MED2 - CARDIO MD2022

PHYSICAL EXAMINATION OF THE blood pressure cuff is released

CARDIOVASCULAE SYSTEM (SYSTOLIC PRESSURE)
o Murmurish phase
DIAGNOSIS OF HEART DIESEASES 5 FINGER APPROACH  Produced by the flow of blood
1. History from the narrowed artery
2. Physical exam underneath the cuff into the wider
3. ECG artery distal to the cuff
4. X-RAY o Third phase
5. Special Laboratory tests  As the narrowed blood vessel
opens up, the “murmur:
BLOOD PRESSURE disappears and the sound becomes
flowing through the artery
o Blood pressure in the arterial system varies during
increases
the cardiac cycle, peaking in systole and falling to its
o Fourth phase
lowest trough in diastole
 The second becomes muffled
o Levels are measured with the blood pressure cuff, or
because the constriction in the
sphygmomanometer
brachial artery diminishes as the
o Pulse pressure
arterial diastolic pressure is
o Difference between systolic and diastolic
approached
pressures
o Fifth phase
o The principal factors influencing arterial pressure
 Disappearance of the korotkoff
are
sounds
o Left ventricular stroke volume
o Distensibility of the aorta and the large Selecting the correct blood pressure cuff
arteries
o Peripheral vascular resistance particularly at o Width of the inflatable bladder of the cuff
the arteriolar level should be about 40% of upper arm
o Volume of blood in the arterial system circumference (about 12-14 cm in the
average adult)
o Length of inflatable bladder should be
about 80% of upper arm
circumference(almost long enough) to
encircle the arm
o If anaroid calibrate periodically before use

ORIGIN OF KOROTKOFF SOUNDS

o First korotkoff sounds

 Produced by the first spurt of
blood that gets through the artery
beneath the cuff and distends the
wall artery, as the constricting

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o If the brachial artery is much below heart level,
blood pressure appears falsely high. The patient’s
own effort to support the arm may raise the blood
pressure
o A loose cuff or a bladder that balloons outside the
cuff leads to falsely high readings
o Correct measurement
o To determine how high to raise the cuff
pressure, first estimate the systolic pressure
by palpation
o As you feel the radial artery with the fingers
of one hand, rapidly inflate the cuff until the
radial pulse disappears
o Read this pressure on the manometer and
add 30 mm Hg
o Avoids the occasional error caused by an
auscultatory gap- a silent interval that may
be present between the systolic and the
diastolic pressures
o Deflate the cuff promptly and completely
and wait 15 to 30 seconds
o Place the bell of stethoscope lightly over
the brachial artery, taking care to make an
air seal with its full rim
o Inflate the cuff rapidly again to the level just
determined it slowly at a rate of about 2 to
3 mm Hg per second
o Note the level at which you hear the sounds
of at least two consecutive beats, this is the
systolic pressure
o Continue to lower the pressure slowly until
the sounds become muffled and then
disappear
o To confirm the disappearance of sounds,
listen as the pressure falls another 10 to 20
mm Hg, then deflate the cuff rapidly to zero
o The disappearance point, which is usually
only a few mm Hg below the muffling point,
enables the best estimate of true diastolic
pressure in adults
o Read both the systolic and the diastolic
levels to the nearest 2 mm Hg
o Wait 2 or more minutes and repeat
.Average your readings. If the first two
readings differ by more than 5 mm Hg take
additional readings
o Avoid slow or repetitive inflations of the
cuff, because the resulting venous
congestion can cause false readings
o Blood pressure should be taken in both
arms at least once
o Difference in pressure of 5 mm Hg and up
to 10 mm Hg
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MED2 - CARDIO MD2022
o Subsequent readings should be made on
the arm with the higher pressure
o In patients taking antihypertensive
medications or patients with a history of
fainting, postural dizziness, or possible
depletion of blood volume, take the blood
pressure in three positions---supine, sitting
and standing (unless contraindicated)
o As the patient rises from the horizontal to a
standing position, systolic pressure drops
slightly or remains unchanged while
diastolic pressure rises slightly
o Another measurement after 1 to 5 mins of
standing may identify orthostatic
hypotension missed by earlier readings, this
repetition is especially useful in the elderly
Special Problems
 Anxiety is a frequent cause of high blood pressure,
especially during an initial visit
 Blood pressure is only elevated in the office (“white
coat hypertension”) and may need to have their
blood pressure measured several times at home or
in a community setting
 For the obese arm, it is important to use a wide cuff
(15 cm). if the arm circumference exceeds 41 cm,
use a thigh cuff(18 cm wide)
 For the very thin arm, a pediatric cuff may be
indicated
 To rule out coarctation of the aorta, two
observations should be made at least once with
every hypertensive patient:
o Compare the volume and timing of the
radial and femoral pulses
o Compare blood pressures in the arm and leg
 To determine blood pressure in the leg, use a wide,
long thigh cuff that has a bladder size of 18 x 42 cm,
and apply it to the mid-thigh
 Center the bladder over the posterior surface, wrap
it securely, and listen over the popliteal artery. If
possible, the patient should be prone
 Ask the supine patient to flex one leg slightly, with
the heel resting on the bed. When cuffs of the
proper size are used for both the leg and the arm,
blood pressures should be equal in the two areas
 A systolic pressure lower in the legs than in the arm
is abnormal
 Weak or inaudible korotkoff sounds
o Consider technical problems such as
erroneous placement of your stethoscope,
failure to make full skin contact
with the bell. And venous

