L8-Cardiovascular II-Physical Examination by zerosoul


									Cardiovascular Physical Examination
Dr. HF Tse Cardiology Division Department of Medicine
Integrated Block 2005

General Inspection
Body built : Body weight and height
• Stunted growth congenital heart disease • Marfan’s syndrome : arm span > height (high arched palate, long slender hands and narrow feet, lens dislocation) Aortic dissection, mitral valve prolapse, aortic regurgitation • Turner’s syndrome : stunted growth
Pulmonary stenosis

webbed neck

Turner’s syndrome

General Inspection
Facial Features
• Williams syndrome: A flattened occiput, broad high forehead, puffy cheeks, low ear, ocular hypertelorism with strabimus, dental abnormalities aortic stenosis • Down’s syndrome : Flattened occiput, small head, slanted eye, large protruding tongue atrial and ventricular septal defects • • Head-nodding movement (de Musset’s sign) Myxedema facies: Putty lids, loss of outer 1/3 of eyebrow, scanty, dry hair, coarse skin, large tongue cardiomyopathy and pericardial effusion aortic regurgitation supravalvular

General Inspection
Facial Features
• Malar flush (cyanotic cheeks with a slight telangiectasia mitral stenosis, pulmonary hypertension, low output status and high venous pressure • Xanthomas (fat despoit in skin) Xanthelesmata (lipid in skin of eye lids) Hyperlipidaemia Corneal arcus in young • Dental caries • Exophthalmos infective endocarditis thyrotoxic heart disease

General Inspection
Facial Features
Central cyanosis: 5g of de-oxygenated haemoglobin, 02 saturation of 80%, observed in warm (tongue) as well as cold areas (nail beds, nose, cheeks, earlobes and lips)
Respiratory causes Pulmonary oedema Cyanotic congenital heart disease Occasionally due to abnormal Hb e.g. sulfmethemoglobin

Peripheral cyanosis : observed cold areas
All causes of central cyanosis Vasoconstriction with reduce blood flow to surface capillary

Malar flush

Tendon Xanthomas

Xanthelesmata Eruptive Xanthomata

General Inspection
Hands & Feet
• Finger clubbing endocarditis • Differential cyanosis (foot clubbing with normal hand) persistent ductus arteriosus (PDA) with a reversed right-to-left shunt due to pulmonary hypertension • Splincter haemorrhage Janeway lesion-painless) • Single palmar crease crepitation Tetralolgy of Fallot • Edema: check for jugular venous pressure and basal congestive heart failure infective endocarditis (other features : Osler’s node-painful, tender, reddish brown lesion; cyanotic congenital heart disease, infective

Finger Clubbing

Signs of Early Clubbing
Normal Clubbing


Prominent distal angle

-Lose of normal angle of curvature of nailfold -Increase floating sensation

-Lose of obliteration of normal angle between the base of the nail and the proximal skin

Arterial System: Introduction
• Examination of the arterial pulse often detect important information about the cardiovascular system • The changes in the pulse contour and amplitude may provide a clue to a proper diagnosis, such as aortic dissection, aortic valve disease.

Arterial System: Physiology
• Arterial pulse wave is related to the cardiac output and the compliance of the arterial system. • The initial peak of the aortic pulse wave reflects the peak velocity of left ventricular systole. The later portion of the pulse wave is produced by the reflection from the peripheral artery. • Aging and decreased compliance due to atherosclerosis accentuated the later portion of the pulse wave. • The aortic pulse contour is altered in the peripheral artery ( amplitude and velocity) peripheral artery should not be used to assess the arterial pulse contour as the changes in aortic pulse contour may become normal in peripheral pulse





Aging Hypertension Atherosclerosis

Figure 2.1. Arterial pulse contour alteration in the peripheral circulation and aging Carotid

Arterial System: Exam Technique
• All accessible arterial pulse should be assessed and to compare bilateral sites: radial brachial subclavian Atherosclerosis carotid Embolic occlusion femoral Dissection popliteal Vascular compression posterior tibial Congenital anomaly dorsalis paedis • Hypertensive patient simultaneous palpation of radial and femoral artery radiofemoral delay coarctation of aorta

Arterial System: Exam Technique
• • • Volume and contour: best felt in carotid or brachial arteries Rate: 60-100 beats/minute Rhythm: Skipped beats (regularly irregular) Irregularly irregular atrial fibrillation Poor cardiac output, aortic stenosis (slow rising, anacrotic), pericardial effusion Increased “bounding” pulse Collapsing pulse Aortic regurgitation, persistent ductus arteriosus, AV fistula, rupture sinus of Valsalva, severe anemia and thyrotoxicosis Characters Volume: Diminished




• • • • • •


Aortic regurgitation • Aortic stenosis AV fistula Persistent ductus arteriosus AV fistula Rupture sinus of Valsalva Hyperdynamic circulation

Anacrotic “Slow Rising”

• Aortic stenosis + aortic regurgitation

Figure 2.2.

