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Physical Examination of Physical Examination of CardiovascularCardiovascular
Dr.Ira Andaningsih SpJPCardiovascular Block 2008
Learning ObjectiveLearning Objective
1. Examine the important surface topographic landmarks of the heart (inspection, palpation, percussion and auscultation).
2. Assessment of the blood pressure and its variation about the cardiovascular disease (orthotastic hypotension, coarct aorta, cardiac tamponade).
3. Assessment of the arterial pulse (a. radialis, a. brachialis, aorta abdominalis, a. femoralis, a. poplitea, a. carotis, a. dorsalis pedis).
Learning ObjectiveLearning Objective4. Assessment of the JVP and hepatojugular
reflux.5. Assessment of the peripheral edema (tibial).6. Students should be able to identify the
normal heart sound (S1, S2).7. Students should be able to identify the
abnormal heart sound (S1, S2, S3, S4, systolic clicks, diastolic opening snaps, murmurs).
ProcedureProcedure
1. Inspection 2. Measurement of blood pressure 3. Arterial pulsation examination 4. JVP examination and hepatojugular reflux 5. Edema examination 6. Percussion 7. Palpation 8. Auscultation
General InspectionGeneral Inspection
Clues for cardiac diagnosis:Is the patient in acute distress?What is the patient’s breathing like?Are accesory muscles being used?Are the patient pale?Is the patient cyanosis?
InspectionInspection
Inspect the head and faceInspect the skinInspect the eyesInspect the mouthInspect the neckInspect the chest configurationInspect the nails and extremities
Head and faceHead and face
- An earlobe crease in a relatively young person (CAD)
- A cyanotic lips, and slight jaundice due to hepatic congestion(RHD)
- Bobbing of the head coincident with each heart beat (severe aortic regurgitation)
Earlobe CreasesEarlobe Creases
Head and faceHead and face Down syndrome is associated with congenital
heart disease. Another diseases are associated with heart
disease is : Marfan’s syndrome, Systemic Lupus Erythematosus, Cushing syndrome have characteristic that can be present in general appearance.
High arched palate (MVP) Palatal ptechiae (infective endocarditis)
SkinSkinCyanosis (central/peripheral?)Pallor Temperature: warmer(severe anemia,
thyrotoxicosis),coolness and pain (claudicatio,occlusion)
Xanthomata(tendon,eruptive)Rash(erythema marginatum)Ptechiae (infective endocarditis)
XanthomataXanthomata
XanthomataXanthomata
EyesEyes
1. Xanthelasma ( CAD)2. Embolic retinal occlusions (rheumatic heart
disease, atheroslerosis of the aorta or arch vessels).
3. Papilledema ( malignant hypertension, cor pulmonale with severe hypoxia,patients with cyanosis and polycythemia).
4. Arcus senilis (CAD)5. Hypertelorism(Pulmonary Stenosis,supravalvar
aortic stenosis
XanthelasmaXanthelasma
Arcus SenilisArcus Senilis
PapilledemaPapilledema
Neck and chest configurationNeck and chest configuration
Webbing of the neck(Turner’s syndrome /coarctatio aorta or Noonan’s syndrome/ pulmonary stenosis)
Distended Jugular veins (CHF)Visible cardiac motion ?Pectus Excavatum (Marfan’s syndr,MVP)Pectus carinatum (Marfan’s syndr)
Pectus ExcavatumPectus Excavatum
Pectus CarinatumPectus Carinatum
Chest ConfigurationChest Configuration
ExtremitiesExtremities
Nicotine staining of the fingers(CHD)Osler’s nodes(infective endocarditis)Splinter hemorrhages(infective
endocarditis)Abnormalities finger/toe:extra
phalanges/toe (ASD)
Splinter HemorrhagesSplinter Hemorrhages
ExtremitiesExtremities
Long,slender fingers(Marfan’s syndrome/Aortic regurgitation).
Quincke’s sign:systolic flushing of the nailbeds, which can be readily detected by pressing a flashlight against the terminal digits( Aortic regurgitation).
