Cardiovascular system examinationCardiovascular system examination

Cardinal symptomsCardinal symptoms Chest painChest pain BreathlessnessBreathlessness PalpitationsPalpitations SyncopeSyncope Easy fatiguabilityEasy fatiguability Swelling of legsSwelling of legs

Chest painChest pain Myocardial ischaemiaMyocardial ischaemia PericarditisPericarditis Aortic dissectionAortic dissection Pulmonary embolismPulmonary embolism AnginaAngina Oesophageal refluxOesophageal reflux Musculoskeletal painMusculoskeletal pain

Chest painChest pain S – SiteS – Site O- OnsetO- Onset C- CharacterC- Character R- RadiationR- Radiation A- associated symptomsA- associated symptoms T- Time( Does the npain follow any patterT- Time( Does the npain follow any patter E- Exacerbating / relieving factorsE- Exacerbating / relieving factors S- SeverityS- Severity

Anginal painAnginal pain

Pericardial pain: Central chest pain, sharp in Pericardial pain: Central chest pain, sharp in character, aggravated by inspiration, cough or character, aggravated by inspiration, cough or postural changespostural changes

Pleuritic chest painPleuritic chest pain Aortic dissection: Severe tearing pain in either Aortic dissection: Severe tearing pain in either

the front or back of the chestthe front or back of the chest

BreathlessnessBreathlessness Abnormal awareness of breathing occuring Abnormal awareness of breathing occuring

either at rest or at an unexpectedly low level of either at rest or at an unexpectedly low level of exertionexertion

CausesCauses Restricted filling: MS, Cons. Pericarditis, Restricted filling: MS, Cons. Pericarditis,

CardiomyopathiesCardiomyopathies Pressure loading: HTN,Aortic stenosisPressure loading: HTN,Aortic stenosis Volume loading: MR,ArVolume loading: MR,Ar Contractile impairment: CAD, DCMContractile impairment: CAD, DCM

Orthopnoea: On lying there is breathlessnessOrthopnoea: On lying there is breathlessness May use extra pillows, Sleep in sitting postureMay use extra pillows, Sleep in sitting posture

Paroxysmal nocturnal dyspnoea: Frank Paroxysmal nocturnal dyspnoea: Frank pulmonary oedema on lying wakes the patient pulmonary oedema on lying wakes the patient from sleep with distressing dyspnoea, and fear from sleep with distressing dyspnoea, and fear of imminent death. of imminent death.

FatigueFatigue Exertional fatigue is an important symptom of Exertional fatigue is an important symptom of

heart failure particulary towards the end of the heart failure particulary towards the end of the day.day.

Deconditioning and muscular atrophy and Deconditioning and muscular atrophy and decreased oxygen supply to exercising muscledecreased oxygen supply to exercising muscle

PalpitationPalpitation Abnoraml awareness of ones heart beatAbnoraml awareness of ones heart beat May be normal during exercise or heightened May be normal during exercise or heightened

emotionemotion Description of rate and rhythm is essentialDescription of rate and rhythm is essential History of “missed”beatsHistory of “missed”beats May be due to rhythm or forced contractonof May be due to rhythm or forced contractonof

the heart.the heart.

SyncopeSyncope Transient hypotensionTransient hypotension Results in abrupt cerebral hypoperfusionResults in abrupt cerebral hypoperfusion Feeling of lightheadednessFeeling of lightheadedness Recovery is usually rapidRecovery is usually rapid Causes: Postural, vasovagal, valvular obstructionCauses: Postural, vasovagal, valvular obstruction

oedemaoedema Pitting or non pittingPitting or non pitting Diurnal variationDiurnal variation

Left sided heart failure vs right sided failure Left sided heart failure vs right sided failure symptomssymptoms

Past historyPast history Rheumatic feverRheumatic fever Thyroid diseasesThyroid diseases DiabetesDiabetes HypertensionHypertension Stroke/ TIAStroke/ TIA

Personal historyPersonal history SmokingSmoking Life styleLife style Alcohol abuseAlcohol abuse

Family historyFamily history Coronary artery diseaseCoronary artery disease HypertensionHypertension CardiomyopathiesCardiomyopathies

Treatment historyTreatment history InjectionsInjections B- blockersB- blockers NSAIDSNSAIDS

General examinationGeneral examination Pulse: Pulse: RateRate RhythmRhythm CharacterCharacter VolumeVolume Peripheral pulsesPeripheral pulses Radio- radial/ Radio- femoral delaysRadio- radial/ Radio- femoral delays

Blood pressureBlood pressure Stages: Korotkoffs soundsStages: Korotkoffs sounds BP cuff- 12cm widthBP cuff- 12cm width