Arterial pulse contour in specific cardiac disorder

Arterial System: Exam. Technique Pulses
• • Pulses alternans: alternate strong and weak pulse amplitude
heart failure

Pulses paradoxus: marked and exaggeration of fall in systolic
blood pressure during inspiration (> 10mmHg) - causes (marked inspiratory decrease in left ventricular filling): pericardial tamponade, severe asthma/COPD, severe heart failure and constrictive pericarditis (uncommon, unless subacute with effusion) - detection: 1) inflated the pressure cuff above systolic blood st pressure; 2) noted the pressure at which 1 Korotkoff sound appear during expiration and the level when all beats become audible; 3) noted the systolic blood pressure when the inspiratory and expiratory Korotkoff sound become equally loud.

Arterial System: Exam. Technique
• Blood pressure measurement:
- Seated posture - Rested for 5 minutes - Measure both arms, erect and supine posture during the 1st visit - By palpitation and/or syhygmomanometer (Korotkoff 1st and 4th sound) - Five phases of Korotkoff sounds: Phase 1: Onset of tapping sound Phase 2: ~10-15mm lower, a murmur may be heard after the taps Phase 3: Reappearance of only the tapping sound Phase 4: Muffling phase with only murmur and tapping sound is disappearing Phase 5: Disappearance of all sound

Venous System: Physiology
• Jugular venous pulse depends on the venous tone, the venous blood volume and right sided cardiac hemodynamics. • Diastole right ventricular filling pressure; systole right atrial pressure. • Two peaks (waves) and 2 descents (tough) are visible in normal condition • Normal intravascular pressure: 4-11 cm H2O

Internal jugulars SVC SVC

Internal jugulars







Ventricular Systole Figure 3.1.

Ventricular Diastole

Changes in venous pressure during cardiac cycle

Jugular Venous Waveform
• A wave:
Reflect right atrial contraction and precedes carotid pulse during right ventricular systole

• X descent:Reflect right atrial relaxation and passive pulling • C wave: • V wave:
Reflect closure of tricuspid valve and is separately visible Reflect filling of right atrial during ventricular systole with tricuspid valve closed and is roughly synchronous with carotid pulse pressure during opening of tricuspid valve

• Y descent:Negative deflection of right atrial

Jugular Venous Pressure


Carotid Pulse

Figure 3.2.

Normal jugular venous pulse

JVP: Examination Technique
• Optimal positioning of the neck (elevate the chin and slightly rotate the head to the left) and tangential lighting is helpful to accentuate the jugular veins • Differentiation of jugular and carotid pulses • Estimating venous pressure: normal < 4.5cm from sternal angle (angle of Louis) at 45°, careful inspection of the upper neck behind the angle of jaw • Assess the jugular venous contours- timing the venous pulse by palpating the carotid pulse or auscultation of heart sound


4.5 cm at 45o

JVP vs. Carotid Pulse
Internal Jugular Vein Location Contour Character Inspiration Posture Compressibility Abdominal compression Lower and lateral Double peak Not palpable More visible but mean pressure decreases Decrease with upright posture Obliterated by pressure Transient increase in pressure Carotid Artery Deeper and medical Single peak Forceful and palpable No change No change Cannot obliterated by pressure No effect

Lower level Expiration Higher Amplitude


Figure 3.4. Changes in jugular venous pulse during respiration

Examination Technique JVP
• JVP: right ventricular failure, fluid overload, SVC obstruction • JVP: hypovolemia or dehydration • Kussmauls sign= JVP on inspiration (decrease compliance or capacity to handle augmented venous return) Causes: constrictive pericarditis, congestive heart failure, peripheral venous congestion from any causes, right ventricular infarction related to inferior MI, pericardial tamponade (uncommon).

Examination Technique JVP

JVP (>4.5 cm)
causes right ventricular failure fluid overload SVC obstruction

causes hypovolemia dehydration

Examination Technique JVP
Character RV compliance forceful RA contraction Causes: pulmonary hypertension, PV/TV stenosis

Giant A wave:

Cannon A wave:

Atrioventicular dissociation Causes: complete heart block atrial flutter, vent pacing, vent tachycardia

Giant V wave:
Causes: TV regurgitation

Kussmauls sign:
JVP on inspiration ( compliance or capacity for venous return) Causes: RV failure, constrictive pericarditis, pericardial effusion/ tamponade

V A V C Y Giant A wave A
Moderate TR Severe TR




Mild TR


Tricuspid Regurgitation (Giant V wave)

