Cardiovascular System
Examination
January 2021
Dr. Dejuma Yadeta
Outline
• Cardiovascular Physiology
• Objectives of CV Examination
• Cardiovascular History
• Physical Examination
• Summarizing Cardiovascular findings
• Cardiovascular Investigations
1. CV physiology
• Network of blood “tubes”( vessels) with central
pump( heart)
• Main function is balanced blood supply to
tissues with pumping( perfusion) and collecting
of blood from tissues.
• Adequate pumping and receiving capacity of
the heart and sufficient patency and tone of the
vessels are critical for normal functioning of
CVS.
Objectives of CV evaluation
To generate adequate information which fits to
specific cardiac syndromes
Identify specific cardiac pathology responsible
for the symptoms and signs
To look for predisposing and precipitating causes
To identify the degree of limitation with their
symptoms and determine prognosis
To identify the appropriate investigation for
workup of the patients
Cardiac Syndromes
1. Heart Failure Syndrome
Symptoms of inadequate pumping( perfusion)
Fatigue, exercise intolerance
Syncope, oliguria ,
Tachycardia, low BP or shock
Symptoms of inadequate receiving of blood- congestion
Systemic fluid accumulation: Leg edema, ascites
Pulmonary congestion: cough, dyspnea, orthopnea, Paroxysmal
Nocturnal dyspnea(PND)
More specific Ones: Orthopnea, PND, Ascending type of body
swelling
Cardiac Synd…
2. Chest Pain Syndromes
• Ischemic Syndromes
Angina
Acute Coronary Syndrome
• Non ischemic
Pericarditis, Acute vascular events( PE
and aortic dissection)
Cardiac syndrome..
3. Arrhythmia : Episodic Presentation
Palpitation, syncope, Sudden cardiac
arrest/death
4. Embolic Presentation(thrombus, vegetation)
Stroke, peripheral arterial disease, mesenteric embolism
Pulmonary embolism
NB: Patients may present with one or combination
of the above syndromes and one syndrome may
cause/precipitate the others syndromes
Causes of CV disorders
1. Underlying Causes
Common Underlying causes include:
• Valvular Heart Disease:
• Ischemic Heart Disease
• Hypertensive Heart Disease
• Congenital heart disease
• Cardiomyopathy
• Cor-pulmonale
Enquire specific question which may give clues to the
above etiologies
Cuases.
2. Predisposing Causes:
These are conditions which increases the chance of
having certain underlying causes and referred as also risk
factors
Eg. Age, Hypertension, smoking, dyslipidemia, diabetes
are risk factors for ischemic heart disease
. Recurrent sore throat and rheumatic fever are risk
factors for rheumatic heart disease
. Alcohol is risk factors for arrhythmia and
cardiomyopathy
Causes
3. Precipitating Causes:
These conditions which usually increase
demand on the heart and result in manifestations
of compensated cardiac pathology.
HEART FAILS: acronym
eg. Anemia, thyrotoxicosis, fever or any
infection, increase salt intake , hypertension,
arrhythmia, infective endocarditis…
II. Vascular Abnormalities
1. Arterial
- Hypertension: systemic and pulmonary :
- Arterial occlusion: Local ischemia
Heart: Angina, Myocardial Infarction
Brain: stroke
Extremities: Intermittent claudication, gangrene
- Aneurism and Hemorrhage: chest pain, stroke, mass effect
and hypovolumia
2. Venous
- Venous thrombosis: localized swelling and
distal embolism( PE)
Manifestations
3 . Lymphatic Abnormalities
Lymphatic Obstruction: Localized hard non-
pitting swelling
Notes in taking history
• First listen to the patients carefully
• Detail each symptom using different attributes
of symptoms
– Mode of onset, duration, frequency
– Exacerbating and relieving factors
– Associated symptoms
– Effect of treatment
– Severity of the symptoms in relation to patients
usual activity level.
Assessing severity of cardiac symptoms
• New York Heart Association(NYHA)
– Class I : Can carry out ordinary activity with out
limitation
– Class II: Symptoms with Ordinary Activity
– Class III: Symptoms with less ordinary activity
– Class IV: Symptoms at rest
Physical Examination
Components of Physical Exam
A. General Examination( peripheral
examination)
B. Arterial Examination
C. Venous System Examination
D. Precordial Examination
General examination
Splinter hemorrhage.
