An Illustrated Guide For

Cardiovascular System
Examination
Bedside Teaching for 2nd year medical Students

Prepared by:
Dr. Farid Ghalli
Clinical Teacher (Hon)
2016
 Cardiovascular System
Examination

Inspection Palpation Auscultation

i. Heart sounds:
• Mitral area M
• Pulmonary area P
• Aortic area A
• Shape of precordium • Tricuspid area T
• Apex beat • Opening snap
• Pulsation in other i. Apex beat
localization ii. Murmurs:
areas
ii. Pulsation in • Mitral area
a. Pulmonary
following areas • Aortic area
b. Parasternal
• Pulmonary • Bruit over carotids
c. Aortic
• Parasternal • Pulmonary area
d. Neck
• Aortic • Tricuspid area
e. Epigastric
iii. Thrills: • Parasternal area
f. JVP
• Mitral iii. Pericardial rub
• Aortic iv. Listening to the base of
lungs.
• Carotid artery
• Pulmonary
• Parasternal
iv. Palpates liver for
hepatojugular reflux,
v. Feels for pulsatile
liver
vi. Palpates for
oedema.
Before Examination :

Wash hands
Introduce yourself
Confirm patient details – name / DOB
Explain the examination
Gain consent
Expose the patient’s chest
Position patient at 45°
Ask patient if they have pain anywhere before you begin!

General Examination
Appearance : Looks Well/Ill , Consciousness , Alert .
Body Built : Average , Thin , Obese ( Depends On BMI ) .
Color : Pale , Cyanosed .
Decubitus : Patient's position in bed .
Distress : Difficulty In Breathing ( Dyspnoeic ) .
Any surrounding Clues : IV Line , Catheter, O2 Mask , ECG , Wheelchair ,
…etc.
Vital Signs
Pulse :
1- Radial Artery .
2- Brachial Artery .
3- Carotid Artery :
- This Is The Best Place To Assess The Pulse Volume And Character .
- Be Careful Not To Compress Both Carotids At Once , For Fear Of Diminishing
Blood Flow To The Brain .
4- Femoral Artery :
- Can Be Felt Midway Between The Pubic Tubercle And The Anterior Superior
Iliac Spine.
5- Popliteal Artery .
6- Posterior Tibial Artery
- Palpate At The Ankle Just Posterior And Inferior To The Medial Malleolus
7- Dorsalis Pedis :
- This Runs Lateral To The Exterior Hallucis Longus Tendon On The Superior
Surface Of The Foot Between The Bases Of The First And Second Metatarsals .

1. Radial artery 2. Brachial artery

3.Axillary Artey 4. Subclavian Artery

5.Carotid Artery 6. Facial Artey

7.Superficial Temporal Artery 8. Dorsalis Pedis Artery

9. Posterior Tibial Artery 10. Abdominal Aorta

11. Femoral Artey pulations and check of radiofemoral delay

Special Pulse Characters:

Detection of Water Hammer Pulse

Synchronization :
1- Radio-Radial Delay :
- Occur Usually Due To Occlusion Or Stenosis On One Side , Dissection Of
Thoracic Aorta Or Aortic Aneurysm .
2- Radio-Femoral Delay :
- Suggest The Diagnosis Of Coarctation Of Aorta .
3- Radio-Brachial Delay :
- Occur In Case Of Aortic Stenosis .
Blood Pressure ( BP ) :

Examination of the Upper Limb

Clubbing .
 Capillary Refill : > 2 Seconds ( Peripheral Vascular Disease , Hypothermia ,
Dehydration , Shock ) .
Capillary Pulsation ( Quinke's Sign ) : Aortic Regurge .
Splinter Hemorrhage ,

Osler Node Which Seen In Palmar Surface Of Fingertip : Infective Endocarditis

Janeway Lesions : Infective Endocarditis

, Petechial Rash , Evidence Of IV Drug Abuse : Infective Endocarditis .

Peripheral Cyanosis .
 Pallor Which Seen In Palmar Creases .
Tendon Xanthoma ( Yellowish Discoloration Of Tendon At Wrist ) :
Hyperlipidemia .

Examination of Head & Neck :

Eye :
- Jaundice .
- Pallor : Anemia
- Conjunctival Hemorrhage : Infective
Endocarditis .

