Physical Examination

Physical Examination of Physical Examination of CardiovascularCardiovascular

Dr.Ira Andaningsih SpJPCardiovascular Block 2008

Learning ObjectiveLearning Objective

1. Examine the important surface topographic landmarks of the heart (inspection, palpation, percussion and auscultation).

2. Assessment of the blood pressure and its variation about the cardiovascular disease (orthotastic hypotension, coarct aorta, cardiac tamponade).

3. Assessment of the arterial pulse (a. radialis, a. brachialis, aorta abdominalis, a. femoralis, a. poplitea, a. carotis, a. dorsalis pedis).

Learning ObjectiveLearning Objective4. Assessment of the JVP and hepatojugular

reflux.5. Assessment of the peripheral edema (tibial).6. Students should be able to identify the

normal heart sound (S1, S2).7. Students should be able to identify the

abnormal heart sound (S1, S2, S3, S4, systolic clicks, diastolic opening snaps, murmurs).

ProcedureProcedure

1. Inspection 2. Measurement of blood pressure 3. Arterial pulsation examination 4. JVP examination and hepatojugular reflux 5. Edema examination 6. Percussion 7. Palpation 8. Auscultation

General InspectionGeneral Inspection

Clues for cardiac diagnosis:Is the patient in acute distress?What is the patient’s breathing like?Are accesory muscles being used?Are the patient pale?Is the patient cyanosis?

InspectionInspection

Inspect the head and faceInspect the skinInspect the eyesInspect the mouthInspect the neckInspect the chest configurationInspect the nails and extremities

Head and faceHead and face

- An earlobe crease in a relatively young person (CAD)

- A cyanotic lips, and slight jaundice due to hepatic congestion(RHD)

- Bobbing of the head coincident with each heart beat (severe aortic regurgitation)

Earlobe CreasesEarlobe Creases

Head and faceHead and face Down syndrome is associated with congenital

heart disease. Another diseases are associated with heart

disease is : Marfan’s syndrome, Systemic Lupus Erythematosus, Cushing syndrome have characteristic that can be present in general appearance.

High arched palate (MVP) Palatal ptechiae (infective endocarditis)

SkinSkinCyanosis (central/peripheral?)Pallor Temperature: warmer(severe anemia,

thyrotoxicosis),coolness and pain (claudicatio,occlusion)

Xanthomata(tendon,eruptive)Rash(erythema marginatum)Ptechiae (infective endocarditis)

XanthomataXanthomata

EyesEyes

1. Xanthelasma ( CAD)2. Embolic retinal occlusions (rheumatic heart

disease, atheroslerosis of the aorta or arch vessels).

3. Papilledema ( malignant hypertension, cor pulmonale with severe hypoxia,patients with cyanosis and polycythemia).

4. Arcus senilis (CAD)5. Hypertelorism(Pulmonary Stenosis,supravalvar

aortic stenosis

XanthelasmaXanthelasma

Arcus SenilisArcus Senilis

PapilledemaPapilledema

Neck and chest configurationNeck and chest configuration

Webbing of the neck(Turner’s syndrome /coarctatio aorta or Noonan’s syndrome/ pulmonary stenosis)

Distended Jugular veins (CHF)Visible cardiac motion ?Pectus Excavatum (Marfan’s syndr,MVP)Pectus carinatum (Marfan’s syndr)

Pectus ExcavatumPectus Excavatum

Pectus CarinatumPectus Carinatum

Chest ConfigurationChest Configuration

ExtremitiesExtremities

Nicotine staining of the fingers(CHD)Osler’s nodes(infective endocarditis)Splinter hemorrhages(infective

endocarditis)Abnormalities finger/toe:extra

phalanges/toe (ASD)

Splinter HemorrhagesSplinter Hemorrhages

ExtremitiesExtremities

Long,slender fingers(Marfan’s syndrome/Aortic regurgitation).

Quincke’s sign:systolic flushing of the nailbeds, which can be readily detected by pressing a flashlight against the terminal digits( Aortic regurgitation).

