CARDIOVASCULAR EXAMINATION- Dr daniel.pptx

CARDIOVASCULAR
EXAMINATION
DCM II

Objectives
1. To be able to approach a cardiovascular disease
2. To understand why every step is important in CVS exam
3. To be able to give different differential diagnosis for some findings

Outline
 Surface anatomy review
 Inspection
 Palpation
 Auscultation
 Conclusion

10/09/2025 5
General Principles/Steps
NOTE: any systemic examination starts with the hand except
CNS.
1. Stand on the right side of patient.
2. Introduce yourself & what you will do.
3. Ask for consent.
4. Wash hands
5. Position pt – 45 ͦ
6. Expose the appropriate area to be examined.
7. Glance for any equipment.

INSPECTION
 General inspection:
 Dyspnoea
 Cyanosis
 Pallor
 Oedema
 Drugs
 Equipments eg. Oxygen concentrator,
ECG monitors etc

Inspection cont…
 Hand
 Nails: clubbing, splinter haemorrhages
 Pallor/cyanosis
 Tendon or palmar xanthomata (hyperlipidemia)
 Janeway lesions, osler's nodes
 Warmth and capillary refill time- shock

Finger clubbing
 Cardiovascular causes
 Cyanotic congenital heart disease
 Infective Endocarditis
 Atrial Myxoma
 Respiratory Causes
 Lung cancer
 Interstitial lung disease
 Suppurative lung disease
 Gastrointestinal causes
 Inflammatory Bowel disease
 Advanced Liver Cirrhosis

Inspection
 Hands/arm conti…
 Radial pulse
 Rate
 Rhythm (regularity of the beat, regular, irregularly irregular, regularly irregular)
 Character (amplitude, volume, collapsing)
 Radial-radial delay (vessel occlusion,Aortic arc aneurism), Radio-femoral delay
(coarctated aorta),
 Brachial pulse (right arm) and Carotid pulse
 For volume and character
 Slow rising- aortic stenosis
 Bounding- aortic regurgitation
 Thready- in sepsis
 Check blood pressure

Different sites for palpating pulses

Normal vital signs for children (ranges)
Age group Heart rate Resp. rate BP systolic BP diastolic
Neonate 100-181 40-60 67-84 35-53
Infant (1–12 months) 100–161 30–53 72–104 37–56
Toddler (1–2 years) 98–149 22–37 86–106 42–63
Preschooler (3–5 years) 80–131 20–28 89–112 46–72
School-aged child (6–9 years)
75–118 18–25
97–115 57–76
Preadolescent (10–11 years) 102–120 61–80
Adolescent (12–17 years)
60–100 12–20
110–131 64–83
Adults 90–139 60–89

Blood pressure measurement
 Ideally measure both arms
 more than 20 mmHg difference may suggest aortic dissection.
 Know the marks for Hypertension and hypotension
 Do you know how to accurately
measure BP?

Inspection conti…
 Face:
 Conjunctivae for pallor
 Xanthelasma
 Sclera for jaundice (congestive HF  hepatic congestion)
 Corneal arcus- for hypercholesterolemia
 Mouth:
 Lips/ tongue for cyanosis,
 angular stomatitis.
 High-arched palate (Marfan’s syndrome)
 Mucosa petechiae (?IE)
 Dental hygiene (? Source of IE)

Inspection conti…
 Neck:
 Carotid artery pulses (medial to SCM)
 Jugular venous pressure (JVP)
 internal jugular= medial to SCM
 external jugular= lateral to SCM)
 The internal jugular is preferable.
 How may you know if it is a jugular pulse
and not from carotid artery?

Jugular venous pressure (JVP)
 JVP provides an indirect measure of central venous
pressure.
 Internal jugular vein (IJV) connects to the right
atrium without any intervening valves.
 External jugular vein branches from subclavian
hence not reliable for JVP
 JVP must be done while patient lying at 450
 Use the right jugular vain. WHY?

How to measure JVP
1. Position patient at 450
2. Ask the patient to turn their head slightly to the left.
3. Inspect and identify the IJV.
 The IJV has a double waveform pulsation & disappears (carotid artery)
4. Measure the JVP by assessing the vertical distance between the
sternal angle and the top of the pulsation point of the IJV
 in healthy individuals, this should be no greater than 8 cm.
 From right atrium to sternal angle is a fixed 5cm
 Therefore from sternal angle should be <3cm

Hepato-jugular reflux
 The hepato-jugular reflux test involves the application of pressure
to the liver whilst observing for a sustained rise in JVP.
How to perform
 Apply direct pressure to the liver.
 Closely observe the IJV for a rise.
 In healthy individuals, this rise should last no longer than 1-2
cardiac cycles (it should then fall).
 If the rise in JVP is sustained and equal to or greater than 4cm
this is deemed a positive result.

Close chest inspection
 Scars/ surgical scars
 Suggest prior thoracic surgery including to the heart
 Chest deformities
 pectus excavatum- sunken chest,
 pectus carinatum- protrusion of sternum (pigeon chest)
 kyphoscoliosis
 Precordium pulsations (hyperactive in heart failure, ventricular
hypertrophy)

Pectus carinatum Pectus excavatum

PALPATION
 Palpate for apex beat, heaves and thrills
– on the precordium
 Apex beat:
 The apex beat is the point of maximum
impulse of the heart
 Found at 5th
intercostal space,
midclavicular line.
 Palpate with fingers placed horizontally
across chest
 Displaced apex beat suggests
cardiomegaly
 A forceful and sustained apex beat may
indicate left ventricular hypertrophy

Palpation
 Heaves:
 Is the precordial impulses that are palpable
 Place the heel of your hand, parallel to left sternal
edge, vertically.
 Heaves are present if the hand lifted with every
beat
 Thrills:
 It is a palpable murmur
 A feel of vibrations due to turbulent flow over a
valve
 Place your hand horizontally across the chest wall
with flat of fingers and palm over each valve area

Palpation conti…
 Abdomen for:
 Hepatomegaly- right heart failure
 Splenomegaly- IE
 Back and lower limbs for:
 Oedema

AUSCULTATION
 Auscultation is done using stethoscope.
 The diaphragm effective at detecting high-frequency sounds
 The bell effective at detecting low-frequency sounds
 To do this best, identify the sternal angle first.
 It helps identify areas for different murmurs
 Areas of valves
 Mitral valve: 5th
ICS, MCL.
 Tricuspid valve: 4th
ICS, at the lower left sternal edge.
 Pulmonary valve: 2nd
ICS, at the upper left sternal edge.
 Aortic valve: 2nd
ICS, at the upper right sternal edge.
 Use the diaphragm first then finish with bell.

Auscultation conti…
 Also auscultate lung bases
anterior & posterior for:
 Pulmonary edema
 Pleural effusion

Complete the examination
 Explain to the patient that the examination is now finished.
 Thank the patient for their time.
 Dispose of PPE appropriately and wash your hands.
 Summarize your findings.
 Document.

Take home message
 CVS is done while patient is lying at 450
 Cardiovascular exam has no percussion
 Others do but has no use
 Other systems are checked
 GIT- hepatomegaly/ splenomegaly
 Respiratory- Lung bases

References
1. AMBOSS
2. GEEKY MEDICS:
https://geekymedics.com/cardiovascular-examination-2/

CARDIOVASCULAR EXAMINATION- Dr daniel.pptx

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