Chest and heart examination

By Dr Wedad Bardisi

Framework for routine examination of the cardiovascular system.

1. Watch the patient face for feature of anxiety, distress, breathlessness…

2. Assess hand wormth, nails for clubbing or splinter haemorrhages.

3. Palpate the radial pulse and assess the rate &rhythm.

4. Locate &palpate the brachial pulse and assess the character.

5. Measure the blood pressure.

Frame work for routine examination of the cardiovascular system

6. With the patient lying supine at 45°, assess the jugular venous pressure and the jugular venous pulse form.

7. Palpate the carotid pulse and assess its character.

8. With the patient‘s chest exposed, inspect the pericardium and assess the breathing pattern and presence of any abnormal pulsation.

9. Palpate the pericardium, locate the apex beat and assess its character, any abnormal vibration or thrills

Cardiac auscultation

10. Listen with the stethoscope and assess heart sound and murmurs.

Systolic murmur is not always pathological.

Diastolic murmurs are difficult to hear.

Ask the patient to roll on left side to detect the diastolic murmur of mitral stenosis at the apex.

Ask the patient to sit and lean forward and hold his breathing after expiration to detect the diastolic murmur of aortic regugitation at lower left sternalborder.

Ask the patient to roll on left side to detect the diastolic murmur of mitral stenosis at the apex.

Frame work for routine examination of the cardiovascular system

11. Percuss and auscultate the chest both front and

back looking for pleural effusions.

12. Lay the patient flat and palpate the abdomen,

feeling in particular for the liver and any dilatation

of the abdominal aorta.

13. Assess the femoral pulses and the popliteal and foot

pulses. Look for ankle or sacral edema.

The best site for cardiac auscultation and the cause of murmur

• Upper right sternal border: Aortic stenosis.

• Upper left sternal border: Pulmonary valve murmur.

• Lower left sternal border: Tricuspid regugitation

• Aortic regugitation

• Apex mitral or aortic valve

• Axilla: Radiating mitral regurgitation

• Below left clavicle: radiating pulmonary valve murmur.

Cardiac Auscultation

Tricuspid regugitatiion, Aorticregugitation ,

mitral or aorticvalve

Differentials of diastolic murmur

• Always pathological.

• Difficult to hear it.

• Diastolic murmur of aortic regurgitation:

Best hear at lower left sternal border.

Radiate to the apex.

Ask pt to sit and lean forward and hold his breath(expiration)

Associted with wide pulse pressure (e.g. 170/60).

Tapping apex beat.

Opening snap.

• Diastolic murmur of mitral stenosis

Best hear at apex when pt rolled on left side.

Murmur does not radiate.

Cardiac Auscultation

Murmur pathology

Pansystolic murmurTricuspid regurgitation

Ventricular septal defect

Mitral regurgitation

Aortic stenosis

Ejection systolic murmurPulmonary stenosis

Normal Heart valve

Diastolic murmurMitral stenosis

Aortic regurgitation

Differentials of systolic murmur

Ejection systolic:

• Innocent systolic murmur.

• Aortic stenosis.

• Pulmonary stenosis.

• Hypertrophic cardiomyopathy.

• Flow murmur.

• Atrial septal defect

• Fever

• Athlete‘s heart

Pansystolic murmur

• Tricuspid regurgitation.

• Mitral regugitation.

• Ventricular septal defect.

• Pulmonary stenosis: below left clavicle.

• Aortic stenosis: upper right sternal border.

• Aortic regurgitation: lower left sternal border.

• VSD, pulmonary valve murmur: upper left sternalborder.

• Mitral regurgitation : axilla

• Mitral regurgitation , stenosis & aortic stenosis: Apex

Heart sounds

Cardiac auscultationaortic valve disease

• Aortic stenosis:

• ejection systolic murmur radiate to the neck.

• Aortic regurgitation:

• early diastolic murmur.

• Ask pt to sit and lean forward and hold his breath (expiration).

• Radiate to apex

• Wide pulse pressure e.g. (170/60)

Cardiac auscultationmitral valve disease

• Mitral regurgitation:

• pansystolic murmur

• Apex radiate to the axilla.

• Mitral stenosis:

• Tapping apex beat.

• Opening snap.

• Mid diastolic murmur.

• Apex when pt. rolled on left side.

• Murmur doesnot radiate

Cardiac auscultationpulmonary valve disease

• Pulmonary stenosis:

• ejection systolic murmur radiate to the left clavicle

• Right ventricular heave.

• VSD: pansystolic murmur

• Radiate all over the pericardium