Cardiovascular

Physical
Examination

Rony M Santoso, MD
What is physical examination?

Physical examination is a fundamental

examining method, it is proceeded by the
sense organs such as eyes, ears, nose and
hands or simple tools stethoscope and plexor.
Purposes

To confirm symptoms discovered during

anamnesis
To find other important signs
Ultimate goal: to establish working diagnosis
Preparing the patient

The heart examination should be made as easy

as possible for the patient,
who usually expects it to be a relatively
distasteful experience. If the physician is
considerate and gentle, the patient should feel
when it is all over, that most of his or her fears
on that score were unfounded.
The ideal examining room is private, warm
enough to avoid chilling, and free from
distracting noise and sources of interruption.
Adequate (preferably fluorescent or natural)
light is essential.
The examining table may be placed with its
head against the wall, but both sides
(particularly the right) and the foot should be
accessible to the examiner.
And the results should be recorded carefully.
Cardiovascular Physical Examination in Adult

Inspection
Palpation
Percussion
Auscultation
Blood pressure measurement

Note : sequence not necessarily as above.

Practically from out-of toward thoracic region
Inspection
Visual

Observe:
color / shape / size / symmetry/
position / movement

Good lighting
General Inspection

Observe the patient for general signs of

cardiovascular disease:

Consciousness General appearance ---

Dyspnea skin color, truncal obesity,
long extremities
Finger clubbing
Respiration ---
Cyanosis orthopnea, Cheyne-Stokes (periodic),
Edema JVE
Position ---
sit quietly (angina), sitting upright
(CHF),
moving about (AMI), leaning forwards
(pericarditis).
CLUBBING IS A SIGN OF CHRONIC HYPOXIA
Palpation
Touch Cardiovascular---
Gather data: Jugular Venous Pulse (JVP)

Temperature - use back of Carotid pulse

hand Radial pulse
Moisture
Texture
Size & Shape
Position & movement
Light palpation (tenderness)
Deep palpation (abdominal
organs / masses)
Locating internal jugular vein
Position: supine with the head of the table elevated 45
degrees.

Location: lateral to the carotid artery, beneath the

sternocleidomastoid muscle.

Look for a rapid, double (sometimes triple) wave with

each heart beat. Use light pressure just above the
sternal end of the clavicle to eliminate the pulsations
and rule out a carotid origin.

Adjust the angle of table elevation to bring out the

venous pulsation
Evaluation of JVP: CVP estimation

Estimation of central venous pressure (most important)

measured as a vertical distance above the sternal
angle
mid-right atrium is 5 cm beneath the sternal angle of
Louis (represents an arbitrary zero point)
elevated JVP= the total right atrial pressure, is > 8
cm of water (NOT mmHG)
Evaluation of JVP: contour
Contour of the jugular venous pulse: result from
interference of venous return with contraction and
relaxation of right atrium and ventricle
A-wave

results from: ATRIAL contraction

Timing: PRESYSTOLIC; Peak near S1

V-wave

results from: PASSIVE filling of the right atrium

Timing: while the tricuspid valve is closed during

ventricular systole
Evaluation of JVP

X-descent
results from ATRIAL RELAXATION

Timing: during ventricular systole, at the same

time as the carotid pulse occurs
Y-descent
results from: a FALL in right atrial pressure
associated with opening of the tricuspid valve
timing: occurs during ventricular diastole
Carotid Pulse
Evaluation
Upstroke - rate of rise: normal, rapid, delayed
Rapid: anxiety, hypertrophic cardiomyopathy, anemia,
thyrotoxicosis
Delayed: aortic stenosis
Volume - normal, increased, decreased
Increased: aortic insufficiency
Decreased: mitral insufficiency, cardiomyopathy, aortic stenosis
Contour - single beating or twice beating carotid pulse
Double carotid impulse
Occurrence at the PEAK of the carotid: aortic regurgitation,
hypertrophic cardiomyopathy, combined aortic
stenosis/regurgitation
Occurrence at the DOWNSTROKE of the carotid represents
an exaggeration of the normal dicrotic pulse seen in
association with:dilated cardiomyopathy, low cardiac output
states, increased peripheral vascular resistance
Radial pulse
How-to..

Compress the radial artery with index and middle

fingers.
Note whether the pulse is regular or irregular.
Count the pulse for 15 seconds and multiply by 4.
Count for a full minute if the pulse is irregular.
Record the rate and rhythm.
Radial pulse

Normal Bradicardia Tachycardia

60-100 bpm <60 bpm >100 bpm
Regular Regularly Irregular Irregularly Irregular
Evenly spaced, Regular pattern with Chaotic, difficult to
may vary slightly skipped beats measure rate
with respiration
Thoracic region examination

Inspection and palpation: Precordial movement

(punctum maximum)

Percussion: cardiac borders

Auscultation:
breath sounds

heart sounds and possible murmurs

Precordial palpation

Patient supine with table head slightly elevated.