engorgement of the patient’s arm from
repeated inflations of the cuff
 Consider also the possibility of shock
 When you cannot hear Korotkoff sounds at all, you
may be able to estimate the systolic pressure by
palpation
 Alternatively methods such as Doppler techniques or
direct arterial pressure tracings may be necessary
 Irregular rhythms produce variations in pressure and
therefore unreliable measurements
 Ignore the effects of an occasional premature
contraction
 With frequent premature contractions or atrial
fibrillation, determine the average several
observations and note that your measurements are
approximate
HEART RATE AND RHYTHM
o ARTERIAL PULSE
o With each contraction, the left ventricle
ejects a volume of blood into the oarta and
into the arterial tree; ensuing pressure
wave moves rapidly through the arterial
system
o By examining arterial pulses, you can count
the rate of the heart and determine its
rhythm
o Assess the amplitude and contour of the
pulse wave, and detect obstructions to
blood flow
o The radial pulse is commonly used to assess
the heart rate
o With the pads of your index and middle
fingers , compress the radial artery until a
maximal pulsation is detected
o If the rhythm is regular and the rate seems
normal, count the rate for 15 seconds and
multiply by 4
o If the rate is unusually fast or slow, count it
for 60 seconds
o When the rhythm is irregular , the rate
should be evaluated by cardiac auscultation
o Irregular rhythm include atrial fibrillation
and atrial or ventricular premature
contractions
 To begin your assessment of rhythm , feel the radial
pulse. If there are any irregularities , check the
rhythm again by listening with your stethoscope at
the cardiac apex
 Is the rhythm regular or irregular? If irregular, try to
identify a pattern:
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MED2 - CARDIO MD2022
o Do early beats appear in a basically regular
rhythm?
o Does the irregularity vary consistently with
respiration?
o Is the rhythm totally irregular?
JUGULAR VENOUS PRESSURE
 JVP is the single most important bedside
measurement from which to estimate the volume
status
 Internal jugular vein is preferred because it is directly
in line with the SVC and right atrium
 Venous pressure falls when left ventricular output or
blood volume is significantly reduced
 It rises when the right heart fails or when increased
pressure in the pericardial sac impedes the return of
blood to the right atrium
 These venous pressure changes are reflected in the
height of the venous column of blood in the internal
jugular veins, termed the JUGULAR VENOUS
PRESSURE
JUGULAR VENOUS PULSATIONS
 The oscillations that you see in the internal jugular
veins(and often in the external as well) reflect
changing pressure within the right atrium
 The right internal jugular vein empties more directly
into the right atrium and reflects these pressure
changes best
 A wave
o Reflects the slight rise in atrial pressure
that accompanies atrial contraction. It
occurs just before the first heart sound
and before the carotid pulse
 X descent
o Starts with atrial relaxation. It
continues as the right ventricle,
contracting during systole, pulls the
floor of the atrium downward
 During ventricular systole, blood continues to
flow into the right atrium from the venae cavae,
the tricuspid valve is closed, the chamber begins

