior axillary line.
Normal :
A change in the percussion from resonance
to dullness 6 cm lateral to the left of
sternum.
Palpation

To evaluate the apical impuls
For assessing localized motion
For assessing generalized motion
For assessing presence or absence of thrills
Point of Maximum Impulse
Most easily performed with sitting position
Only the fingertips should be applied in the
5
th
intercostal space,midclavicular line
If not felt,move in the area of cardiac apex.
PMI usually within 10 cm of the midsternal
line and no larger than 2-3 cm in diameter.
If laterally or felt in 2 interspaces it is
cardiomegaly.
Technique Assessing PMI
Assessing Localized Motion
Patient in supine position
Use the fingertips to assess any localized
motion
The presence of a systolic impulse in 2
nd

intercostal space to the left of sternum is
suspect Pulmonary Hypertension

Technique Assessing
Localized Motion
Assessing Generalized Motion
Use the proximal portion of the hand to
palpate for any large area motion,called
heave or lift
Palpates each of the 4 main cardiac area
The 2
nd
impuls in the area of PMI is usually
felt in association with S3.
The use of an aplicator stick can be helpful
to reinforce visually what has been palpated
Technique Assessing
Generalized Motion
Technique Assessing
Genaralized Motion
Assessing Thrills

The presence of thrills indicates a loud
murmur.
Use the head of metacarpal and applying
very gentle pressure on the skin
If too much pressure thrills will not be felt
Auscultation of the Heart
The bell of the stetoscope should be applied
slightly to the skin
For:low-pitched sounds (gallop, murmur of
atrioventricular stenosis)
The diaphragm of the stetoscope should be
pressed tightly to the skin
For: high-pitched sounds (valve
closure,systolic event, regurgitant murmur)
Standard Auscultation
Position

Supine
Left lateral decubitus
Upright
Upright, leaning forward
Auscultation Position
Auscultation Cardiac Area