How

How to
to Examine
Examine the
the Heart
Heart
and
and Blood
Blood Vessels
Vessels
Joel Niznick MD FRCPC

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 Look
Look at
at the
the patient
patient

• Sick/well
• Comfortable/in distress
• Cyanosed/plethoric
• Wet/dry
• Young/old
• Male/Female
• Establish probabilities of disease
– History will have told you what to suspect

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 Common
Common Clinical
Clinical
Scenarios
Scenarios

• Younger people • Older people

– Functional murmur – Aortic sclerosis vs
vs MVP vs aortic stenosis
bicuspid AV

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 Probabilities
Probabilities
• Males more • Females more
commonly have aortic commonly have mitral
valve disease valve disease
– Young – BAV • MVP > rheumatic
– Elderly - Degenerative heart disease

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 Inspect
Inspect

• Facies/body habitus
– Cyanosis
– Xanthelasma
– Arcus senilis
– Conjunctival hemorrhages
• Syndromes
– Marfan’s
– Down’s
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 Hands
Hands

• Clubbing
• Capillary return
• Digital ischaemia
• Splinter hemorrhages
• Osler’s nodes
• Janeway lesions

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 Blood
Blood pressure
pressure

• At rest 5” RECOMMENDED BLOOD PRESSURE

MEASUREMENT TECHNIQUE

• Both arms
2.
2.
••The
Thecuffcuffmust
mustbebelevel
levelwith
withheart.
heart.
••IfIfarm
armcircumference
circumfe renceeexceeds
xceeds 33
33cm,cm,
aalarge
largecuff
cuff must
mu stbbe
e used.
used.
••Place
Pla cestethoscope
stethoscopediaphr
diaphragm
agmover
over
brachial
brachia lartery.
artery.

1.
1. 3.
3.
••The
Thepatient
patientshould
should St ethoscope ••The
Thecol umn ofof

• Legs if young
be column
berelaxed
relaxedand
andthethe mercury
arm mercurymust mustbe be
armmu st bbe
must e
vertical
supported. vertical. .
supported. Mercury ••Infla
Inflate to occludethe
te to occlude the
••Ensure
Ensurenonotight
tight machine pulse.
pulse. Deflate
Deflateat at22to
to
clothing
clothingco nstricts
constricts 33mm/s.
mm/s.Measure
Measure
the
thearm.
arm. systolic
systolic(first
(firstsound)
sound)
and
anddiadiastolic
stolic
(disapp earance) toto
(disappearance)

hypertensive
nea
nea rest 22mm
rest mmHg.Hg.

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 Look
Look at
at the
the Fundi
Fundi

OSU Interactive Physical Exam Guide

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 Look
Look at
at the
the Fundi
Fundi

• Disc
• Vessel
• Hemorrhages
• Exudates

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 Pulses
Pulses

• Rate
• Rhythm
• Volume
– Quincke’s
– Water hammer
– Brachio-radial delay

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 Carotid
Carotid

• Upstroke-normal/brisk/delayed/anacrotic
• Volume-normal/increased/decreased
• Auscultate:
– Bruit
– Murmur
– S2 audible ? Over carotid?

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 Carotid
Carotid Tutorial
Tutorial

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 JVP
JVP

• Height
• Waveform
• Specific patterns
• Response to maneuvers
– Inspiration
– HJR

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 JVP
JVP Inspection
Inspection

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 JVP
JVP Summary
Summary

• Confirm it’s the JVP you are seeing

– Compressibility
– Waveform
– Manoeuvers
• Identify the height – start at 30o
• Identify the waveform

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 If unable to see JVP-lie patient flat
If still unable to see JVP-sit patient…...bridging
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uprightthe care gap
 Use
Use the
the hand
hand made
made ruler
ruler

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 Normal
Normal JVP
JVP Waveform
Waveform

a c v

x
y
x′

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 JVP
JVP Inspection
Inspection

• Look for descents not

waves
• Descents are easier to
see due to greater
amplitude and
frequency
• Time deepest descent
with systole. This is
the X’ descent
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 Specific
Specific JVP
JVP patterns
patterns
Condition Pattern
Normal waveform X' deeper than Y
Post CABG X' shallower, now = Y
Atrial fibrillation CV wave
Tricuspid regurgitation CV wave
Complete heart block Irregular cannon A waves
Tamponade ↑ JVP brisk X' > Y
Constriction ↑JVP brisk X' & Y descents
X' less exaggerated than Y
RV infarction
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↑ JVP –low amplitude
…...bridging the care gap
 Precordium
Precordium

• Palpate: Aortic → Pulmonary → LSB →

Apex → Left decubitus
• Thrills
• Palpable HS
• Lifts
• Apex: size/position/motion

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 Auscultation
Auscultation

• Follow same sequence

• Aortic → Pulmonary → LSB → Apex →
Left decubitus → Upright lening forward
• Diaphragm except for apex (use both here)
• Identify HS, then extra sounds, them
murmurs
• Dynamic maneuvers

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 Palpation
Palpation -- Precordium
Precordium

Parasternal:
• Palpable P2-pulmonary HTN
• Thrill
– VSD/HCM
• RV lift
– RVH
– Severe MR