- Xanthelasma : Hyperlipidemia .
 Mouth :
- Cyanosis : Lips For Peripheral Cyanosis & Tongue For
Central Cyanosis .

Cheeks :
- Mitral Facies : Severe Mitral Stenosis .

Neck :
- Lymph Nodes (See respiratory system examination).
- Jugular Vein .
- Carotid Artery .

5. Neck veins and carotid arterial pulsations

Normal waveforms of the jugular venous pulse.

venous waves.mp4

JVP Waves :
a - Wave : Caused By Atrial Contraction .
c - wave : Due To Closure of Tricuspid Valve .
x - Descent : Atrial Relaxation .
v - Wave : Increasing pressure in right atrium with atrial filling .
y - Descent : Commencement of Ventricular Filling As Tricuspid Valve Opens .

How to differentiate between arterial and venous neck pulsations?

Types of neck
pulsations.mp4
Examination of the Lower Limb

- Skin Changes , Muscle Wasting , Loss Of Hair .

- Oedema : Pitting / Non-Pitting - Unilateral / Bilateral - Level .
- Pulse : Femoral - Popliteal - Dorsalis Pedis - Posterior Tibial ( See pulse section
above) .

Check Lower limb oedema Pitting oedema

Local Heart Examination :

Inspection :

Observe the patient from the end of the bed

1. Symmetry : localised bulge or retraction
2. Deformity : Kyphosis , Scoliosis , Pectus Excavatum , Pectus Carinatum

3. Previous Scars : Median Sternotomy , Lateral Thoracotomy .

4- Dilated Veins

5. Any Visible Pulsations : Determine The Site .

- Epigastric Pulsation : Right Ventricle , Aorta Or Left lobe of the liver (
Differentiated By Palpation ) .
- Lt Parasternal Pulsation : Right Ventricle Enlargement.
- Aortic Area Pulsation ( 2nd Right ICS ) : Aortic Aneurysm , Systemic
Hypertension .
- Pulmonary Area Pulsation ( 2nd Left ICS ) : Pulmonary Hypertension .
- Suprasternal / Carotid Pulsation : Aortic Regurgitation ( Corrigan's Sign ) .

Palpation:
" Don't Forget To Warm Your Hand "
1- Apex Beat .
- Definition : Lower Most And Outer Most Visible And Palpable Pulsation Over
The Chest .
- Normal Site : 5th Left ICS ,1 Cm Medial To Mid-Clavicular Line .
- Normal Size : Less Than 2 Intercostal Space And Localized .
- Normal Character : Gentle Tap .

Apex beat – normal position is 5th intercostal space – mid-clavicular line

left lateral decubitus

2. Parasternal Heave :
- Rest The Heel Of The Hand Just To The Left Of The Sternum With The Fingers
Lifted Slightly Off The Chest .
- Normally No Impulses But In Right Ventricular Enlargement , The Heel Of
Hand Is Lifted Off The Chest With Each Systole .

3. Other Pulsations

Figure : Seven areas to be examined for abnormal cardiovascular pulsations by inspection and palpation. (From
Schlant RC, Hurst JW.

Pulmonary area pulsations Aortic area pulsations

Epigastric Pulsations

4. Thrills ( Palpable Murmurs ) :

 Auscultation:
# Component Of Auscultation :
1- Heart Sound .
2- Murmurs .
3- Additional Sounds .

1. Heart Sounds :
A- 1st Heart Sound ( S1) :
- Due To Closure Of Mitral And Tricuspid Valves ( Indicate Beginning Of
Ventricular Systole ) .
- Heard At :
Mitral Area : 5th Left ICS , Mid-Axillary Line ( By Bell Of Stethoscope ) .
Tricuspid Area : 4th ICS , Parasternal ( By Diaphragm Of Stethoscope ) .
B- 2nd Heart Sound ( S2) :
- Due To Closure Of Pulmonary And Aortic Valves .
- Heard At :
Pulmonary Area : 2nd Left ICS .
Aortic Area: 2nd Right ICS .
C- 3rd Heart Sound ( S3) :
- This Is A Low-Pitch Mid-Diastolic Sound Occurring After S2 . ( Can Just Be
Heard With The Bell ) .
- Physiological : Soft Sound Heard Only At The Apex, Normal In Fit Adults Up To
Age 30 .
- Pathological : As In left Ventricular Failure .
D- 4th Heart Sound ( S4) :
- This Is A Late Diastolic Sound ( Just Before S 1 ) .
- Caused By Atrial Contraction Against A Stiff Ventricle .
- Never Physiological .
- Causes Are Hypertrophic Cardiomyopathy , Aortic Stenosis, Pulmonary HTN ,
Pulmonary Stenosis .
- Don't Occur If The Patient Is In Atrial Fibrillation .

