General : 1. General appearance 2. Skin 3. Head and Neck 4.
Chest 5. Abdomen 6. Extremities Cardiovascular Examination
Slide 3
GENERAL APPEARANCE : Any examination begins with an assessment
of the general appearance of the patient : - Is the patient in pain
or resting quietly, dyspneic or diaphoretic? - Does the patient
choose to avoid certain body positions to reduce or eliminate pain,
as might be the case with suspected acute pericarditis? -Are there
clues indicating that dyspnea may have a pulmonary cause, such as a
barrel chest deformity with an increased anterior posterior
diameter,tachypnea, and pursed-lip breathing? A chronically
ill-appearing emaciated patient may suggest the presence of
longstanding heart failure or another systemic disorder, such as a
malignancy. Height and weight should be measured routinely, and
body mass index should be calculated.
Slide 4
SKIN : Cyanosis : - Central : Central cyanosis is evident when
systemic arterial concentration of deoxygenated hemoglobin (Hb) in
the blood exceeds 5 mg/dL. - Peripheral(acrocyanosis) : Is usually
related to reduced extremity blood flow due to small vessel
constriction, as seen in patients with severe heart failure, shock,
or peripheral vascular disease; it can be aggravated by the use of
adrenergic -blockers with unopposed -mediated constriction. -
Differential : Refers to isolated cyanosis affecting the lower but
not the upper extremities in a patient with a large patent ductus
arteriosus (PDA)and secondary pulmonary hypertension with right
-to-left to shunting at the great vessel level.
Slide 5
Peripheral cyanosis Central cyanosis
Slide 6
Differential cyanosis
Slide 7
Cont. Jaundice, which may be visible first in the sclerae, has
a broad differential diagnosis but in the appropriate setting can
be consistent with advanced right heart failure and congestive
hepatomegaly or late-term "cardiac cirrhosis.
Slide 8
HEAD AND NECK : A high-arched palate is a feature of Marfan
syndrome and other connective tissue disease syndromes. Many
patients with congenital heart disease have associated
hypertelorism, low-set ears, or micrognathia. The funduscopic
examination is an often underutilized method by which to assess the
microvasculature, especially among patients with established
atherosclerosis, hypertension, or diabetes mellitus. The finding of
an elevated JVP implies a cardiovascular etiology.
Slide 9
CHEST : Midline sternotomy or infraclavicular scars at the site
of pacemaker/defibrillator generator implantation should not be
overlooked. Obstructive lung disease is suggested by a barrel chest
deformity, especially with tachypnea, and use of accessory
muscles.
Slide 10
ABDOMEN : In some patients with advanced obstructive lung
disease, the point of maximal cardiac impulse may be in the
epigastrium. The liver is frequently enlarged and tender in
patients with chronic heart failure. Splenomegaly may be a feature
of infective endocarditis. Ascites is a nonspecific finding but may
be present with advanced chronic right heart failure.
Slide 11
Cont. In nonobese patients, the aorta typically is palpated
between the epigastrium and the umbilicus. The sensitivity of
palpation for the detection of an abdominal aortic aneurysm
(pulsatile and expansile mass) decreases as a function of body
size. Because palpation alone is not sufficiently accurate to
establish this diagnosis, a screening ultrasound examination is
advised. The presence of an arterial bruit over the abdomen
suggests high-grade atherosclerotic disease.
Slide 12
EXTREMITIES : The temperature and color of the extremities, the
presence of clubbing can be surmised quickly during the
examination. Clubbing implies the presence of central right to-left
shunting, although it has also been described in patients with
endocarditis and etc. The Janeway lesions are nontender, slightly
raised hemorrhages on the palms and soles, whereas Osler's nodes
are tender, raised nodules on the pads of the fingers or toes.
Splinter hemorrhages are classically identified as linear petechiae
in the midposition of the nail bed and are suggestive of
ENDOCARDITIS.