PallorPallor ClubbingClubbing CyanosisCyanosis OedemaOedema LymphadenopathyLymphadenopathy JaundiceJaundice

oedemaoedema Pitting or non pittingPitting or non pitting

Jugular venous pressureJugular venous pressure

Cardiac examinationCardiac examination Inspection: Inspection: - deformity- deformity - Sternotomy scar- Sternotomy scar - Posture of the patient- Posture of the patient - Breathlessness- Breathlessness - -

PalpationPalpation Apex beat: Lowest and most lateral point at which Apex beat: Lowest and most lateral point at which

the cardiac impulse is feltthe cardiac impulse is felt Normal: 5Normal: 5thth intercostal space mid clavicular line intercostal space mid clavicular line Displacement from the normal site indicates cardiac Displacement from the normal site indicates cardiac

enlargement; usually due to dilatation(MR,AR)enlargement; usually due to dilatation(MR,AR)

In hypertrophy the cardiac location may be In hypertrophy the cardiac location may be normal(AS)normal(AS)

Cardiac AuscultationCardiac Auscultation

Cardiac auscultation is most Cardiac auscultation is most useful part of CVS examination useful part of CVS examination

which gives anatomical, which gives anatomical, physiological and hemodyanamic physiological and hemodyanamic

information of normal and information of normal and abnormal cardiac function.abnormal cardiac function.

InstrumentInstrument DiaphragmDiaphragm BellBell

Auscultatory areasAuscultatory areas

Auscultatory eventsAuscultatory events SoundsSounds

S1S1 S2S2 S3 or S4S3 or S4 ClicksClicks

Systolic murmursSystolic murmurs Diastolic murmursDiastolic murmurs Pericardial rubPericardial rub

Systolic Vs DiastolicSystolic Vs Diastolic CarotidsCarotids ApexApex

S1S1 Closure of mitral and Closure of mitral and

tricuspid valvetricuspid valve Medium pitchMedium pitch DiaphragmDiaphragm Heard in all areasHeard in all areas

S2S2 Closure of Aortic and Closure of Aortic and

Pulmonary valvesPulmonary valves AV and PV donot close AV and PV donot close

simultaneouslysimultaneously 2 components of S2 2 components of S2

A2 and P2A2 and P2

S1 A2 P2

S1 A2 P2

Inspiration

Expiration

S3 and S4S3 and S4

ClicksClicksJust as closure of AV valves and Just as closure of AV valves and

Semi-lunar valves cause S1 and S2, Semi-lunar valves cause S1 and S2, their opening also may produce their opening also may produce sounds called Clicks, but that sounds called Clicks, but that

happens only when they are diseased.happens only when they are diseased.

MurmursMurmursMusical sounds created by turbulent Musical sounds created by turbulent

flow across an abnormal valve or flow across an abnormal valve or abnormal flow across a normal valveabnormal flow across a normal valve

Describing murmursDescribing murmurs Which part of cardiac cycle?Which part of cardiac cycle? Site of maximum intensity?Site of maximum intensity? Loudness grade?Loudness grade? Quality?Quality? Pitch?Pitch? Any specific radiation?Any specific radiation? Change with specific maneuver?Change with specific maneuver?

Types of murmursTypes of murmurs SystolicSystolic- begin and end in systole- begin and end in systole DiastolicDiastolic- begin and end in diadtole- begin and end in diadtole ContinuousContinuous- begin in systole and spill over - begin in systole and spill over

into diastole across S2into diastole across S2

Systolic murmursSystolic murmurs PansystolicPansystolic

Mid-systolic or ejection Mid-systolic or ejection systolicsystolic

Late systolicLate systolic

S1 A2 P2

S1 A2 P2

S1 A2 P2

Pansystolic murmursPansystolic murmurs Mitral regurgitationMitral regurgitation Tricuspid regurgitationTricuspid regurgitation Ventricular Septal Ventricular Septal

defectdefect

S1 A2 P2

Ejection systolic murmursEjection systolic murmurs Aortic stenosisAortic stenosis Pulmonic stenosisPulmonic stenosis Flow murmursFlow murmurs

S1 A2 P2

Late systolic murmursLate systolic murmurs Mitral valve prolapseMitral valve prolapse

S1 A2 P2

Diastolic murmursDiastolic murmurs Early diastolicEarly diastolic

Mid diastolicMid diastolic

Late diastolic/ Late diastolic/ PresystolicPresystolic

S1 A2 P2

S1 A2 os

S1 A2 P2

Early diastolic murmursEarly diastolic murmurs ARAR PRPR

S1 A2 P2

S1 A2 P2

Mid diastolic murmursMid diastolic murmurs Mitral stenosisMitral stenosis Tricuspid stenosisTricuspid stenosis Increased flow across MVIncreased flow across MV

VSDVSD PDAPDA MRMR

S1 A2 os

S1 A2

Late diastolic/ PresystolicLate diastolic/ Presystolic Mitral stenosisMitral stenosis

S1 A2 P2

Continuous murmursContinuous murmurs PDAPDA AV fistulaAV fistula

Describing murmursDescribing murmurs Which part of cardiac cycle?Which part of cardiac cycle? Site of maximum intensity?Site of maximum intensity? Loudness grade?Loudness grade? Quality?Quality? Pitch?Pitch? Any specific radiation?Any specific radiation? Change with specific maneuver?Change with specific maneuver?