Constrictive Pericarditis

Figure 3.5. Common abnormalities of jugular venous pulse

Precordial Impulse: Physiology
• Palpitation of precordial impulse provide information about cardiac activity on the chest wall • Contraction of left ventricular free wall and septum with anterior movement during the first half of systole apex beat or apex impulse • Normal apical impulse: a gentle, nonsustained tap located within 10cm of the midsternal line in the 4th or 5th intercostal space • Right ventricle located beneath the sternum and its activity is not normally felt • Cardiac hypertrophy or dilatation abnormal systolic and diastolic impulse over left or right ventricular

Precordium : Examination Technique
• Inspection: chest wall abnormalities, visible apex and hepatic pulsation, surgical scar • Position: in supine or 30° and in left lateral decubitus position (45-60°), in sitting position from behind • Palpation: Location of apex beat- normal- 5th intercostal space, mid clavicular line; absent apical impulse Thick chest wall, emphysema, dextrocardia Character of apex beat Other palpable events, heart sounds and thrill (loud murmurs) Parasternal or right ventricular impulse: heath RV hypertrophy • Percussion: pericardial effusion

Examination Technique Apex Beat


>MCL and 5th ICS
Causes: cardiac enlargement

Palpable 1 HS Causes: mitral stenosis


Causes: LV hypertrophy

LV volume Causes: volume overload, eg aortic regurgitation

Localized pulsations

Point of maximum impulse may be

Aortic aneurysm

Pulmonary artery dilatation

Ventricular aneurysm

Apex beat

Heaves or lifts

Precordium : Auscultation Technique
- Timing: with carotid pulse (onset of pulse = 1st heart sound) - Bell : low pitch e.g mitral stenosis murmur Diaphragm : all sounds/murmurs - Location: Apex neck, axilla - Added sound: 3rd heart sound (~0.12 s after S2, a thud or boom, best heard by bell at apex); opening snap (~0.1 s after S2, short, sharp click, best heard with diaphragm at LSB); 4th heart sound (similar character as S3, but usually later and before S1), Gallop rhythm heart failure - Heart murmur LSB pulmonary area aortic area

Auscultation Technique: Heart Sound

Auscultation Technique: Heart Sound
Heart sounds :
S1 S2 S3 S1

Closure of MV





1st HS 1st HS

tachycardia, mitral stenosis, high cardiac output first degree AV block, impaired LV contraction complete heart block and atrial fibrillation

Varying 1st HS

Auscultation Technique: Heart Sound
Aortic V Pul V

Physiological Splitting:

2nd HS pulmonary hypertension, ASD, Dilated pulmonary artery 2nd HS Aging, pulmonary stenosis

Auscultation Technique: Heart Sound
Fixed Splitting: ASD

Paradoxical splitting LBBB

delay closure of AV as in

Auscultation Technique: Heart Sound
Other heart sounds:
S1 S2 S3 S1





3rd HS physiological in young person, rapid LV filling or heart failure (LV vol overload) 4th HS always pathological (atrial filling) valvular prosthesis

mechanical heart sounds Gallop rhythm

Mechanism of Murmur

Auscultation Technique: Murmur
• Grading : Grade 1 : Just audible 2 : quiet 3 : moderately loud 4 : loud + thrill 5 : very loud + thrill 6 : audible without a stethoscope • Timing: Systolic or diastolic • Characters • Site of maximum propagation and radiation • Effect of posture and respiration • Effect of maneuver

Auscultation Technique: Murmur
Systolic murmurs :
Aortic stenosis - radiate to carotids - slow upstroke - low vol pulse Pulmonary stenosis Ejection

Atrial septal defect - fixed splitting of S2 - loud S2

Auscultation Technique: Murmur
Systolic murmurs :
Mitral regurgitation - radiate to axilla - loudest at axilla - soft S1 Tricuspid regurgitation - giant V wave - with inspiration Ventricular septal defect - widely radiating - loudest at left sternal area - thrill Pansystolic

Auscultation Technique: Murmur
Diastolic murmurs:
Early Aortic regurgitation - blowing and high pitch - loudest at left sternal border - Ejection systolic murmur - best with patient exhale and lean foreard

Auscultation Technique: Murmur
Diastolic murmurs:
Mid or Late Mitral stenosis - rumbling and low pitch - loudest at apex - with exercise Associated with MR Other diastolic murmur - Graham steel: PR - Austin flint: AR

Auscultation Technique: Murmur
Continuous murmur : AS/AR Patent ductus arteriosus
- cyanosis - left parasternal heave - collapsing pulse

Auscultation Technique: Murmur
Hypertrophic Cardiomyopathy:
- Ejection systolic murmur - no radiation, but increase with Valsava manouevre, and during squatting to standing - jerky pulse - double apex beat - S4

Other Examinations:
Examination of the lungs : • Bilateral basal crackles : heart failure Examination of the abdomen: • Pulsibile and enlarged liver: TR

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