History & Physical

Examination
of
The Cardiovascular System
Diara Jossiean M. Rogacion
Clinical Clerk 2020-2021 Group 5B
Department of Medicine
November 5, 2020
At the end of this lecture, the Clinical Clerk should be able to:

1. Assess cardiac symptoms by performing a concise history taking

2. Identify the major risk cardiovascular factors in evaluating cardiovascular diseases during
history taking
3. Enumerate and perform the techniques in the physical examination of the cardiovascular
system beginning with the general appearance
4. Evaluate the blood pressure of an adult individual according to the JNC 8 Guidelines
5. Assess the jugular venous pressure, jugular venous pulsations, and carotid pulsations
6. Perform the palpation of the point of maximal impulse and the heart sounds
7. Assess the different heart sounds and identify heart murmurs through auscultation
8. Perform the special maneuvers needed in evaluating patients with cardiovascular diseases
 Before starting the
history taking and
physical examination
it is important to establish
rapport by introducing yourself,
asking the patient’s name and age,
and explaining the examinations
to be done.
 Common cardiovascular
symptoms:
● Chest pain
● Shortness of breath
● Palpitations
● Edema or swelling

History Taking
Risk factors to
for patients with cardiovascular
pathology should be direct and look out for:
perceptive.
● Family history of cardiac
It is essential to explore the presenting diseases
symptoms and the patient’s risk factors ● Cigarette smoking
through other aspects of the patient’s history ● Poor diet
such as the past medical history, family ● Physical inactivity
history, and social history.
● Obesity
● Hypertension
Remember: CLITAA ● Hyperlipidaemia
● Diabetes mellitus
Key Steps in the
Physical Examination of the CVS

Pressure and Palpation and Special

Inspection Auscultation
Pulses Percussion Techniques
Positioning the Patient Blood Pressure Point of Maximum Impulse Heart Sounds Standing and Squatting
Skin Jugular Venous Pressure Heaves, Lifts, and Thrills Heart Murmurs Valsalva Maneuver
Head and Neck Jugular Venous Pulsations Heart Sounds Isometric Handgrip
Chest Transient Arterial Occlusion
Extremities
 01
History Taking:
Assessing Cardiac
Symptoms
Physical Activity
Quantify the patient’s baseline level of activity

Do symptoms develop:
● When or after climbing of stairs?
○ How many steps?
● When walking?
● When doing housework?
○ Are these simple or
strenuous activities?
● When at rest?
 Physical Activity
Quantifying the patient’s baseline level Functional Capacity Objective Assessment

of activity is especially important in the Patients with cardiac disease but without resulting limitation of
assessment of the functional status of Class I physical activity. Ordinary physical activity does not cause undue
fatigue, palpitations, dyspnea, or anginal pain.
patients with heart failure to predict
patient outcome, based on the New Patients with cardiac disease resulting in slight limitation of physical
Class II activity. They are comfortable at rest. Ordinary physical activity results
York Heart Association Classification in fatigue, palpitation, dyspnea, or anginal pain.
(NYHA).
Patients with cardiac disease resulting in marked limitation of physical
Class III activity. They are comfortable at rest. Less than ordinary activity causes
fatigue, palpitation, dyspnea, or anginal pain.

Patients with cardiac disease resulting in inability to carry on any

physical activity without discomfort. Symptoms of heart failure or the
Class IV anginal syndrome may be present even at rest. If any physical activity is
undertaken, discomfort is increased.
Adapted from Jameson, J.L. et al. (2018). Harrison’s principles of internal
medicine (20th edition). New York, NY: McGraw-Hill Education.
Chest Pain
Questions to ask:
● How would you describe the pain?
● Does it radiate in the neck, shoulder, back or arm?
● How intense is the pain from 1-10, 10 being the
highest?
● Is pain related to exertion?
● What kind of activities bring on the pain?
● Does it wake you up at night?
● Any associated symptoms?
● What do you do to make it better?
Shortness of Breath
Questions to ask:
● Dyspnea: uncomfortable awareness of breathing

○ Does this occur at rest, during activities, or after climbing

stairs?

○ Important to ask if the patient is physically active, i.e. an

athlete

■ Sudden shortness of breath is more serious in an

athlete than in a person who only walks from one
room to another

● Orthopnea: Does your shortness of breath occur when the you are
lying down? Does it improve when you sit or stand?

