CVS EXAMINATION

XANTHELASMA
MALAR FLUSH
 SYMPTOMS & SIGNS
• DYSPNOEA
• ORTHOPNOEA
• PAROXYSMAL NOCTURNAL DYSPNOEA (PND)

• PLATYPNOEA
• DEF : Dyspnoea in UPRIGHT POSITION
• CAUSES
• Lt atrial thrombus
• Lt atrial tumors – Myxomas
• Pulmonary arteriovenous fistula
• TREPOPNOEA
• DEF : Dyspnoea in RT/LT LAT DECUBITUS POSITION
• CAUSES
• Heart disease
 DYSPNOEA
DEFINITION
• Abnormally uncomfortable AWARENESS OF BREATHING
 GRADING OF DYSPNOEA IN CARDIOVASCULAR DISEASE
NEW YORK HEART ASSOCIATION (NYHA)
CLASS
I NO Symptoms
• W ordinary physical activity
II Symptoms
• W ordinary activity
• Slight limitation of physical activity
III Symptoms
• W less than ordinary activity
• Marked limitation of activity
IV Symptoms
• W any activity/even at rest

• NOTE
• NORM INDIVIDUALS : Also develop dyspnoea on severe exertion; BUT Recovery time is SHORT
• HEART DISEASE PTS : Recovery time PROLONGED
 CAUSES
CARDIAC RESPIRATORY
• MAJ SYMPTOM LEFT HEART FAILURE • BA
• CHRONIC OBSTRUCTIVE LUNG DISEASE
• CONGENITAL HEART DISEASES • Chr bronchitis
• Shunts & Valvular lesions • Emphysema
• CHRONIC RESTRICTIVE LUNG DISEASE
• ACQUIRED VALVULAR HEART DISEASES • Parenchymal
• CARDIOMYOPATHIES • ILD
• CORONARY HEART DISEASE • Pneumoconiosis
• HYPERTENSIVE HEART DISEASE • Extra parenchymal
• Ankylosing spondylitis
• Guillain-Barré syndrome
• Kyphoscoliosis
• Myasthenia gravis
• Obesity
• PNEUMONIAS
• PULMONARY EMBOLISM/NEOPLASM
• TRACHEAL/LARYNGEAL OBSTRUCTION
 CAUSES
• HAEMATOLOGICAL
• Severe anaemia
• INHALATION OF TOXIC FUMES & GASES
• MISCELLANEOUS
• Anxiety
• Hysterical hyperventilation
 ORTHOPNOEA
DEF
• Dyspnoea in RECUMBENT POSITION
• RELIEVED BY : Elevation of head w pillows/Sitting up

TIMING
• OCCURANCE
• Anytime
• 1-2 min after assuming recumbency
• RECOVERY : Immediate on sitting up

CAUSES
• Acute lt heart failure
• Extreme degree of CCF
 MECHANISM
• GRAVITATIONAL EFFECTS
• Gravitational effects on fluid  Loss of Intravascular fluid into Interstitial space
• Oedema fluid return to vascular system in horizontal position  Augment venous return 
• Failing lt ventricle NOT able to cope w extra vol of blood  ↑ Pulmanary capillary & venous pressure 
• Pulmonary interstitial oedema  ↓ Airway compliance  Orthopnoea
• ELEVATED DIAPHRAGM IN LYING POSTURE  ↓ Vital capacity of lung 
• Orthopnoea
 PAROXYSMAL NOCTURNAL DYSPNOEA (PND)
DEF
• Dyspnoea at NIGHT
• Awakening pt from sleep

TIMING
• OCCURANCE
• Night
• 2-5 h after onset of sleep
• RECOVERY : 10-30 min after assuming upright posture
 CAUSES
• EARLIEST SYMPTOM OF LEFT HEART FAILURE
• Aortic valve disease
• Atrial fibrillation
• Cardiomyopathy
• HT
• IHD
• Mitral disease/Atrial tumours (rare)