Listen to normal heart sounds:

http://www.easyauscultation.com/course-contents?courseid=22

2- Murmurs :
- Comment On ( Timing , Site Of Maximum Intensity , Radiation , Grade ,
Relation To Position ) .
Timing :
- You Must Decide Whether The Noise Occurs In Systole Or Diastole ( Compare
To Carotid Artery To Be Sure ) .
# Systolic Murmurs :
- Ejection Systolic :
Start Quietly At The Beginning Of Systole .
Caused By : Pulmonary Stenosis , Aortic Stenosis .
- Pansystolic :
 Lasts For The Whole Of Systole And Tends To Be Due To Backflow Of Blood
From A Ventricle To An Atrium .
Caused By : Tricuspid Regurgitation , Mitral Regurgitation ,VSD .
- Late Systolic :
There Is An Audible Gap Between S1 And The Start Of The Murmur , Which
Then Continues Until S2 .
Typically This Is Due To Tricuspid Or Mitral Regurgitation Through A
Prolapsing Valve .
# Diastolic Murmurs :
- Early Diastolic :
It Starts Loudly At S2 And Decrescendos During Diastole .
Usually Due To Aortic Or Pulmonary Regurgitation .
- Mid-Diastolic :
Begin Later In Diastole And May Be Brief Or Continue Up To S 1 .
Usually Due To Mitral Or Tricuspid Stenosis .
# Continuous Murmurs :
- Heard Throughout Both Systole And Diastole .
- Common Causes : PDA , A-V Fistula .
 Site Of Maximum Intensity :
- The Site That You Can Hear The Murmur Louder .
- Aortic Regurgitation Is Heard Louder If You Ask The Patient To Sit Up And
Lean Forward , Then Listen At The Left Sternal Border .
- Mitral Stenosis Is Louder If You Ask The Patient To Lie On Their Left Side ,
Then Listen With The Bell At The Apex .
Mitral Area Tricuspid Area

Pulmonary Area Aortic Area

Best Position for Aortic valve Left Lateral Pos. for Mitral stenosis
Auscultation

Radiation :
- Murmur Of Aortic Stenosis Will Radiate To The Carotids .
- Murmur Of Mitral Regurgitation radiates to The Left Axilla .

Grade :
- Grading The Murmurs According To Loudness Into Six Grades ( Levine's
Grading System ) :
Listen to Heart murmurs:
http://www.easyauscultation.com/heart-murmur

3- Additional Sounds :
A- Opening Snap :
- Sudden Opening Of The Stiffened Valve Can
Cause An Audible High-Pitched Snap In Early
Diastole .
- Present In Mitral Or Tricuspid Stenosis .
B- Systolic Ejection Click :
- High-Pitched Click Heard Early In Systole ,
Caused By The Opening Of A Stiffened
Semilunar Valve .
- Present In Aortic Stenosis , And Associated With Bicuspid Aortic Valves .
C- Pericardial Friction Rub :
- Scratching Sound Has Three Components Occurring At Any Time During
Cardiac Cycle , Heard With Each Heartbeat And Caused By Inflamed Pericardial
Membranes .
- It Is Louder As The Patient Is Sitting Up , Leaning Forward , And Heard Best In
Expiration .

Additional Informations
1- Surface Anatomy of the heart:
2- Check Sacral Oedema

References :
1- OSCE And Clinical skills handbook: Hurley KF, second edition.Elsevier Canada 2011

2- Online osceskills website. www.osceskills.com

3- Macleod`s clinical examination ,thirteenth ed. 2013

4- Step by Step Clinical examination Skills:Iqbal F , first edition 2009

5- Merck Manual:cardiovascular examination.profesional online version.