1.
cardiac examination
Abbas A. A. Shawka

2.
Cardiac examination include …
1. General examination related to heart
2. Regional examination (of the precordium)

3.
General examination

4.
General examination related to heart
1. Hands and arms
 peripheral cyanosis
 Osler’s nodes, janeway’s lesions and splinter hemorrhage
 Clubbing,
 Radial and brachial pulse
2. Face
 Central cyanosis and dental caries
 anemia, Jaundice
 Malar rush, corneal arcus, xantholesmata, petechial rush on conjunctiva
 Fundiscopy for retinopathy and roths spots.
3. Neck
 JVP,
 Carotid pulse
4. Lower limbs
 Odema
 Dorsalis pedis,posterior tibial, popliteal and femoral pulses.
 Veins (varicosed, DVT)
 Petechial rush

5.
5. Chest
• Lung base for crackles and pleural effusion
6. Abdomen
• Hepatomegaly, ascites, Sacral odema

6.
Malar rush
• Should be considered in COPD
• An indicator for pulmonary hypertension.

7.
Petechial rush
• Petechial rush and fever is transient finding in IE.
• May be misdiagnosed with meningiococcal diseases.

8.
Do not forget to ...
• Put your stethoscope on lung base to hear crackles and pleural
effusion.

9.
Pulse
• The pulse waveform depends upon heart rate, stroke volume, left
ventricular outflow obstruction, arterial elasticity and peripheral
resistance.
• Comment on pulse in rate, rhythm, volume and character.
• Volume represent the stroke volume and left ventricular filling,
increased volume occurs when there is delay in ventricula filling and
so on.
• Pulse volume is representitive for pulse pressure
• Pulse pressure = Systolic BP – Diastolic BP

10.
Pulse character
• Slow rising pulse occurs in severe aortic stenosis.
• Collapsing pulse occurs in aortic regurg
• Bisferins puls occured in concomitant aortic stenosis and regurg.
• Pulsus paradoxus is exagerated in normal variation of of the volume
with respiratory cycle thus increased in expiration and decreased in
inspiration and this seen in cardiac tamponade and in asthma.
• Pulsus alternans is rare and seen in advanced heart failure.

11.
JVP vs. Arterial pulsation
1. Abdomino-jagular reflux
2. Occlusion
3. Waveforms
• a wave result from atrial contraction
• v wave result from atrial filling in systole
• c wave rarely seen when tricuspid valve close
1. Changes with repiration
• JVP decreases with inspiration due to decreasesd ITP.

12.
Regional examination

13.
Precordium examination
1. Inspection
2. Palpitation
3. Percussion
4. Auscultation

14.
Inspection

15.
Inspection
• Chest deformities
• Pigenon’s chest, barrel chest, excavatum carinatum
• Kyphosis or scoliosis
• scars
• Midline sternotomy (valves, coronary arteries)
• Left Submammary scar (closed mitral valvotomy)
• Infraclavicular scar (defibrillato or pace-maker)
• Visible pulsations
• Location dependent
• LVH in apical, aortic aneurysms in suprasternal, right sternal border and
epigastric area, pulmonary artery enlargement in pulmonary area

16.
Palpitation

17.
Palpitation
• Palpitation is in the same area of auscultation
• 5 auscultation areas
1. Mitral area
2. Tricuspid area
3. Erb’s area (left parasternal area)
4. Pulmonary area (left 2nd intercostal space)
5. Aortic area (right 2nd intercostal space)

18.
Erb’s area
1
2
3
45

19.
What to palpate ?
1. Apex beat
2. Heaves
3. Thrills
4. Palpable heart sounds

20.
How to palpate ?
Palpable hear sound
Heaves
Thrills

21.
Apex beats (1)
• Lower most lateral most palpable impulses.
• Normally located at 5th intercostal space at or medial to mid-clavicular
line.
• Resulting from rotating of heart, moving forward and striking of the
chest wall.
• Apex beats are able to slightly lifting your fingers overlying it
• Should be palpable at semi-recumbient position and if not at lateral
decubitus position.
• Has characteristics that should be observed.
• It felt with tips of your fingers (!)

