THE

CARDIOVASCULAR
SYSTEM

Clinical Examination

Dr. Andrew Turley. James Cook University Hospital

 Introduction

Examination Routine
What to do and how to do it.
Important physical signs.

Practice after lunch!!

Already covered
Clinical History
 Aims

To provide an overview to the

examination of the cardiovascular
system.
 Learning Objectives

By the end of the session the students will be

able to,
Demonstrate examination of the
cardiovascular system in a logical manner.
Recognise the difference between abnormal
and normal findings.

Communicate effectively with patients in

context of examination.
Gain confidence in clinical examination.
 Timetable

Mini-Lecture

Lunch 12.30-1.30pm

Supervised Bedside teaching

Clinical History 1.30-3pm
Bedside clinical examination 3.30-5pm
Examination

General Examination routine

Inspection
Palpation
(Percussion)
Auscultation

Adopt a systematic and

fluent approach to the
examination.
Examination

Suggested CVS Exam routine

General Inspection
Hands
Pulse
BP
Head & Neck
JVP, Carotids, Anaemia, Cyanosis
Praecordium
Auscultation
Extras
 Examination

What is the most important start to any exam ??

Introduce yourself to the

patient and let them know
what you are about to do
 Examination

Marks are awarded for:

Indicates intention to wash hands.
Introduces self to patient.
Explains to patient what he/she wants to do.
Displays an appropriate, considerate manner to
the patient.
Thanks the patient at the end.
 Exam: General Inspection

If the patient is not exposed then ask if you may

expose them (always expose ankles/lower legs ?
scars).
The patient should be reclined at a 45 angle.
Look for the obvious (whilst stood at end of bed).
Breathlessness
Pallor
Sweating
Scars
Props: Oxygen pipes, Inhalers, GTN spray, BM Machine
Make some comments.
 Exam: General Inspection

Does the patient

suffer with a
condition
associated with
cardiovascular
disease?

Downs Syndrome.
 Exam: General Inspection
Marfans Syndrome.

Myotonic Dystrophy
 Exam: General Inspection

Sternotomy scar and NO saphenous vein scar

Think VALVE replacement
Exam: Hands

Start with the nails and

look for clubbing,

Increased Curvature

Loss of nail bed angle

Fluctuant nail beds

Examine BOTH hands

at eye level.
Exam: Hands

Cardiovascular
causes of clubbing
can be:
Congenital Cyanotic
Heart Disease
Atrial Myxoma
Endocarditis
Exam: Hands

Next look for Splinter

Haemorrhages,

A sign of systemic
vasculitis which may
indicate Infective
Endocarditis.

They can also be caused

by trauma so remember
to bear in mind the
patients occupation.
 Exam: Hands

Other points to
note:
Temperature
Perfusion
Pallor
Tar staining
Extensor tendon
swellings
(xanthomas)
Exam: Pulse
Start by palpating the
radial pulse.

At this site asses,

Rate
Rhythm

You should not asses

volume/character at
the radial artery.
 Exam: Pulse

Next move to the

brachial artery (or
carotid artery) to
? assess,

Volume
?
Character
Exam: Blood Pressure

You now want to

measure the blood
pressure.

A single
measurement is
acceptable unless
the history suggests
aortic dissection.
Exam: Head & Neck: FACE
Jaundice
Best seen in
the sclera.
Exam: Head & Neck: FACE

Anaemia
Exam: Head & Neck: FACE

Xanthelasma
Exam: Head & Neck: FACE

Corneal arcus
Exam: Head & Neck: FACE

Central
Cyanosis
Exam: Head & Neck: TEETH

Infective
Endocarditis
Exam: Head & Neck: Carotid Pulses

Palpate carotid pulse.

ONE at a time!
Ask patient to hold breath.
Listen for bruits with bell or diaphragm.
May hear transmitted murmur.
Exam: Head & Neck: JVP

The JVP is best examined by

looking across the neck.

A double waveform should be

seen for each cardiac cycle.
Exam: Head & Neck: JVP

Top of venous pulsation

Sternal Angle Height

Of
JVP
In
Top of venous pulsation
cms

Sternal Angle
 Exam: Head & Neck: JVP

Carotid Pulsation JVP Pulsation

1 per cardiac cycle 2 per cardiac cycle
Palpable Not palpable
Position Varies depending on
independent position
Does not enhance Enhances with
with hepatojugular hepatojugular
reflex reflex
 Exam: Head & Neck: JVP

Normal for JVP not to be seen.