Extremities Extremities Clubbing of the fingers and toes(central

cyanosis/congenital).It may also appear within a few weeks of the development of infective endocarditis.

Edema of the extremities (CHF) Edema in only one leg(obstructive venous or lymphatic

disease than to heart failure) Pain and cool in the extremities with cyanotic(arterial

occlusion).

Clubbing FingerClubbing Finger

Measurement of Blood Measurement of Blood PressurePressure

The principles:Direct (intra arterial catheter)Indirect (Sphigmomanometer)Korotkoff sounds 1-5.Determinant BP by palpationDeterminant BP by auscultation

Assess BP by PalpationAssess BP by Palpation

Assess BP by AuscultationAssess BP by Auscultation

Blood pressureBlood pressure

Rule out orthostatic hypotensionRule out Supravalvar Aortic StenosisRule out Coarctation of AortaRule out Cardiac Tamponade

Rule out Orthostatic Rule out Orthostatic HypotensionHypotension

1. Patient recumbent for at least 5 minute, measure the baseline BP and pulse

2. Patient standing and measure the BP and pulse3. Orthostatic hypotension if: Systolic BP drop 20 mm Hg or more with

development of symptom such as dizzyness or syncope(in most patients,also increase HR)

Rule out Supravalvular Aortic Rule out Supravalvular Aortic StenosisStenosis

If BP in the right arm high, measure BP in the left arm (auscultatory )

Supravalvar Aortic Stenosis if: Hypertension in the right arm and Hypotension in the left arm

Rule out Coarctation of the Rule out Coarctation of the AortaAorta

If the BP is elevated in the arm, measure BP in the lower extremities.

Patient lie down on the abdomen ,the cuff is placed around the posterior aspect of the midthigh

The stethoscope is placed over the popliteal fossa If wide cuff not available,place the reg.cuff in the

distal border maleoli and stethoscope is placed over posterior tibial or dorsalis pedis artery.

Coarc Aorta if BP in the leg is lower than in the arm

Rule out Cardiac TamponadeRule out Cardiac TamponadeParadoxical pulse (pulsus paradoxus)Patient breathe as normal as possibleInflate cuff until no sounds are heard.Gradually deflate until soundsare heard in

expiration only.Note this pressure.Continue deflate slowly untilsounds are

heard during inspiration.Note this pressureAbN if difference 10 mmHg,N if 5 mmHg

Arterial Pulsation ExaminationArterial Pulsation Examination

Determinant the cardiac rateDeterminant the cardiac rhythmPalpation Carotid arteryPalpation Radialis/Brachialis pulsePalpation Abdominal Aorta pulsePalpation Femoralis/Popliteal pulsePalpation Posterior Tibial/Dors.Pedis pulse

Determinant Cardiac RateDeterminant Cardiac Rate

Assessed by the radial pulse. The examiner stand in the front of the patient Grasp both radial arteries with the 2nd,3rd and 4th

fingers. Count the pulse for 30 seconds x 2. If patient in irregular rhythm(AF) presents,patient

has pulse deficit. Only assessment by auscultation on the heart can count the cardiac rate.

Technique evaluating Radial Technique evaluating Radial PulsePulse

Determinant cardiac rhythmDeterminant cardiac rhythm

The ECG is the best method for diagnosing cardiac rhythm.

Regular rhythm: regular on palpationRegularly irregular:irregularity in a definite

pattern(premature beats, bigeminy)Irregularly irregular:has no pattern (Atrial

Fibrillation).

Palpation Carotid ArteryPalpation Carotid Artery Patient in the supine position,examiner in the right

side Auscultate carotid artery for bruits first. If bruits presents do not palpate the artery,if the

cholesterol plaque is present it can produce an embolus

Place 2nd and 3rd fingers on the thyroid cartilage and slip them laterally between trachea and m.sternocleidomastoid

Technique Auscultation Technique Auscultation Carotid ArteryCarotid Artery

Technique Evaluating Carotid Technique Evaluating Carotid Artery PulseArtery Pulse

Palpation Carotid ArteryPalpation Carotid Artery

Palpation should be performed low in the neck to avoid pressure on carotid sinus (can cause drop in BP and HR)

Each carotid artery is evaluated separately.Never press on both carotid artery in the

same time.