Extremities Extremities Clubbing of the fingers and toes(central
cyanosis/congenital).It may also appear within a few weeks of the development of infective endocarditis.
Edema of the extremities (CHF) Edema in only one leg(obstructive venous or lymphatic
disease than to heart failure) Pain and cool in the extremities with cyanotic(arterial
occlusion).
Clubbing FingerClubbing Finger
Measurement of Blood Measurement of Blood PressurePressure
The principles:Direct (intra arterial catheter)Indirect (Sphigmomanometer)Korotkoff sounds 1-5.Determinant BP by palpationDeterminant BP by auscultation
Assess BP by PalpationAssess BP by Palpation
Assess BP by AuscultationAssess BP by Auscultation
Blood pressureBlood pressure
Rule out orthostatic hypotensionRule out Supravalvar Aortic StenosisRule out Coarctation of AortaRule out Cardiac Tamponade
Rule out Orthostatic Rule out Orthostatic HypotensionHypotension
1. Patient recumbent for at least 5 minute, measure the baseline BP and pulse
2. Patient standing and measure the BP and pulse3. Orthostatic hypotension if: Systolic BP drop 20 mm Hg or more with
development of symptom such as dizzyness or syncope(in most patients,also increase HR)
Rule out Supravalvular Aortic Rule out Supravalvular Aortic StenosisStenosis
If BP in the right arm high, measure BP in the left arm (auscultatory )
Supravalvar Aortic Stenosis if: Hypertension in the right arm and Hypotension in the left arm
Rule out Coarctation of the Rule out Coarctation of the AortaAorta
If the BP is elevated in the arm, measure BP in the lower extremities.
Patient lie down on the abdomen ,the cuff is placed around the posterior aspect of the midthigh
The stethoscope is placed over the popliteal fossa If wide cuff not available,place the reg.cuff in the
distal border maleoli and stethoscope is placed over posterior tibial or dorsalis pedis artery.
Coarc Aorta if BP in the leg is lower than in the arm
Rule out Cardiac TamponadeRule out Cardiac TamponadeParadoxical pulse (pulsus paradoxus)Patient breathe as normal as possibleInflate cuff until no sounds are heard.Gradually deflate until soundsare heard in
expiration only.Note this pressure.Continue deflate slowly untilsounds are
heard during inspiration.Note this pressureAbN if difference 10 mmHg,N if 5 mmHg
Arterial Pulsation ExaminationArterial Pulsation Examination
Determinant the cardiac rateDeterminant the cardiac rhythmPalpation Carotid arteryPalpation Radialis/Brachialis pulsePalpation Abdominal Aorta pulsePalpation Femoralis/Popliteal pulsePalpation Posterior Tibial/Dors.Pedis pulse
Determinant Cardiac RateDeterminant Cardiac Rate
Assessed by the radial pulse. The examiner stand in the front of the patient Grasp both radial arteries with the 2nd,3rd and 4th
fingers. Count the pulse for 30 seconds x 2. If patient in irregular rhythm(AF) presents,patient
has pulse deficit. Only assessment by auscultation on the heart can count the cardiac rate.
Technique evaluating Radial Technique evaluating Radial PulsePulse
Determinant cardiac rhythmDeterminant cardiac rhythm
The ECG is the best method for diagnosing cardiac rhythm.
Regular rhythm: regular on palpationRegularly irregular:irregularity in a definite
pattern(premature beats, bigeminy)Irregularly irregular:has no pattern (Atrial
Fibrillation).
Palpation Carotid ArteryPalpation Carotid Artery Patient in the supine position,examiner in the right
side Auscultate carotid artery for bruits first. If bruits presents do not palpate the artery,if the
cholesterol plaque is present it can produce an embolus
Place 2nd and 3rd fingers on the thyroid cartilage and slip them laterally between trachea and m.sternocleidomastoid
Technique Auscultation Technique Auscultation Carotid ArteryCarotid Artery
Technique Evaluating Carotid Technique Evaluating Carotid Artery PulseArtery Pulse
Technique Evaluating Carotid Technique Evaluating Carotid Artery PulseArtery Pulse
Palpation Carotid ArteryPalpation Carotid Artery
Palpation should be performed low in the neck to avoid pressure on carotid sinus (can cause drop in BP and HR)
Each carotid artery is evaluated separately.Never press on both carotid artery in the
same time.