MECHANISM
• ↓ PaO2 & SYMPATHETIC SUPPORT DURING SLEEP
• GRAVITATIONAL EFFECTS
• Gravitational effects on fluid  Loss of Intravascular fluid into Interstitial space
• Oedema fluid return to vascular system in horizontal position  Augment venous return 
• Failing lt ventricle NOT able to cope w extra vol of blood  ↑ Pulmanary capillary & venous pressure 
• Pulmonary interstitial oedema  ↓ Airway compliance  Orthopnoea
• ELEVATED DIAPHRAGM IN LYING POSTURE  ↓ Vital capacity of lung 
• Orthopnoea
 INSPECTION PROC
• Ask pt to remove all clothing above waist
• INSPECTION OF PRECORDIUM
• W pt sitting at 45°
• Look for Chest deformity, Apex beat/impulse, Visible pulsations, Surgical scars
 INSPECTION
• PRECORDIUM
• CHEST WALL DEFECTS
• APEX BEAT/IMPULSE
• VISIBLE PULSATIONS
• Juxta apical
• Suprasternal
• Parasternal
• Epigastric
• On rt side
• In neck
• At the back
• DILATED VEINS
• SCARS & SINUSES
 PRECORDIUM
• Ant aspect of chest • ABNORM
• Overlying heart & great vessels • BULGING
• Enlarged heart
• Mediastinal tumor
• NORM • Pericardial effusion
• Smooth contour • Pleural effusion
• Slightly convex • Scoliosis
• Symmetrical w chest wall on rt side • FLATTENED
• Congenital deformity
• Fibrosis of lung
 APEX IMPULSE
• DEF : Lowermost & Outermost Cardiac impulse
• PRODUCED BY
• Lt ventricle
• Lt ventricular portion of interventricular septum
• NORM SITE : 5th lt intercostal space
• Just inside midclavicular line
• NOT VISIBLE IF/IN
• Behind a rib
• ∴ Turn pt to lt lat position
• Visible in ant axillary line
• Obese pt
• Emphysema/Pericardial effusion
 VISIBLE PULSATIONS
• CAROTID A PULSATIONS
• Aortic regurgitation
• Coarctation of aorta
• Hyperdynamic states
• Systemic hypertension
• AORTIC PULSATIONS
• Dilatation of ascending aorta
• Aortic aneurysm
• Aortic regurgitation
• PULMONARY A PULSATION
• High output states
• Pulmonary artery dilatation
• Pulmonary hypertension
• Pulmonary hypercirculation (ASD)
• ECTOPIC PULSATION
• Ischaemic heart disease
• Left ventricular dysfunction
• Aneurysm
• Cardiomyopathies
 OTHER VISIBLE PULSATIONS OVER CHEST WALL
• HEPATIC PULSATIONS • SUPRACLAVICULAR (i.e. in neck)
• Tricuspid regurgitation • Aneurysms
• Tricuspid stenosis • Carotid
• Subclavian a
• EPIGASTRIC (i.e. lying upon or over stomach) • Exopthalmic goiter
• Aortic pulsation in person w thin chest wall
• Aneurysm of aorta • ON RT SIDE OF CHEST
• Rt ventricular enlargement • Dextrocardia
• Rt atrial enlargement
• JUXTA APICAL (i.e. near apex) • Shift of heart
• Ventricular aneurysms
• INFRA SCAPULAR (i.e. at the back)
• LT PARASTERNAL (i.e. situated beside sternum) • @ SUZZMAN’S SIGN
• Aneurysm of aorta • In coarctation of aorta
• Lt atrial enlargement
• Rt ventricular enlargement
• SUPRASTERNAL (i.e. situated above/top of sternum)
• Aortic
• Aneurysm
• Regurgitation
• Coarctation
• Abnormal thyroidea ima artery
• Pulsating thyroid gland
 DILATED VEINS OVER CHEST WALL
• SVC & IVC obstruction
• Rt sided heart failure
• Intrathoracic obstruction

