Cardiovascular Examination

Techniques

Nino Kasradze MD
Heart and Heart Chambers – anatomy
• The Right Atrium (RA) – forms the right
border of the heart and is usually not
identifiable on physical examination.
• The right Ventricle (RV) – occupies the
most of the anterior cardiac surface,
narrowing superiorly meets the
pulmonary artery at the level of third left
cartilage.
• The Left Atrium (LA) - lies mostly posterior
and can not be examined directly.
• The Left Ventricle (LV) - lies to the left of
and behind the right ventricle, forming the
left border of the heart. The tip of the left
ventricle produce the Apical Impulse, a
systolic beat usually found in the 5th ICS
 Components of Assessment - Inspection
Inspection –
The medical provider closely observes visually, but also uses hearing
and smell to gather data throughout the assessment - assesses
details of the patient’s appearance, behavior, and movement.
Inspection begins with the initial patient contact and continues
through the entire assessment.
Adequate natural or artificial lighting is essential for distinguishing
the color, texture, and moisture of body surfaces.
The medical provider inspects each area of the body for size, color,
shape, position, movement, and symmetry, any deviations from
normal.
 Components of Assessment - Palpation

Palpation uses the sense of touch. The hands and fingers are
sensitive tools that can assess skin temperature, turgor, texture,
and moisture, as well as vibrations within the body and shape or
structures within the body. Specific parts of the hand are more
effective at assessing different qualities.
 Components of Assessment - Palpation (a)
The dorsum (back) surfaces of the hand and fingers are used for
gross measure of temperature.
The palmar (front) surfaces of the fingers and fingerpads are
used to assess firmness, contour, shape, tenderness, and
consistency.
The fingerpads are best at fine discrimination. Use fingerpads to
locate pulses, lymph nodes, and other small lumps, and to assess
skin texture and edema.
Vibration is palpated best with the ulnar, or outside, surface of
the hand.
For light palpation, apply light pressure with the dominant hand, using
a circular motion to feel the surface structure; press down no more
than 1 cm.
Advanced Health care providers usually perform deep
palpation
 Components of Assessment - Percussion
Percussion is the act of striking one object against another to
produce sound. The fingertips are used to tap the body over body
tissues to produce vibrations and sound waves. The characteristics of
the sounds produced are used to assess the location, shape, size, and
density of tissues. Abnormal sounds suggest alteration of tissues,
such as an emphysematous lung, or the presence of a mass, such as
an abdominal tumor. A quiet environment allows sounds to be heard.
Advanced health care providers usually perform percussion.
 Components of Assessment - Auscultation
Auscultation is the act of listening with a stethoscope to sounds
produced within the body. This technique is used to listen for blood
pressure, and heart, lung, and bowel sounds. Four characteristics of
sound are assessed by auscultation:

(1) pitch (ranging from high to low);

(2) loudness (ranging from soft to loud);
(3) quality (e.g., gurgling or swishing);
(4) duration (short, medium, or long).

When auscultating, use the proper part of the stethoscope

(diaphragm or bell) for specific sounds. Use the bell of the
stethoscope to detect low-pitched sounds .Hold the bell lightly
against the body part being auscultated. Use the diaphragm of the
stethoscope to detect high-pitched sounds .
 Landmarks for Palpable Pulses
Dorsalis pedis pulse:
• Between the tendos of estensor hallucis
longus and extensor digitorum longus.
• On the superior surface of the foot between
the bases of the 1st and 2nd metatarsals.
 Landmarks for Palpable Pulses (2)
Posterior tibialpulse:
-2 to 3 cm posterior to the medial malleolus
Posterior tibial artery
-Palpate at the ankle just posterior and inferior
to the medial malleolus.
 Landmarks for Palpable Pulses (3)
Popliteal Pulse:
-Deep within the popliteal fossa (knee in 15 degree of flextion)
- Popliteal artery is surrounded by strong tendons. It can be
difficult to feel and requires more pressure than you expect.
- With the patient lying flat and knees slightly flexed, press into the
centre of the popliteal fossa with tips of the fingers of the left
hand and use the fingers of the right hand to add extra pressure
to these.
 Landmarks for Palpable Pulses (4)
Femoral Pulse:
-Inferior to the inguinal ligament, midway between pubic symphysis and
anterior superior iliac spine (the lateral corners of the pubic hair triangle)
-Femoral artery
The femoral pulsation can be felt midway between the pubic tubercle and
the anterior superior iliac spine. .
The patient is usually undressed by this point in the examination and
should be lying on a bed or couch with their legs outstretched. Ask them
to lower their clothes a little more, exposing the groins.
 Landmarks for Palpable Pulses (5)
Radial Pulse:
- Anterolateral aspect of wrist. (remember that
forearm is supinated in anatomical position)
- Use your 1st and 2nd fingers to feel just lateral to
the tendon of the flexor carpi radialis, medial to
the radial styloid process at the wrist.
 Landmarks for Palpable Pulses (6)

