CARDIOVASCULAR SYSTEM EXAMINATION

INSPECTION:

1. SHAPE AND SYMMETRY OF CHEST WALL:

NORMAL: bilaterally symmetrical, antero posterior diameter to transverse diameter - 5:7

2. CHEST DEFORMITIES:

-Funnel shaped chest: Marfans syndrome.

-pigeon shaped chest: Rickets.

3. PRECORDIAL BULGE:

-Chronic cardiomegaly.

4. TRACHEAL POSITION :

-Central/ shifted

5. APICAL IMPULSE:

-4TH intercostal space, just lateral to the midclavicular line.

6. OTHER VISIBLE PULSATIONS:

- Aortic area, pulmonary area, epigastric region, suprasternal area, carotid area.

7. DILATED VEINS, SCARS and SINUSES.

PALPATION

1. JUGULAR VENOUS PULSE (JVP):-Keep the patient at 45 degree .-Turn head to left side.-Draw transverse line over the upper border of oscillatory column in the internal jugular vein and at the level of Sternal angle.-Using cm ruler , vertical distance between both horizontal line measure JVP.-If distance >3cm (JVP elevated).-5cm is added to obtain an estimate of mean right atrial pressure in cms of blood.

-Causes for raised JVP: right ventricular failure, tricuspid stenosis or regurgitation, pericardial effusion, fluid overload.

2.APEX BEAT:

PROCEDURE: Start by doing this with entire hand, gradually become more specific until it is felt under one finger.

*palpating with hand.

*locating with finger.

*best studied in left lateral position of the patient.

a) LOCATION: 4th intercostal space just lateral to mid-clavicular line.

Cause for shift in apex beat : Left or right ventricular hypertrophy, Dextrocardia.

b) CHARACTER :

TAPPING APEX BEAT- mitral stenosis (slight increase in amplitude).

HYPERDYNAMIC APEX BEAT: systemic hypertension, aortic stenosis, volume overload.

HEAVING APEX BEAT: (both amplitude and duration is increased).aortic regurgitation, vsd.

DIFFUSE APEX BEAT: left ventricular aneurysms.

DOUBLE APICAL IMPULSE: aortic stenosis or regurgitation.

TRIPLE OR QUADRUPLE APEX BEAT: HOCM.

ABSENT APEX BEAT: obese children ,impulse behind the rib

3.TRACHEAL POSITION :

TRAIL’S SIGN: t is the undue prominence of the clavicular head of sternomastoid on the side to which trachea is deviated.

4 .PARA STERNAL HEAVE: Palpable thrust which lifts the hand in parasternal region.

Palpated by ulnar aspect of palm. Also can be demonstrated by placing a pen on the left parasternal region, which will move perpendicular

to chest wall. Seen in right ventricular enlargement, left atrial enlargement.

GRADING OF PARASTERNAL IMPULSE (AIIMS grading):

GRADE 1: visible but not palpable.

GRADE 2: visible and palpable but obliterable.

GRADE 3: visible and palpable but not obliterable.

5. THRILLS/PALPABLE MURMURS:

These accompany any organic murmur of GRADE 3 or more.

TYPES: Aortic thrills, Pulmonary thrills, Left lower parasternal thrills, Apical thrills.

TIMING: systolic thrills, diastolic thrills, continuous thrills.

PERCUSSION:

BORDERS OF HEART: RIGHT , LEFT, UPPER AND LOWER BORDERS.

Helps in finding position and enlargement of heart as in- Dextrocardia. Pericardial effusion. Dilated cardiomyopathy.

PROCEDURE:

a) RIGHT BORDER: First percuss for liver dullness →take 1 intercostal space above →from here go medially →presence of dull note at right sternal border signifies right border of heart.

b) LEFT BORDER Localise the apex beat →take 1 intercostal space above →from here go medially → presence of dull note signifies left border of heart.

AUSCULTATION

AREAS OF AUSCULTATION:

A) MITRAL AREA: 5th left intercostal space in the midclavicular line.B) TRICUSPID AREA: 4th left intercostal space just lateral to lower end of sternum.C) 1st AORTIC AREA: 2nd right intercostal space, close to sternum.

2nd AORTIC AREA /ERB’S AREA:3rd left intercostal space, close to sternum.D) PULMONARY AREA: 2nd left intercostal space, close to sternum.E) GIBSON’S AREA: 2nd left intercostal area away from sternum.(PDA murmur is best heard here)F) OTHER AREAS: carotid, supraclavicular, axillary areas.

Back- interscapular, infrascapular areas ( bruits in the back).

AUSCULTATE THE AREAS FOR FOLLOWING SOUNDS:

1) HEART SOUNDS-S1, S2, S3 ,S4. INTENSITY (soft/loud) SLPITTING OF SOUNDS.

a) S1- produced by closure of atrioventricular valves.(M1 + T1) → SOFT S1: mitral and tricuspid regurgitation, mitral and tricuspid stenosis. → LOUD S1: tricuspid stenosis , high output states. → SPLITTING S1: RBBB with pulmonary hypertension, ebsteins anomaly. → REVERSE SPLITTING: Right ventricular pacing, ectopic beats from RV.

b) S2-Produced by closure of aortic and pulmonary valves.(A2 + P2) → SOFT S2: Aortic/pulmonary valve calcification. →LOUD S2: Systemic and pulmonary hypertension. →SPLIT S2: Atrial septal defect, pulmonary embolism , right ventricular failure. →REVERSE SPLITTING S2: LBBB, Aortic stenosis (severe).

c ) S3/PROTODIASTOLIC SOUND/VENTRICULAR GALLOP: Auscultate with bell of stethoscope at apex. → PHYSIOLOGICAL: Children and athletes. → PATHOLOGICAL: High output states ,ASD, VASD, PDA, IHD.

d) S4/PRESYSTOLIC GALLOP/ATRIAL GALLOP: → Hypertrophic cardiomyopathy, systemic hypertension.

2) ADDED SOUNDS:a) OPENING SNAP.b) EJECTION CLICK.c) GALLOP RHYTHM.d) ATRIAL GALLOP.e) VENTRICULAR GALLOP.

3) PERICARDIAL RUB: → Viral pericarditis, tuberculous pericarditis, acute rheumatic fever, SLE.

4) HEART MURMURS:

→ They are relatively prolonged series of auditory vibrations produced due to turbulence that arise when blood velocity increase due to increased flow or due to flow through a constricted or irregular orifice. Murmurs should be described in the following way:

Area over precordium where murmur is heard. Whether murmur is systolic/diastolic. Timing and character of murmur(ESM,PSM,MDM,EDM) Intensity of murmur(grading). Pitch of murmur (low/high). Whether murmur is best heard with bell or diaphragm of stethoscope. Conduction of murmur. Variation with respiration( Lt sided murmurs best heard in expiration & vice versa). Posture in which murmur is best heard.

LEVINE AND FREEMAN’S GRADING OF MURMURS :

SYSTOLIC MURMUR

GRADE:1.very soft.(heard in quiet room)2.soft.3.moderate.4.loud with thrill.5.very loud with thrill (heard with stethoscope).6.very loud with thrill (even when stethoscope is slightly away from chest wall)

DIASTOLIC MURMURS.

GRADE:1.very soft.2.soft.3.loud.4.loud with thrill.