HISTORY TAKING & PHYSICAL

EXAMINATION OF
CARDIOVASCULAR SYSTEM
Resource Person : dr. M. Yusak, SpJP (K)
Outline

History Taking
Physical Examination
Case Discussion
History taking
Major Complaint

Chest pain

Dyspnea

Edema

Palpitation

Syncope

Intermittent claudication
Chest Pain
Quality

Relieving
Location
factor

Severity
Chest Radiation
pain

Alleviating
factors &
Triggers
associated
symptoms
Duration
Rhee JW et al. Ischemic Heart Disease. In Lilly LS (ed). Pathophysiology of Heart Disease 9th ed. 2011
Roger Hall, Iain Simpson. Cardiovascular History & Physical Examination. In Camm AJ et al The ESC Textbook of
Cardiovascular Medicine. 2009
Risk factors for Ischaemic Heart Disease

Diabetes
Dislipidemia Smoking
mellitus

Family
Hypertension Obesity
history
Dyspnea

difficulty getting their breath

Distinguish cardiac cause and another cause of dyspnea
Cardiac breathlessness is made worse by lying flat (orthopnea)
PND is a very specific symptom and indicates severe cardiac
dysfunction
 Ankle Swelling

Unilateral or bilateral Drugs

Calcium channel blockers
Proximal extent of oedema
Other
Pitting/non-pitting
Cirrhosis
Cardiac Nephrotic syndrome
Congestive cardiac failure Protein-losing enteropathy
Right ventricular failure Deep vein thrombosis
Cor pulmonale Hypothyroidism
Constrictive pericarditis Lymphedema
Palpitations

= awareness of the heartbeat and feel thumping in the chest

Heart racing or pounding or fluttering in the chest

Regular or
irregular

Associated Onset and

symptoms offset

Palpitation

Precipitating
Duration
factors
Syncope

= Transient loss of consciousness

What was patient due to cerebral
hypoperfusion doing at the time
Standing for
prolonged period
Syncope
Standing up
suddenly
Prodromal
symptoms
Abnormal
movements
Sensation of room
spinning
Roger Hall, Iain Simpson. Cardiovascular History & Physical Examination. In Camm AJ et al The ESC Textbook of
Cardiovascular Medicine. 2009
Intermittent Claudication

Pain in one or both calves, thighs or buttocks

Brought on by walking a certain distance

Worse on walking uphill

Relieved by rest

Suggest peripheral arterial disease

Past Medical History
Rheumatic fever

Previous cardiac investigation

Previous myocardial infarction

Coronary angioplasty & stent insertion

Coronary artery bypass grafting

Pacemaker insertion
Medications

Anti-anginal agents
Use of sublingual nitrate spray
Antihypertensive agents
Anti-arrhythmics
Statins
Platelet inhibitors, e.g., Aspirin
Anticoagulants, e.g., Warfarin

Allergies
Physical examination
General Physical Examination
General Appearance

Age
Posture
General health status
Vital signs
Peripheral oxygen saturation
Skin

Central or peripheral cyanosis

Differential cyanosis
Head & Neck

High-arched palate Marfan syndrome

Hypertelorism, low-set ears, micrognathia, and a webbed neck
Down syndromes
Proptosis Graves disease
Palpation of the thyroid gland assesses its size, symmetry, and
consistency
Chest & Abdomen

Thoracic cage abnormalities

Intercostal artery collaterals
Ascites
Abdominal aorta
Extremity

Clubbing fingers
Arachnodactyly characterize Marfan syndrome
Janeway lesions, Oslers nodes, splinter hemorrhage
Edema
Fang JC dan OGara PT. Evaluation of the Patient. In Douglas LM et al (ed). Braunwalds Heart Disease 10th ed.
Philadelphia: 2015.
Cardiovascular Examination
 Pulse
Asses
Rate
Rhythm
Pulse character
Radiofemoral difference
Rate
If the rhythm is regular and the rate seems normal
count the rate for 15 seconds and multiply by 4
If the rate is unusually fast or slow
count for 60 seconds

03 36 6 12 1 10 > 10 Trained
Mo Mo Mo Yo Yo Athletes

100-150 90-120 80-120 70-130 60-100 40-60

 Rhythm
If irregular:
1. Do early beats appear in a basically regular rhythm?
2. Does the irregularity vary consistently with respiration?
3. Is the rhythm totally irregular?
Peripheral Pulse
 Carotid Pulse

- Provides valuable information about cardiac function.