● Paroxysmal Nocturnal Dyspnea (PND): Do you have sudden

episodes of shortness of breath at night, while lying down? Do
they awaken you?
Palpitations
Questions to ask:
● What activities were done prior to feeling a rapid
heartbeat?
● Are you ever aware of your heartbeat?
● What is it like? Regular or irregular?
● How long did it last?
● Did it develop suddenly or gradually?
Edema
Questions to ask:
● Have you had any swelling anywhere? Where?
Anywhere else?
● When does it occur?
● Is it worse in the morning or at night? When sitting,
standing, or lying on your bed?
● Are the rings tight on your fingers? Is there
difficulty wearing socks or shoes?
● Is there associated pain? Redness?
● Are your eyelids also puffy or swollen in the
morning?
Common
cardiovascular Chest Pain Palpitations

pathologies
pain in the chest, shoulder, back, neck or Atrial presents with chest discomfort and
Myocardial arm; precipitated by exertion (stable fibrillation palpitations; confirmed through
ischemia angina); may last more than 30 minutes irregularly irregular rhythm on ECG
(myocardial infarction)

Aortic anterior chest pain, often tearing or ripping,

dissection often radiating into the back or neck

sharp, pleuritic chest pain, usually relieved Paroxysmal rapid heartbeat with sudden onset and
Pericarditis by sitting upright and aggravated by supraventric offset
coughing, deep inspiration, and lying supine ular
tachycardia
Pulmonary chest pain associated with palpitations and
embolism shortness of breath

Shortness of Breath Edema

Pulmonary may present as sudden dyspnea Congestive usually presents with chest discomfort,
embolism heart failure shortness of breath, and bipedal edema

Left ventricular may present as orthopnea or paroxysmal Possible periorbital edema and/or edema of the hands
heart failure nocturnal dyspnea co-morbid and feet may also be seen in nephrotic
diseases: syndrome; an enlarged waistline can be due
Renal disease, to ascites in liver diseases
Mitral stenosis liver disease
 02
History Taking:
Assessing the Risk Factors
Global Risk
Factors of
Cardiovascular
Diseases ● Family history
○ pre-mature CVD (at age <55 years in first-degree male
relatives and age <65 years in first-degree female
relatives)
● Cigarette smoking
● Poor diet
○ high salt and high cholesterol diet
● Physical inactivity
● Obesity
● Hypertension
● Hyperlipidemia
● Diabetes mellitus
Bickley, L.S. & Szilagyi, P.G. (2008). Bates’ Guide to Physical Examination and History
Taking (11th edition). New York, NY: Lippincott Williams & Wilkins.
Identify the risk factors as you work through the history.

Identifying Data What is the patient’s age? Sex?

Is this the first admission?

Past Medical Is there a previous history of cardiovascular disease?

Is the patient diagnosed with hypertension? Diabetes? Dyslipidemias? Other co-morbid diseases such as stroke,
History renal or liver disease?
Is the patient on any current medications?
Is there a history of surgery or procedures (e.g. coronary artery bypass grafts, coronary artery stents, heart valve
replacements)?
Are there any known allergies?

Family History Do any of the patient’s parents or siblings have any heart problems? Hypertension? Diabetes? At what age were they
diagnosed?

Social History How does the patient describe their community?

Does the patient need assistance at home (e.g. stairlifts)? Who is caring or supporting the patient?
Does the patient smoke and/or drink alcoholic beverages? How much and how often?
Is there history of illicit drug use?
What is the patient’s usual diet? Does the patient exercise regularly?
What is the patient’s occupation? Does the patient drive?
 03
Physical Examination
Inspection
Positioning the Patient
● The patient should lie supine, with the upper body and head of the bed raised to about 30 degrees
○ Additional positions may be performed for elucidation of specific findings
● Examiner should stand at the patient’s left side

Patient Position Examination

Inspect and palpate the precordium: the 2nd right and left interspaces; the right ventricle; and
Supine, with the head the left ventricle, including the apical impulse (diameter, location, amplitude, duration). Listen
elevated 30 degrees at the 2nd right and left interspaces, along the left sternal border, across to the apex with the
diaphragm.

Palpate the apical impulse, if not previously detected. Listen at the apex with the bell of the
Left lateral decubitus stethoscope. Low-pitched extra sounds such as an S3, opening snap, diastolic rumble of mitral
stenosis can be heard through this position.

Listen at the right sternal border for tricuspid murmurs and sounds with the bell. Soft
Sitting, leaning forward, decrescendo higher-pitched diastolic murmur of aortic insufficiency can be heard through
after full exhalation this position.