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 Palpation
Palpation -- Apex
Apex
Apex:
• Palpable in 1 of 5 adults age 40
• Best felt with fingertips or finger pads
Normal Location:
• No more than 10 cm from mid-sternal line in the supine position
• Left decubitus position not reliable for apical location
Normal Size:
• No larger than 3 cm (about 2 finger breadths)

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 Apex–Dynamic
Apex–Dynamic Abnormalities
Abnormalities

Sustained Apex:
• correlates with pressure overload or LVF
• ( > 2/3 systole-hangs out to S2)
• AS, LVH or LV systolic dysfunction
Hyperdynamic Apex:
• correlates with volume overload AR/MR
• palpable S4 (atrial kick)
• palpable S1 (MS)
• palpable non-ejection click (MVP)

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 Apex–Dynamic
Apex–Dynamic Abnormalities
Abnormalities

Atrial kick:
• Palpable S4
– Loss of LV compliance
– LVH 2o Hypertension
– Aortic Stenosis
– Hypertrophic Cardiomyopathy

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 Auscultation
Auscultation

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 What
What are
are we
we listening
listening for?
for?

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Normal First & Second Sounds
Normal First & Second Sounds 2
Splitting of the Second Sound
Timing of Cardiac Sounds
Fourth Heart Sound S4 Gallop
Third Heart Sound S3
Systolic Murmurs
Diastolic Murmurs
 Common
Common Murmurs
Murmurs

Systolic Murmurs
• Aortic stenosis
• Mitral insufficiency
• Mitral valve prolapse
• Tricuspid insufficiency
Diastolic Murmurs
• Aortic insufficiency
• Mitral stenosis

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S1 S2…...bridging the care gap S1
 Auscultation
Auscultation
Grading of Murmurs:
Grade 1 - only a staff man can hear
Grade 2 - audible to a resident
Grade 3 - audible to a medical student
Grade 4 - associated with a thrill or palpable heart sound
Grade 5 - audible with the stethoscope partially off the
chest
Grade 6 - audible at the bed-side

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 Characteristics
Characteristics of
of aa
“functional”
“functional” murmur
murmur

• Short and soft SEM

• Normal S1 and S2
• Normal cardiac impulse
• No evidence for any hemodynamic
abnormality

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 Functional
Functional (Innocent)
(Innocent) Murmurs
Murmurs
Common
Common in
in asymptomatic
asymptomatic adults
adults
• Characterized by
– Grade I – II @ LSB
– Systolic ejection pattern - no ↑ with Valsalva/↓ upright

S1 S2
– Normal precordium, apex, S1
– Normal intensity & splitting of second sound (S2)
– No other abnormal sounds or murmurs
– No evidence of LVH
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 Characteristic
Characteristic of
of the
the NOT
NOT
Innocent
Innocent Murmur
Murmur
• Diastolic murmur
• Loud murmur - grade IV or above
• Regurgitant murmur
• Murmurs associated with a click
• Murmurs associated with other signs or
symptoms e.g. cyanosis
• Abnormal 2nd heart sound – fixed split,
paradoxical split or single
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 Integrating
Integrating Pulse
Pulse with
with HS
HS and
and
Murmurs
Murmurs

www.blaufuss.org
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 Examining
Examining the
the Peripheral
Peripheral
Pulses
Pulses

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 Retinal

Carotids

Brachial
Ulnar Renal
Radial
Femoral
Popliteal
Posterior
Tibial
Dorsal
Pedis
 Examination
Examination of
of Pulses
Pulses
• Grading:
– Normal/Increased/Decreased/Absent
– 2+/3+/1+/0
– Allen’s test
• Trophic changes/Ulceration
• Perfusion
– Pallor on elevation
– Rubor on dependency
– Venous refill with dependency (should be less than 30 seconds)
• Bruits

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 Trophic
Trophic Changes
Changes

Shiny, hairless skin,

dystrophic nail
changes and
dependent rubor
associated with
peripheral arterial
occlusive disease of
the patient's right foot

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 Pallor
Pallor on
on elevation
elevation

Rubor on
dependency

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 Digital
Digital Ischaemia
Ischaemia
Gangrene
Gangrene

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 A
A Practical
Practical Guide
Guide to
to Clinical
Clinical
Medicine
Medicine -- UCSD
UCSD
Acute Arterial
Chronic Arterial
Insufficiency:
Insufficiency
Mottled Appearance of
with Ulcers
Skin

http://medicine.ucsd.edu/clinicalmed/extremities.htm
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 Measurement of the Ankle-Brachial
Index (ABI)

Hiatt©W. N Engl JMedical

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2001;344:1608-1621
 Venous
Venous Abnormalities
Abnormalities
Varices
Varices

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 Spider
Spider Veins
Veins

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 Venous
Venous Insufficiency
Insufficiency

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 Stasis
Stasis Dermatitis/Ulceration
Dermatitis/Ulceration

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 Edema
Edema

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 Cellulitis
Cellulitis vs
vs DVT
DVT

Cellulitis Right Deep Venous Thrombosis

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www.cvtoolbox.com
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