Always examine from the patient's right side.
Inspect for precordial movement. Tangential lighting
will make movements more visible.
Palpate for precordial activity in general; feel for
"extras" such as thrills or exaggerated ventricular
impulses.
Palpate for the point of maximal impulse (PMI or
apical pulse or punctum maximum).
Normal location in the 4th or 5th intercostal space
medial to the midclavicular line and size <of a
quarter.
Note the location, size, and quality of the impulse.
Auscultation

Carotid bruit
Cardiac
Heart sound
Murmur
Pulmonary
Breath sound
Extra sound
Carotid bruit

Should be done if the patient is late middle aged or

older: a sign of arterial narrowing and risk of a stroke
Place the bell of the stethoscope over each carotid
artery in turn. The diaphragm may be used if the
patient's neck is highly contoured.
Ask the patient to stop breathing momentarily.
Listen for a blowing or rushing sound--a bruit. Do not
be confused by heart sounds or murmurs
transmitted from the chest.
 Cardiac Ausc ~ physiology

Heart sounds are mainly produced by or related to valves

activities during one cardiac cycle
Cardiac Ausc.: heart sound

S1: closure of mitral and tricuspid valves

S2: closure of aortic and pulmonic valves
S3:
Due to ventricle reaches its elastic limit
During early diastole at the end of early ventricular filling
(protodiastolic gallop)
Low pitch
Normal in young adults.
Pathology:
over-filled ventricle (CHF); ventricle regurgitation or high
output state (eg hyperthyroid)
Cardiac ausc.: heart sound

S4:
Due to atrial contraction against stiff, non compliant
ventricle; in hypertrophic ventricle such as chronic
hypertension, aortic stenosis
During late diastole (presystolic gallop)

Low pitch
Cardiac Ausc. : Technique
Listen for heart sounds S1, S2, (S3), (S4), as well as the grade
and configuration of any murmurs ("two over six" or "2/6",
"pansystolic" or "crescendo").
Patient supine with the head of the table slightly elevated.
Always examine from the patient's right side. A quiet room is
essential.
Examine each valve location (next slide)
Have the patient roll on their left side
Listen with the bell at the apex.
This position brings out S3 and mitral murmurs.
Have the patient sit up, lean forward, and hold their breath in
exhalation
Listen with the diaphragm at the left 3rd and 4th interspace
near the sternum.
This position brings out aortic murmurs.
Cardiac Ausc. : location

Aortic: right 2nd

interspace near the
sternum
Pulmonic: left 2nd
interspace near the
sternum
Tricuspid: the left 3rd, 4th,
and 5th interspaces near
the sternum
Mitral: at the apex
(punctum maximum)
Murmur Grade..

Grade Volume Thrill

1/6 Very faint, only heard with optimal conditions No
2/6 Loud enough to be obvious No
3/6 Louder than grade 2 No
4/6 Louder than grade 3 Yes
5/6 Heard with stethoscope partially off the chest Yes
6/6 Heard with the stethoscope completely off the chest Yes
 Cardiac Ausc. : murmurs

Systolic

Diastolic
Pulmonary auscultation
Breath sounds are created by turbulent air flow
In inspiration, air moves into progressively smaller
airways with the alveoli as its final location. As air
hits the walls of these airways, turbulence is created
and produces sound.
In expiration, air is moving in the opposite direction
towards progressively larger airways. Less
turbulence is created, thus normal expiratory breath
sounds are quieter than inspiratory breath sounds.
Breath sounds

Normal Abnormal Adventitious

Tracheal Absent/decreased Crackles (rales)

Vesicular Bronchial in Wheeze

Bronchial abnormal location Ronchi

Bronchovesicular Stridor

Pleural rub

Mediastinal crunch

(Hamman's sign)
Normal breath sounds
Tracheal Breath Sound
Can be heard over the trachea
Not routinely auscultated.
Very loud and relatively high-pitched.
The inspiratory and expiratory sounds are more or less equal in
length

Vesicular Breath Sound

the major normal breath sound and is heard over most of the
lungs.
soft and low-pitched.
The inspiratory sounds are longer than the expiratory sounds.
Vesicular breath sounds may be harsher and slightly longer if
there is rapid deep ventilation (eg post-exercise) or in children
who have thinner chest walls. As well, vesicular breath sounds
may be softer if the patient is frail, elderly, obese, or very
muscular.
Normal breath sounds

