Clinical Examination of Cardiovascular System includes
Examination of
- Precordium
- Blood vessels
Precordium
- Anterior aspect of chest wall overlying the heart
Important Landmarks
Midclavicular line
- Vertical line dropped from the mid point of the clavicle
Parasternal line
- Vertical line passing through costochondral junction
Anterior axillary line
- Vertical line dropped from anterior border of axilla
Mid axillary line
- Vertical line dropped from center of axilla
Posterior axillary line
- Vertical line dropped from posterior border of axilla
Borders of the Heart
Base of the heart
- Line joining right 3rd sternocostal articulation to a point at the level of left 2nd intercostal space, internal to parasternal line
Right border of the heart
- Right 3rd sternocostal articulation to right 7th intercostal articulation – slightly curved
Left border of the heart
- Point at the level of Left 2nd intercostal space internal to parasternal line to apex beat
Position of the Heart Valves
Mitral valve
- Oblique, paced behind inner end of left 4th costal cartilage and adjoining part of sternum
Tricuspid valve
- Oblique, behind right 5th costal cartilage
Aortic Valve
- Oblique, across left half of sternum at the level of lower border of left 3rd costal cartilage
Pulmonary valve
- Horizontal, at upper border of left 3rd costal cartilage
Note
Aortic murmurs often best heard in the left third intercostal space close to the sternum – second aortic area or Erb’s point
Examination of Blood Vessels
Always examination of Cardiovascular System
has to be preceded by
- Examination of Arterial Pulse
- Blood Pressure recording
- Examination of venous pulse: Jugular Venous Pulse
Jugular Venus Pressure
- Provides an indirect measure of central venous pressure
- Because the internal jugular vein connects to the right atrium without any intervening valves, resulting in a continuous column of blood
- Changes in right atrial pressure are reflected in the Internal Jugular Vein (Raised - distension)
- The Internal Jugular Vein runs between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid.
- Measuring JVP in External Jugular Vein is a less reliable indicator of Central Venous Pressure
JVP measurement
- Examine neck veins with patient reclining at an angle of about 45o (Semi- recumbant position)
- Look for the pulsations of jugular vein
- Pressure is expressed in cms. of water: vertical distance between the top of the column of the blood & the sternal angle
- Normally, venous pressure appears just at the upper border of the clavicle
- Venous pressure above the clavicle is considered as raised JVP
Jugular venous pulse wave
A wave
- Atrial contraction
X descent (part 1)
- Atrial relaxation
C wave
- Bulging of Cusps
X descent (part 2)
- Atrial relaxation
V wave
- Atrial filling with valves closed
Y descent
- Ventricular filling
Difference between venous & arterial pulse
- Venous pulse is better seen than felt whereas the arterial pulse is better felt than seen
- Venous pulse has a definite upper level, which falls during inspiration when blood is drawn into the heart
- By exerting moderate pressure above the clavicle with a finger, the venous pulse can be obliterated, but not the arterial pulse
Inspection
1) Skeletal deformities
- Spine
- Thoracic cage
- Bulge
- Congenital Heart Disease
- Depression
2) Dilated/engorged veins over the neck and precordium
Superior or Inferior Venacaval obstruction
3) Position of trachea
4) Pulsations:
- Apical impulse
- Epigastric pulsations
- Suprasternal pulsations
5) Any scars & sinuses
Palpation
1) Apex beat:- Lowermost and outermost point of definite cardiac impulse
Normally the apex beat touches & slightly elevates the examining finger
Abnormal characters of Apex beat
- Tapping apex
- Advanced Mitral Stenosis
- Well sustained apex
- Left Ventricular Hypertrophy
- Ill sustained apex
- Right Ventricular Hypertrophy
2) Left parasternal heave
- Present in right ventricular hypertrophy
3) Thrills
- Palpable murmurs
4) Tenderness
- Pain is patient's perception, while tenderness is a sign that a clinician elicits
Percussion
- To determine the left border of the heart
Auscultation
1) Mitral area
- S1S2 heard , S1 coincides with the carotid, S1heard better than S2 , no murmurs
2) Tricuspid area
- S1S2 heard , S1 coincides with the carotid, S1heard better than S2 , no murmurs
3) Aortic area
- S1S2 heard , S1 coincides with the carotid, S2 heard better than S1 , no murmurs
4) Pulmonary area
- S1S2 heard , S1 coincides with the carotid, S2 heard better than S1 , no murmurs
Splitting of the second heart sound
- During inspiration, the chest wall expands and causes the intrathoracic pressure to become more negative
- This increases venous return from the body into the right atrium
- Simultaneously, there is a reduction in blood volume returning from the lungs into the left ventricle
- Since there is an increase in blood volume in the right ventricle, the pulmonary valve (P2 component of S2) stays open longer during ventricular systole
- Whereas the aortic valve (A2 component of S2) closes slightly earlier due to a reduction in left ventricular volume and ventricular emptying time
- Heard in the pulmonary area
- Splitting narrows during expiration
Observation findings
Inspection
Ausculation
Report
The clinical examination of Cardiovascular System of my subject _______ aged ____ yrs is normal.