Increased JVP.
Heart Failure
Acute PE
Pericardial effusion
Decreased JVP.
Dehydration
 Exam: Praecordium

Look
For
Obvious
Deformity

Pigeon Chest Funnel Chest

 Exam: Praecordium
Look for
Obvious Scars

Median Sternotomy
CABG, Valve, Transplant
Congenital disease
Exam: Praecordium

Lateral
Thoracotomy
Coarctation Repair
 Exam: Praecordium

Look
For
Obvious
Scars

PPM/ICD
 Exam: Praecordium

Locate Apex Examine for Heaves/Thrills

 Exam: Praecordium (apex beat)
1 23

2nd 1. Mid Clavicular Line

3rd 2. Anterior Axillary
4th Line
5th
3. Mid Axillary Line

Intercostal Spaces
 Apex Beat

The most inferior Displaced apex in

and lateral point at cardiovascular
which the cardiac disease indicates
impulse can be left ventricular
felt. dilatation.
 Exam: Praecordium Heaves and
Thrills
Heave Thrills
Palpate firmly the Palpable murmurs.
left border of the
sternum.
Indicates right
ventricular
hypertrophy.
Exam: Auscultation
 Exam: Auscultation

Bell

Low pitched murmurs eg. Mitral Stenosis

Press hard enough only to make a seal with the skin
The hole must be rotated to the bell in order for it to work
 Exam: Auscultation

Diaphragm

Normal / High pitched murmurs.

Use for general purpose auscultation
 Exam: Auscultation

Earpiece

Angled to provide a better fit into the auditory cannal.

During use point forward unless you have an abnormal shaped head !
 Exam: Auscultation

1. Apex: Mitral Valve

2. Sternal Edge:
Tricuspid Valve
BELL
& 3. L 2nd Space:
Pulmonary Valve
DIAPHRAGM

4. R 2nd Space:
Aortic Valve
 Exam: Auscultation
Heart Sounds:

LUB DUB

First Second
Mitral Valve Aortic Valve
Tricuspid Valve Pulmonary Valve
SYSTOLIC
 Exam: Auscultation

Heart Murmurs: SYSTOLIC

Mitral
Regurgitation

Tricuspid
Regurgitation

First Second

Pan Systolic Murmur

 Exam: Auscultation

Heart Murmurs: SYSTOLIC

Aortic
Stenosis

Pulmonary
Stenosis
VSD

First Second

Ejection Systolic Murmur

 Exam: Auscultation

Heart Murmurs: DIASTOLIC

Aortic
Regurgitation

First Second

Early Diastolic Murmur

 Exam: Auscultation

Heart Murmurs: DIASTOLIC

Mitral
Stenosis

First Second

Mid Diastolic Murmur

 Exam: Auscultation (extras)

Heart Murmurs: EXTRAS

Mitral Murmurs
Mitral Area
Patient in Left Lateral
Breath Held in Expiration
Radiate to Axilla
 Exam: Auscultation (extras)

Heart Murmurs: EXTRAS

Aortic Murmurs
Aortic Area
Sit Patient Forward
Breath Held in Expiration
Radiates to Carotids
 Exam: Extra points
Is there anything else you
wish to do ?
Examine the peripheral
pulses.
Check for radio radial or
radio femoral delay.
Listen at the lung bases.
Check for sacral oedema.
Check for peripheral oedema.
Measure the BP if not
already done.
Fundoscopy.
Dipstix Urine.
 Summary

What is the most important start to any exam ??

Introduce yourself to the

patient and let them know
what you are about to do
 Summary

Marks are awarded for:

Indicates intention to wash hands.
Introduces self to patient.
Explains to patient what he/she wants to
do.
Displays an appropriate, considerate manner
to the patient.
Thanks the patient at the end.
 Summary

Suggested CVS Exam routine

General Inspection
Hands
Pulse
BP
Head & Neck
Anaemia, Cyanosis, Jaundice, Teeth, JVP, Carotids
Praecordium
Auscultation
Extras
 Recommended Reading

Lecture notes on History Taking and

Examination.
Blackwell Scientific Publications.

Clinical Medicine
Kumar & Clark
Saunders
Examination: The End

Any Questions So Far ???

 Lunch
12.30-1.30pm

Thankyou for your attention