The document provides an outline for examining the cardiovascular system. It discusses general examination including inspection of hands and lower extremities. It also details examination of vessels and blood pressure including measuring pulse and blood pressure. Additional sections cover jugular venous pressure, precordial/heart examination involving inspection, palpation, auscultation and percussion, and examining for murmurs. Common findings and abnormalities are described throughout.

1. Examination of cardiovascular System
By Ame M.

2. Outline
• Introduction
• General examination
• Examination of vessels and Blood pressure
– Pulse
– Blood pressure
– Jugular venous pressure
– Examination of central(neck) and peripheral vessels
• Precodial examination
– Inspection
– Palpation
– Auscultation and
– Percussion??

3. Introduction of Normal Anatomy

5. Different Valves of the Heart and Normal Blood
Flow

6. Examination of cardiovascular system
• General examination
• Examination of vessels and Blood pressure
– Pulse
– Blood pressure
– Jugular venous pressure
– Examination of central(neck) and peripheral vessels
• Pericardial examination
– Inspection
– Palpation
– Auscultation and
– Percussion??

7. General examination
• Examination of the hands
• Cyanosis(central and peripheral)
• Look for any malformation
• Examination of eye
• Examination of lower extremities

8. Examination - Hands
• Clubbing
• Splinter haemorrhages (infective endocarditis)
• Osler’s nodes (tender)
• Janeway lesions (non-tender)
• Xanthomata (Hyperlipidaemia)

9. Clubbing
Splinter Haemorrhages

10. Cont
Clubbing Janeway lesions

11. General examination cont
Cyanosis (central) Peripheral cyanosis

12. Did Abraham Lincoln have Marfan’s Syndrome?
High arched palate

13. Cont
• Examination of abdomen may be important to see
manifestation of cardiac illness
– Tender hepatomegaly
– Pulsatile liver (tricuspid regurgitation)
– Ascites
– Splenomegaly
– Abdominal aortic aneurysm

14. Examination of the Arterial pulse
• Radial artery
• Rate (normal = 60-100)
– Bradycardia (<60)
– Tachycardia (>100)
• Rhythm
– Regular
– Irregular
• Radio-femoral delay (coarctation of the aorta) – comparing radial and femoral
pulse
• Character and volume volume

15. Cont
Radial pulse Other area to check pulse

16. Peripheral Pulses
Dorsalis pedis pulse Posterior tibial pulse

17. Blood Pressure Measurement
• Instrument
– Sphygmomanometer
– Anaeroid and mercury type
• Blood pressure has two component
– Systolic
– Diastolic pressure
• Normal <140/90 mmHg (lower in diabetes)
• Korotkoff sounds
• Use larger cuff width for large arms

18. Cont

19. cont
• It has different parts
– Cuff
– Bladder

20. SELECTING THE CORRECT BLOOD PRESSURE CUFF
• Width of the inflatable bladder of the cuff should be about
40% of upper arm
• circumference (about 12–14 cm in the average adult)
• Length of inflatable bladder should be about 80% of upper
arm circumference (almost long enough to encircle the arm)
• If anaeroid, recalibrate periodically before use

21. GETTING READY TO MEASURE BLOOD PRESSURE
• Ideally, ask the patient to avoid smoking or drinking caffeinated
beverages for 30 minutes before the BP is taken and to rest for at
least 5 minutes.
• Check to make sure the examining room is quiet and comfortably
warm.
• Make sure the arm selected is free of clothing or any problem on
the hand
• Palpate the brachial artery to confirm that it has a viable pulse.
• Position the arm at the level of heart
• If the patient is seated, rest the arm on a table a little above the
patient’s waist; if standing, try to support the patient’s arm at the
midchest level.

22. How to measure

24. Jugular Venous Pressure
• JVP reflects pressure in the right atrium, or CVP also blood
volume, status of tricuspid valve and diastolic event in RV.
• Best assessed from pulsations in the right internal jugular vein.
• It shouldn’t be done in children < 12 yrs.
• The JVP is the elevation at which the highest oscillation point, or
meniscus, of the jugular venous pulsations is usually evident in
euvolemic pts
• Estimate CVP maximal 3cm from sternal angle + 5cm from atrium
(Right atrial pressure)

25. Jugular Venous Pressure
• Steps
– Position patient 30/45
– Tangential light
– Identify internal jugular venous pulsation(right)
– Extend a long rectangular object or card horizontally from this point
and a centimeter ruler vertically from the sternal angle, making an
exact right angle.
– Measure the vertical distance in centimeters

26. Jugular Venous Pressure

31. Examination of Heart/Precordium
• Inspection
• Palpation
• Auscultation
• Percussion ???

32. Precordium - Inspection
• Scars
• Chest deformity
– Pectus excavatum
– Pectus carinatum
• Pacemaker box
• Apex beat

33. Precordium - Palpation
• Apex beat
– Location
– Character
• Heaving
• Thrusting
• Double
• Tapping
• Paradoxical
• Left parasternal heave
• Thrills (palpable murmurs)
– Systolic
– Diastolic
• Palpable P2 (pulmonary hypertension)

34. Precordium – Auscultation
Heart Sounds
• Bell – low pitched sounds
• Diaphragm – high pitched sounds
• Mitral Tricuspid Pulmonary Aortic areas
• S1 (first heart sound)
• S2 – Splitting (A2, P2)

36. Precordium – Auscultation
Murmurs
• Timing of murmur
– Systolic
– Diastolic
– Continuous
• Site of maximal intensity
• Loudness
– Grades I-VI
– Thrill
• Pitch
• Radiation
• Dynamic manoeuvres
– Respiration
• Left-sided  on exp.
• Right-sided  on insp.
– Valsalva
– Squatting

37. Heart Murmurs
• Systolic
– Pansystolic
• Mitral regurgitation
• Tricuspid regurgitation
• Ventricular septal defect
– Ejection systolic
• Aortic stenosis
• Pulmonary stenosis
• HOCM
• Atrial septal defect
– Late systolic
• Mitral valve prolapse
• Diastolic
– Early diastolic
• Aortic regurgitation
• Pulmonary regurgitation
– Mid-diastolic
• Mitral stenosis
• Tricuspid stenosis
• Atrial myxoma
• Continuous
– Patent ductus arteriosus
– Arteriovenous fistula
• Pericardial friction rub

38. Heart Murmurs cont….
 Grading of Murmurs
1. Heard only with special effort
2. Soft, but readily detected
3. Prominent, but not loud
4. Loud, usually accompanied by a thrill
5. Very loud (stethoscope angled on chest)
6. Heard with stethoscope off the chest

39. Thankssssss……..