CLI N ICAL EXAMINATION

OF THE
CARD I OVASCULAR
SYSTEM
Anatomical landmarks
Introduction
Different lines
 LAND MARKS
• MIDCLAVICULAR LINE:Is a vertical line drawn
from center of the clavicle
• That is- a point midway between middle of
supra sternal notch and tip of acromion.
Different lines
Sternal angle and ICS

Parasternal
line
 AREAS OF AUSCULTATION
• MITRAL AREA- Left 5th intercostal space half
inch medial to midclavicular line.

• TRICUSPUD AREA-Right 5th intercostal space.

• PULMONARY AREA-Left 2nd intercostal space.

• AORTIC AREA-Right 2nd intercostal space.

Examinati on of Cardiovascular
System

1) General Examination
2) Examination of Arterial Pulse
3) Examination of the Neck Veins
4) Examination of the Precordium
General Examination
P allor
I cterus
C yanosis
C lubbing
Lymphadenopathy
E dema
 General Examination

Vitals:
• Pulse rate
• Temperature
• Respiratory rate
• Blood pressure
 Examination of arterial pulse
 Rate
 Rhythm
 Volume
 Character
 Condition of t h e vessel wall
 Equality on both sides
 Radio-femoral delay
 Other Peripheral Pulses
• RATE-Normal pulse rate-60 to 100 beats per
minute.
• Above 100-TACHYCARDIA
• Below 60-BRADYCARDIA
• Count the pulse COMPLETELY for 1 minute.
 RHYTHM
• RHYTHM-Is a spacing order at which
successive pulse waves are felt.
• If spacing is constant, pulse is said to be
regular.
• If spacing is NOT CONSTANT, pulse is said to be
irregular
 VOLUME
• It is the degree of expansion of the arterial
walls during each pulse wave.
• Normally- volume is NORMAL AND EQUAL ON
BOTH THE SIDES.
 CHARACTER
• Character of the pulse is best appreciated-by
palpating the carotid artery in the neck.
 CONDITION OF THE VESSEL WALL
Normally-arterial wall is not palpable.

In oldage it is palpable because it is thickened

and may be tortous.
 RADIOFEMORAL DELAY
• Normally there is no radio femoral delay.

• Compare the appearance of FEMORAL PULSE

with appearance of RADIAL PULSE and see if
there is any delay.
 OTHER PERIPHERAL PULSES
• Palpate femoral, popliteal, posterior tibial and
dorsalis pedis artery of both sides.

• Check the pulses are well felt and appear

simulatneously.
Radial artery
Brachial artery
Carotid artery
Femoral artery
Popliteal artery
Posterior tibial artery
Dorsalis pedis
Examination of neck veins
 I t is best e xami ned in good light while
t h e p a t i e n t reclines a t 45°.

 At 45° Venous p r e s s u r e a p p e a r s j u s t a t
t h e u p p e r border of clavicle.

 E s t i m a t e t h e J V P by observing
t h e level of pulsation i n t h e
i n t e r n a l j ugu l ar vein.
Examination of neck veins
 JVP
The JVP level reflects right atrial
pressure.
JVP in health should be ≤4 cm above
this angle when the patient lies a t 45°.
The sternal angle is approximately
5 cm above the right atrium.
JVP+5cm= right atrial pressure
(CVP) (normally <7 mmHg/9 cmH2O)
 Procedure
The JVP is best seen on the patient’s right
side.
■Position the patient supine, reclined a t 45°,
with the head on a pillow to relax the
sternocleidomastoid muscles.
■ Look across the patient’s neck from the right
side.
■Identify the jugular vein pulsation in the
suprasternal notch or behind the
sternocleidomastoid muscle.
 WAVES OF JVP
• JVP produces three characteristic waves
a wave- due to atrial systole
c wave- due to rise in atrial pressure in right
atrium during isovlumetric ventricular
contraction phase.
v wave -due to rise in right atrial pressure before
tricuspid valve opens during diastole
Examination of neck veins
 Examination of the Precordium
•Precordium is t h e a r e a of t h e chest wall lying in
front of t h e h e a r t .

 Inspection
 Palpation
 Percussion
 Auscultation
•The subject should be examined in t h e r e c u m b e n t a n d sitting
position, a n d in good light.
 Inspection
 Inspection for Chest wall abnormalities
 Inspection for Position of tra che a
 Inspection for Apex beat
 Inspection for Ot h e r pulsations
 Inspection for Dilated a n d engorged veins
 Inspection for Surgical or any Scars
Chest wall(Skeletal) abnormaliti es

 Precordial Bulging
 Pectus excavatum (funnel chest)
 Pectus carinatum (pigeon chest)
 Kyphosis (forward bending of spine)
 Scoliosis (sideward bending of spine)
•may displace the h e a r t a nd affect
palpation and auscultation
Chest wall(Skeletal) abnormaliti es
 Apex beat
• Lowest and the Outermost point of
defi nite cardiac impulse can be
palpated.
Dilated and engorged veins

