Physical Examination of

The Cardiovascular
System
Cardiovascular Department
Medical Faculty Hasanuddin University
Wahidin Sudirohusodo General Hospital
Makassar
ANATOMY
Anterior Surface of the Heart
 ANATOMY
The Sectional
Anatomy of
the Heart
CARDIAC
CYCLE
PHYSICAL EXAMINATION
The jugular venous pressure
The arterial pulse
The PMI and any heaves, lifts, or bruits
The S1 and S2
Extra sounds both in systole and
diastole
Cardiac murmurs
JUGULAR VENOUS PRESSURE

STEPS FOR ASSESSING JVP :

Raise the head slightly on a pillow
Raise the head of the bed to 30 o

Use tangential lighting to identify EJV then

IJV
Raise or lower the head of the bed to see
oscillation point
Identify the highest point of pulsation
JUGULAR VENOUS PRESSURE
JUGULAR VENOUS PRESSURE
JUGULAR VENOUS PRESSURE

Normal pressure (30o) 3-4 cm above

the sternal angle
Hypovolemic patients 0o
Hypervolemic patients 60o 90o
45o 4.5 cm above sternal angle
JUGULAR VENOUS
PULSATION
Normal Jugular Venous Pulsation
JUGULAR VENOUS
PULSATION

Abnormal
A-Wave

Large A-wave &

Slow Y-descent
JUGULAR VENOUS
PULSATION

Ventricularized
JVP

Atrial Fibrillation
ARTERIAL PULSE
Radial artery, brachial artery, dorsalis
pedis artery, femoral artery, carotid
artery
Assess : volume, contour, frequency,
and regularity
ARTERIAL PULSE
Normal pulse

Anacrotic pulse (pulsus parvus et

tardus) AS
ARTERIAL PULSE
Pulsus bisferiens AR, AR+AS, IHSS

Pulsus alternans congestive heart

failure
ARTERIAL PULSE
Pulsus paradoxus cardiac
tamponade, constrictive pericarditis,
COPD, hypovolemic shock
Waterhammer pulse AR
ARTERIAL PULSE
EXAMINATION OF THE
HEART
INSPECTION AND PALPATION
EXAMINATION OF THE
HEART
INSPECTION AND PALPATION
EXAMINATION OF THE
HEART
INSPECTION AND PALPATION
EXAMINATION OF THE
HEART
PERCUSSION
Estimation of cardiac size
Cardiac dullness
 HEART SOUNDS

AUSCULTATION
S1 mitral and tricuspid valve
S2 aortic and pulmonal valve

S3 the rush of blood during early diastole

S4 atrial contraction
 HEART SOUNDS

AUSCULTATION
 HEART SOUNDS

AUSCULTATION
HEART SOUNDS
Variations of the S1

Tachycardia, mitral stenosis

1st degree AV Block, MR,

CHF, CHD

Complete heart block, AF

RBBB, PVC
HEART SOUNDS
Variations of the S1
Splitting of S1
 HEART SOUNDS
Variations of the S2
Splitting of S2
 HEART SOUNDS

Variations of the S2
Increased A2 systemic hypertension,
dilated aortic root
Increased P2 pulmonary hypertension,
dilated pulmonary artery, ASD
Decreased A2 AS

Decreased P2 increased AP diameter of

the chest, PS
 HEART SOUNDS

Extra Heart Sounds in Systole

Aortic ejection sound : dilated aorta,
aortic valve disease (congenital stenosis)
Pulmonic ejection sound : dilated pulm.
artery, PH, PS

Mitral Valve Prolapse (MVP)

 HEART SOUNDS

Extra Heart Sounds in Diastole

Mitral Stenosis (MS)

Physiologic : children, pregnancy

Pathologic : decreased myocardial
contractility, myocardial failure, MR,
TR

Left-sided S 4 : HHD, CAD, AS,

cardiomyopathy
Right-sided S 4 : PH, PS
HEART SOUNDS (MURMURS)
Midsystolic Murmurs
No evidence of CV disease. Found in : children,
young adults, or even elders

Temporary increase in blood flow : anemia, fever,

pregnancy, hyperthyroidism

Location : 2nd 3rd left ICS. Radiation : toward the left shoulder
& neck. Intensity : soft loud (thrill). Pitch : medium. Quality :
often harsh
HEART SOUNDS (MURMURS)

Location : 2nd right ICS. Radiation : often to the neck & LSB,
even apex. Intensity : soft loud (thrill). Pitch : medium, maybe
higher. Quality : often harsh. Aids : sitting & leaning forward

Location : 3rd 4th left ICS. Radiation : down to the LSB to the
apex or base, not to the neck. Intensity : variable. Pitch :
medium. Quality : harsh. Aids : squatting, straining down
 HEART SOUNDS (MURMURS)
Pansystolic Murmurs
Location : apex. Radiation : to left axilla, less often to the LSB.
Intensity : soft loud (apical thrill). Pitch : medium high.
Quality : blowing. Aids : do not become louder in inspiration

Location : lower LSB. Radiation : to the right of the sternum,

xiphoid area, left MCL, not into the axilla. Intensity : variable.
Pitch : medium. Quality : blowing. Aids : inspiration

Location : 3rd,4th, 5th left ICS. Radiation : often wide. Intensity :

often very loud with thrill. Pitch : high. Quality : often harsh.
HEART SOUNDS (MURMURS)
Diastolic Murmurs
Location : 2nd 4th left ICS. Radiation : if loud, to the
apex, perhaps to the RSB. Intensity : grade 1 3.
Pitch : high. Quality : blowing (maybe mistaken for
breath sounds). Aids : heard best with sitting, leaning
forward, with breath held in exhalation.

Location : limited to the apex. Radiation : little - none.

Intensity : grade 1 4. Pitch : low. Aids :placing the
bell exactly on the apical impulse, left lateral position,
mild exercise, exhalation
 HEART SOUNDS (MURMURS)

Heart Sounds With Both Systolic and

Diastolic Components
Timing : (1) atrial systole, (2) vent. systole,
(3) vent. diastole.
Location : variable, 3rd ICS to the left of the
sternum.
Radiation : little.
Intensity : variable.
Pitch : high.
Quality : scratchy, scraping.
Aids : heard best with leaning forward,
exhales, and holds breath.
 HEART SOUNDS (MURMURS)

Heart Sounds With Both Systolic and

Diastolic Components
Timing : continuous murmur in both systole
and diastole, often with a silent
interval late in diastole
Location : 2nd left ICS.
Radiation : toward the left clavicle.
Intensity : usually loud with thrill.
Pitch : medium.
Quality : harsh, machinery-like.
 HEART SOUNDS (MURMURS)

Heart Sounds With Both Systolic and

Diastolic Components
Timing : continuous murmur without a silent
interval.
Location : above the medial third of the
clavicles, especially on the right.
Radiation : 1st and 2nd ICS.
Intensity : soft moderate.
Pitch : low.
Quality : humming, roaring.
REFERENCES
Bickley, Lynn S. Bates Guide to Physical
Examination and History Taking, 8th edition.
Philadelphia : Lippincott Williams & Wilkins.
2003.

Braunwald, Eugene., Goldman, Lee. Primary

Cardiology, 2nd edition. Philadelphia :
Saunders. 2003.

Martini, F. H. Fundamentals of Anatomy and

Physiology, 5th edition. New Jersey: Pretince
Hall. 2001.
 Akhtar Fajar Muzakkir, MD
Cardiac Centre, Wahidin Sudirohusodo Hospital
0811462710/04115282327
enzobearzot@yahoo.com