Slide 13
Slide 14
Slide 15
Osler's nodes Splinter hemorrhage Janeway lesions
Slide 16
Cont. Lower extremity or presacral edema in the setting of an
elevated JVP defines volume overload and may be a feature of
chronic heart failure or constrictive pericarditis. Lower extremity
edema in the absence of jugular venous hypertension may be due to
lymphatic or venous obstruction or, more commonly, to venous
insufficiency, as further suggested by the appearance of
varicosities, venous ulcers (typically medial in location), and
brownish cutaneous discoloration from hemosiderin
deposition(eburnation). Muscular atrophy,shiny skin or the absence
of hair along an extremity is consistent with severe arterial
insufficiency.
Slide 17
Cardiovascular Examination
Slide 18
JUGULAR VENOUS PRESSURE : Jugular venous pressure is the single
most important bedside measurement from which to estimate the
volume overload. The internal jugular vein is preferred because the
external jugular vein is valved and not directly in line with the
superior vena cava and right atrium. Venous pressure traditionally
has been measured as the vertical distance between the top of the
jugular venous pulsation and the sternal inflection point (angle of
Louis). A distance >4.5 cm at 30 elevation is considered
abnormal. Venous pulsations above clavicle in the sitting position
are clearly abnormal, as the distance between the clavicle and the
right atrium is at least 10 cm.
Slide 19
Slide 20
Slide 21
Elevated jugular venous pressure indicates increased right
atrial pressure which can be caused by various pathologic
conditions such as : 1.fluid overload 2. right ventricular failure
3. restriction of right atrial and right ventricular filling (eg,
constrictive pericarditis) 4. superior vena cava obstruction
Slide 22
Kussmaul's sign is defined by either a rise or a lack of fall
of the JVP with inspiration and is classically associated with :
constrictive pericarditis Although it has been reported in patients
with : 1.restrictive cardiomyopathy 2.massive pulmonary embolism
3.right ventricular infarction
Slide 23
ABDOMINOJUGULAR REFLEX (HEPATOJUGULAR REFLUX) : It is elicited
with firm and consistent pressure over the upper portion of the
abdomen, preferably over the right upper quadrant, for at least 10
s. A positive response is defined by a sustained rise of more than
3 cm in JVP for at least 15 s after release of the hand. In normal
subjects this maneuver transiently increases jugular pressure by
only approximately 1-3 cm. In patients with right ventricular
failure, however, sustained elevation of venous pressure usually
greater than 3 cm is observed during discontinued compression.
Slide 24
ASSESSMENT OF BLOOD PRESSURE : Blood pressure is best measured
in the seated position with the arm at the level of the heart,
using an appropriately sized cuff, after 5 10 min of relaxation.
When it is measured in the supine position, the arm should be
raised to bring it to the level of the mid-right atrium. The length
and width of the blood pressure cuff bladder should be 80% and 40%
of the arm's circumference, respectively. an inappropriately small
cuff, resulting in marked overestimation of true blood pressure. an
inappropriately large cuff, resulting in underestimation of true
blood pressure. The cuff should be inflated to 30 mmHg above the
expected systolic pressure and the pressure released at a rate of
23 mmHg/s.
Slide 25
Cont. Blood pressure should be measured in both arms, and the
difference should be less than 10 mmHg. A blood pressure
differential that exceeds this threshold may be associated with :
1. atherosclerotic or inflammatory subclavian artery disease 2.
aortic coarctation 3. aortic dissection Systolic leg pressures are
usually as much as 20 mmHg higher than systolic arm pressures.
Greater legarm pressure differences are seen in patients with :
1.extensive and calcified lower extremity peripheral arterial
disease.
Slide 26 140/90 mmHg and at least two non-clinic-based
measurements 20 mmHg or in diastolic pressure >10 mmHg in
response to assumption of the upright posture from a supine
position within 3 min. It can be exacerbated by advanced age,
dehydration and certain medications.">
Cont. The blood pressure measured in an office or hospital
setting may not accurately reflect the pressure in other venues.
"White coat hypertension" is defined by at least three separate
clinic base measurements >140/90 mmHg and at least two
non-clinic-based measurements 20 mmHg or in diastolic pressure
>10 mmHg in response to assumption of the upright posture from a
supine position within 3 min. It can be exacerbated by advanced
age, dehydration and certain medications.