Bronchial Breath Sound

Very loud, high-pitched and sound close to the stethoscope.
There is a gap between the inspiratory and expiratory phases, and the
expiratory sounds are longer than the inspiratory.
If heard anywhere other than over the manubrium, usually an indication
of consolidation

Bronchovesicular Breath Sound

Intermediate intensity and pitch.
The inspiratory and expiratory sounds are equal in length.
Best heard in the 1st and 2nd ICS (anterior chest) and between the
scapulae (posterior chest) - ie over the mainstem bronchi.
when heard anywhere other than over the mainstem bronchi, usually
indicate an area of consolidation.
Pulmo Ausc. : location
Abnormal breath sounds
Absent or Decreased Breath Sounds
ARDS: decreased breath sounds in late stages
Asthma: decreased breath sounds
Atelectasis: If the bronchial obstruction persists, breath sounds are
absent unless the atelectasis occurs in the RUL in which case adjacent
tracheal sounds may be audible.
Emphysema: decreased breath sounds
Pleural Effusion: decreased or absent breath sounds. If the effusion is
large, bronchial sounds may be heard.
Pneumothorax: decreased or absent breath sounds

Bronchial Breath Sounds in Abnormal Locations

Bronchial breath sounds occur over consolidated areas. Further testing
of egophony and whispered petroliloquy may confirm your suspicions.
Adventitious sounds
Crackles (Rales)
Discontinuous, nonmusical, brief sounds heard more commonly on
inspiration.
Mechanism: Small airways open during inspiration and collapse
during expiration causing the crackling sounds. Another explanation
for crackles is that air bubbles through secreations or incompletely
closed airways during expiration.
Can be classified as fine (high pitched, soft, very brief) or coarse
(low pitched, louder, less brief).
When listening to crackles, pay special attention to their loudness,
pitch, duration, number, timing in the respiratory cycle, location,
pattern from breath to breath, change after a cough or shift in
position.
Crackles may sometimes be normally heard at the anterior lung
bases after a maximal expiration or after prolonged recumbency.
Conditions: ARDS, asthma, bronchiectasis, chronic bronchitis,
consolidation, early CHF, interstitial lung disease, pulmonary edema
Adventitious sounds

Wheeze
Continuous, high pitched, hissing sounds heard normally on
expiration but also sometimes on inspiration.

Produced when air flows through airways narrowed by

secretions, foreign bodies, or obstructive lesions.
Note when the wheezes occur and if there is a change after a
deep breath or cough. Also note if the wheezes are monophonic
(suggesting obstruction of one airway) or polyphonic (suggesting
generalized obstruction of airways).

Conditions: asthma, CHF, chronic bronchitis, COPD, pulmonary

edema
Adventitious sounds
Rhonchi
Rhonchi are low pitched, continous, musical sounds that are similar to
wheezes. They usually imply obstruction of a larger airway by secretions.

Stridor
Inspiratory musical wheeze heard loudest over the trachea during
inspiration.
Suggests an obstructed trachea or larynx: a medical emergency

Pleural Rub
Creaking or brushing sounds produced when the pleural surfaces are
inflammed or roughened and rub against each other.
May be discontinuous or continuous sounds.
Can usually be localized a particular place on the chest wall and are
heard during both the inspiratory and expiratory phases.
Conditions: pleural effusion, pneumothorax

Mediastinal Crunch (Hammans sign)

Crackles that are synchronized with the heart beat and not respiration.
Heard best with the patient in the left lateral decubitus postion. As with
stridor, mediastinal crunches should be treated as medical emergencies.
Conditions: pneumomediastinum
Examination of the Heart

In the present era of technological advances,

particularly in the various imaging modalities,
there is a growing conception among practicing
physicians in cardiovascular medicine that
bedside physical examination is unnecessary
and does not provide useful information.
Controversies and Personal
Perspectives

In todays clinical practice, bedside examination

is considered unnecessary and waste of time.
Indeed, the investigative tools available today
are far superior to bedside examination in
establishing the diagnosis of the anatomic
abnormality and severity of the patophysiologic
consequences.
However.
Only bedside examination allows you to know
the patient, understand the patients
sufferings and expectations, and establish
rapport with the patient.

So, I believe that we should practice more ---

not less --- bedside physical examination.
The Future.
As an investigation tool is likely to be
compromised with the increasing availability
of sonographic and other allied imaging
techniques.

It should be remember, however, that the

bedside physical examination is still the
cheapest and, in certain circumstances, most
informative investigation
The cardiovascular physical examination
remains the most widely used method to
screen for heart disease.