- Useful for detecting stenosis or insufficiency of the aortic valve.
- Assess: quality of the carotid upstroke, its amplitude and contour, and presence
or absence thrills or bruits.
- Patient should be lying down with the head of the bed still elevated to about
30.
Pulse Character
Smooth, rounded. Notch is not palpable.

Diminished, feels weak and small, slowed upstroke.

Ex.: Hypovolemia, severe AS, increased peripheral resistance.

Increased, strong. Rapid rise and fall, the peak brief.

Ex.: AR, MR, VSD.

Increased arterial pulse, double systolic peak.

Ex.: Severe AR with/without AS, HOCM.

The pulse alternates in amplitude from beat to beat, rhythm regular.

Ex.: LV heart failure.

The normal beat alternating with a premature contraction. The pulse varies in
amplitude. Ex: AES, VES.

Systolic pressure decreases by more than 10 mm Hg during inspiration.

Ex.: Pericardial tamponade, constrictive pericarditis, obstructive lung disease.
 Blood Pressure
Measurement the lateral force per unit area of vascular wall.
Systolic blood pressure is controlled by the stroke volume and the
stiffness of the arterial vessels.
Diastolic blood pressure is controlled primarily by peripheral
resistance.
Infant & Children:
 Korotkoff Sounds

Sounds produced by the pulsations of an artery under a partially

constricting blood pressure cuff (N. S. Korotkoff, 1905).
Divided by 5 phases.
 TECHNIQUES OF EXAMINATION EXAM

Points to Remember rapidly inate the cuff until the radial pulse disappears. Read this pressure on
the manometer and add 30 mm H g to it. U se of this sum as the target for sub-
sequent inations prevents discomfort from unnecessarily high cuff pressures.
I t also avoids the occasional error caused by an auscultatory gapa silent in- An un
terval that may be present between the systolic and the diastolic pressures. gap m
estima
Deate the cuff promptly and completely and wait 15 to 30 seconds. (e.g.,
p. ___
Now place the bell of a stethoscope lightly over the brachial artery, taking care diasto
to make an air seal with its full rim. Because the sounds to be heard (K orotkoff

Fossa cubiti should be at the level of the heart sounds) are relatively low in pitch, they are heard better with the bell.

Arm muscle must be relaxed

Cuff width should be 40% of arm circumference
Too small overestimated If you
record

Too big under estimated

(e.g.,
gap fr

Determine roughly the systolic pressure

Deflate cuff slowly
Measure in both arms

LRQ&RS\
I nate the cuff rapidly again to the level just determined, and then deate it
slowly at a rate of about 2 to 3 mm H g per second. Note the level at which
you hear the sounds of at least two consecutive beats. This is the systolic
pressure.

Continue to lower the pressure slowly until the sounds become mufed and In som

XDW
then disappear. To conrm the disappearance of sounds, listen as the pres- and th
sure falls another 10 to 20 mm H g. Then deate the cuff rapidly to zero. farthe
The disappearance point, which is usually only a few mm H g below the muf- aortic

( YDO
ing point, enables the best estimate of true diastolic pressure in adults. never
than 1
both

C H A PT ER 3 B EG I N N I N G T H E PH YSI C A L EX A M I N A T I O N : G EN ERA L SU RV EY A N D V I T A L SI
Factors Affecting Blood Pressure

Anxiety, stress pain

Exercise
Exposure to cold
Postprandial state
Drugs
Pregnancy
 Blood Pressure
Compare between sites
Both arms differ < 10 mmHg
> 10 : subclavian steal syndrome, supravalvular AS, aortic coarctation or
dissection
Legs > arms differ < 20 mmHg
> 20 : Hill Sign (AR)
Legs < arms
PAD, aortic coarctation or dissection
 Pulse Pressure
Systolic blood pressure Diastolic blood pressure
Wide
Increase in stroke volume, often with a decrease in peripheral resistance
Ex: Fever, anemia, exercise, hyperthyroidism, pregnancy, arteriovenous fistulas,
aortic regurgitation, septic, anaphylaxis
Reduced arterial compliance
Ex: Atherosclerosis or stiff large arteries

Narrow
Increased peripheral resistance
Ex: Increased circulating catecholamines in heart failure
Decreased stroke volume
Ex.: Aortic stenosis, mitral stenosis, decreased intravascular volume
 Jugular Venous Pressure

Important clinical indicator of cardiac function and right heart

hemodynamics.
Best estimated from Internal Jugular Vein, usually on right side.
JVP Measurement
Features of Jugular Venous Pulse
and Carotid Pulse
Waveform
of the JVP
JVP Abnormalities
 Abdominojugular reflux

Firm and consistent pressure over the right upper quadrant

abdomen for at least 10-15 seconds.
Positive response A sustained rise of more than 3 cm.
Predict heart failure and a pulmonary artery wedge pressure
higher than 15 mm Hg.
 Kussmauls Sign

A rise in venous pressure with inspiration.