Adapted from: Bickley, L.S. & Szilagyi, P.G. (2008). Bates’ Guide to Physical Examination and
History Taking (11th edition). New York, NY: Lippincott Williams & Wilkins.
Inspection
barrel chest (pectus carinatum), funnel chest (pectus excavatum)
Chest deformities severe kyphosis and compensatory lumbar, pelvic, and knee flexion of ankylosing
spondylitis should prompt careful auscultation for a murmur of aortic regurgitation

Precordium flat, bulging, tenderness, visible thrills and/or heaves, adynamic, dynamic

Neck veins distended neck veins may indicate heart failure

Periorbital area edema, sunken

Oral mucosa pink or pale

Size of the tongue enlarged, hypertrophied, or with fasciculations

Pharynx pink, pale, or reddish

peripheral cyanosis: cyanosis of the extremities, clubbing of nails

Cyanosis central cyanosis: pallor and dryness of the lips, oral mucosa, and conjunctivae (pink
or pale)

clubbing of the nails implies the presence of central right-to-left shunting; Janeway
Extremities lesions and Osler nodes are seen in infective endocarditis
 Inspection

Pectus carinatum Pectus excavatum Ankylosing spondylitis

Inspection

Clubbing of nails Janeway lesions Osler nodes

 04
Physical Examination
Pressure and Pulses
Assess the Vital Signs
Blood Pressure Assessment

Palpatory Blood Pressure

● Palpate the brachial artery to confirm a viable pulse and position the arm
at heart level (roughly at the 4th ICS near the parasternal border).
● Secure the cuff snugly (not too tight, not too loose).
○ Lower border of the cuff should be about 2.5 cm (2 fingerbreadths) above the
antecubital crease. Loose cuff lead to a falsely high reading.
● Palpate for the radial artery then inflate the cuff. Take note when the
radial artery will be pulseless. Then, deflate the manometer.
● Get palpatory blood pressure then add 30 mmHg.
○ Palpatory BP is important to avoid error caused by auscultatory gap, especially
in patients with atherosclerotic disease or elderlies who may already have stiff
vessels.
Assess the Vital Signs
Blood Pressure Assessment

Auscultatory Blood Pressure

● Note: Systolic and diastolic pressures are defined by the first and fifth
Korotkoff sounds, respectively.
● Re-inflate the manometer.
● Take the auscultatory BP by positioning the stethoscope bell over the
brachial artery.
○ Inflate cuff to 20-30 mmHg above the palpatory BP.
● Deflate the manometer at around 3 mmHg/beat. Take note of the 1st and
last Korotkoff sound.
○ Korotkoff sounds are better heard with the bell because of its low pitch.
■ “BelLow” = Bell is for low pitch sounds
● Report acquired BP.
Assess the Vital Signs
Blood Pressure Assessment

Systolic and Diastolic BP JNC 8 ACC/AHA 2017

< 120 and < 80 Normal BP Normal BP

120-129 and < 80 Pre-hypertension Elevated BP

130-139 or 80-89 Pre-hypertension Stage I Hypertension

140-159 or 90-99 Stage I hypertension Stage II Hypertension

> 160 or > 100 Stage II hypertension Stage II Hypertension

Assess the Vital Signs
Blood Pressure Assessment

● In some cases, the blood pressure should be measured in both arms, and
the difference should be less than 10 mmHg
○ A difference of more than 10 mmHg may be suggestive of
atherosclerotic or inflammatory subclavian artery disease,
supravalvular aortic stenosis, aortic coarctation, or aortic dissection
● Systolic leg pressures are usually as much as 20 mmHg higher than
systolic arm pressures
○ Greater leg-arm pressure differences are seen in patients with
chronic severe aortic regurgitation, as well as in patients with
extensive and calcified lower extremity peripheral arterial disease
Jugular Venous Pressure
● This is usually performed at the right side of the patient.
● Incline the patient in a 30-degree angle.
○ Hypervolemia: JVP is high so you need to raise the head of the
patient.
○ Hypovolemia: JVP will be low so you need to lower the head of the
patient.
● Ask the patient to turn their head to the left side exposing the jugular
veins.
● Turn off the light, use a penlight and via tangential lighting locate the
internal jugular vein.
● Locate the highest point of oscillation/pulsation. Mark the area.
● Place the ruler vertically at the sternal angle of Louis; place the
ruler/cardboard horizontally at the mark of the IJV creating a 90-degree
angle.
● Look at the vertical distance.
● Add 5 cm to value measured to estimate the total above the right atrium.
● Report the findings measured in cmH2O.

Note: Venous pressure measured at > 3 cm, or possibly 4 cm, above the sternal
angle, or more than 8 cm or 9 cm in total distance above the right atrium, is
considered above normal.
Jugular Venous Pulsations
Oscillations in the internal jugular vein and in the external
jugular vein reflect changes in pressures in the right atrium
upon contraction and relaxation.

Careful inspection reveals that these undulations are composed

of two quick peaks and two troughs.