General Examination
Arterial Examination.. BP
1. Arterial Exam.. Pulse
Venous Examination Jugular Venous Pulse(JVP)
JVP
Assessment of central venous pressure.
• Top line – level of the higest visible point of
distention
• Bottom line – level of the sternal angle
• Measure: the vertical distance between the
sternal angle and the highest level of jugular
distention
Venous Pulsation Link
• https://
stanfordmedicine25.stanford.edu/the25/neck-
exam-jugular-venous-pressure-measurement.
html
Precordial Examination
Inspection
• Aims
A. Apical Impulse : Most lateral and downward
pulse
• Normal: Localized to 5th intercostal space
• Characterize
-Sustained : LVH
- Diffuse( more than in two interspace)- L dilatation
- Shift: LV enlargement or mediastina shift
- Absent: Pericardial effusion
Inspection..
B. Activity of the precordium
– Silent/quiet
– Active : Precordium actively moves with each
beat or there are multiple pulsation over the
precordium
• hyperdynamic situations or valvular lesions
Absent in pericardial effusion and some obese
individuals.
Inspection…
C. Chest wall deformity
D. Scar
2. Palpation
• Aims
A. Point of Maximal impulse(PMI): Area where
maximum precordial pulse is felt. Usually found
at site of apical impulse
B. Palpable heart sound
P2 in pulmonary hypertension
C. Parasternal( RVH) and apical( LVH) heaves
D. Thrill : Palpable murmur.
Percussion
• Rarely done
• Useful to know the extent of dullness
Auscultation
• Aims
A. Heart Sound
Created by closure of heart valves or filling of
the heart chambers
S1( First heart Sound): Closure of AV valves
S2 Second Heart Sound) ; Closure of
Semilunar Valves
S3: Not commonly heard : Indicate rapid ventricular
filling in complaint( dilated ventricle). Can be heard in
young individuals less than 30yrs. It is sign of heart failure
Heart Sounds…
– S4 : Created by atrial kick at late stage of diastole
( pre-systole) with stiff ventricle
– Usually pathological
– Absent with atria firillation.
• Listen in all 5 listening areas for S1 and S2 using the
diaphragm of the stethoscope
• Then listen at the apex with the bell
• The diaphragm and the bell ...
• The diaphragm is best for detecting high-pitched
sounds like S1, S2, and also S4 and most murmurs
• The bell is best for detecting low-pitched sounds like
S3 and the rumble of mitral stenosis
Landmarks
Land marks
Table 17.1 Characteristics
of Heart Sounds
Links to Heart Sound
• http://www.easyauscultation.com/course-
contents?courseid=22
Auscultation..
B. Murmurs: Created by an abnormal flow
across abnormal valves or congenital defects
but it can also occur in individuals with normal
valvular pathology(functional, innocent).
Table 17.3 Distinguishing
Heart Murmurs
Other Ways to Describe Murmurs
• Pitch (high? Low?)
• Quality (rumbling? blowing? harsh? musical?
scratchy?)
• Radiation
Auscultation..
3. Additional Sounds
– Opening snap
– Clicks
– Friction rub
Summarizing Cardiac Findings
• Specific Physiologic abnormalities
– Heart Failure
– Ischemic
– Arrhythmia
• Underlying Pathology( valvular , hypertensive,
cardiomyopathy ,Ischemic heart disease..)
• Precipitating Causes( HEART FAILS)
• Severity( NYHA class)
Basic Investigations
• Structural and functional abnormalities of the heart
- Echocardiography, MRI
• Arrhythmia and Myocardial ischemia
ECG ( Resting and Exercise)
• Pulmonary Congestion cardiac enlargement
Chest X-ray
• Vascular Abnormality
Doppler studies ,Angiography, MRI
Other investigations
• Risk factor assessment
- Serum Lipid levels and glucose
• Biochemical tests
-Troponin, CKMB= Myocardial necrosis
- Brain Natriuretic peptide( BNP)= heart
Failure
• Complete Blood count( Anemia and infection), renal
function tests, blood culture(Infective
endocarditis) , ASO titer( Rheumatic Recurrence)
Links to Heart Sound
• http://www.easyauscultation.com/course-
contents?courseid=22
