Examination of the Cardiovascular System

Posted: July 18, 2010 by gerardloh in Medicine

by Dr James Joseph, MD, CSMU (UKRAINE) 2010]

1. Introduce yourself and ask for permission to examine the heart. This is good bedside manner and will help to establish rapport with px.

2. Make sure the patient is positioned at 450 and adequately exposed.

3. Observe carefully for tachypnea, orthopnea, cyanosis, and “spot diagnoses” that are associated with heart diseases:

•Eg: Presence of titilbation (head-nodding) and Corrigan’s sign in the neck will greatly help in the diagnosis of aortic incompetence.

Malar flush = mitral stenosis

Turner’s syndrome= coarctation and bicuspid aortic valve

Down’s syndrome = ASD, VSD and Fallot’s tetralogy

Noonan’s syndrome = pulmonary valve dysplasia and hypertrophied cardiomyopathy

Marfan’s syndrome= aortic or mitral incompetence

Myx0edema facies = pericardial effusion
Corneal Arcus

Slide 9

4. Upper limbs:

a) Palms

– moisture -> dry @ moist
– temperature -> warm @ cold – colour -> pink @ pale

b) Finger
– cyanosis -> peripheral cyanosis
– capillary filling


– stigmata of IE: Osler nodes, Janeway lesion, Splinter  hemorrhage

Splinter haemorrhage may also be seen in trauma, connective tissue diseases, and trichinella infection

Osler’s node is uncommon but important sign of infective endocarditis
Raised tender nodules on the pulp of the fingers, toes, thenar or hypothenar eminences

Janeway lesions (non-tender erythematous maculo-papular lesions containing bacteria)

– tendon xanthomas
– nicotine stain

c) Pulse

Begin by feeling the patient’s right radial pulse carefully with the index and middle fingers of the left hand (The radial pulse will be easier to feel if the wrist is slightly flexed)

Note down:
•Rate (count 60 seconds rather than 15 seconds X 4: you may miss ectopics coming later)
•Rhythm -> regular @ irregular
•Character (particularly looking for collapsing pulse)
•Radio –radial delay
•Radio – femoral delay (in coartation of aorta)

ØThe rest of the pulses are examined to determine if they are present and equal on both sides


Undergraduates are expected to detect atrial fibrillation (irregularly irregular pulse) and a collapsing pulse.

The collapsing pulse is best elicited by grabbing the patient’s left wrist with your left hand (bottom, left). After you have detected the pulsation of his radial pulse in your palm, gradually relax the grip of your hand until the radial pulse just disappear. Then with the help of your right hand, lift the patient’s arm in the air (bottom, right) while maintaining the same grip pressure. If the pulse returns, it has become more forceful and thus deemed collapsing.
Causes of collapsing pulse:
aortic incompetence
hyperdynamic circulation: severe anaemia, thyrotoxicosis, Paget’s disease
peripheral arteriovenous fistula
Arterosclerotic aorta (in elderlies)

d ) and don’t forget to measure the patients’ BLOOD PRESSURE

5. Neck

a) Carotid pulse
– Volume
– Character
– Bruits

b) Jugular venous pressure
•Examine the internal jugular vein (JVP) in the neck carefully to determine the height (usually this will be sufficient for undergraduates)
•Turn the patient’s face slightly away and look for a pulsation in the neck . If present, determine if it is arterial or venous.
•If it is a venous, measure its height at the sternal angle with the help of 2 rulers always keeping your eyes at the level of the horizontal ruler . When the height is more than 3 cm above the sternal angle, the JVP is raised.

Causes of elevated JVP
•Right ventricular failure
•Volume overload
•SVC obstruction
•Tricuspid stenosis or regurgitation
•Pericardial effusion
•Constrictive pericarditis

6. Head

high-arched palate (Marfan’s syndrome)

– stigmata of hyperlipidemia (xanthelasma) & thyroid disease

7. Lower Limbs
a) pitting edema

b) peripheral pulses
c) cyanosis, cold limbs, trophic changes, ulceration (peripheral vascular disease)
d) clubbing of toes

Specific examination of praecordium

Every auscultation, listen for…

•1st & 2nd heart sound & their intensity
•Extra heart sound (S3 & S4)
•Additional sound ( opening snap, systolic ejection click)
•Fixed splitting  2nd heart sound (only in pulmonary area, ASD

