Physical Examination of

The Cardiovascular System

Cardiovascular Department
Wahidin Sudirohusodo General Hospital
Makassar
ANATOMY
Anterior Surface of the Heart
ANATOMY
The Sectional
Anatomy of
the Heart
CARDIAC
CYCLE
PHYSICAL EXAMINATION
The jugular venous pressure
The arterial pulse
The PMI and any heaves, lifts, or bruits
The S1 and S2
Extra sounds both in systole and
diastole
Cardiac murmurs
JUGULAR VENOUS PRESSURE
STEPS FOR ASSESSING JVP :
Raise the head slightly on a pillow
Raise the head of the bed to 30
o
Use tangential lighting to identify EJV then
IJV
Raise or lower the head of the bed to see
oscillation point
Identify the highest point of pulsation


JUGULAR VENOUS PRESSURE
JUGULAR VENOUS PRESSURE
JUGULAR VENOUS PRESSURE
Normal pressure (30
o
) 3-4 cm above
the sternal angle
Hypovolemic patients 0
o
Hypervolemic patients 60
o
90
o
45
o
4.5 cm above sternal angle
JUGULAR VENOUS PULSATION
Normal Jugular Venous Pulsation
JUGULAR VENOUS PULSATION
Abnormal
A-Wave
Large A-wave &
Slow Y-descent
JUGULAR VENOUS PULSATION
Ventricularized
JVP
Atrial Fibrillation
ARTERIAL PULSE
Radial artery, brachial artery, dorsalis
pedis artery, femoral artery, carotid
artery
Assess : volume, contour, frequency,
and regularity

ARTERIAL PULSE
Normal pulse






Anacrotic pulse (pulsus parvus et
tardus) AS

ARTERIAL PULSE
Pulsus bisferiens AR, AR+AS, IHSS





Pulsus alternans congestive heart
failure
ARTERIAL PULSE
Pulsus paradoxus cardiac
tamponade, constrictive pericarditis,
COPD, hypovolemic shock
Waterhammer pulse AR

ARTERIAL PULSE
EXAMINATION OF THE HEART
INSPECTION AND PALPATION
EXAMINATION OF THE HEART
INSPECTION AND PALPATION
EXAMINATION OF THE HEART
INSPECTION AND PALPATION
EXAMINATION OF THE HEART
PERCUSSION
Estimation of cardiac size
Cardiac dullness
HEART SOUNDS
AUSCULTATION
S
1
mitral and tricuspid valve
S
2
aortic and pulmonal valve
S
3
the rush of blood during early diastole
S
4
atrial contraction


HEART SOUNDS
AUSCULTATION


HEART SOUNDS
AUSCULTATION


HEART SOUNDS
Variations of the S
1




Tachycardia, mitral stenosis
1
st
degree AV Block, MR,
CHF, CHD
Complete heart block, AF
RBBB, PVC
HEART SOUNDS
Variations of the S
1
Splitting of S
1



HEART SOUNDS
Variations of the S
2
Splitting of S
2

HEART SOUNDS
Variations of the S
2
Increased A
2
systemic hypertension,
dilated aortic root
Increased P
2
pulmonary hypertension,
dilated pulmonary artery, ASD
Decreased A
2
AS
Decreased P
2
increased AP diameter of
the chest, PS


HEART SOUNDS
Extra Heart Sounds in Systole



Aortic ejection sound : dilated aorta,
aortic valve disease (congenital stenosis)
Pulmonic ejection sound : dilated pulm.
artery, PH, PS
Mitral Valve Prolapse (MVP)
HEART SOUNDS
Extra Heart Sounds in Diastole



Mitral Stenosis (MS)
Physiologic : children, pregnancy
Pathologic : decreased myocardial
contractility, myocardial failure, MR,
TR
Left-sided S
4
: HHD, CAD, AS,
cardiomyopathy
Right-sided S
4
: PH, PS
HEART SOUNDS (MURMURS)
Midsystolic Murmurs



No evidence of CV disease. Found in : children,
young adults, or even elders
Temporary increase in blood flow : anemia, fever,
pregnancy, hyperthyroidism
Location : 2
nd
3
rd
left ICS. Radiation : toward the left shoulder
& neck. Intensity : soft loud (thrill). Pitch : medium. Quality :
often harsh
HEART SOUNDS (MURMURS)



Location : 2
nd
right ICS. Radiation : often to the neck & LSB,
even apex. Intensity : soft loud (thrill). Pitch : medium, maybe
higher. Quality : often harsh. Aids : sitting & leaning forward
Location : 3
rd
4
th
left ICS. Radiation : down to the LSB to the
apex or base, not to the neck. Intensity : variable. Pitch :
medium. Quality : harsh. Aids : squatting, straining down
HEART SOUNDS (MURMURS)
Pansystolic Murmurs


Location : apex. Radiation : to left axilla, less often to the LSB.
Intensity : soft loud (apical thrill). Pitch : medium high.
Quality : blowing. Aids : do not become louder in inspiration
Location : lower LSB. Radiation : to the right of the sternum,
xiphoid area, left MCL, not into the axilla. Intensity : variable.
Pitch : medium. Quality : blowing. Aids : inspiration
Location : 3
rd
,4
th
, 5
th
left ICS. Radiation : often wide. Intensity :
often very loud with thrill. Pitch : high. Quality : often harsh.
HEART SOUNDS (MURMURS)
Diastolic Murmurs


Location : 2
nd
4
th
left ICS. Radiation : if loud, to the
apex, perhaps to the RSB. Intensity : grade 1 3.
Pitch : high. Quality : blowing (maybe mistaken for
breath sounds). Aids : heard best with sitting, leaning
forward, with breath held in exhalation.
Location : limited to the apex. Radiation : little - none.
Intensity : grade 1 4. Pitch : low. Aids :placing the
bell exactly on the apical impulse, left lateral position,
mild exercise, exhalation
HEART SOUNDS (MURMURS)
Heart Sounds With Both Systolic and
Diastolic Components


Timing : (1) atrial systole, (2) vent. systole,
(3) vent. diastole.
Location : variable, 3
rd
ICS to the left of the
sternum.
Radiation : little.
Intensity : variable.
Pitch : high.
Quality : scratchy, scraping.
Aids : heard best with leaning forward,
exhales, and holds breath.
HEART SOUNDS (MURMURS)
Heart Sounds With Both Systolic and
Diastolic Components


Timing : continuous murmur in both systole
and diastole, often with a silent
interval late in diastole
Location : 2
nd
left ICS.
Radiation : toward the left clavicle.
Intensity : usually loud with thrill.
Pitch : medium.
Quality : harsh, machinery-like.
HEART SOUNDS (MURMURS)
Heart Sounds With Both Systolic and
Diastolic Components


Timing : continuous murmur without a silent
interval.
Location : above the medial third of the
clavicles, especially on the right.
Radiation : 1
st
and 2
nd
ICS.
Intensity : soft moderate.
Pitch : low.
Quality : humming, roaring.
REFERENCES
Bickley, Lynn S. Bates Guide to Physical
Examination and History Taking, 8
th

edition. Philadelphia : Lippincott Williams &
Wilkins. 2003.

Braunwald, Eugene., Goldman, Lee. Primary
Cardiology, 2
nd
edition. Philadelphia :
Saunders. 2003.

Martini, F. H. Fundamentals of Anatomy
and Physiology, 5
th
edition. New Jersey:
Pretince Hall. 2001.

Akhtar Fajar Muzakkir, MD
Cardiac Centre, Wahidin Sudirohusodo Hospital
0811462710/04115282327
enzobearzot@yahoo.com