22.
Apex beats (2)
1. Pressure loaded or heaving apex beat represent hypertrophy
• Forceful, sustained and not displaced
• Seen in hypertension and Aortic stenosis
2. Volume loaded or thrusting apex beat represent dilation
• Displaced, diffused not sustained
• Occurs in advanced mitral regurgitation or aortic regurgitation.
3. Dyskinetic abex beat
• Uncoordinated, felt over a large area
• Seen in left ventricular dyfunction
4. Double apex beat
• 2 impulses in systole and seen in cardiac myopathy
5. Tapping apex beat
• Non-displaced, seen in mitral stenosis represent palpable first heart sound (S1).

23.
Heaves
• Palpable impulses that is lift your hand (not fingers) noticiblly.
• They results from RVH and LVH
• LVH heaves are felt on mitral (apical) area.
• RVH heaves are felt on the left parasternal area.
• They best to be felt by your hand bell.
• So, in examination you should but your hand bell
(metacarpophalangeal joints) only in apical and left parasternal area
vertically.

24.
Thrills
• Skin vibrations indicating of loud murmur.
• Could be felt with metacarbal bones at any area of the 4 valvular
areas (mitral, tricuspid, pulmonary or Erb’s and aortic areas).
• There is systolic and diastolic thrills (depend wheather this is a systolic
or diastolic murmur)
• Thrill associated with mitral stenosis is best felt in lateral decubitus
position.
• Remember, any murmur could produce thrill.

25.
Palpable heart sounds
• Heart sound are not palpable in normal, healthy individual.
S1 Mitral Mitral stenosis
S2 Pulmonary Pulmonary hypertension
S3 Mitral Constrictive pericarditis or pericardial knock
S4 Mitral Hypertrophic obstructive cardiomyopathy

26.
Putting all together you should look for ..
1. Mitral area
• Apex beats
• Heaves
• Thrills
• Palpable S1, S3 and S4.
2. Left parasternal area
• Thrills
• Heaves
3. Erb’s area
• Only thrills
4. Left 2nd intercostal space (pulmonary area)
• Palbablel S2 (P2)
• Thrills
5. Right 2nd intercostal space (aortic area)
• Thrills only

27.
Cont’d …
6. Patient in lateral decubitus position
• Thrills of mitral stenosis
• Apex beat if not felt previously
7. Patient on stand
• Thrills on pulmonary and aortic area (vulvular stenosis)

28.
Percussion

29.
Percussion
• Clinical benefits of percussion is in cases of
(1) Emphysema  dullness on cardiac apex
(2) Pericardial effusion  dullness on sternum
(3) Ascending aortic aneurysm  dullness on right 2nd intercostal space

30.
Auscultation

31.
Notes on inspiration and expiration
• Inspiration lead to decrease intrathoracic pressure
• Expiration lead to increase intrathoracic pressure
• Inspiration make a load on heart due to increase VR and SV.

32.
Auscultations
• Auscultatory area is the same areas that are palpated in palpation.
Erb’s
area
1
2
3
45

33.
Bell or diaphragm ?!
• High pitched sounds are best heard with diaphragm
• Low pitch sound are best heard with bell
High pitch sounds Low pitch sounds
S1 S3
S2 S4
All systolic murmurs Mitral stenosis
All diastolic murmurs except mitral stenosis
Opening snaps

34.
So, …
1. Put your diaphragm at all areas when patient in semi recumbient
position and when leaning forward with focefull expiration to
examine aortic regurgitation.
2. Put your stethoscope bell at
• Mitral area for left ventricular S3 and S4 and mitral stenosis
• Left and right parasternal areas for right ventricular S3 and S4
• Mitral area at lateral decubitus position for mitral stensosi.