Palpation Carotid ArteryPalpation Carotid Artery

Normal :Smooth, upstroke stepper more rapid than downstroke

Diminished : Small, weak pulse (anacrotic) Increased:Large,strong,hiperkinetic

(waterhammer) Double peaked pulse :Prominent percussion

and dicrotic wave (bisferiens)

The Arterial PulseThe Arterial Pulse

Palpation Brachialis pulsePalpation Brachialis pulse

The examiner use the thumbs to palpate.Can be felt medially under the tendon of the

biceps muscle.Examiner standing in front of the patient

simultaneously can be felt both brachial arteries.

Technique Palpation Technique Palpation Brachialis PulseBrachialis Pulse

Palpation Abdominal AortaPalpation Abdominal Aorta

Performed by palpating deeply but gently into the mid abdomen.

Presence of mass with laterally pulsatile suggest abdominal aneurysm.

In thin individual normal pulsatile can be palpated.

Technique Auscultation Technique Auscultation Abdominal AortaAbdominal Aorta

Palpation Femoral PulsePalpation Femoral Pulse Patient in the supine position and examiner in the

right side. The lateral corners of the pubic hair triangle are

observed and palpated. Both femoral artery may be compared

simultaneously. If one of the artery is diminished or absent

auscultation for bruits is necessary. If presence indicate obstructive aortoiliofemoral

disease.

Technique Palpation Femoral Technique Palpation Femoral PulsePulse

Palpation Popliteal PulsePalpation Popliteal Pulse

Often difficult to assess. Each artery is evaluated separately. Patient in supine position Examiner hold the leg in a mild degree of flexion

and places the thumbs on the patella and presses the remaining fingers of both hands in the fossa poplitea medial to lateral biceps femoris tendon

Firm pressure is usually required to feel pulsation

Technique Palpation Popliteal Technique Palpation Popliteal PulsePulse

Palpation Dorsalis Pedis Palpation Dorsalis Pedis PulsePulse

Is best felt by dorsoflexion of the foot.Easily palpated in the grove between the

extensor digitoum longus and hallucis longus tendon.

May be felt simultaneously

Technique Palpation Dorsalis Technique Palpation Dorsalis Pedis PulsePedis Pulse

Technique Palpation Posterior Technique Palpation Posterior Tibial PulseTibial Pulse

Grading of PulsesGrading of Pulses

0 Absent1 Diminished2 Normal3 Increased4 Bounding

Jugular Venous PulseJugular Venous PulseProvide information about the wave forms

and the right atrial pressure.Pulsation internal jugular vein are beneath

the sternocleidomastoid muscle.Only the right internal jugular vein is

evaluated because its straighter than left.External jugular vein is easier to visualize

but less accurate and should be not used.

Jugular Wave FormsJugular Wave Forms Patient lie flat without pillow so that the neck will

not be flexed. The patient’s trunk at approximately 25º to the

horizontal. The higher the venous pressure,the greater elevation

will be required.The lower the venous pressure, the lower the elevation needed.

Patient’s head turned slightly to the right and slightly down to relax the right sternocl.mastoid.

With small flashlight shine the light to the neck.

Technique Evaluating Jugular Technique Evaluating Jugular Wave FormsWave Forms

Jugular Wave Pressure Jugular Wave Pressure ExaminationExamination

The standard reference is manubriosterno angle/ angulus ludovici

Determine the height of venous distension by noting the top of the wave forms in the int jug.venous pulsation.

Imaginary horizontal line from this height to the sternal angle

Measure the distance The angle of elevation of the head of the bed is also

estimated.