Palpation Carotid ArteryPalpation Carotid Artery
Normal :Smooth, upstroke stepper more rapid than downstroke
Diminished : Small, weak pulse (anacrotic) Increased:Large,strong,hiperkinetic
(waterhammer) Double peaked pulse :Prominent percussion
and dicrotic wave (bisferiens)
The Arterial PulseThe Arterial Pulse
Palpation Brachialis pulsePalpation Brachialis pulse
The examiner use the thumbs to palpate.Can be felt medially under the tendon of the
biceps muscle.Examiner standing in front of the patient
simultaneously can be felt both brachial arteries.
Technique Palpation Technique Palpation Brachialis PulseBrachialis Pulse
Palpation Abdominal AortaPalpation Abdominal Aorta
Performed by palpating deeply but gently into the mid abdomen.
Presence of mass with laterally pulsatile suggest abdominal aneurysm.
In thin individual normal pulsatile can be palpated.
Technique Auscultation Technique Auscultation Abdominal AortaAbdominal Aorta
Palpation Femoral PulsePalpation Femoral Pulse Patient in the supine position and examiner in the
right side. The lateral corners of the pubic hair triangle are
observed and palpated. Both femoral artery may be compared
simultaneously. If one of the artery is diminished or absent
auscultation for bruits is necessary. If presence indicate obstructive aortoiliofemoral
disease.
Technique Palpation Femoral Technique Palpation Femoral PulsePulse
Palpation Popliteal PulsePalpation Popliteal Pulse
Often difficult to assess. Each artery is evaluated separately. Patient in supine position Examiner hold the leg in a mild degree of flexion
and places the thumbs on the patella and presses the remaining fingers of both hands in the fossa poplitea medial to lateral biceps femoris tendon
Firm pressure is usually required to feel pulsation
Technique Palpation Popliteal Technique Palpation Popliteal PulsePulse
Palpation Dorsalis Pedis Palpation Dorsalis Pedis PulsePulse
Is best felt by dorsoflexion of the foot.Easily palpated in the grove between the
extensor digitoum longus and hallucis longus tendon.
May be felt simultaneously
Technique Palpation Dorsalis Technique Palpation Dorsalis Pedis PulsePedis Pulse
Technique Palpation Posterior Technique Palpation Posterior Tibial PulseTibial Pulse
Grading of PulsesGrading of Pulses
0 Absent1 Diminished2 Normal3 Increased4 Bounding
Jugular Venous PulseJugular Venous PulseProvide information about the wave forms
and the right atrial pressure.Pulsation internal jugular vein are beneath
the sternocleidomastoid muscle.Only the right internal jugular vein is
evaluated because its straighter than left.External jugular vein is easier to visualize
but less accurate and should be not used.
Jugular Wave FormsJugular Wave Forms Patient lie flat without pillow so that the neck will
not be flexed. The patient’s trunk at approximately 25º to the
horizontal. The higher the venous pressure,the greater elevation
will be required.The lower the venous pressure, the lower the elevation needed.
Patient’s head turned slightly to the right and slightly down to relax the right sternocl.mastoid.
With small flashlight shine the light to the neck.
Technique Evaluating Jugular Technique Evaluating Jugular Wave FormsWave Forms
Jugular Wave Pressure Jugular Wave Pressure ExaminationExamination
The standard reference is manubriosterno angle/ angulus ludovici
Determine the height of venous distension by noting the top of the wave forms in the int jug.venous pulsation.
Imaginary horizontal line from this height to the sternal angle
Measure the distance The angle of elevation of the head of the bed is also
estimated.