Slide 27
PULSUS PARADOXUS :Systemic arterial pressure normally falls by
less than 10 mmHg during inspiration, but this decline is not
palpable at the peripheral pulse. Moderate to severe cardiac
tamponade, and occasionally constrictive pericarditis, induce
hemodynamic changes that enhance the inspiratory fall in systolic
blood pressure. This exaggerated drop in systemic blood pressure
during inspiration is termed pulsus paradoxus. To measure pulsus
paradoxus, the cuff is deflated more slowly than usual. During
deflation, the first Korotkoff sounds are audible only during
expiration, but with further deflation, Korotkoff sounds are heard
throughout the respiratory cycle. The difference between these two
sounds quantifies pulsus paradoxus.
Inspection And Palpation :: Palpation of the heart begins with
the patient in the supine position at 30 and can be enhanced by
placing the patient in the left lateral decubitus position. The
left ventricular apex beat may be visible in the midclavicular line
at the fifth intercostal space in thin chested adults.
Characteristics such as size and location should be noted. The
normal apical impulse is less than 2 cm in diameter and moves
quickly away from the fingers; it is better appreciated at end
expiration, with the heart closer to the anterior chest wall.
Slide 31
Enlargement of the left ventricular cavity is manifested by a
leftward and downward displacement of an enlarged apex beat. In
thin, tall patients and patients with advanced obstructive lung
disease and flattened diaphragms, the cardiac impulse may be
visible in the epigastrium. Systolic and diastolic thrills signify
turbulent and high-velocity blood flow. Their locations help
identify the origin of heart murmurs. Cont.
Normal heart sound is prodused by valve closure. The first
heart sound (S1) includes mitral and tricuspid valve closure. S1 is
best heard with the diaphragm of the stethoscope. The intensity of
S1 is normally maximal over the cardiac apex. S1 :
Slide 36
S2 : Aortic and pulmonic valve closure constitutes the second
heart sound (S2). The two components of S2 are best heard with the
diaphragm of the stethoscope and over the left second interspace
close to the sternal border. S2 sound may be splitted normaly or
pathologically : With normal or physiologic splitting, the A2P2
interval increases with inspiration and narrows during expiration.
This physiologic interval will widen with right bundle branch block
because of the further delay in pulmonic valve closure and in
patients with severe MR because of the premature closure of the
aortic valve. Reversed or paradoxical splitting refers to a
pathologic delay in S2 aortic valve closure, such as that which
occurs in patients with left bundle branch block,severe AS.
Slide 37
The intensity of any heart sound, however, can be reduced by
any process that increases the distance between the stethoscope and
the responsible cardiac event, including : 1.Obstructive lung
disease 2.Obesity 3.Pneumothorax 4.Pleural effusion 5.Pericardial
effusion
Slide 38
SYSTOLIC SOUNDS : 1.Ejection sound (AS, PS ) 2.Click ( MVP ) An
ejection sound is a high-pitched early systolic sound. It is best
heard with the diaphragm of the stethoscope. It usually is
associated with a deformed but mobile aortic or pulmonic valve.
ejection sounds are heard frequently in patients with mild to
moderate valve stenosis; they may be absent in severe calcific
stenosis, presumably due to the loss of valve mobility. Nonejection
sounds (clicks), are related to mitral valve prolapse and may be
followed by murmur. This click-murmur complex will move away from
the first heart sound with maneuvers that increase ventricular
preload, such as squatting. On standing, the click and murmur move
closer to S1.
S3 And S4 : S3 and S4 are low-frequency diastolic sounds and
are best heard with the bell of the stethoscope. S3 is just after
S2 and S4 occurs prior to S1. S3 occurs as passive ventricular
filling begins after actual relaxation is completed. S4 occurs
after the P wave on the electrocardiogram and coincides with atrial
systole and with the apical impulse. A left-sided S3, S4 is best
heard over the left ventricular (LV) apex. A right -sided S3, S4 is
usually better heard over the lower left sternal border and becomes
louder with inspiration.