Neck Vein DistentionNeck Vein Distention

JVPJVP At 45ºelevation,Jug.pulse is 7 cm above the sternal

angle. At 45º,upper limit of normal 4-5 cm above the

sternal angle. At 30º,upper limit of normal 6 cm. At supine position,normal if equal or lower than

the sternal angle. At 90º when neck vein distended up to the jaw

margin that the RA pressure is high(>15 mmHg)

Hepato Jugular Reflux Hepato Jugular Reflux ExaminationExamination

Abdominal Compression Assessing high jugular venous pressure. Pressure over the liver can grossly assess RV

function. Patient in supine position,mouth open and

breathing normally Places the right hand over the liver (right upper

quadran),apply a firm,progressive prssure. Compression is maintained for 10 seconds.

Hepato Jugular RefluxHepato Jugular RefluxNormal response: transient increase in

distension during the first few cardiac cycles,followed by a fall to baseline level.

RV failure : remained distended during the compression and falls rapidly(at least 4 cm) on sudden release.

If test incorrect (patient’s mouth closed),a valsava maneuver will result inaccurate.

Edema ExaminationEdema ExaminationFingers are pressed into dependent area for

2-3 seconds.If pitting edema is present,the fingers will

sink into the tissue and when removed,the impression of the fingers will remain.

Usually quantified from 1+ to 4+If 4+ is usually to the sacrum(bedridden

patient)

Technique Evaluating Pitting Technique Evaluating Pitting EdemaEdema

Pitting Edema over the Pitting Edema over the SacrumSacrum

Landsmark of the ChestLandsmark of the Chest

Landsmark of the chestLandsmark of the chest

Technique PercussionTechnique Percussion

Percussion of the heart Percussion of the heart

Performed at the 3rd ,4th ,and 5th intercostal space from the left anterior axillary line to the right anterior axillary line.

Normal : A change in the percussion from resonance

to dullness ± 6 cm lateral to the left of sternum.

PalpationPalpation

To evaluate the apical impulsFor assessing localized motionFor assessing generalized motionFor assessing presence or absence of thrills

Point of Maximum ImpulsePoint of Maximum Impulse

Most easily performed with sitting positionOnly the fingertips should be applied in the

5th intercostal space,midclavicular lineIf not felt,move in the area of cardiac apex.PMI usually within 10 cm of the midsternal

line and no larger than 2-3 cm in diameter. If laterally or felt in 2 interspaces it is

cardiomegaly.

Technique Assessing PMITechnique Assessing PMI

Assessing Localized MotionAssessing Localized Motion

Patient in supine positionUse the fingertips to assess any localized

motionThe presence of a systolic impulse in 2nd

intercostal space to the left of sternum is suspect Pulmonary Hypertension

Technique Assessing Technique Assessing Localized MotionLocalized Motion

Assessing Generalized MotionAssessing Generalized MotionUse the proximal portion of the hand to

palpate for any large area motion,called “heave” or “lift”

Palpates each of the 4 main cardiac areaThe 2nd impuls in the area of PMI is usually

felt in association with S3.The use of an aplicator stick can be helpful

to reinforce visually what has been palpated

Technique Assessing Technique Assessing Generalized MotionGeneralized Motion

Technique Assessing Technique Assessing Genaralized MotionGenaralized Motion

Assessing ThrillsAssessing Thrills

The presence of thrills indicates a loud murmur.

Use the head of metacarpal and applying very gentle pressure on the skin

If too much pressure thrills will not be felt

Auscultation of the HeartAuscultation of the HeartThe bell of the stetoscope should be applied

slightly to the skinFor:low-pitched sounds (gallop, murmur of

atrioventricular stenosis)The diaphragm of the stetoscope should be

pressed tightly to the skinFor: high-pitched sounds (valve

closure,systolic event, regurgitant murmur)

Standard Auscultation Standard Auscultation PositionPosition

SupineLeft lateral decubitusUprightUpright, leaning forward

Auscultation PositionAuscultation Position

Auscultation Cardiac AreaAuscultation Cardiac Area

Physical Examination

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