Neck Vein DistentionNeck Vein Distention
JVPJVP At 45ºelevation,Jug.pulse is 7 cm above the sternal
angle. At 45º,upper limit of normal 4-5 cm above the
sternal angle. At 30º,upper limit of normal 6 cm. At supine position,normal if equal or lower than
the sternal angle. At 90º when neck vein distended up to the jaw
margin that the RA pressure is high(>15 mmHg)
Hepato Jugular Reflux Hepato Jugular Reflux ExaminationExamination
Abdominal Compression Assessing high jugular venous pressure. Pressure over the liver can grossly assess RV
function. Patient in supine position,mouth open and
breathing normally Places the right hand over the liver (right upper
quadran),apply a firm,progressive prssure. Compression is maintained for 10 seconds.
Hepato Jugular RefluxHepato Jugular RefluxNormal response: transient increase in
distension during the first few cardiac cycles,followed by a fall to baseline level.
RV failure : remained distended during the compression and falls rapidly(at least 4 cm) on sudden release.
If test incorrect (patient’s mouth closed),a valsava maneuver will result inaccurate.
Edema ExaminationEdema ExaminationFingers are pressed into dependent area for
2-3 seconds.If pitting edema is present,the fingers will
sink into the tissue and when removed,the impression of the fingers will remain.
Usually quantified from 1+ to 4+If 4+ is usually to the sacrum(bedridden
patient)
Technique Evaluating Pitting Technique Evaluating Pitting EdemaEdema
Technique Evaluating Pitting Technique Evaluating Pitting EdemaEdema
Pitting Edema over the Pitting Edema over the SacrumSacrum
Landsmark of the ChestLandsmark of the Chest
Landsmark of the chestLandsmark of the chest
Technique PercussionTechnique Percussion
Technique PercussionTechnique Percussion
Percussion of the heart Percussion of the heart
Performed at the 3rd ,4th ,and 5th intercostal space from the left anterior axillary line to the right anterior axillary line.
Normal : A change in the percussion from resonance
to dullness ± 6 cm lateral to the left of sternum.
PalpationPalpation
To evaluate the apical impulsFor assessing localized motionFor assessing generalized motionFor assessing presence or absence of thrills
Point of Maximum ImpulsePoint of Maximum Impulse
Most easily performed with sitting positionOnly the fingertips should be applied in the
5th intercostal space,midclavicular lineIf not felt,move in the area of cardiac apex.PMI usually within 10 cm of the midsternal
line and no larger than 2-3 cm in diameter. If laterally or felt in 2 interspaces it is
cardiomegaly.
Technique Assessing PMITechnique Assessing PMI
Assessing Localized MotionAssessing Localized Motion
Patient in supine positionUse the fingertips to assess any localized
motionThe presence of a systolic impulse in 2nd
intercostal space to the left of sternum is suspect Pulmonary Hypertension
Technique Assessing Technique Assessing Localized MotionLocalized Motion
Assessing Generalized MotionAssessing Generalized MotionUse the proximal portion of the hand to
palpate for any large area motion,called “heave” or “lift”
Palpates each of the 4 main cardiac areaThe 2nd impuls in the area of PMI is usually
felt in association with S3.The use of an aplicator stick can be helpful
to reinforce visually what has been palpated
Technique Assessing Technique Assessing Generalized MotionGeneralized Motion
Technique Assessing Technique Assessing Genaralized MotionGenaralized Motion
Assessing ThrillsAssessing Thrills
The presence of thrills indicates a loud murmur.
Use the head of metacarpal and applying very gentle pressure on the skin
If too much pressure thrills will not be felt
Auscultation of the HeartAuscultation of the HeartThe bell of the stetoscope should be applied
slightly to the skinFor:low-pitched sounds (gallop, murmur of
atrioventricular stenosis)The diaphragm of the stetoscope should be
pressed tightly to the skinFor: high-pitched sounds (valve
closure,systolic event, regurgitant murmur)
Standard Auscultation Standard Auscultation PositionPosition
SupineLeft lateral decubitusUprightUpright, leaning forward
Auscultation PositionAuscultation Position
Auscultation Cardiac AreaAuscultation Cardiac Area