Slide 41
Cont. S3 can be heard in healthy young adults. However, it is
usually abnormal in patients over the age of 40 years signifies
heart failure. S4 can be heard in many healthy older adults without
any other cardiac abnormality. An S4 is more common among patients
with chronic left ventricular hypertrophy or active myocardial
ischemia. An S4 is not present with atrial fibrillation.
Slide 42
Opening Snap : The opening snap is a high-frequency, early
diastolic sound associated with mitral or tricuspid valve opening.
The opening snap results from rapid opening of the valve to its
maximal open position. It is absent when the valve is heavily
calcified and immobile. The opening snap is best heard with the
diaphragm of the stethoscope The OS of mitral stenosis is heard
best over medial to the cardiac apex. A tricuspid valve opening
snap is heard best over the lower left sternal border.
Slide 43
Slide 44
MURMURS : Heart murmurs result from audible vibrations that are
caused by increased turbulence. MURMUR DESCRIPTION The character of
a murmur is described by a number of features, including : 1.
intensity (grade) 2. frequency 3. timing 4. shape 5. location 6.
radiation 7. response to bedside maneuvers
Slide 45
Intensity Six grades are used to classify the intensity of a
murmur : grade 1 murmur is very soft and is heard only with great
effort. grade 2 murmur is easily heard but not particularly loud.
grade 3 murmur is loud but is not accompanied by a palpable thrill
over the site of maximal intensity. grade 4 murmur is very loud and
is accompanied by a thrill. grade 5 murmur is loud enough to be
heard with only the edge of the stethoscope touching the chest.
grade 6 murmur is loud enough to be heard with the stethoscope
slightly off the chest. The frequency of the murmur determines the
pitch, which may be high or low.
Slide 46
Timing The duration of a murmur is assessed by determining the
length of systole or diastole that the murmur occupies : 1.
systolic murmurs: - Midsystolic - Early systolic - Late systolic -
Holosystolic (or pansystolic) 2. diastolic murmurs: - Early
diastolic - Mid-diastolic 3. Continuous murmurs
Slide 47
Shape The time course of murmur intensity corresponds to the
"shape" of a diagram of murmur intensity over time. - Crescendo
(increasing) -Decrescendo (diminishing) -Crescendo-decrescendo
(increasing-decreasing or diamond shaped) -Plateau (unchanged in
intensity) crescendo plateau Diamond shape decrescendo
Slide 48
Location The location on the patient's chest where the murmur
is loudest is typically described as apical or parasternal.
Parasternal murmurs are further described by the intercostal space
and right or left side of the sternum. Radiation Response to
maneuvers
Slide 49
Slide 50
SYSTOLIC MURMURS : A systolic murmur starts with or after S1
and terminates before or at S2. Systolic murmurs are recognized by
identifying S1 and S2 and timing them with the carotid pulse.
Systolic murmurs are further classified according to the time of
onset and termination in systole: 1. A midsystolic murmur (MSM)
begins after S1 and ends before A2 (left sided) or P2 (right
sided). Both S1 and S2 are audible 2.A holosystolic (or
pansystolic) murmur starts with S1 and extends up to A2 (left
sided) or P2 (right sided), obscuring both S1 and S2 3.An early
systolic murmur obscures S1 and extends for a variable length in
systole but does not extend up to S2 4.A late systolic murmur
starts after S1 and obscures A2 (left sided) or P2 (right
sided)
Slide 51
Midsystolic murmurs: Mid-systolic murmurs begin at a short
interval after S1 and end before S2. The intensity of the MSM
increases (crescendo) during acceleration of blood flow early in
systole; intensity declines (decrescendo) with the later
deceleration of flow, resulting in a crescendo-decrescendo
configuration. Includes : 1. Innocent 2. Increased semilunar blood
flow 3. Aortic stenosis (supravalvular,subvalvular,valvular) 4.
pulmonic stenosis (supravalvular,subvalvular,valvular,functional)
5.HOCM
Slide 52
Innocent Murmur : These innocent or benign "flow" murmurs are
typically midsystolic in timing. Innocent MSM can be heard in
children and young adults that is best heard over the left second
interspace. The "innocence" of an MSM should not depend upon the
duration or intensity of the murmur, but on the absence of other
abnormal findings.