**Auscultatory features of heart murmurs
1) When does it occur?
– Time the murmur using heart sounds, carotid pulse and the apex beat, is it systolic or diastolic?
– Does the murmur extend throughout systole or diastole or is it confined to a shorter part of the cardiac cycle?
2) How loud is it? (intensity)
– Grade 1: Very soft (only audible in ideal conditions)
– Grade 2: Soft
– Grade 3: Heard all over the precordium
– Grade 4: Loud, with palpable thrill (ie, a tremor or vibration felt on palpation)
– Grade 5: Very loud, with thrill. May be heard when stethoscope is partly off the chest
– Grade 6: Very loud, with thrill. May be heard with stethoscope entirely off the chest
3) Where is it heard best? (location)
– Listen over the apex and base of the heart, including the aortic & pulmonary areas
4) Where does it radiate?
– Evaluate radiation to the neck, axilla or back
5) What does it sound like? (pitch & quality)-> harsh/blowing/rough
– Pitch is determined by flow ( high pitch indicates high-velocity flow)
– Is the intensity constant or variable?
Heart sounds

If there is a murmur, 5 things to comment:

1) timing -> systolic/diastolic
2) area of greatest intensity
3) Radiation -> axilla? neck?
4) Grading -> 1-6
5) changes with alteration of position
( left lateral position@ sitting forward)
6) effect of dynamic maneuvers( mainly respiratory)
à ask pt to inspire, expire fully n hold

Eg: There is a pansystolic murmur best heard over the mitral area with radiation to  axilla, graded 3/6 and accentuated during inspiration and left lateral position

Site of murmur radiation
1. mitral regurgitation à left axilla
2. aortic stenosis à right side of neck
3. aortic regurgitationà left sternal bord
c) Fundus
– hypertensive retinopathy
– Roth spots (IE)
d) Abdomen
– palpate liver & spleen(enlarge?)
– percuss -> ascites (shifting    dullness)
e) Check for temperature chart , urine output , CXR (if present)
f) Take BP if forget b4 this
*** DDx of chest pain
1) Anxiety/emotion
2) Cardiac: angina, MI, myocarditis, pericarditis, mitral valve prolapse
3) Aortic: aortic dissection, aneurysm
4) Esophageal: esophagitis, esophageal spasm, Mallory-Weiss syndrome
5) Lungs/pleura: bronchospasm, pulmonary infarct, pneumonia, tracheitis, pneumothorax, pulmonary embolism
6) Musculoskeletal: osteoarthritis, rib fracture/injury, intercostal ms injury
7) Neurological: prolapsed intervertebral disk, herpes zoster
  1. MalaysianMedicalStudent says:

    The government shud actually ban graduates from UKRAINE, RUSSIA, INDONESIA, BANGLADESH AND ROMANIA from practising locally without sitting for a thorough examination set and marked by Universiti Malaya. This is becoz tooo many docs are coming from these countries and their quality is just HORRIBLE.They are spoiling the noble profession due to their EXTREME low levels of knowledge, inappropriate techniques, laziness, trying to evade work and creating a crowded population of doctors in Malysia. Ouantity is not important….Quality is what matters

    • gerardloh says:

      Strongly disagree. It’s up to individuals whether these graduates work hard or choose to be lazy. There are bad apples everywhere. Would you dare say all UM/local grads are perfect at their jobs? I beg to differ. Students lucky enough to enter local universities have the chance to practice locally before graduating, familiarize with the local working conditions, ofcourse they have the upper hand. Whereas overseas, chances are the locals do not like foreigners performing procedures on them. Unfortunately it is so, however,practically we may be understrength but theoretically we may be superior. Do not scrutinize other grads just because they are not familiar with local protocols. We are working hard to improve our “Msian medical knowledge” here at HOW, our objectives are clear and intentions perfect. So if you do not wish to contribute, y bother? Mind your own business and bring your comments elsewhere. Thank You.

  2. student says:

    thanks for the interesting information, i liked it very much…

  3. gerardloh says:

    Hi there,
    Unfortunately, this photo was taken off another source which I do not remember. I guess you may use it for your book.
    All the best!

  4. Pat P. Ang says:

    I wish I can contribute some works about tropical diseases, virology, or infectious disease, please contact me if I was permitted to do. Thanks.

    With Love from Moscow,

  5. T-s says:

    Thank you verrrrry much its really helpful ..
    Jazakom allah khairan ..

  6. Arz Muhammad says:

    Thanks its really informative and helpful. thanx

  7. balika says:

    really helpful thanx

  8. dr, jakta says:

    Thank you verrrrry much its really helpful .

  9. Harina Horsi says:

    Thank you so much! It’s very clear. 🙂

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