Physical Examination ofThe Cardiovascular SystemCardiovascular DepartmentWahidin Sudirohusodo General HospitalMakassar

ANATOMYAnterior Surface of the Heart

ANATOMYThe Sectional Anatomy of the Heart

CARDIAC CYCLE

PHYSICAL EXAMINATIONThe jugular venous pressureThe arterial pulseThe PMI and any heaves, lifts, or bruitsThe S1 and S2Extra sounds both in systole and diastoleCardiac murmurs

JUGULAR VENOUS PRESSURESTEPS FOR ASSESSING JVP :Raise the head slightly on a pillowRaise the head of the bed to 30oUse tangential lighting to identify EJV then IJVRaise or lower the head of the bed to see oscillation pointIdentify the highest point of pulsation

JUGULAR VENOUS PRESSURE

JUGULAR VENOUS PRESSURE

JUGULAR VENOUS PRESSURENormal pressure (30o) 3-4 cm above the sternal angleHypovolemic patients 0oHypervolemic patients 60o 90o45o 4.5 cm above sternal angle

JUGULAR VENOUS PULSATIONNormal Jugular Venous Pulsation

JUGULAR VENOUS PULSATIONAbnormal A-WaveLarge A-wave &Slow Y-descent

JUGULAR VENOUS PULSATIONVentricularizedJVPAtrial Fibrillation

ARTERIAL PULSERadial artery, brachial artery, dorsalis pedis artery, femoral artery, carotid arteryAssess : volume, contour, frequency, and regularity

ARTERIAL PULSENormal pulse

Anacrotic pulse (pulsus parvus et tardus) AS

ARTERIAL PULSEPulsus bisferiens AR, AR+AS, IHSS

Pulsus alternans congestive heart failure

ARTERIAL PULSEPulsus paradoxus cardiac tamponade, constrictive pericarditis, COPD, hypovolemic shockWaterhammer pulse AR

ARTERIAL PULSE

EXAMINATION OF THE HEARTINSPECTION AND PALPATION

EXAMINATION OF THE HEARTINSPECTION AND PALPATION

EXAMINATION OF THE HEARTINSPECTION AND PALPATION

EXAMINATION OF THE HEARTPERCUSSIONEstimation of cardiac sizeCardiac dullness

HEART SOUNDSAUSCULTATIONS1 mitral and tricuspid valve S2 aortic and pulmonal valveS3 the rush of blood during early diastole S4 atrial contraction

HEART SOUNDSAUSCULTATION

HEART SOUNDSAUSCULTATION

HEART SOUNDSVariations of the S1

Tachycardia, mitral stenosis 1st degree AV Block, MR, CHF, CHDComplete heart block, AFRBBB, PVC

HEART SOUNDSVariations of the S1Splitting of S1

HEART SOUNDSVariations of the S2Splitting of S2

HEART SOUNDSVariations of the S2Increased A2 systemic hypertension, dilated aortic rootIncreased P2 pulmonary hypertension, dilated pulmonary artery, ASDDecreased A2 ASDecreased P2 increased AP diameter of the chest, PS

HEART SOUNDSExtra Heart Sounds in Systole

Aortic ejection sound : dilated aorta, aortic valve disease (congenital stenosis) Pulmonic ejection sound : dilated pulm. artery, PH, PSMitral Valve Prolapse (MVP)

HEART SOUNDSExtra Heart Sounds in Diastole

Mitral Stenosis (MS) Physiologic : children, pregnancy Pathologic : decreased myocardial contractility, myocardial failure, MR, TR Left-sided S4 : HHD, CAD, AS, cardiomyopathy Right-sided S4 : PH, PS

HEART SOUNDS (MURMURS)Midsystolic Murmurs

No evidence of CV disease. Found in : children, young adults, or even eldersTemporary increase in blood flow : anemia, fever, pregnancy, hyperthyroidism

HEART SOUNDS (MURMURS)

HEART SOUNDS (MURMURS)Pansystolic Murmurs

HEART SOUNDS (MURMURS)Diastolic Murmurs

HEART SOUNDS (MURMURS)Heart Sounds With Both Systolic and Diastolic Components

HEART SOUNDS (MURMURS)Heart Sounds With Both Systolic and Diastolic Components

HEART SOUNDS (MURMURS)Heart Sounds With Both Systolic and Diastolic Components

REFERENCESBickley, Lynn S. Bates Guide to Physical Examination and History Taking, 8th edition. Philadelphia : Lippincott Williams & Wilkins. 2003.

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

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

Akhtar Fajar Muzakkir, MDCardiac Centre, Wahidin Sudirohusodo Hospital0811462710/04115282327enzobearzot@yahoo.com

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