Seen with right- sided volume overload and reduced RV compliance.
Associated with :
- constrictive pericarditis
- restrictive cardiomyopathy
- pulmonary embolism
- RV infarction
- advanced systolic heart failure.
 Ankle Brachial Index
Ratio of the systolic BP measured at the ankle to the systolic BP measured at the
brachial artery.
The normal ABI should be 1.0 or greater.
ABI of less than 0.90 is considered abnormal.
90% to 95% sensitive and 98% to 100% specific for angiographically verified
peripheral arterial stenosis.
Heart Inspection
Scars
Median sternotomy
CABG
Valve replacement
Lateral thoracotomy
Infraclavicular (pacemaker)
Pectus excavatum
Pacemaker box
Apex beat
Heart Inspection
Pectus Carinatum
Abnormal protrusion of the anterior chest wall
Heart Inspection
Pectus Excavatum
Sunken / funnel chest
Heart Palpation
Locate the apex
Palpate any heaves or thrills
Heart Palpation
Palpation all over the front of the chest pick up abnormal
movement of the chest wall related to the contraction of the
underlying heart, and thrills (palpable murmurs).
Coarctation
Palpation of the back widespread diffuse pulsation secondary
to large collaterals running in the muscles of the back
Pulmonary hypertension
the pulmonary artery dilates produces an impulse in the
second left intercostal space and the loud pulmonary component
of the S 2 may also be appreciated as a sharp snapping feeling in
this area.
Heart Palpation
Apical Impulse
Point of maximal impulse
Usually located in the fifth intercostal space at the level mid-
clavicular line
Patient lying in bed on their left side heart in contact with the
chest wall
Abnormalities
A forceful apex concentric LV hypertrophy
Impulse displaced to the left and have a more diffuse heaving
nature eccentric LV hypertrophy
Sharp tapping impulse MS
In-drawing of the intercostal spaces during systole
Constrictive pericarditis
Left Parasternal Heave RV hypertrophy
Heart Auscultation
Sounds From CVS

Cardiac sounds :
- Normal
- Abnormal
Extra Cardiac Sounds
- Arterial system : Bruit
- Venous System : Humm (esp in young children)
 Heart Sounds
S1

Location Pitch Source Accentuated with Diminished with

Apex High Closure of mitral 1. Shortened PR 1. Lenghtened PR
and tricuspid interval Interval
valve 2. Mild mitral 2. MR
stenosis 3. Severe MS
3. High output 4. Stiff Left
states Ventricle

Split S1 occurs in patients with RBBB

Due to delayed RV contraction
Heart Sounds
Heart Sounds
S2
Location Pitch Source Accentuated with Diminished with
2nd High Closure of aortic 1. Systemic HT 1. Severe
Intercostal and pulmonic 2. Pulmonary HT aortic/pulmo
LSB valves stenosis

Component of S2 (A2 and P2) vary with the respiratory cycle

Physiologic Splitting
Expansion of the chest intrathoracic more negative increase capacitance
pulmonary vessel temporary delay in diastolic back pressure in pulmonary
artery P2 delayed
capacitance intrathoracic VR SV shorten LV emptying A2
earlier
Heart Sounds

S1 A2 P2

S1 A2 P2

S1 A2 P2

S1 P2 A2
Heart Sounds
Ejection Clicks
Location Pitch Source Causes
Aorta: apex High 1. Aortic/pulmonary 1. Stenosis aorta/pulmoner
and base valve stenosis 2. Dilated artery
Pulmo: base ascend to artery pulmonary/aorta
decrease abruptly
2. Dilated artery
pulmonary/aorta
sudden tensing root
ec blood flow

Coincidence with opening of aortic/pulmonary valve

Pulmonary Ejection clicks intensity diminised during inspiration
Heart Sounds
Mid to Late Clicks
Location Pitch Source Causes
Mitral: Apex High Prolapse of 1. Mitral/tricuspid valve
Tricuspid: LLSB mitral/tricuspid valve to prolapsed.
the atrium during
ventricular contraction
Heart Sounds
Opening Snap
Location Pitch Source Causes
Apex High Opening of stenotic 1. MS/TS
mitral/tricuspid valve