1. a wave: reflects the slight rise in atrial pressure that

accompanies atrial contraction; occurs just before S1
and before the carotid pulse
2. x descent: atrial relaxation starts; descent continues as
the right ventricle contracts during systole and as blood
continues to flow into the right atrium from the venae
cavae
3. v wave: the tricuspid valve is closed, the chamber begins
to fill, and right atrial pressure begins to rise again
4. y descent: the tricuspid valve opens and blood in the
right atrium flows passively into the right ventricle; right
atrial pressure falls again
 05
Physical Examination
Palpation and Percussion
Palpation of the Apex Beat
● With the patient lying supine, expose the anterior
chest.
● Inspect the precordium. If you see something
pulsating, that is a dynamic precordium (abnormal).
Not seeing anything signifies an adynamic
precordium (normal).
● Use the palmar aspect (specifically, the ball) of the
hand to look for the most lateral impulse. This is the
point of maximal impulse.
● Use a finger to determine the amplitude of the
impulse.
● Identify and characterize the apex beat by frequency,
size, duration.
○ e.g. The point of maximal impulse is brisk and
tapping, 7 cm lateral to the midsternal line in the
5th intercostal. The diameter is around 2.5 cm. It
lasts through the first 2/3 of systole.
Palpation for Heaves, Lifts, Thrills, and Heart Sounds
● Palpate for heaves and lifts using your palm and/or your finger pads held flat or obliquely
against the chest.
○ Lifts and heaves are sustained impulses usually produced by an enlarged chambers and
occasionally by ventricular aneurysms.
● Palpate for thrills. Press the ball of your hand (the padded area of your palm near the wrist)
firmly on the chest to check for a buzzing or vibratory sensation from underlying vascular
turbulence from heart murmurs.
○ If present, auscultate this area for murmurs. Thrills are more easily palpated in the
patient position that accentuates the murmur, such as the leaning forward to enhance
detection of aortic insufficiency.
● Palpate for S1 and S2. Using firm pressure, place your right hand on the chest wall. With your left
index and middle fingers, palpate the carotid artery in the lower third of the neck.
○ Identify S1 just before the carotid upstroke and S2 just after the upstroke.
● Palpate for S3 and S4. Apply lighter pressure at the cardiac apex to determine the presence of
any extra movements.
● Additionally, assess the right ventricle by palpating the right ventricular area at the lower left
sternal border and in the subxiphoid area, the pulmonary artery in the left 2nd interspace,
and the aortic area in the right 2nd interspace.
 06
Physical Examination
Auscultation
Know the location of the auscultatory sites
Auscultation
● Ask the patient to be in a supine position.
● Use the diaphragm of the stethoscope to listen
throughout the precordium.
● Start your auscultation at the:
○ Aortic Region (2nd ICS, right sternal
border)
○ then, auscultate the Pulmonic Region (2nd
ICS, left sternal border)
○ then, the Tricuspid Region (around 4th to
5th intercostal spaces at the left sternal
border)
○ and finally, the Mitral Region (near the
apex of the heard between the 5th and 6th
intercostal spaces in the left
mid-clavicular line)
When to use the diaphragm or bell?
Diaphragm
The diaphragm is better
used for high-pitched
sounds of S1 and S2, the
murmurs of aortic and
mitral regurgitation, and
pericardial friction rub.
Bell
The bell is more sensitive
to low-pitched sounds
such as that of S3 and S4
and the murmur of mitral
stenosis.
 07
Physical Examination
Special Techniques
Special Maneuvers
● Used to aid in the identification of systolic murmurs and heart failure

Standing and Valsalva Maneuver Isometric Handgrip Transient Arterial

Squatting Occlusion

Mitral valve prolapse Hypertrophic Systolic murmurs: Mitral regurgitation,

cardiomyopathy mitral regurgitation, aortic regurgitation,
Hypertrophic aortic regurgitation, and ventricular
cardiomyopathy vs. Heart failure ventricular septal septal defect
aortic stenosis defect
Pulmonary
hypertension Diastolic murmurs:
pulmonic stenosis
and mitral stenosis.
 08
Sample Case
Case:
ID: 60-year old male
CC: Progressive shortness of breath of 5 days duration
HPI: 4 months PTC, patient developed persistent episodes of shortness of breath, especially upon
exertion. 5 days PTC, patient reports awakening at night due to shortness of breath with associated
dry cough, alleviated by sitting on the edge of the bed for 30 minutes.

(+) fatigue, weight loss

(-) chest pain, leg pain or fainting spells

PMHx: Past history of myocardial infarction, hypertension, T2DM, and stasis dermatitis of the left
leg; history of aorto-coronary bypass 1 year prior
Family Hx: Coronary artery disease (father), T2DM (mother)
Social Hx: Smoker of 25 years, smokes 25 cigarettes per day; sleeps with two or three pillows at
night

Based on history alone:
Congestive Heart Failure
Primary Impression
Congestive Heart Failure usually presents with
shortness of breath and episodes of orthopnea,
strengthened by the history of cardiovascular
pathologies, chronic smoking, and known diagnoses of
both hypertension and T2DM.
Important physical examination targets:
1. Inspection of neck veins
2. Jugular venous pressure: Increased JVP may
suggest right-sided heart failure
3. Additional auscultation of the lungs: inspiratory
crackles may be heard bilaterally in the lower
lung fields
 Thank you!
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