Ulnar Pulse:
- Anteromedial aspect of the wrist.
 Landmarks for Palpable Pulses (7)
Brachial Pulse:
- Medial to the biceps tendon in the cubital fossa
- Brachial artery
Feel at the medial side of the antecubital fossa, just
medial to the tendinous insertion of the biceps.
 Landmarks for Palpable Pulses (8)

Carotid Pulse:
- Between the trachea and the
sternocleidomastoid muscle at the level of
the thyroid cartilage.
- Carotid artery
Find the larynx, move a couple of
centimetres laterally and press backwards
medial to the sternomastoid muscle.
- This is the best place to assess the pulse
volume and waveform
- Be sure not to compress both carotids at
once for fear of stemming blood flow to the
brain—particularly in the frail and elderly.
- Never palpate both Carotid arteries
 Inspection of Precardium
• Precardium - refers to the part of the chest overlying the heart
• Patient position : Supine, 30-45 degrees angle, chest exposed.

Look for :
✔ Scars (evidence of previous surgery)
✔ Any abnormal shape or movements
✔ Pacemaker or implantable defibrillator*
✔ Any visible pulsations

*Usually implanted over the left pectoral region

 Palpation of Precardium
Explain to the patient what are you doing and gain consent before
touching. Place the flat of your right hand on the chest wall to the left,
then to the right of the sternum.
Can you feel any pulsation ?*
Palpate the Apical Impulse (the apex beat)

*identification of location and characteristics of pulsation helps in clinical diagnosis.

 Apical Impulse: Examination (1)
• Patient position : Supine with head of the bed elevated at 30 degree.
• Inspection: Inspect the precardium for the Apical Impulse. Tangential
lighting* may improve the visibility of impulses.
• Palpation : palpate the Apical Impulse with the pads of your fingers.
Describe the location, amplitude, diameter and duration.
• Usually found in 5th ICS, at or just medial to the midclavicular line
• Normal amplitude is a gentle tap. Diameter is usually <2.5cm
• Duration – normal apical impulse lasts through the first 2/3 of systole
 Auscultation of Precardium

Technique:
A sensible approach would be to listen with the
diaphragm at each area and then repeat using the bell.
You can then ‘go back’ and concentrate on any
abnormalities.
You can then examine other areas looking for the
features of certain murmurs and extra sounds.
The ‘bell’ of the stethoscope is used to detect lower-
pitched sounds.
The diaphragm is used to detect higher-pitched sounds.
 Heart Sounds – S1,S2

The heart sounds are produced when the heart valves close: onset of
systole increases intraventricular pressure, causing closure of Mitral and
Tricuspid valves and opening of Aortic and Pulmonic valves.
The Closure of Mitral and Tricuspid valves is Heard as the first heart
sound – S1.
As diastole begins, the ventricles relax and interventricular
pressure decreases, allowing Aortic and Pulmonary valves to close and
producing the Second Heart Sound – S2.
 Heart Sounds – S3 and S4
A period of rapid ventricular filling follows S2 and may be marked a
Third Heart Sound – S3.
A fourth Heart Sound –S4 not often heard in normal adults, marks
atrial contraction and immediately precedes S1 of the next beat.
 Auscultation - Four Standard Areas

The four areas are:

• Mitral: 5th intercostal space in the mid-axillary line (the apex)

• Tricuspid: 5th intercostal space at the left sternal edge

• Pulmonary: 2nd intercostal space at the left sternal edge

• Aortic: 2nd intercostal space at the right sternal edge.