More advance, shorter interval

Greater the left atrial pressure, the earlier mitral valve open, and louder
Heart Sounds
S4 - Atrial Gallop
Location Pitch Source Causes
Apex Low Atrium vigorusly Ventricular
contracting against a compliance
stiffened ventricle (hypertrophy/ischemia)

Coincides with contraction of atrium

Quadruple Rhythm S1-S2 + S3-S4
Summation gallop S3-S4 combine
Pericardial Knock
High pitched, after S2, result from abrupt cessation of ventricular
filling in early diastole. In patient with severe pericarditis
Murmur
Sound generated by
turbulence blod flow
Example: AS
Mechanism :
Partial obstruction
Increase flow through normal
structure Example: anemia
Ejection into dilated chamber
Regurgitant flow across
incompetent valve
Abnormal shunting of blood
from one vascular chamber Example: aneurismal dilatation of aorta
to low pressure chamber

Example: VSD
Murmur
Murmur Description

Example : a grade III-IV high pitch, cresendo-decrescendo systolic murmur, best

heard at the upper right sternal border, radiating toward the neck, not vary with
inspiration.
Murmur
Murmur Grading
Systolic Murmur
Ejection type
Timing : Systole, after S1
Pitch : High
Shape : -gap- Crescendo-decresendo + click (mild MS)
Peak occurs later in more severe stenosis
Position : Base
Radiation : aorta : neck. Pulmonic : neck/left shoulder
Maneuver : Sits upright : /diminish
Example : AS/PS. Increase flow (ASD/young)
Systolic Murmur
Pansystolic
Timing : Systole
Pitch : High
Shape : uniform
Position :
Mitral : Apex. With blowing quality
Tricuspid : LLSB
VSD : LLSB + thrill
Radiation : Mitral: left Axilla, Tricuspid: LLSB RLSB
Maneuver : inspiration : (tricuspid)
Example : MR/TR, VSD
Systolic Murmur
Late Systolic
Timing : Systole
Pitch : High
Shape : Click - uniform
Position : Apex
Radiation : Axilla
Maneuver : -
Example : Subvalvular MR (MVP/chordal rupture)
Diastolic Murmur
Early Decrescendo
Timing : Diastole
Pitch : High
Shape : After S2 -Decrescendo terminate before S1
Position : Aorta : along LSB. Pulmonic : base
Radiation : -
Maneuver : AR : exhaling . PR : Inspiration
Example : AR/PR
Continuous Murmur
Murmur throughout cardiac cycle without audible gap between
systole and diastole.
Result from condition in which there is a persistent pressure
gradient.
Continous
Shape : Crescendo S2-Decresendo
Example : PDA
To and From
Shape : S1-crescendo-decresendo-S2-decresendo-terminate
before S1
Example : AS+AR/PS+PR
Case 1

22-year-old man was evaluated in our department because of

dyspnea during a long-distance military march, palpitation, easy
fatigability and reccurrent respiratory infections.
Cardiac auscultation revealed a normal S1 heart sound, a systolic
ejection murmur at the upper left sternal border and fixed splitting
of the 2nd heartsound.
The ECG showed sinus rhythm with peaked P waves in lead II and
right axis deviation
The chest X-ray showed enlargement of central pulmonary arteries
 DIAGNOSIS
Atrial Septal Defect
Case 2

40 year-old man brought to the ER with symptoms of chest pain and

dyspnea. Chest pain started about 1 year ago; became progressively
worse, accompanied DOE.
Blood pressure 130/80 mmHg. He had weak carotid pulse. No JVD.
Cardiac auscultation revealed midsystolic murmur at right upper
sternal border and paradoxial split oh the second heart sound.
Vesicular breath sound was heard, no rhonki, wheezing.
 DIAGNOSIS
Aortic Stenosis
Case 3

A 29-year-old primigravida with a 24-week twin gestation had a

near syncopal episode while at work. The patient is a nurse, and at
the end of her shift she complained of feeling light-headed and
dizzy. Her blood pressure was found to be 100/80, heart rate 145
times/minute, irreguler.
Opening snap was heard after the the second heart sound (S2),
Mid-diastolic rumbling murmur with presystolic accentuation heard
after the opening snap. The murmur is best heard at the apical
region and is not radiated.
 DIAGNOSIS
AF
MITRAL STENOSIS