CVS Examination - 16-11-2021
CVS Examination - 16-11-2021
CVS Examination - 16-11-2021
EXAMINATION ROUTINE:
Proceed as follows:
1. Look at the patient carefully.
➢Dyspnoeic or orthopnoeic (LVF), cachexia (in severe
heart failure).
2. Face:
➢Malar flush (in MS).
➢Marfanoid face.
➢Corneal arcus and xanthelasma related to
atherosclerosis in IHD, Argyll Robertson Pupil (related to
AR), mouth (high arch palate in Marfan Syndrome).
EXAMINATION ROUTINE:
1. Anemia
2. Cyanosis (TOF) and Eisenmenger Syndrome].
3. Edema (leg and sacrum in CCF).
4. In hands:
➢ Clubbing.
➢ Koilonychia.
➢ Cyanosis.
➢ Splinter hemorrhage.
➢ Osler node (red, raised, palpable, tender nodule on the pulp of
finger or toes; also, in thenar or hypothenar area).
➢ Janeway lesion (nontender, red, maculopapular lesion on palm or
pulp finger).
➢ Xanthoma: Palmar or tendon (atherosclerosis in IHD).
➢ Tobacco stain (smoker, IHD).
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EXAMINATION OF PULSE
The usual instructions are:
– Examine the pulse.
– Examine the pulse and relevant.
– Examine the pulse and auscultate the heart.
Usually any of the following findings will be present:
– Irregular pulse (AF and ectopics).
– High-volume pulse or Water Hammer Pulse.
– Bradycardia (complete heart block).
– Unequal radial pulse.
– Absent pulse.
– Radiofemoral delay and radio radial delay or inequality.
▪Anatomical aberration.
▪Blockage by embolism or narrowing.
▪Takayasu syndrome.
▪Iatrogenic (Blalock Taussig shunt in TOF and AV fistula
for hemodialysis).
▪Dissecting aneurysm.
▪Coarctation or aorta (before the origin of left subclavian
artery). Brachial artery catheter with poor technique or
tied during surgery.
PULSE:
1) Rate.
2) Rhythm.
3) Volume (must see collapsing pulse).
4) Character.
5) Condition of the vessel wall.
6) Radio-femoral delay and radio-radial
delay or inequality.
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CAUSES OF BRADYCARDIA:
1) Sinus bradycardia due to any cause.
2) Second-degree heart block.
3) Complete heart block.
4) Nodal rhythm.
CAUSES OF SINUS BRADYCARDIA:
i. Physiological (due to increased vagal tone):
Athlet, during sleep.
ii. Pathological:
▪Acute inferior MI.
▪Myxedema/ Hypothyroidism.
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2. RHYTHM:
A. Regularly irregular:
i. Sinus arrhythmia (pulse rate increases on
each inspiration, decreases on each
expiration). It is abolished by exercise.
ii. Occasional ectopics. Second-degree heart
block (Mobitz Type 1, Wenckebach Type).
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RHYTHM: CONT.
B. IRREGULARLY IRREGULAR (irregular in
rhythm and volume):
i. Atrial fibrillation.
ii. Multiple ectopics.
iii. Atrial flutter with variable block.
iv. Paroxysmal atrial tachycardia with
variable block.
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3. VOLUME OF PULSE:
A. CAUSES OF HIGH-VOLUME PULSE:
i. AR.
ii. Hyperdynamic circulation due to any cause.
iii. PDA.
iv. Hypertension.
B. CAUSES OF LOW-VOLUME PULSE:
i. Shock.
ii. AS.
iii. MS.
iv. Chronic constrictive pericarditis.
v. Pericardial effusion.
vi. PH.
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4. CHARACTER OF PULSE:
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JVP:
JUGULAR VENOUS PULSE OR
JUGULAR VENOUS
PRESSURE
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DEFINITION OF JVP:
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R L
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THE DIFFERENCES BETWEEN VENOUS OR ARTERIAL
PULSE IN NECK.
VENOUS ARTERIAL
1. IT IS WAVY (TWO PEAKS WITH CARDIAC NOT WAVY
CYCLE)
2. IT HAS AN UPPER LIMIT NO DEFINITE UPPER LIMIT
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CAUSES OF RAISED JVP:
1) CCF (Right heart failure).
2) Pericardial effusion.
3) Chronic constrictive pericarditis.
4) Fluid overload - e.g., renal disease.
5) Pulmonary embolism.
6) Pulmonary hypertension
7) TR and PS.
8) SVC obstruction (nonpulsatile).