to fill, and right atrial pressure begins to rise
again, creating the second elevation, the v wave
 When the tricuspid valve opens early in diastole,
blood in the right atrium flows passively into the
right ventricle and right atrial pressure falls
again, creating the second trough or y descent
 Venous pressure measured at greater than 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 elevated above
normal
 Increased pressure suggest right-sided heart
failure or less commonly , constrictive
pericarditis, tricuspid stenosis or superior vena
cava obstruction
 In patients with obstructive lung disease, venous
pressure may appear elevated on expiration
only; the veins collapse on inspiration
 JVP-
o Measurement of the highest oscillation
point (meniscus) of the jugular venous
pulsations
o Reflects pressure in the right atrium
(central venous pressure)
o Provides information about volume
status and cardiac function
o The vertical distance in cm above the
sternal angle where your card crosses
the ruler
 Internal jugular pulsations
o Soft, undulating
o 3 elevations, 2 trough per beat
o Rarely palpable
 Carotid pulse
o Almost always palpable
o Vigorous thrust with single outward
component
o Pulse not affected by pressure
o Unchanged by position
o Pulse not affected by inspiration
 The height of the internal jugular pulsations
o Eliminated by light pressure on vein
just above clavicle
o Level changes with position
o In euvolemic patient, level drops as
patient becomes more upright
o Level usually falls with inspiration
 Venous pressure elevated above normal when
o 3-4 cm above the sternal angle with the
head of the bed elevated to 30 deg or
o 7-8 cm in total distance above the right
atrium
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 Euvolemic
o Hypervolemic (eg CHF or renal failure)
o Hypovolemic patients (eg GI bleed,
marked dehydration)
 Observe the amplitude and timing of the jugular
venous pulsations
 Prominent a waves indicate increased resistance
to right atrial contraction, as in tricuspid stenosis
 The a waves disappear in atrial fibrillation
 Larger v waves characterize tricuspid
regurgitation
CAROTID PULSE
 Provide valuable information about cardiac function
and is useful for detecting stenosis or insufficiency of
the aortic valve
 Assess amplitude and contour
 Amplitude of the pulse correlates well with the pulse
pressure
 Contour of the pulse wave, namely the speed of the
upstroke , the duration of its summit, and the speed
of the down stroke
 Normal upstroke is brisk. It is smooth, rapid and
follows S1 almost immediately. The summit is
smooth, rounded and roughly midsystolic. The
downstroke is less abrupt than the upstroke
 Any variations in amplitude, either from beat to beat
or with respiration
 Small, thread, or weak pulse in cardiogenic shock
 Bounding pulse in aortic insufficiency (eg Chronic
severe AR): carotid upstroke has a sharp rise and
rapid fall-off (Corrigan’s or Water-hammer pulse)
 Bifid pulse
o 2 systolic peaks eg (Advanced AR, HOCM)
 Delayed carotid upstroke in aortic stenosis (pulsus
parvus et tardus)
 Pulses alterans
o (beat-to-beat variation of pulse
amplitude;seen in pxs with severe LV
systolic dysfunction )
 Pulsus paradoxus
o Fall in systolic pressure > 10 mmHg with
inspiration seen in pxs with tamponade;
paradoxical pulse(respiratory variation)
THRILLS AND BRUITS
 During palpation of the carotid artery, you may
detect humming vibrations or thrills
 You should listen over both carotid arteries with the
 MED2 - CARDIO MD2022
diaphragm of your stethoscope for a bruit, a  Estimate the amplitude of the impulse. It is usually
murmur-like sound of vascular rather than cardiac small and feels brisk and tapping
origin

INSPECTION AND PALPATION

 Careful inspection of the anterior chest may reveal

the location of the apical impulse or point of
maximal impulse (PMI)
 Assess the right ventricle by palpating the right  Duration is the most useful characteristics of the
ventricular area at the lower left sternal border and apical impulse for identifying hypertrophy of the lest
in the subxiphoid area, the pulmonary artery in the ventricle
nd nd
left 2 interspace , an dthe aortic in the right 2
interspace


rd th
Place the tips of your curved fingers in the 3 , 4
th
and 5 interspaces and try to feel systolic impulse of
the right ventricle
 A marked increase in amplitude with little or no
change in duration occurs in chronic volume
overload of the right ventricle , as from an atrial
 Ventricular impulses may heave or lift your fingers
septal defect
 Check for thrills by pressing the ball of your hand
 Am impulse with increased amplitude and duration
firmly on the chest
occurs with pressure overload of the right ventricle,
 If subsequent auscultation reveals a loud murmur ,
as in pulmonic hypertension
go back and check for thrills over that area again

ND
LEFT 2 INTERDPACE –PULMONIC AREA: overlies
APICAL IMPULSE OR POINT OF MAXIMAL the pulmonary artery
IMPULSE o A prominent pulsation here often
accompanies dilatation or increased flow in
the pulmonary artery. A palpable S2
suggests increased pressure in the
pulmonary artery (pulmonary hypertension)

ND
RIGHT 2 INTERSPACE-AORTIC AREA: this
interspace overlies the aortic outflow tract
o A palpable S2 suggests systemic
hypertension. A pulsation here suggests a
dilated or aneurysmal aorta