Site of max intensity?Site of max intensity? Mitral valve- apical areaMitral valve- apical area Tricuspid valve- lower Lt sternal edgeTricuspid valve- lower Lt sternal edge Aortic valve – 2Aortic valve – 2ndnd right ICS right ICS Pulmonary Valve- 2Pulmonary Valve- 2ndnd left ICS left ICS

Describing murmursDescribing murmurs Which part of cardiac cycle?Which part of cardiac cycle? Site of maximum intensity?Site of maximum intensity? Loudness grade?Loudness grade? Quality?Quality? Pitch?Pitch? Any specific radiation?Any specific radiation? Change with specific maneuver?Change with specific maneuver?

Loudness Loudness Grade-1 heard after intense effort in a quiet Grade-1 heard after intense effort in a quiet

roomroom Grade 2 easily heardGrade 2 easily heard Grade 3 loud murmur with no thrillGrade 3 loud murmur with no thrill Grade 4 loud murmur with thrillGrade 4 loud murmur with thrill Grade 5 murmur heard with rim touchingGrade 5 murmur heard with rim touching Grade 6 murmur heard with St off the chestGrade 6 murmur heard with St off the chest

Describing murmursDescribing murmurs Which part of cardiac cycle?Which part of cardiac cycle? Site of maximum intensity?Site of maximum intensity? Loudness grade?Loudness grade? Quality?Quality? Pitch?Pitch? Any specific radiation?Any specific radiation? Change with specific maneuver?Change with specific maneuver?

Quality?Quality? RumblingRumbling MS, TSMS, TS BlowingBlowing MR, TR,ARMR, TR,AR Machinery murmurMachinery murmur PDAPDA

Describing murmursDescribing murmurs Which part of cardiac cycle?Which part of cardiac cycle? Site of maximum intensity?Site of maximum intensity? Loudness grade?Loudness grade? Quality?Quality? Pitch?Pitch? Any specific radiation?Any specific radiation? Change with specific maneuver?Change with specific maneuver?

Pitch?Pitch? High pitchHigh pitch MR, TR, ARMR, TR, AR Low pitchLow pitch MS, TSMS, TS Harsh (mixed)Harsh (mixed) VSD, ASVSD, AS

Describing murmursDescribing murmurs Which part of cardiac cycle?Which part of cardiac cycle? Site of maximum intensity?Site of maximum intensity? Loudness grade?Loudness grade? Quality?Quality? Pitch?Pitch? Any specific radiation?Any specific radiation? Change with specific maneuver?Change with specific maneuver?

Radiation?Radiation? MRMR axilla, Interscapular areaaxilla, Interscapular area ARAR LLSELLSE ASAS CarotidsCarotids

MSMS TSTS donot radiatedonot radiate TRTR

Describing murmursDescribing murmurs Which part of cardiac cycle?Which part of cardiac cycle? Site of maximum intensity?Site of maximum intensity? Loudness grade?Loudness grade? Quality?Quality? Pitch?Pitch? Any specific radiation?Any specific radiation? Change with specific maneuver?Change with specific maneuver?

Dyanamic auscultationDyanamic auscultation Respiratory variationRespiratory variation PosturePosture Valsalva maneuverValsalva maneuver Handgrip exerciseHandgrip exercise AmylnitriteAmylnitrite

Respiratory variationRespiratory variation How to see?How to see? Why does it change murmurs?Why does it change murmurs? Implication?Implication?

Right sided murmurs increase with inspirationRight sided murmurs increase with inspiration Left side murmurs increase with expirationLeft side murmurs increase with expiration

PosturePosture Certain murmurs are best appreciated in Certain murmurs are best appreciated in

specific postures.specific postures. MS in left lateralMS in left lateral AR in sitting postureAR in sitting posture

Drugs Drugs AmylnitriteAmylnitrite

How does it act?How does it act? What is the effect?What is the effect?

Pericardial rubPericardial rub Leathery qualityLeathery quality 3 components3 components Sitting and leaning forwardsSitting and leaning forwards

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