COMPLETE CARDIAC PHYSICAL EXAMINATION

- The Cardiac PE involves all parts of the physical examination

- 1. General : Check for signs of cardiorespiratory distress which will dictate the pace of the
the examination. Check for level of sensorium as a possible sign of low perfusion
- 2. Vital signs will provide the initial clues to the presence of a cardiovascular disorder. Check
HR and Respiratory rate full minute. Check for BMI and other anthropometry measures are:
Waist circumference( measured at the iliac crest) and waist-to-hip ratio (using the widest
circumference around the buttocks) can predict long-term cardiovascular risk.
- 2. SKIN: check for central cyanosis under the tongue and peripheral cyanosis signs on the
fingers toes, nose and ears. Check for differential cyanosis which may affect the lower but
not the upper extremities in PDA and Pulmonary artery hypertension. Check for rashes,
telangiectasias, petechias and ecchymoses which can be part of cardiac syndromes
- 3. HEAD AND NECK: assess the state of dentition as a potential source of infection that can
cause infective endocarditis. Check for fascies that accompany some cardiac disease. Check
for abnormalities like high arched palate ( Marfan syndrome), large protruding tongue (
amyloidosis), bifid uvula ( Loeys Dietz s), orange tonsils ( Tangier’s dse) and ptosis. Check the
fundus in the evaluation of patients with hypertension, atherosclerosis, diabetes,
endocarditis, neurologic signs or symptoms, or known carotid or aortic arch disease.
- 4. CHEST AND LUNGS: check for retractions as sign of severity of respiratory compromise.
Assess the percussion and auscultatory findings that can delineate respiratory from cardiac
diseases
- 5. CARDIAC PE
BP

JVP -Measure jugular venous pressure (JVP)—the vertical distance between

this highest point and the sternal angle, normally less than 3–4 cm (
1.36 cmH20= 1.0 mmHG)
Hepato-j - firm and con sistent pressure over the upper abdomen, preferably the
ugular right upper quadrant, for at least 10 seconds. A sustained rise of more
reflex than 3 cm in the venous pressure for at least 15 seconds after
resumption of spontaneous respiration is a positive response. A
Positive hepatojugular reflex is a sign of venous hypertension

Inspecti -check for chest deformities and inspect for visible precordial impulses
on
Palpatio -Palpate for Heaves – palpable precordial impulse, a pulsation that
n feels rolling under your fingers
-Lifts – forceful pulsation whch seems to lift your fingers upward
-Thrills – palpable vibration
-Palpate for Apical Impulse:
Normally located in 5th interspace 7 cm to 9 cm lateral to the
midsternal line, typically at or just medial to the left midclavicular line,
1- 2.5 cm diameter

Ausculta - Use the diaphragm in the areas for relatively high-pitched sounds like
tion S1, S2
-Use bell for low pitched sounds at the lower left sternal border and
apex
-Auscultatory points : Right 2 ICS, Left 2ICS PSL, Left 4ICS PSL, and Left
5ICS MCL. Listen at each area for the quality of S1 and S2, check for
extra sounds in systole and diastole. Note for Murmurs
 - Characterize murmurs as to:
a. timing ( systolic vs diastolic)
b. shape of sound of murmurs ( plateau, cresendo or descrescendo)
c. location of maximal intensity
d. radiation ( to the base , along the parasternal border or to the apex)
e. Pitch ( high, medium or low pitched)
f. quality ( bowing, harsh, muscial or rumblind)
g. Intensity on a 6 point scale

Pulses -Pulse grading:

- assess Rate – number of beats per minute
- assess Rhythm – regularity of beats
- assess Symmetry – pulses on both sides of the body should be
similar
- assess Amplitude – strength of the beat
- Scale : 4= bounding, 3= increased, 2=normal, 1=weak,
0=absent non-palpable

- 6. ABDOMINAL PE: Check for signs of hepatic congestion as a manifestation of right sided
heart failure. Liver span is normally 6-12 cm along the mid clavicular line.
 - 7. EXTREMITIES : Inspect for clubbing, arachnodactyly and nail changes. Check for janeway
lesions ( non0tender, slightly raised areas of hemorrhage on palms and soles), osler nodes (
tender, raised nodules on pads of fingers and toes) and splinter hemorrhages ( linear
petechiaes in the mid nail bed) as signs of infective endocarditis. Check for edema and
grade accordingly.