ABOUT AUSCULATION

 Rene Hyacinth Laennec, 1816, Paris

 Assess the diameter of the apical impulse. In the
 Laennec is shown using her ear to auscultate the
supine patient, it usually measures less than 2.5 cm
heart prior to his invention of a quire of paper held
and occupies only one interspace. It may be larger in
in his left hand, the forerunner of the stethoscope
the left lateral decubitus position
 In the left lateral decubitus position, a diameter
greater than 3 cm indicates left ventricular
enlargement

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CLINICAL VALVULAR AREAS AUSCULTATION: S2

(AUSCULTATION)
 Etiology
o Sudden deceleration of forward flow during
aortic and pulmonary valve closure
o Best heard at the base of the heart
o Normal split widens on inspiration

 Diaphragm
o Better for picking up the relatively high-
pitched sounds of S1 and S2, the murmurs
of aortic and mitral regurgitation, and
pericardial friction rubs. Listen throughout
the precordium with the diaphragm ,
pressing it firmly against the chest
 Bell
o More sensitive to the low pitched sounds of
S3 and S4 and the murmur of mitral
stenosis. Apply the bell lightly, with just
enough pressure to produce an air seal with
its full rim. Use the bell at the apex, then
move medially along the lower sternal
border

HOW TO IDENTIFY S1 FROM S2

 S1 coincides with apex upstroke

 S1 is heard immediately before carotid upstroke
 S1 with shorter interval from S2
 Apex- S1 louder than S2
 Base- S2 louder than S1, S2 splits on inspiration

CARDIAC AUSCULATION –THIRD HEART

SOUND

AUSCULTATION: S1  Believed to be caused by sudden limitation of

 Mitral and tricuspid valve closure
 The intensity of S1 is determined by the distance
over which the anterior leaflet of the mitral valve
must travel to return to its annular plane
longitudinal expansion of the LV wall during brisk
early diastolic filling
 Generated during the rapid filling phase
 Children and young adults may have physiologic S3
 Sometimes persists up to 40 years of age especially
in women
 Abnormal after 40

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AUSCULTATION: S3

PHYSIOLOGICAL
Due to increased velocity of
ventricular expansion
Eg tachycardia, nervousness
PATHOLOGICAL
Due to loss of compliance
or distensibility of the
ventricle
Eg heart failure

CARDIAC AUSCULTATION-FOURTH HEART

SOUND

 May be normal in healthy adults

 Requires active contribution from the atrial
contribution to the ventricular filling, ceases during
atrial fibrillation
 An abnormal S4 occurs when augmented atrial
contraction generates presystolic ventricular
distension so that the receiving chamber can
contract with greater force
 Common in HD and almost universal during angina
and AMI HEART MURMUR

 Series of auditory vibrations that are more

prolonged than a sound and characterized according
to
o Timing
o Intensity
o Frequency
o Configuration
o Quality
o Duration
AUSCULTATION: S4 o Direction of radiation

 Atrial gallop, presystolic gallop , S4 gallop

 Rarely physiological
 Commonly pathological
o Decreased distensibility or compliance of
the LV
 Best heard with the use of bell at the apex with the
patient on left lateral decubitus

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o Audible to a medical student
 GRADE 4
o Associated with a thrill or palpable heart
sound
 GRADE 5
o Audible with the stethoscope partially off
the chest
 GRADE 6
o Audible at the bed-side

 Location of maximal intensity

 Radiation or transmission from the point of maximal
intensity
 Intensity
 Pitch- high , medium or low
 Quality- blowing, harsh, rumbling and musical

GRADING OF MURMURS

 GRADE 1
o Only a staff man can hear
 GRADE 2
o Audible to a resident
 GRADE 3
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MID SYSTOLIC MURMURS

 Occurs in five settings:

o Obstruction to ventricular outflow
o Dilatation of the aortic root or pulmonary
trunk
o Accelerated systolic flow into the aorta and
pulmonary trunk
o Innocent murmurs
o Mitral regurgitation

 Aortic stenosis
o Distinguished from MR
o Increase in intensity after a PVC or long
cycle length of AF
 Rapid ejection into normal aortic or pulmonary
trunk
o Pregnancy
o Fever
o Anemia
o Thyrotoxicosis
 Mitral regurgitation
o Ischemic heart disease associated with
regional wall motion abnormalities
o Impaired integrity of the mitral apparatus