Slide 53
Increased semilunar blood flow : An MSM also occurs in the
presence of normal valves when flow across the semilunar valve is
significantly increased, as occurs in the following settings : -
Anemia - pregnancy - thyrotoxicosis - fever
Slide 54
Aortic stenosis : In valvular AS, the maximum intensity is
appreciated over the right second interspace. A thrill may be
palpable over the same area. The murmur radiates up into the neck
and over both carotid arteries. I t is often difficult to estimate
the severity of the valve lesion on the basis of the physical
examination findings. A aortic ejection sound at the onset of the
murmur may be heard. S2 is paradoxically splitted in mod.-severe
aortic stenosis. In severe cases S4 maybe heard.
Slide 55
Pulmonic stenosis : The murmur of valvular pulmonic stenosis is
best heard over the left second interspace. When the murmur is loud
it radiates to the left side of the neck and is frequently
accompanied by a palpable thrill. A pulmonic ejection sound at the
onset of the murmur may be heard. S2 is widely split.
Slide 56
HOCM : The obstructive form of hypertrophic cardiomyopathy
(HOCM) is associated with a mid- systolic murmur that is usually
loudest along the lower left sternal border and without radiation
to the carotid artery. The systolic murmur of HOCM usually can be
distinguished from other causes on the basis of its response to
bedside maneuvers, including valsalva, passive leg raising, and
standing/squatting.
Slide 57
Holosystolic Murmurs : Holosystolic murmurs are usually
regurgitant murmurs and occur when blood flows from a chamber whose
pressure throughout systole is higher than pressure in the chamber
receiving the flow. There are three causes of holosystolic murmurs:
- MR - TR - VSD
Slide 58
MR : The holosystolic murmur of chronic MR is best heard at the
apex and radiates to the axilla. it is usually plateau in
configuration because of the wide difference between left
ventricular and left atrial pressure throughout systole.
Slide 59
TR : The holosystolic murmur of chronic TR is loudest at the
left lower sternal border. Usually increases in intensity with
inspiration. An enlarged and pulsatile liver maybe seen.
Slide 60
VSD : The murmur of a VSD (without significant pulmonary
hypertension)is holosystolic and loudest at the mid -left sternal
border (third and fourth interspaces ), where a thrill is usually
present. The character and timing of the systolic murmur change
with large VSDs due to increased right ventricular and pulmonary
artery pressure and an elevated pulmonary vascular resistance.
Instead of being holosystolic, it becomes early systolic and the
peak of the murmur occurs earlier. Thus, a loud holosystolic murmur
in a patient with a VSD indicates favorable hemodynamics (eg,
relatively normal right-sided pressures).
Slide 61
Early Systolic Murmurs : Early systolic murmurs begin with S1,
do not extend to S2, and generally have a decrescendo
configuration. Early systolic murmurs may result from : - MR - TR -
VSD.
Slide 62
MR, TR : An equalization of left atrial and left ventricular
pressure may occur, preventing the regurgitant flow during whole
part of systole. Thus, the regurgitant murmur terminates before S2.
Since the regurgitant flow is maximal at the beginning of systole
and decreases with increasing left atrial pressure, a decrescendo
configuration of this early systolic murmur is common
Slide 63
VSD : In a large VSD with pulmonary hypertension, the murmur
may be early systolic in timing, since the increasing right
ventricular pressure during late systole decreases the
left-to-right shunt. Findings of pulmonary hypertension are always
present.
Slide 64
Late Systolic Murmurs : A late systolic murmur starts after S1
and, if left-sided, extends to A2. Mitral valve prolapse Mitral
valve prolapse is the most common cause of a late systolic murmur.
It is best heard with the diaphragm of the stethoscope, over or
just medial to the cardiac apex. It is usually preceded by
click.