• Bodybuilders
 SCARS & SINUSES OVER CHEST WALL
• Scars of Previous cardiac surgery
• Midline sternotomy scar = Previous Aortic valve replacement/Coronary a bypass surgery
• Lt submammary scar = Mitral valvotomy
• Infraclavicular scars = Defibrillator/Pacemaker implantation
• Sinuses
• Tuberculosis of spine (seen in the past)
 AREAS OF CHEST WALL
AREA SITE
AORTIC • 2nd rt intercostal area
PULMONARY • 2nd lt intercostal area
ERB’S AREA/NEO AORTIC AREA • 3rd lt intercostal area
TRICUSPID • Lower end of sternum
• Near ensiform cartilage
MITRAL • 5th lt intercostal space
• Just inside mid-clavicular line
 GENERAL RULE FOR PALPATION
• FINGERTIPS • OPTIMUM PALPATION AREA ON HAND
• Feel pulsation
• FINGER BASE
• Feel thrills
• HAND BASE
• Feel heaves
 PALPATION PROC
• Ask pt to remove all clothing above waist
• PALPATION OF APEX BEAT/IMPULSE
• Place rt hand flat over precordium
• To obtain general impression of cardiac impulse
• Place fingers on chest parallel to rib spaces
• To locate apex beat
• IF YOU CANNOT FEEL IT : Ask pt to roll on to lt side
• Note position
• Assess character
• PALPATION FOR THRILLS
• Use flat of fingers
• Palpate at apex & both sides of sternum
• PALPATION FOR HEAVE
• Apply heel of rt hand firmly to lt parasternal area
• Ask pt to hold breath in expiration
 PALPATION POINTS
• APEX BEAT

• THRILLS
• PARASTERNAL HEAVE
• PALPABLE HEART SOUNDS @ SHOCKS
• OTHER PULSATIONS
 APEX BEAT

APEX BEAT PALPATION (NNL)

• Pt in supine position • Lower most & Outer most point
• Stand on rt of pt • Where max cardiac impulse felt
• Place rt palm over pericardium • As gentle thrust to palpating finger
• 1st palpate apex w palm
• Then localization w finger tip
• Definite localization w pulp of finger
• Observe Amplitude & Duration • NORM
• Measure Distance from mid-clavicular line • POSITION
• Look for chest wall/spinal deformities & tracheal position • In 5th lt intercostal space
• Before commenting on position & character • 1 cm med to mid-clavicular line/
• If NOT palpable • 10 cm lat to midsternal line
• Make pt sit leaning forward and try • CHARACTER
• If NOT localizable on lt • Confined to 1 intercostal space/
• Palpate rt for presence • < 2.5 cm in diameter
• Dextrocardia/Pseudo-dextrocardia
• Lasts for < ½ or 50% of systole
 ABNORMALITIES OF APEX BEAT
• ABSENT APEX
• DIFFUSE APEX
• HEAVING APEX
• HYPERDYNAMIC APEX
• TAPPING APEX

• DOUBLE APICAL IMPULSE

• RETRACTILE IMPULSE
• TRIPLE/QUADRUPLE IMPULSE
• ABSENT APEX • HEAVING APEX
• Lasts > 2/3rd systole
• CARDIAC CAUSES
• Dextrocardia • LV pressure/systolic overload
• Dilated cardiomyopathy • Aortic stenosis
• LV dysfunc • Coarctation of aorta
• CAD • HOCM
• Systemic HT
• Pericardial effusion
• NON-CARDIAC CAUSES
• HYPERDYNAMIC APEX
• Emphysema • Lasts < 2/3rd systole
• Lt pleural effusion
• Obesity • LV vol/diastolic overload
• Thick chest wall • Aortic & Mitral regurgitation
• AV fistulas
• High output states
• Patent ductus arteriosus, VSD
• DIFFUSE APEX • Thin chest wall
• Occupy > 1 intercostal space/
• > 3 cm in diameter
• TAPPING APEX
• Palpable 1st heart sound
• LV aneurysm • Sharp Short Tap
• LV dilatation
• Aortic regurgitation • Mitral stenosis
• RV enlargement
• LV dysfunc
• DOUBLE APICAL IMPULSE
• Hypertrophic obstructive
cardiomyopathy
• LBBB
• LV aneurysm