9) Others: Occasionally in pregnancy, exercise,
anxiety and anemia.
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JVP: CONT.
GIANT ‘V’ WAVE:
Tall, sinuous, oscillating up to ear lobule.
Example: TR.
GIANT X DESCENT:
Chronic constrictive pericarditis and Cardiac
tamponade.
SLOW Y DESCENT:
TS.
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KUSSMAUL SIGN:
It means raised JVP during inspiration due to
reduction of right ventricular output. It is best seen
with the patient at 90 degree with normal
breathing (normally, JVP falls during inspiration).
Causes:
– Pericardial effusion (usually, cardiac tamponade).
– Chronic constrictive pericarditis.
– Right ventricular infarction.
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PRECORDIUM EXAMINATION:
INSPECTION:
❖Deformity of chest (kyphosis, scoliosis, lordosis, pectus
excavatum or carinatum).
❖Pacemaker or ICD.
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PALPATION:
1. APEX BEAT:
▪ Site (localize the intercostal space. Do not forget
Dextrocardia).
▪ Distance from midline.
▪ Nature (normal, tapping, heaving, thrusting and
diffuse).
2. THRILL:
▪ Site (apical or basal or other intercostal space).
▪ Nature (systolic or diastolic): Feel carotid pulse at the
same time. If coincides with carotid pulse, it is systolic
and if it does not coincide (comes after or before), it is
diastolic.
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❖HEAVING:
Forceful, sustained, lifting the examining finger (pressure
overloaded). Example: LVH and AS.
❖THRUSTING:
Forceful, less sustained, lifting the examining finger
(volume overloaded).
• Example: left ventricular dilatation (MR & AR).
❖TAPPING APEX:
Neither sustained nor forceful, not lifting the finger. It is
the palpable first heart sound. Example: MS (rarely TS).
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❖ CAUSE:
▪RVH
➢PH,
➢COR PULMONALE,
➢PS AND PR &
➢TR.
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PURCUSSION:
Usually not done; may be helpful to diagnose pericardial
effusion (area of cardiac dullness is increased) and
emphysema (cardiac dullness is oblitered).
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AUSCULTATION:
1. See first and second heart sounds in all areas. At the same
time, palpate right carotid pulse simultaneously with
thumb. First heart sound coincides with carotid pulse, the
second sound does not (comes after).
2. Murmur:
– Site (apical, parasternal, aortic or pulmonary area).
– Nature: Systolic (pansystolic or ejection systolic), diastolic (mid-
diastolic or early diastolic) by feeling carotid pulse at the same
time (systolic coincides with carotid pulse, and diastolic does not
coincide).
– Radiation (PSM to left axilla and ESM to neck).
– Relation with respiration (right sided murmur increases on
inspiration and left sided murmur increases on expiration).
– Grading of murmur (2/6 or 4/6).
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AUSCULTATION: CONT.
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HEART SOUNDS:
1. FIRST HEART SOUND:
– Loud in MS, TS (occasionally in anxiety & exercise).
– Soft or absent in MR, myocarditis and cardiomyopathy.
2. SECOND HEART SOUND: Splitting is better heard in
pulmonary area, in inspiration due to prolonged
right ventricular systole.
CAUSES OF WIDE SPLITTING OF SECOND SOUND:
– PS.
– RBBB.
– ASD.
– Wide and fixed splitting: ASD.
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MURMUR:
❖SYSTOLIC.
❖DIASTOLIC.
❖CONTINUOUS.
SYSTOLIC MURMUR
1. Pansystolic murmur:
➢MR.
➢TR.
➢VSD.
➢AORTOPULMONARY SHUNT.
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3. Late systolic:
MVP and Papillary muscle dysfunction.
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DIASTOLIC MURMUR:
1. EDM (Early diastolic murmur) (soft, high pitched,
blowing): Causes:
➢AR.
➢PR (Graham Steell murmur in left second, third, and
fourth space).
2. MDM (Mid diastolic murmur):
➢MS.
➢TS.
➢Left Atrial Myxoma.
➢Austin Flint Murmur in AR.
➢Carey Coombs Murmur (Due To Mitral Valvulitis In
Acute Rheumatic Fever, RF).
➢ASD (Due To Increased Flow Through Tricuspid Valve).
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CONTINUOUS MURMUR:
➢PDA.
➢AV fistula (coronary, pulmonary or systemic).
➢Aortopulmonary fistula (congenial/B-T shunt).
➢Venous hum.
➢Rupture of Sinus of Valsalva to right ventricle or
atrium.
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GRADING OF MURMUR:
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