ANATOMY OF THE HEART

EMBRYOLOGY OF THE CARDIAC SYSTEM

( source: harrisons)
The heart starts to form in the third week of gestation and is nearly fully formed by 8 weeks’ gestation.
Mesodermal precardiac cells migrate to form the cardiac crescents (primary heart fields) in anterior lateral
plate mesoderm, which are then brought together to form a primary linear heart tube by ventral closure of the
embryo. Cells of the second heart field continue to proliferate outside the heart and are added to the heart
tube over
the course of embryogenesis, contributing to the atria, the RV, andoutflow tract. Additionally, cardiac neural
crest cells migrate into the developing heart in the 5th–6th weeks and are essential for septation of the
outflow, formation of the semilunar valves, and patterning of the aortic arches. Once formed, the heart tube
grows and elongates by addition of cells from the second heart field. The ends of the heart tube are relatively
fixed by the pericardial sac so that as it elongates it must loop (bend), and in the vast majority of hearts, the
loop falls to the right (D-loop). Further elongation pushes the mid-portion of the tube (future ventricles)
inferior or caudal to the inflow, resulting in the normal relationship between the atria and ventricles. Further
growth
pushes the outflow medially and is associated with outflow rotation, both processes essential for normal
alignment of the outflow. Finally, the proximal part of the outflow is incorporated in the RV, shortening the
outflow in association with further rotation. While this remodeling is occurring, the outflow is undergoing
septation under the influence of cardiac neural crest cells. Septation proceeds from distal to proximal,
culminating in formation and muscularization of the infundibular, or muscular, outflow septum, which inserts
onto the superior endocardial cushion at the rightward rim of the outflow foramen, walling the aorta
into the LV via the outflow foramen and the PA directly into the RV.

VENTRICULAR SEPTAL DEFECT AND ITS TYPES

Ventricular Septal Defects VSDs are the most common congenital anomaly recognized at birth; however, they
account for only ~10% of CHD in the adult, due to the high rate of spontaneous closure of small VSDs during the
early years of life. Large VSDs usually cause symptoms of heart failure and poor somatic growth and are most often
surgically closed before adulthood. Several classification systems for VSDs exist. Figure 269-5B illustrates various
locations of VSDs; the most common location is in the membranous septum (also referred to as perimembranous or
outlet defects). Muscular defects that persistinto adult life are often pressure and flow restricted, resulting in no
significant hemodynamic consequence. AV canal defects, also referred to as inlet defects, are located in the crux of
the heart and are associated with abnormalities of the AV valve leaflets. Subpulmonary defects, also known as conal
septal defects, are commonly associated with prolapse of the right coronary cusp and aortic insufficiency. The
outcome for adults with small VSDs without evidence of ventricular dilation orpulmonary hypertension is generally
excellent.

GROSS CHANGES IN VENTRICULAR SEPTAL DEFECT

MURMUR, AND HOW TO ASSESS A GIVEN MURMUR
ASSESSMENT OF THE PATIENT WITH A HEART MURMUR
The cause of a heart murmur can often be readily elucidated from a systematic evaluation of its major attributes:
timing, duration, intensity, quality, frequency, configuration, location, andradiation when considered in the light of
the history, general physicalexamination, and other features of the cardiac examination, asdescribed
The majority of heart murmurs are midsystolic and soft (grades I–II/VI). When such a murmur occurs in an
asymptomatic child or youngadult without other evidence of heart disease on clinical examination,
it is usually benign and echocardiography generally is not required. Bycontrast, two-dimensional and Doppler
echocardiography (Chap. 241)are indicated in patients with loud systolic murmurs (grades ≥III/
VI), especially those that are holosystolic or late systolic, and in mostpatients with diastolic or continuous murmurs.