• RETRACTILE IMPULSE
• Indrawing of apical impulse
• @ BROADBENTS SIGN

• Constrictive pericarditis

• TRIPLE/QUADRUPLE IMPULSE
• HOCM
 PALPABLE HEART SOUNDS, HS
@ SHOCKS
• 1st HS
• Palpable S1 – Producing tapping apex beat over mitral area = Mitral stenosis
• 2nd HS
• Palpable S2 over aortic area = Aneurysms of aortic root/Aortitis/Sys HT
• Palpable S2 over pulmonary area = Pulmonary HT
• PALPABLE 2ND HS K.A. DIASTOLIC SHOCK/KNOCK
• 3rd HS
• Palpable S3 over mitral area = LVF/Mitral regurgitation (MR)
• 4th HS
• Palpable S4 over mitral area = Aortic stenosis/Hypertrophic obstructive cardiomyopathy, HOCM

• AORTIC EVENTS
• Better felt keeping pt in sitting leaning forward
• Breath held in expiration
• MITRAL EVENTS
• Better felt keeping pt in left lat position
 HEAVE, THRILLS, OTHER PULSATIONS
• PROC
• Lay fingertips lightly over each of 5 precordial landmarks described
• In auscultation sequence
• NO firm pressure
• As obliterate pulsations
• Palpate each area for
• Heaves
• Lift/Rolling sensation on hand base
• Thrills
• Vibration on palm/finger base
• Other pulsations/Lifts
• Lift fingers upward
 PARASTERNAL HEAVE
• LT PARASTERNAL HEAVE • GRADING OF PARASTERNAL IMPULSE
• Systolic impulse (AIIMS GRADING)
• In lt parasternal region • Grade I
OR • Visible; But NOT palpable/
• Systolic elevation of lt lower costal cartilages • Just touches hand
• Produced by • Grade II
• Contraction of • Visible; Palpable; Obliterable
• Dilated Hypertrophied RT VENTRICLE • Grade III
• PROC • Visible; Palpable; but NOT obliterable
• Pt in supine position
• Stand on right hand side of patient
• IN
• Feel lift on hand base • Rt ventricular enlargement
• AT TIMES
• Aneurysm of aorta/Enlarged lt atrium
• Push rt ventricle up
• W/O rt ventricular enlargement
METHOD FOR PALPATION FOR PARASTERNAL HEAVE
 THRILLS
• Palpable vibrations
• In time w cardiac cycle
• PALPABLE EQUIVALENTS OF HEART MURMURS
• PROC
• Pt in supine position
• Stand on right hand side of patient
• Feel vibration on palm of hand
• RESULT
• Thrills
• Indicates murmur organic
 TYPES OF THRILLS
• CAROTID THRILLS @ CAROTID SHUDDERS • PULMONARY THRILLS
• Aortic stenosis • SYSTOLIC
• Pulmonary stenosis, PS
• AORTIC THRILLS
• Atrial septal defect, ASD
• SYSTOLIC • Ventricular septal defect, VSD
• Aortic stenosis, AS • Patent ductus arteriosus, PDA
• DIASTOLIC • CONTINOUS
• Aortic regurgitation, AR • Patent ductus arteriosus, PDA
• Acute severe
• Rupture of sinus Valsalva
• Due to eversion, inf, perforation
• Syphilitic • LT LOWER PARASTERNAL THRILLS
• SYSTOLIC
• Ventricular septal defect, VSD
• APICAL THRILLS
• SYSTOLIC
• Mitral regurgitation, MR
• Aortic stenosis, AS
• DIASTOLIC
• Mitral stenosis, MS
 PERCUSSION
• PROC - ?
• IMP IN DETECTING
• Enlargement & Position of heart
• Pericardial effusion
• Dil cardiomyopathy
• Dextrocardia
• W or W/O Situs inversus
• Aortic dilatation
• Aneurysm of aorta
• Pulmonary a dilatation
• Pulmonary HT
• Idiopathic pulmonary a dilatation
 AUSCULTATION
• HEART AUSCULTATED FOR • IDEAL STETHOSSCOPE
• HEART SOUNDS • Earpiece
• MURMURS • Well fitting
• ADDED SOUNDS • Long tube
• S3 • 25 cm length
• S4 • 0.325 cm diameter
• Diaphragm
• Diastolic knock • 4 cm diameter
• OS • USE : Auscultate high pitched sounds & murmurs
• Pericardial rub • 1st HS
• Prosthetic valve sounds • 2nd HS
• Tumour plop • Clicks
• Opening snaps
• Pericardial rubs, knocks
• Systolic murmurs
• Early diastolic murmurs
• Tumour plops
• Bell
• 2.5 cm diameter
• USE : Auscultate low pitched sounds & murmurs
• 3rd HS
• 4th HS
• Mid diastolic murmurs
 AUCULTATORY AREAS
AREA SITE
AORTIC • 2nd rt intercostal space
• Close to sternum
GIBSON’S AREA • 1st lt intercostal space
• Close to sternum
• PDA MURMUR BEST HEARD HERE (GIBSON’S
MURMUR)
PULMONARY • 2nd lt intercostal space
• Close to sternum
ERB’S/NEO AORTIC/2ND AORTIC AREA • 3rd lt intercostal space
• Close to sternum
TRICUSPID • Lower end of sternum
• Near ensiform cartilage
MITRAL • 5th lt intercostal space
• Just inside mid-clavicular line
 OTHER AREAS OF AUSCULTATION
• Carotids