35.
On auscultation, you should determine ..
• S1 (loud, normal, diminished)
• S2 (loud, normal, diminished)
• S3
• S4
• Opening snaps
• Ejection clicks
• Mid-systolic click
• Prosthetic valve sounds
• Pericardial rub
• Murmurs

36.
S1
• Sound of MV and TV closure.
• MV closure precedes TV closure.
• Best heard at the mitral (apex) area.

37.
S2
• Produced by AV and PV closure.
• S2 is best heard at left second ICS.
• S2 = A2 + P2
• A2 normally precedes P2 on inspiration (physiological splitting)
• Physiological splitting is best heard at pulmonary area.
• Accentuated A2 = essential HTN (Snap shut)
• Accentuated P2 = Pulmonary HTN (snap shut)

38.
S3
• Most clinically significant heart sound.
• Represents ventricular filling during early diastole.
• Pathological if found in >40yrs
• Best heard at apex with lateral decubitus position
• Occurs with regurgitation type of murmurs involve any type of valves, due
to stretching of MV and TV rings leading to regurgitation and volume
overload.
• It is the 1st sign of CHF.
• Produces a ventricular gallop.
• Heard after S2 as lub-dub-dum

39.
S4
• It is always pathological.
• Represents atrial contraction in late diastole and a wave in JVP.
• Best heard at the apex.
• Results from decreased ventricular compliance, and may present with
S3 in volume-overloadded left or right ventricle.
• S4 and a wave in JVP are absent in atrial fibrillation.
• It produce atrial gallop.
• Summation gallop = S3+S4
• Heard before S1 as da-lub-dub

40.
Opening snaps
• Restricted opening of stenosed MV (rarely TV)
• Heard after S2 in MS in mitral area by diaphragm.
• Audible when valve is mobile.
• When LA pressure is high = after S2 immediately.
• When LA pressure is low = after S2 later.
• At the end of ventricular systole, the aortic and pulmonic valves close,
generating the second heart sound, s2. ~ is followed by a brief period of
isovolumic relaxation; during this time, ventricular pressures fall. When
ventricular pressures are less than atrial pressures, the mitral and tticuspid
valves open. Normally, the opening of these heart valves is inaudible.
However, if the mitral valve leaflets become stenotic or abnormally
narrowed while remaining somewhat mobile, they create an opening snap
(OS).

41.
Ejection clicks
• Result from restricted opening of stenosed AV and PV
• Heard after S1 on aortic OR pulmonary area.
• Indicate valvular lesion and only when valve is mobile.

42.
Mid-systolic click
• Occurs in mitral valve prolapse (regurgitation)

43.
Prosthetic valve sounds
• Prosthetic produces quiet opening sound and loud closure sound
• Mitral valve prosthesis = S1 (loud) + S2 + click (quiet)
• Aortic valve prosthesis = S1 + click (quiet) + S2 (loud)

44.
Pericardial rub
• Best heard with stethoscop. Diaphragm when patient leaning forward
and breathing out.

45.
Murmurs (1)
• Causes are :
(1) Structural valve diseases
(2) Stretching of valve rings (Functional murmurs)
• Murmurs often radiates (MR to axilla) and (AS to neck)
• 6 grades according to intensity
• Grade 1 and 2 are very hard to hear
• Grade 3 is easy to hear
• Grade 4 and 5 with thrill
• Grade 6 is audible without stethoscope.

46.
Murmurs (2)
• Right sided murmurs are often intensify during deep inspiration
(why?)
• Left sided murmurs do not change intensity with deep inspiration.
• Stenosis murmur = problem with opening
• Regurgitation murmurs = problem with closing

47.
Murmurs (3)
• Systolic murmurs
• AS
• PS
• MR
• TR
• Diastolic murmurs
• MS
• TS
• AR
• PR

48.
Murmurs (4)
• MS is accompanied by opening snap due to forceful opening of
partially movable valve by strong atrial contraction.

49.
Murmurs (5)
• AS and PS produces ejection type of murmur which has a diamond
shape.

50.
Murmurs (6)
• MR and TR are pan-systolic murmurs

51.
Murmurs (7)
• AV and PV regurgitation are diastolic murmurs heard after S2.

52.
Comment on murmur
1. Site of maximal intensity
2. Timing of murmur
3. Characteristics
• All ejection murmurs are harsh
• Regurgitate = blowing
• MS = rumbiling
4. Radiation
5. Grading of murmur

53.
Systolic murmurs
• AS
• PS