 SuperiorVenaCava or Inferior Vena

Cava obst ruct ion
 C oa r c t a t i o n of a o r t a
 Palpati on
 Palpation for Apex Beat (Position a n d
Character)
 Palpation for Position of tra c he a
 Palpation for P a r a s t e r n a l Heave
 Palpation for Thrills
 EXAMINATION OF PULSE
• Place three middle fingers on the radial artery
• Obliterate the flow of blood by pressing the
INDEX FINGER
• Empty the vessel by the RING FINGER
• Palpate the artery by the MIDDLE FINGER
• Normal pulse rate 60-100 beats per minute
• Above 100- TACHYCARDIA
• Below 60-BRADYCARDIA
Apex beat
 Apex beat
 Position
Normally in the fifth left intercostal
space half inch medial to the mid-
clavicular line
Enlargement of the heart due to
hypertrophy or dilatation may shift the
apex beat.
 Apex beat
Palpation of apex beat-
This is done by first placing the palm on
the precordium to feel the apical
impulse.
Then place the ulnar border of the palm
on the pulsation area horizontally.
Finally apex beat is localised by the tip
of the middle or the index finger
Apex beat is defined as the lower most
and outer most definite cardiac impulse
 Apex beat
The apex beat may not be palpable in
some normal persons because:

•I t may be located behind a rib.

•The chest wall may be thick due to fat or
muscle.
•The emphysemat ou s lung ma y cover
p ar t of th e h ea rt .
•Plural effusion, pericardial effusion
•Dextrocardia
Position of the trachea
 POSITION OF TRACHEA
• Place the tip of the index and ring finger of the
right hand on the sternoclavicular joints on
either sides.
• Place the middle finger on the suprasternal
notch.
• Gently push the middle finger forward to feel
tracheal rings
• Normally trachea is centrally placed.
 Parasternal Heave
 Palpate with ulnar border of your h a n d
 Over left parasternal line
 Present in Right Ventricular Hypertrophy
 Thrills

 A thrill is a palpable murmur,

 Produced when blood passes through a
narrowed valve, or when there is
abnormal blood flow, as in congenital
defects, or if the blood flow is rapid.
 Percussion
 Percussion for Borders of the H ea rt
 Percussion
• Right border of t h e he a rt ,
which is formed by t h e right
at rium, lies behind t h e
sternum
 BORDERS OF HEART
• RIGHT BORDER OF THE HEART-extends from
right 3rd sternocostal articulation above to
right 7th intercostal articulation below.

• LEFT BORDER OF THE HEART-From 2nd

intercostal space to parasternal heave above
to apex beat below.
 PERCUSSION
• Apply the left hand fingers firmly on the
surface of the chest.

• The right hand finger should strike the middle

phalanx of the left finger perpendicularly.

• Percussion should be carried out from more

resosnant to less resonant areas.
 Pe rcu s s i o n
Percussion is done in t h e
5th, 4th, a n d 3rd intercostal
spaces, s t a rt i n g in t h e left
midaxillary line a n d going
towards t h e h e a r t till t h e
notes change from resonance
to dullness.
Cardiac dullness is because of
the surrounding viscera.
Cardiac dullnes increased in
pericardial effusion and
decreased in emphysema
 Auscultati on
Au sc ul t a t i on for H e a r t Sounds

First sound (S1)

This corresponds to mitral and
tricuspid valve closure at the onset
of systole.

Second sound (S2)

This corresponds to aortic and
pulmonary valve closure following
ventricular ejection.
 STETHOSCOPE
• Ausultation of the heart is done by using
stethoscope.

• Stethoscope consists of ear knobs, rubber

tube, broad diaphragm.

• Place the diaghram of the stethoscope over

the chest to hear the heart sounds.
Auscultation
 Auscultati on
•Listen with your stethoscope diaphragm:
 At each site identify the S1 and S2 sounds.
 Assess their character and intensity; note
any splitting of the S2.
 Auscultati on
•Murmurs
•He art m u r m u r s are produced by
turbulent flow across a n abnormal valve,
septal defect or outflow obstruction.
 Clinical Examination of CVS
Na me:
Age:
Sex:
Address:
Occupation:
Ge ne r al Physical Examination:
Young p a t i e n t moderately built a n d moderately nourished, well
oriented to t i m e place a n d person, conscious a n d cooperative

P allor
I cterus VITALS:
C yanosis T e mpera tu re
P ulse
C lubbing R espiratory
E dema Rate
L ympha BP
 Examination of the Precordium

Inspection:
 Trach ea C e n t r a l i n Position
 No sk e leta l deformity s e en
 No d ilated or engorged
veins p r e s e n t
 Apical imp u lse n o t
seen/seen a t Left 5 t h
Intercostal space m ed i al to
Midclavicular line.
 No sc ar s or o t h e r visible
p u lsat io n s se en
Examination of the Precordium
• Palpation:
 Apical Impulse felt a t Left 5 t h
Intercostal space medial to
Midclavicular line and is of Normal
Character
 Trachea centrally Placed
 No tenderness present
 Parasternal Heave absent
 No thrills Present
 Examination of the Precordium

• Percussion
 All borders of the heart normally located
 Left border of the heart clearly
percussed, Dullness noted from left
2 n d Intercostal space medial to
Parasternal line to apex
 Examination of the Precordium
•Auscultation:
 Mitral Area: S1 a n d S2 Heard, S1 Prominent, No added
sounds or m u rm u rs
 Tricuspid Area: S1 a n d S2 Heard, S1 Prominent, No
added sounds or m u r m u r s
 Aortic Area: S1 a n d S2 Heard, S2 Prominent, No added
sounds or m u m m e r s
 Pulmonary Area: S1 a n d S2 Heard, S2
Prominent, No added sounds or m u rm u rs

Report: Cardiovascular Syste m of t h e subject

appears to be Normal