• Inter & Infrascapular areas

• Axilla
• Supra- & Infraclavicular areas
 BEST SITES FOR
HEARING ABNORMALITY
 HEART SOUNDS
• DEF
• Relative, Brief, Auditory vibrations
• W variable Freq, Intensity, Quality
 1ST HS (S1) 2ND HS (S2)
PRODUCED BY Closure of AV valves Closure of valves
• Mitral (M1) • Aortic (A2)
• Tricuspid (T1) • Pulmonary (P2)
HEARD AT • Aortic area
• Pulmonary area
CHARACTERISTICS • High frequency • High frequency
APPRECIATED AS Single sound Split sound
• As mitral valve closes 20-30 msec • As aortic valve closes before
before tricuspid valve pulmonary valve
INDICATES Onset of systole
NOTE Timed w simultaneous palpation of
carotid pulse
ON PHONOCARDIOGRAM PRODUCED Vibrations of
ALSO BY • Heart muscles
• Vessels
• Adnexal structures
 1ST HS (S1)
ABNORMALITIES
ABSENT - IN OLD AGE DUE TO
LOUD • Mitral stenosis
• Thickened mitral valve leaflets
• Open till end of diastole
(norm)
• Close forcefully in
ventricular systole (norm) 
Loud S1 (abnorm due to
thickeneing)
• Tricuspid stenosis
• High output states
• Short PR interval
• Except in Wolff-Parkinson-White
syndrome
2ND HS (S2)
• Absent A2 – Calcific aortic stenosis
• Absent P2 – Chr emphysema
DUE TO
• Loud A2 –
• Systemic hypertension
• Aortic aneurysm
• Syphilitic aortic regurgitation
• Atherosclerosis
• Loud P2 –
• Pulmonary hypertension
• Pulmonary artery dilatation.
• A2 + P2 – DUE TO
• Delay A valve closure
• Arteriosclerotic heart
disease
• Lt ventricular outflow
obstruction
• Eisenmonger complex
• Early P valve closure
• WPW syndrome
• Resulting in summation effect
 SOFT • Mitral regurgitation DUE TO
• Tricuspid regurgitation • Soft A2
• Right or left ventricular dysfunction • Calcific aortic stenosis
• Tricuspid stenosis (valve calcification) • Rheumatic AR
• Mitral stenosis (valve calcification) • Soft P2 – Calcific pulmonary stenosis
• Obesity
• Aortic regurgitation – Acute
• Prolonged PR interval
VARIABLE • Atrial fibrillation
• Extrasystoles
• Complete heart block
PECULIARITIES • CANNON SOUND RINGING A2
• Complete heart block • Atherosclerotic AR