EARLY SYSTOLIC MURMURS LATE SYSTOLIC MURMURS

 TRICUSPID REGURGITATION  Mitral valve prolapse

o Medium frequency because normal right o Diminution of LV volume, softer and longer
ventricular systolic pressure generates murmur
comparatively low-velocity regurgitant flow o Increase in LV volume, louder and shorter
 VENTRICULAR SEPTAL DEFECT murmur
o Soft, pure high-frequency early systolic
murmur at the mid or lower left sternal
edge;small VSD
o Non restrictive VSD when elevation in
pulmonary vascular resistance decreases
late systolic shunting

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HOLOSYSTOLIC MURMUR
 Tricuspid regurgitation
o Holosystolic when there is substantial
elevation of RV pressure
o Carvallo Sign
 Ventricular Septal Defect
o Left ventricular systolic pressure and
resistance exceed the RV systolic pressure
from the onset to the end of systole
 Direction of radiation determines chest wall
distribution
 When the direction of the intrarterial jet is forward
and medial against the atrial septum, murmur
radiates to the left sternal edge, base or the neck
 When the direction is directed posterolaterally,
murmur radiates to the axilla, angle of the left
scapula, and occasionally to the vertebral column
EARLY DIASTOLIC MURMUR
 Blowing, decrescendo
 Aortic regurgitation
o Best heard with diaphragm, the patient
leaning forward during a held, deep
exhalation
o The configuration reflects the volume and
rate of regurgitation flow
 Graham Steel murmur
o Diastolic murmur of secondary pulmonary
regurgitation
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MED2 - CARDIO MD2022
o High pitched early diastolic murmur due to
high velocity regurgitation flow across
pulmonary valve
o Pulmonary hypertension
MID DIASTOLIC MURMUR
 Mitral stenosis
o Reinforced when heart rate and mitral valve
flow are transiently increased by cough or
sit-ups
o In atrial fibrillation, duration is a useful sign
of the degree of obstruction
 Tricuspid stenosis
o Occurs in the presence of atrial fibrillation
o Differs from MS
 Loudness of the murmur increases
with inspiration
 Confined to a relatively localized
area along the left lower sternal
edge
 Across unobstructed AV valves in the presence of
augmented volume and velocity of flow
o Pure mitral regurgitation
o Large left to right shunt through VSD
 Across unobstructed tricuspid valves
o Tricuspid regurgitation
 AUSTIN FLINT MURMUR
o Mid- diastolic murmur , low pitched
rumbling heard at the apex
o Occurs in aortic regurgitation due to
vibration of the AMVL as it is buffered
simultaneously by the blood jets from the
left atrium and the aorta
 Pulmonary valve regurgitation
o Pulmonary pressure is not elevated
o Regurgitation accelerates as RV pressure
dips below the diastolic pressure in the
pulmonary trunk

o Late diastolic equilibrium of pulmonary
arterial and RV pressures eliminate
regurgitant flow
LATE DIASTOLIC MURMUR
 Coincides with phase of ventricular filling that
follows atrial systole
 Occasionally heard in complete heart block when
atrial contraction falls in late diastole
CONTINUOUS MURMURS
MED2 - CARDIO MD2022
 Arterial continuous murmurs
o Constricted arteries
o Mammary soufflé
o Systemic to pulmonary arterial collaterals
 Continuous venous murmurs
o Cervical venous hum
 Most common
PERICARDIAL FRICTION RUB
 Triple phased, mid-systolic and pre-systolic
 Systolic phase is most consistent
 After open heart surgery

DYNAMIC AUSCULTATION

 Some murmurs are affected by maneuvers to change

intensity of murmurs. These are the following
manuebers
o Respiratory variations
o Valsalva maneuver
 Forceful attempt to exhale against
a closed glottis after a normal
breath
 2 part process
 Straining process
 Relaxation period
 Performed for 10 seconds while
examinee listens to the intensity
changes in heart murmurs
 Most murmurs and sounds
diminished in intensity during
valsalva manuever due to
decreased ventricular filling and
 Aortopulmonary connections cardiac output EXCEPT MITRAL
 Arteriovenous connections VALVE PROLAPSE which increases
 Disturbances of flow patterns in arteries in intensity and duration
 Disturbances of flow patterns in veins  HOCM murmur is also increased
 Arteriovenous continuous murmurs during valsalva because of a
o Congenital or acquired decrease in ventricular volume and
o AV fistulas an increase in the pressure
o Coronary artery fistulas gradient
o Anomalous origin of the left coronary artery o Postural changes
o Sinus of valsalva o Exercise
o Pharmacologic agents
o Post premature beat
o Transient arterial occlusion

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