Slide 65
DIASTOLIC MURMURS : A diastolic murmur starts with or after S2
and ends at or before S1. Diastolic murmurs are also classified
according to the time of onset and termination of the murmur in
diastole: 1. An early diastolic murmur starts with A2 (left sided)
or P2 (right sided) and extends into diastole for a variable
duration. 2. A mid-diastolic murmur starts after S2 and terminates
before S1.
Slide 66
Early Diastolic Murmurs : Early diastolic murmurs, most often
due to aortic or pulmonary regurgitation, typically start at the
time of semilunar valve closure and their onset coincides with S2.
An aortic regurgitation murmur begins with A2; pulmonary
regurgitation begins with P2. Includes : - AR - PR
Slide 67
Aortic regurgitation : The murmur of aortic regurgitation is
best heard with the diaphragm of the stethoscope.It could be best
heard over the right second interspace, while the patient sits and
leans forward with the breath held in full expiration. The
radiation of an aortic regurgitation murmur is toward the cardiac
apex. The configuration of the aortic regurgitation murmur is
usually decrescendo because the magnitude of regurgitation
progressively declines.
Slide 68
Pulmonic regurgitation : The murmur has a decrescendo
configuration like that of aortic regurgitation; differentiation is
difficult if not impossible by auscultation alone. The murmur may
increase in intensity during inspiration and can be more localized.
It is best heard over the left second interspaces. Pathologic
pulmonic regurgitation is most frequently a result of pulmonic
hypertension.
Slide 69
Mid-Diastolic Murmurs : Mid-diastolic murmurs result from
turbulent flow across the atrioventricular valves during the rapid
filling and atrial contracture phase because of mitral or tricuspid
valve stenosis and an abnormal pattern of flow across these valves.
Includes : - MS(Mitral stenosis) - TS ( tricuspid stenosis )
Slide 70
MS, TS : The mid-diastolic murmur of mitral stenosis is best
heard with the bell of the stethoscope over the apex in the left
lateral decubitus position. Tricuspid stenosis is best heard along
the lower left sternal border. Presystolic accentuation is absent
in patients with atrial fibrillation. It characteristically starts
with an opening snap.
Slide 71
CONTINUOUS MURMURS : Continuous murmurs are defined as murmurs
that begin in systole and extend up to diastole without
interruption. They do not necessarily need to occupy the total
duration of systole and diastole. Their presence throughout the
cardiac cycle implies a pressure gradient between two chambers or
vessels during both systole and diastole. The continuous murmur
associated with a patent ductus arteriosus is best heard at the
upper left sternal border. Other cause of a continuous murmur
include an arteriovenous fistula constructed to provide dialysis
access.
Slide 72
Slide 73
Effects of Physiologic Interventions on the Intensity of Heart
Murmurs and Sounds : Respiration : Right-sided murmurs and sounds
generally increase with inspiration, except for the PES.Left-sided
murmurs and sounds are usually louder during expiration. Valsalva
maneuver : Most murmurs decrease in length and intensity. Two
exceptions are the systolic murmur of HOCM, which usually becomes
much louder, and that of MVP, which becomes longer and often
louder. Positional changes : With standing, most murmurs diminish,
with two exceptions being the murmur of HOCM, which becomes louder,
and that of MVP, which lengthens and often is intensified. With
squatting,most murmurs become louder, but those of HOCM and MVP
usually soften and may disappear. Passive leg raising usually
produces the same results.The intensity of the murmurs associated
with MR, VSD, and AR will increase in response to maneuvers that
increase LV afterload, such as hand grip and vasopressors.
Slide 74
Slide 75
PERICARDIAL DISEASE : A pericardial friction rub is nearly 100%
specific for the diagnosis of acute pericarditis, though the
sensitivity of this finding is not nearly as high, as the rub may
come and go over the course of an acute illness or be very
difficult to elicit. Classically, the three components are
ventricular systole, rapid early diastolic filling, and late
presystolic filling after atrial contraction in patients in sinus
rhythm. It is necessary to listen to the heart in several
positions. Additional clues may be present from the history and
12-lead electrocardiogram. The rub typically disappears as the
volume of any pericardial effusion increases.