TAMBOUR QUALITY A2
• Syphilitic AR
SPLITTING
 3RD HS (S3) 4TH HS (S4)
@ • Protodiastolic sound • Presystolic sound
• Ventricular gallop • Atrial gallop
PRODUCED BY Initial passive filling of ventricle Rapid emptying of atrium
• Into non-compliant ventricle
VENTRICULAR DISTENSION SOUND ATRIAL CONTRACTION SOUND
PHYSIOLOGICAL • Children • Children
• Young adults (< 40 y) • Yound adults
• Preg
• Athletes • RECORDABLE, INAUDIBLE
PATHOLOGICAL • High output states • CAD
• Angina pectoris
• Congenital heart disease • Myocardial infarction
• ASD, VSD, PDA • Hypertrophic cardiomyopathy
• Systemic HT
• Constrictive pericarditis
• Hypertrophic cardiomyopathy
• Ischaemic heart disease
• Pulmonary/Systemic HT
• Regurgitant lesions of
• Aortic, Mitral, Tricuspid valves
 RV S3 LV S3
SITE Tricuspid area Mitral area
ACCENTUATED ON Inspiration Expiration
Pathological ALWAYS Physiological/Pathological
 HEART MURMURS
• DEF
• Relatively Prolonged Auditory vibrations
• Variable Intensity, Frequency, Quality
• As result of turbulence
• MECH OF TURBULENCE
• ↑ Flow/Flow through constriction/irreg orifice  ↑ Blood velocity  Turbulence
• CHARACTERISTICS OF MURMURS
• Area over precordium where murmur best heard
• Heard best w bell/diaphragm
• MDM – Bell
• ESM, EDM, PSM – Diaphragm

• Systolic/Diastolic
• Timing
• Intensity (i.e. grading)
• Pitch (i.e. high/low)
• Conduction

• Variation w respi
• LT SIDED MURMURS – Best heard in Expiration
• RT SIDED MURMURS – Best heard in Inspiration
• Variation w posture
• MDM OF MS – Best heard in Lt lat position
• EDM OF AR – Best heard in Sitting leaning forward position on Holding breath during Expiration
• Variation w dynamic auscultation
 GRADING OF INTENSITY OF MURMUR
GRADE SYSTOLIC MURMUR DIASTOLIC MURMUR
(I.E. LEVINE GRADING SCALE) (NOT GIVEN IN MACLEOD’S)
I Very soft Very soft
• Heard by expert in opt cond
II Soft Soft
• Heard by non-expert in opt cond
III Moderate Loud
• Easily heard
IV Loud w Thrill Loud w Thrill
V Very loud w Thrill
• Heard w sthethoscope
• Often over wide area
VI Very loud w Thrill
• Heard w/o sthethoscope
• Even slightly away from chest wall
 SYSTOLIC MURMURS
• MURMURS DURING SYSTOLE
• TYPES
• EARLY SYSTOLIC MURMURS
• MID-SYSTOLIC MURMURS (EJECTION SYSTOLIC MURMURS)
• LATE SYSTOLIC MURMURS
• PANSYSTOLIC MURMURS

EARLY SYSTOLIC MURMURS

• Ventricular Septal Defect (VSD)
• Very small muscular VSD
• Large VSD + Pulmonary HT
• Acute severe Tricuspid Regurgitation (TR)
• Acute severe Mitral regurgitation (MR)
MID-SYSTOLIC MURMURS (EJECTION SYSTOLIC MURMURS)
• Aortic Stenosis (AS)
• Pulmonary Stenosis (PS)
• Hypertrophic cardiomyopathy (HOCM)

FEATURES AS PS
SITE Rt 2nd IS Lt 2nd IS
CONDUCTION To rt carotid To lt infraclavicular area
ACCENTUATION ON Expiration Inspiration
VARIATION OF MURMUR Murmur becomes softer Murmur becomes louder
W VALSALVA MANOEUVRE
EJECTION CLICK NO variation w respi Best heard over
pulmonary area
during expiration
P2 - Absent/Soft
A2 Absent/Soft -
S2 Reverse split Widely split
ASSOCIATED AR ‘+’ ‘-’
LATE SYSTOLIC MURMURS
• Tricuspid valve prolapse syndrome
• Mitral valve prolapse syndrome
• Papillary muscle dysfunc
PANSYSTOLIC MURMURS
• Mitral Regurgitation (MR)
• Tricuspid Regurgitation (TR)
• Ventricular Septal Defect (VSD)

FEATURES MR TR VSD
SITE Apex Lt parasternal 5th/6th IS Lt parasternal 3rd/4th IS
CONDUCTION To axilla, base, back Localised Localised
ACCENTUATION ON Expiration Inspiration Inspiration