(Note that these areas do not relate exactly to the anatomical position of the
Valves)
The four standard areas for auscultation
of the precordium and the valves that
are best heard at each area are :
• A = Aortic P = Pulmonary T = Tricuspid M = Mitral (B = Bicuspid)
How to listen:

• Place the diaphram of the stethoscope along

the left sternal border at the left second ICS
and listen for each heart sound.
• Continue listening at the left 3rd, 4th and 5th ICS
and at the side of apical impulse.
• Finally listen the Axillae (where mitral murmurs can radiate)
and over the carotid arteries (where aortic murmurs may
radiate).
• Repeat this sequence for low-pinched sounds by
using the bell of the stethoscope
 Assessing the Apical Pulse by Auscultation (1)

An apical pulse is assessed when:

• Giving medications that alter heart rate and rhythm.
• In addition, if a peripheral pulse is difficult to assess accurately
because it is irregular, feeble, or extremely rapid, assess the apical
rate.
• Apical pulse measurement is also the preferred method of pulse
assessment in children less than 2 years of age
In adults, the apical rate is counted for 1 full minute by listening
with a stethoscope over the apex of the heart.
 Apical Pulse Auscultation (2)
Heart sounds – S1 and S2 which are produced by closure of the
valves of the heart, are characterized as “lub-dub.”
The apical pulse is the result of closure of the mitral and tricuspid
valves (“lub”) and the aortic and pulmonic valves (“dub”).
The combination of the two sounds is counted as one beat.
 The Assessment of an Apical Pulse – Steps (1)
• Check Medical record for the frequency of
pulse assessment
• Perform hand hygiene and put on PPE in
indicated (usually gloves are not used)
• Identify the patient
• Insure the privacy – close the doors and
curtains
• Discuss the procedure with patient
• Use the alcohol swab to clean the diaphragm
of stethoscope
• Use another swab to clean the earpieces if
necessary
 The Assessment of an Apical Pulse – Steps (2)
• Assist the patient to a sitting or
reclining position and expose the
chest area
• Move the patient clothing to expose
only the Apical side
• Hold the Stethoscope diaphragm
against the palm of your hand for a
few seconds
• Palpate the space between the 5th
and 6th ribs – 5th ICS and move to the
left midclavicular line
• Place the stethoscope diaphragm
over the Apex of the Heart
 The Assessment of an Apical Pulse – Steps (3)

• Listen for the heart sounds (“lub-dub”), each “lub-dub” counts

as one beat
• Using a watch with a second hand, count the heartbeats for 1
minute
• Note the rhythm of the bits
• When the measurement is completed cover the patient and
help to a position of comfort
• Clean the stethoscope again with alcohol swabs and perform
hand hygiene
 Assessing the Apical–Radial Pulse Deficit
• Measurement of the apical–radial pulse deficit
may be utilized to assess the effectiveness of
the contractions of the heart, specifically the
left ventricle. Counting of the pulse at the apex
of the heart and at the radial artery
simultaneously is used to assess the apical–
radial pulse deficit.
• A difference between the apical and radial
pulse rates is called the pulse deficit and
indicates that all of the heartbeats are not
reaching the peripheral arteries or are too
weak to be palpated.
• Two medical providers are required to perform
this skill; one listens with a stethoscope over
the apex of the heart for the apical heart rate
and the other counts the pulse rate at the
radial artery. (video)
Tips (1):
• If you are unsure which is the 1st and 2nd
heart sound—or where a murmur is occurring
—you can palpate one carotid pulse whilst
listening to the heart—enabling you to ‘feel’
systole. The carotid pulsation occurs with S1.
• Mitral valve closure is the main component of
S1 and the volume depends on the force with
which it closes.
Tips (2):
• S3 - This is a low frequency (can just be heard
with the bell) sound just after S2 . Described
as a ‘triple’ or ‘gallop’ rhythm. ‘Da-da-dum’ or
‘ken-tuck-y’.
• Physiological S3: soft sound heard only at the
apex, normal in children and fit adults up to
the age of 30.
• S4 - Never physiological. Sounds like ‘Da-lub
dub’ or ‘Ten-ne-ssee’ – just before S1
Tips (3):
• The diaphragm of the stethoscope is best for
auscultating relatively high-pinched sounds,
such as S1,S2.
• The bell of the stetoscope is more sensitive to
low-pinched sounds, such as S3,S4.
! Apply the bell lightly with just enough pressure
to produce an air seal with its full rim.
! Applying to much pressure to the bell converts
it to the diaphragm.
Thank you for your attention!