The Cardiovascular System

By
Dr Ali Sheikh
MBBS, DMU, MD, PhD, Post-Doctorate
Associate Professor, Cardiology
College of Medicine, ALJOUF University, KSA
 Outlines
 General examination of the cardiovascular
system
 Examination of the precordium
General examination of the cardiovascular
system
 Look at the patient’s general appearance.
 Cyanosis
 Hyperlipidaemia
 Arterial pulses
 Blood pressure
 Jugular venous pressure
The face and eyes

Facial clues to heart disease

 Central cyanosis
 Central cyanosis is an important sign.
 The most common cardiac cause is pulmonary
oedema(due to heart failure)
 Patients with congenital heart disease may
have central cyanosis resulting from the
development of a right-to-left shunt and finger
clubbing.
Features of hyperlipidaemia.

Xanthelasma.

Skin xanthomata over knees.

Corneal arcus (arrow).

Eruptive xanthomata
Hyperlipidemia: Xanthomata associated with coronary artery disease on the extensor
tendons of the hand and on the Achilles tendon.
 Jugular venous pressure
 The JVP level reflects right atrial pressure.
 The sternal angle is approximately 5 cm above
the right atrium, so the JVP in health should
be ≤4 cm above this angle when the patient
lies at 45°.
 When a healthy subject sits upright the pulse
is hidden behind the clavicle and sternum.
Inspecting the jugular venous pressure from the Measuring the height
side (the internal jugular vein lies deep to the of the JVP
sternocleidomastoid muscle).
Measuring the JVP.
 Common abnormalities
 The commonest cause of an elevated JVP is
heart failure.
 It is also elevated in other disorders
characterized by fluid overload, e.g.
o Renal failure,
o Hepatic failure,
o IV fluid administration.
EXAMINATION OF PRECORDIUM
 Examination of precordium
 The precordium is the anterior chest surface
overlying the heart and great vessels.
Anterior view of the chest wall of a man showing skeletal
structures and the surface projection of the heart.
 Examination of precordium
 Explain that you wish to examine the chest
and ask the patient to remove all clothing
above the waist.
 Examination of precordium
 INSPECTION
 PALPATION
 PERCUSSION
 AUSCULTATION
 INSPECTION
• Look for surgical scars, visible pulsations and
chest deformity.
Cardiovascular examination: positioning the patient
 PALPATION
 Place your right hand flat over the precordium
to obtain a general impression of the cardiac
impulse.
 Locate the apex beat by lying your fingers on
the chest parallel to the rib spaces; if you
cannot feel it, ask the patient to roll on to his
left side.
 Assess the character of the apex beat and
note its position.
 Use your hand to palpate the cardiac impulse.

Palpate the cardiac impulse

Localize the apex beat with a finger (roll the patient, if necessary,

into the left lateral position).

 Normal findings
 The apex beat is normally in the fifth left
intercostal space at, (the space below the 5th
rib) or medial to, the mid-clavicular line.
 Count the rib spaces down from the sternal
angle - which is at the junction of the sternum
and second rib.
 PERCUSSION
 Percussion in the estimation of cardiac size.
 When you cannot feel the apical impulse,
however, percussion may suggest where to
search for it.
 Starting well to the left on the chest [from the
left anterior axillary line to the right anterior
axillary line], percuss from resonance toward
cardiac dullness in the 3rd, 4th, 5th, and
possibly 6th interspaces.
 AUSCULTATION
 Auscultation of heart sounds and murmurs is a
rewarding and important skill of physical
examination that leads directly to several
clinical diagnoses.
 AUSCULTATION
Normal Heart Sounds
 Listening with a stethoscope to a normal heart,
one hears a sound usually described as “lub,
dub, lub, dub.”
 The “lub” is associated with closure of the
atrioventricular (A-V) valves at the beginning of
systole,
 The “dub” is associated with closure of the
semilunar (aortic and pulmonary) valves at the
end of systole.
 AUSCULTATION
 The “lub” sound is called the first heart sound
(S1) , It is best heard at the apex
 The “dub” is called the second heart sound(S2)
, and is best heard at the left sternal edge. It is
louder and higher pitched than the first sound,
and normally the aortic component is louder
than the pulmonary one.
 AUSCULTATION
General considerations
 Auscultation requires a stethoscope equipped
with a bell and a diaphragm.
 The bell emphasizes low-pitched sounds such
as the murmur of mitral stenosis.
 The diaphragm filters out these sounds and
helps to identify high-pitched sounds such as
normal heart sounds and most systolic
murmurs.
 AUSCULTATION
 Listen first at the apex and identify the two
heart sounds.
 Simultaneously feel the carotid pulse with
your thumb to time the sounds and murmurs.
 The first heart sound precedes the carotid
pulsation, the second sound follows it.
Auscultatory areas.
 Third heart sound
 A third heart sound (S3) is a low-pitched early
diastolic sound best heard with the bell at the apex.
 A third heart sound is therefore heard after the
second as 'lub-dub- dum'.
 A third heart sound is a normal finding in children,
young adults and during pregnancy.
 This is usually pathological after the age of 40 years.
 The commonest causes are left ventricular failure
and mitral regurgitation
 Fourth heart sound
 A fourth heart sound (S4) is less common.
 It is soft and low pitched, best heard with the
bell of the stethoscope at the apex.
 It occurs just before the first sound (S1) (da-
lub-dub).
 It is always pathological.
 A fourth heart sound may be heard in left
ventricular hypertrophy, hypertension and
aortic stenosis.
 Added sounds
• An opening snap:
 An opening snap is commonly heard in mitral
(rarely tricuspid) stenosis.
 It results from sudden opening of a stenosed
valve and occurs early in diastole, just after
the second heart sound
 The opening snap of mitral stenosis is best
heard at the apex.
An opening snap
 Added sounds
• Ejection clicks
 Ejection clicks occur early in systole just after
the first heart(S1) sound, in patients with
congenital pulmonary or aortic stenosis .
 The mechanism is similar to that of an
opening snap.
Ejection clicks
 Added sounds
 Midsystolic clicks occur in mitral valve
prolapse and may be associated with a late
systolic murmur .
 They are high pitched and best heard at the
apex.
Midsystolic clicks
 Murmurs
 Heart murmurs are produced by turbulent
blood flow across an abnormal valve, septal
defect or outflow obstruction, or by increased
volume or velocity of blood flow through a
normal valve.
 Murmurs
 When you hear a murmur first determine
whether it is systolic or diastolic.
 Systole begins with the first heart sound (S1)
(mitral and tricuspid valve closure).
 Common abnormalities
 Systolic murmurs.
 Diastolic murmurs.
 Systolic murmurs

Features of mitral regurgitation

 Aortic stenosis

Systolic murmurs

The ejection systolic murmur precedes an ejection click (EC). A fourth heart
sound may be heard at the apex.
Listen with the lightly applied bell with the patient in the left
lateral position for the murmur of mitral stenosis.

Auscultation for mitral stenosis Mid-diastolic murmur

Features of mitral stenosis
Listen with the diaphragm with the patient leaning forward for
the murmur of aortic incompetence.

Diastolic murmurs

Auscultation for aortic regurgitation Early diastolic murmur

 Diastolic murmurs

Features of aortic regurgitation

 Reference Books
 Macleod's Clinical Examination
 Hutchison's Clinical Methods
 Text book of Physical Diagnosis
 Gray's Anatomy
Thank you