This document summarize the main important steps in examination of cardiovascular system or examination of the precordium.
The main clinical related points are also illustrated in the presentations.
This file is very important for OSCE exam and other practical skills exams.
General examination related to heart
1. Hands and arms
Osler’s nodes, janeway’s lesions and splinter hemorrhage
Radial and brachial pulse
Central cyanosis and dental caries
Malar rush, corneal arcus, xantholesmata, petechial rush on conjunctiva
Fundiscopy for retinopathy and roths spots.
4. Lower limbs
Dorsalis pedis,posterior tibial, popliteal and femoral pulses.
Veins (varicosed, DVT)
• Lung base for crackles and pleural effusion
• Hepatomegaly, ascites, Sacral odema
• Should be considered in COPD
• An indicator for pulmonary hypertension.
• Petechial rush and fever is transient finding in IE.
• May be misdiagnosed with meningiococcal diseases.
Do not forget to ...
• Put your stethoscope on lung base to hear crackles and pleural
• The pulse waveform depends upon heart rate, stroke volume, left
ventricular outflow obstruction, arterial elasticity and peripheral
• 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
• Pulse volume is representitive for pulse pressure
• Pulse pressure = Systolic BP – Diastolic BP
• 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.
JVP vs. Arterial pulsation
1. Abdomino-jagular reflux
• 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.
• 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)
What to palpate ?
1. Apex beat
4. Palpable heart sounds
How to palpate ?
Palpable hear sound
Apex beats (1)
• Lower most lateral most palpable impulses.
• Normally located at 5th intercostal space at or medial to mid-clavicular
• Resulting from rotating of heart, moving forward and striking of the
• Apex beats are able to slightly lifting your fingers overlying it
• Should be palpable at semi-recumbient position and if not at lateral
• Has characteristics that should be observed.
• It felt with tips of your fingers (!)
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).
• 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
• 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
• Remember, any murmur could produce thrill.
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
Putting all together you should look for ..
1. Mitral area
• Apex beats
• Palpable S1, S3 and S4.
2. Left parasternal area
3. Erb’s area
• Only thrills
4. Left 2nd intercostal space (pulmonary area)
• Palbablel S2 (P2)
5. Right 2nd intercostal space (aortic area)
• Thrills only
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)
• 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
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.
• Auscultatory area is the same areas that are palpated in palpation.
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
All systolic murmurs Mitral stenosis
All diastolic murmurs except mitral stenosis
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.
• Sound of MV and TV closure.
• MV closure precedes TV closure.
• Best heard at the mitral (apex) area.
• 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)
• 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
• It is the 1st sign of CHF.
• Produces a ventricular gallop.
• Heard after S2 as lub-dub-dum
• 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
• 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
• 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.
• Occurs in mitral valve prolapse (regurgitation)
• Best heard with stethoscop. Diaphragm when patient leaning forward
and breathing out.
• 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.
• Right sided murmurs are often intensify during deep inspiration
• Left sided murmurs do not change intensity with deep inspiration.
• Stenosis murmur = problem with opening
• Regurgitation murmurs = problem with closing
• Systolic murmurs
• Diastolic murmurs
• MS is accompanied by opening snap due to forceful opening of
partially movable valve by strong atrial contraction.
• AS and PS produces ejection type of murmur which has a diamond
• MR and TR are pan-systolic murmurs
• AV and PV regurgitation are diastolic murmurs heard after S2.
Comment on murmur
1. Site of maximal intensity
2. Timing of murmur
• All ejection murmurs are harsh
• Regurgitate = blowing
• MS = rumbiling
5. Grading of murmur