CVS Examination

CVS Examination • Dr.Amr Khayat, MBBS Member of Saudi General Surgery Society Member of Saudi Society for Vascular Surgery Member of Saudi Association for Plastic Surgery

CVS Examination • General • General appearance • The hands • The face • The neck • The praecordium • Inspection • Palpation • Auscultation

The Praecordium • Inspection • Deformities • Apex beat • Visible pulsations • Scars • Palpation • Apex beat • Parasternal heave • Palpable thrills • Auscultation • Heart sounds • Added sounds • Cardiac murmurs

1- General Appearance • Look for: • (ABCDE) • Respiratory distress • Cachexia • Dysmorphic features

Patient Position in CVS Examination

2- The Hand • Look For : • Clubbing • Cyanosis • Splinter hemorrhage • Osler nodes (tender) • Janway lesions (not tender) • Muscle Wasting.

2- The Hand • Radial pulse: • Rate • Rhythm: [regular, irregular (irregularly irregular, regularly irregular)] • Character and volume (collapsing, alternans) • Radio-radial delay • Radiofemoral delay • Condition of the vessel wall • Blood pressure

3- The Face • Eye’s : Pallor , Jaundice, Xanthelasma. • Mitral features (rosy cheeks, bluish tinge). • Central cyanosis in the tongue

4- The Neck • Palpate the carotid artery medial to sternomastoid muscle for character (bisferience, collapsing, alternans, jerky) • Inspect the height of the JVP by inspecting the internal jugular vein

4- The Neck • Jugular pulse can be distinguished from arterial pulse by: • It is a complex wave (flicker twice) • Jugular is visible but not palpable • JVP decreases with inspiration • It is filled from above after removing pressure applied to the base of the neck.

5- The Precordium • By INSPECTION: • Scars • Skeletal abnormalities (pectus excavatum, kyphoscoliosis) • Visiable Apex beat • Other visible pulsations

5- The Precordium • By PALPATION: • Apex beat: • Site (the most lateral and most inferior; normally in the 5th left intercostals space in the mid clavicular line) • Displaced or not • Character (heaving, double impulse, tapping) • Parasternal impulse: • By the heel of the hand rested just to the left of the sternum. • Palpable murmurs (thrills): • Start at the apex then the left sternal edge then the base of the heart.

5- The Precordium • By AUSCULTATION: • Start in the mitral area with the bell to hear low pitch sounds like in mitral stenosis then use the diaphragm. • Then move to the tricuspid area (5th Lt. intercostal) • Then to pulmonary area (2nd Lt. intercostal) • Then to aortic area (2nd Rt. intercostal) • On auscultation listen to: • Heart sounds (S1, S2) • Abnormalities in heart sounds (loud, soft, increased splitting, fixed splitting, reversed splitting) • Additional sounds (S3, S4) • Heart murmurs

What to look for in murmurs • Site • Intensity ( 6 grades ) • Time (systole , diastole) • Duration (early , pan , late) • Radiation (axilla , carotid) • Pitch (High, Low) • Special character

6- The Back • Percussion and auscultation of the lung bases looking for signs of pulmonary edema like: • Crepitation • Dull percussion , decrease air entry (pleural effusion ) • In the back look for sacral edema as well

7- The Abdomen • Look for • Ascitis • Hepatomegaly

8- The Lower Limbs • Palpate the: • Femoral artery (below inguinal ligament 1/3 of the way up from the pubic tubercle) • Popliteal artery (behind the knees) • Post. tibial (below medial malleolus half the way between the calcaneus and medial malleolus) • Dorsalis pedis (between the 1st and 2nd metatarsal bone lateral to flexor hallosis longus) • Then look for lower limb edema.

THANK YOU

1. A 45 year old man comes into your office complaining of heart palpitations. You listen at his heart apex with the diaphragm of the stethoscope and hear a mid systolic click (an extra beat in between the 1st and 2nd heart sound). What is the likely diagnosis? • A-Mitral stenosisB-Aortic regurgitationC-Mitral valve prolapseD-Mitral regurgitation

2. A 50 year old woman comes into your office citing exercise intolerance. You listen to her heart at the lower left sternal border with the bell of the stethoscope and hear an S3 sound (an extra, low frequency heart beat occurring after the 2nd heart sound). What is the likely diagnosis? • A-Patent ductus arteriosisB-Aortic stenosisC-Congestive heart failureD-Mitral stenosis

3.If a patient has atrial fibrillation (the atria no longer respond to heart pace-making cells) an S4 heart sound (an extra, low frequency beat occurring before the first heart sound) will not exist. • A-TrueB-False

4. A 10 year old boy comes into your office with no symptoms or complaints. When listening with the bell of the stethoscope at the apex, you hear an S3 heart sound. What is the diagnosis? • A-Chronic heart failureB-Pulmonic StenosisC-Tricuspid StenosisD-Normal heart sound

5. A 40 year old man comes into your office complaining of exercise intolerance. You listen to his heart at the 3rd left intercostal space with the diaphragm and hear a murmur that is saw-like in quality that begins after S1 (first heart sound) and ends before S2 (2nd heart sound) during systole (while the heart is contracting). What is a likely diagnosis? • A-Aortic regurgitationB-Tricuspid stenosisC-Mitral stenosisD-Aortic Stenosis

6. The diastolic murmur of tricuspid stenosis (narrowing and hardening of the tricuspid valve cusps) can only be heard with the diaphragm of the stethoscope. • A-TrueB-False

7. A 70 year old man comes into your office complaining of heart palpitations. You listen to his heart at the lower left sternal border with the bell of the stethoscope and hear a rumbling murmur that occurs only during diastole (while the ventricles are filling). What is the likely diagnosis? • A-Mitral stenosisB-Tricuspid stenosisC-Aortic stenosisD-Tricuspid regurgitation

8. A 55 year old woman comes into your office complaining of exercise intolerance. You listen to her heart at the 2nd right intercostal space with the diaphragm of the stethoscope and hear a diastolic murmur of blowing quality. What is the likely diagnosis? • A-Aortic stenosisB-Aortic regurgitationC-Mitral regurgitationD-Tricuspid regurgitation

9. A 67 year old man enters your office with no complaints. You listen to his heart at the apex and hear an opening snap when listening with the diaphragm and a rumbling diastolic murmur when listening with the bell. What is the likely diagnosis? • A-Pulmonic stenosisB-Tricuspid stenosisC-Mitral stenosisD-Aortic stenosis

10. Now for a whopper: A 60 year old woman enters your office with no symptoms to complain of. You listen to her heart at the 2nd left intercostal space and hear a mid-systolic murmur accompanied with wide fixed splitting of the S2 heart sound (Usually the 2nd heart sound is split and widens with inspiration at the 2nd left intercostal space). What is the diagnosis? • A-Pulmonic regurgitationB-Mitral regurgitationC-Tricuspid regurgitationD-Atrial septal defect