Cardiovascular Examination

Andi Wahjono Adi,MD,FIHA

Department of Cardiology and Vascular Medicine, Muhammadiyah University
Hospital
Medical Faculty of Muhammadiyah University
Cardiovascular Examination
History taking (Dyspnea/chestpain/fainting etc)
Skin (Cyanosis,clubbing finger)
Congenital and Acquired Facies(marfan syndrome
etc)
Eyes (Jaundice,yellowished rim iris etc)
Edema
Extremities (Spider finger,Wrist sign etc)
Chest and Respiration(pectus exacatus and or
carinatus, cheyene stokes, etc)

J. Constant, 2003
Clubbing finger

E. Braunwald,
4
Jugular Vein Anatomy

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Jugular Venous Pressure

Angle of Louis

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Jugular vein waveforms

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J. Constant, 2003
Differences jugular vein VS carotid artey

E. Braunwald,
2012
Inspection
Wall chest
Voussure cardiac
Apex beat
Ventricular heave
Palpation
Apex beat
Thrill
Ventricular heave

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Hepatojugular Reflux

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 Percussion

Lung-liver border
Right heart border
Cardiac waist
Heart silhoutte
Auscultation

Heart sound
Extra heart sound
Murmur

J. Constant, 2003
Auscultation Location

Polaski and Tatro,1996

S1 (First Heart Sounds)
The normal first heart sound (S1) comprises mitral (M1) and
tricuspid (T1) valve closure.
The two components usually are best heard at the lower left
sternal border in younger subjects.

S2(Second Heart Sound)

The second heart sound (S2) comprises aortic (A2) and
pulmonic (P2) valve closure.
Best heard at the second left interspace with the patient in
the supine position.
Increase in the intensity of P2 relative to A2, indicate
pulmonary artery hypertension.
With fixed splitting, the A2-P2 interval indicating ostium
secundum ASD.

Learn the
heart.,2015
Heart Sounds

Normal physiologic splitting of the second heart sound because

of augmented venous return to the right heart during inspiration

P.A.McCullough,19
99
S3 - "ventricular
gallop
Occurs in early diastole S4 - "atrial gallop
Occurs during passive LV Occurs in late diastole
filling
Occurs during active LV filling
May be normal at times
Almost always abnormal
Requires a very compliant LV
Requires a non-compliant LV
Can be a sign of systolic CHF
Can be a sign of diastolic CHF

Learn the
heart.,2015
Clinical Heart Sound of S1,S2,S3,S4

A. Jeremies,D.L. Brown,20
Extra Heart Sounds
SYSTOLIC EJECTION CLICK
A systolic ejection click frequently indicates a bicuspid aortic
valve. This sound is heard just after the 1st heart sound (S1).
MITRAL VALVE PROLAPSE CLICK
Mitral valve prolapse produces a mid-systolic click usually
followed by a uniform, high-pitched murmur.
OPENING SNAP
Theincreased left atrial opening pressures causes an opening
snap (OS) to occur when the mitral valve leaflets suddenly
tense and dome into the left ventricle in early diastole.
TUMOR PLOP
Early diastolic low pitched sound just after the S2 heart
sound.
PERICARDIAL KNOCK
Present in patients with constrictive pericarditis as the early
filling of the left ventricle is limited from the constrictive
process. Learn the
Murmur
Major causes of cardiac murmurs :
Blood is forced through a tight area, turbulent
blood flow ensues.
Blood abnormally travels backward through an
incompetent valve causing turbulence when it
meets normal, forward blood flow.
Blood is forced through a congenital anomaly
from one chamber to another, as in an atrial
septal defect (ASD) or ventricular septal defect
(VSD), a murmur is produced again due to
turbulence.
Increased flow of blood through a normal valve.
Learn the
heart.,2015
Murmur
Murmurs are described by their timing in the
cardiac cycle, intensity, shape, pitch,
location, radiation, and response to
dynamic maneuvers.
Learn the
heart.,2015
1.Timing

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2.Grading

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heart.,2015
3. Shape
The shape of a murmur describes the change of
intensity throughout the cardiac cycle. Murmurs
are either crescendo, decrescendo,
crescendo-decrescendo, or uniform.

Learn the
heart.,2015
3. Pitch
High pitch i.e. aortic stenosis.
Low pitch i.e. mitral stenosis
High pitched sounds are heard with the
diaphragm of the stethoscope while low pitched
sounds are heard with the bell.

4. Location
A = aortic valve post (right upper sternal border
or RUSB)
P = pulmonic valve post (left upper sternal border
or LUSB)
Learnsternal
T = tricuspid valve post (left lower the border
or LLSB) heart.,2015
M = mitral valve post (apex)
5. Radiation
While murmurs are usually most intense at one
specific listening post, they often radiate to other
listening posts or areas of the body.
For example, the murmur of aortic stenosis
frequently radiates to the carotid arteries and the
murmur of mitral regurgitation radiates to the left
axillary region.

Learn the
heart.,2015
Dynamic Auscultation

A. Jeremies,D.L. Brown,20
Arterial Pulsation
Pulsus Bisferiens
Pulsus Celer/Corrigan/water hammer
Pulsus alternan
Pulsus defisit
Pulsus parvus et tardus
Pulsus paradoxus
 0, absent
1, Decrease
2, normal
3, Bounding

J. Constant, 2003
Ankle Brachial Index
V. Aboyans, 2012
J. Constant, 2003
THANK YOU