Important points one should note while taking Cardiovascular case.. By MANOJ KUMAR, Rangaraya Medical College

1. CARDIOVASCULAR
EXAMINATION
 INSPECTION
 PALPATION
 PERCUSSION
 AUSCULTATION
- Manoz
marwin

2. PERCUSSION

3.  It is done to see the enlargement of the
dullness of the cardiac region
 Left border APEX
 Right border RIGHT STERNAL MARGIN

4. Useful in :
 Cardiac causes – Cardiomegaly, pericardial
effusion, pulmonary artery
dilatation, dilated
cardiomyopathy, etc.
* See if the dullness extends beyond the
apical impulse as in case of Pericardial
effusion.

5. Useful in :
 Respiratory causes : Pleural effusion,
hydropnemothorax,
collapse, fibrosis.
* To find the cause of displaced heart due
to lung conditions
• Presence of diaphragmatic hernia and
eventration of diaphragm can be
suspected.

6. Auscultation

7. Auscultatory areas

8. 1. Mitral area – 5th left ICS in mid-clavicular line
(corresponds to apex beat)
2. Tricuspid area – 4th left ICS just lateral to the
lower end of the sternum
3. Aortic area
• First aortic area – 2nd right ICS close to
sternum
• Second aortic area
or ERB’S area – 3rd left ICS close to
sternum
* The early diastolic murmur of AR and pansystolic
murmur of VSD are best heard at ERB’S AREA

9. 4. Pulmonary area – 2nd left ICS close to
sternum
5. Gibson’s area – 2nd left ICS away from
sternum
* The murmur of patent ductus arteriosus is
best heard at gibson’s area

10. Other areas of Auscultation
 Carotids
 Supraclavicular region
 Infraclavicular region
 Axillary region
 Back – interscapular and infrascapular
regions, bruits in the back

11. Check for
 Heart sounds
 Heart murmurs
 Gallops
 Opening snap
 Ejection click
 Pericardial knocks
 Pericardial rub
 Diastolic knock
 Prosthetic valve sounds

12. Heart sounds
The heart sounds are audible vibrations of
variable intensity, frequency and quality
generated by beating of heart, closure of heart
valves and the resultant blood flow through it.
Four heart sounds• S1
• S2
• S3
• S4

13. First heart sound (S1)
 Produced by closure of AV valves
 Best audible at apex
 Indicates the beginning of ventricular systole
 Split is not normally heard but heard in
phonocardiogram.

14. Factors that affect intensity of
S1
 Position of AV valve cusps at the onset of
ventricular systole
 Heart rate
 Pliability of the valve cusps
* S1 may be normal, soft, loud or variable
intensity.

15. Soft S1
 Mitral regurgitation
 Tricuspid regurgitation
 Ventricular dysfunction
 Calcified, stenosed mitral valve
 Calcified, stenosed tricuspid valve
 Aortic regurgitation
 Conditions associated with prolonged PR
interval
 Miscellaneous conditions

16. Loud S1
 Mitral stenosis
 Tricuspid stenosis
 Atrial septal defect
 Mechanical prosthetic valve
 High output states
 Short PR interval, tachycardia
 Atrial myxoma
 In normal children

17. Varying intensity of S1
 Atrial fibrillation
 Complete heart block
 Extra systoles

18. Canon sound(bruit de canon)
 Loud S1 heard intermittently in complete heart
block and in interference, dissociation when
the ventricles contract shortly after atria.
 Associated with short PR interval

19. Splitting of S1
 Components – M1 and T1
 Appreciated when
 Causes
• Early closure of mitral valve
• Delayed closure of tricuspid valve
• Right bundle branch block
• Pulmonary hypertension
• Left ventricular pacing
• Ectopic beats
• Idioventricular rhythm of left ventricle

20. Reverse splitting of S1
 Delayed mitral component
 Tricuspid component is heard earlier than
mitral component
 Causes
• Right ventricular pacing
• Ectopic beats
• Idioventricular rhythm of right ventricle

21. Second heart sound(S2)
 Produced by closure of pulmonary and aortic
valve
 Indicates the beginning of diastole
 Normal splitting• Two components – A2 and P2
• A2 louder than P2
• Appreciable during inspiration

22. Abnormalities of aortic
component
 Intensity – Accentuated or diminished
 Timing – Early or late
Accentuated diminished
• Systemic hypertension
• Aortic regurgitation
• When aortic valve is immobile
as in fibrosis or calcification
• If absent as in aortic valve
atresia
Early Delayed
• VSD
• MR
• Constrictive pericarditis
• When left ventricular ejection
is prolonged as in aortic
valvular or subvalvular stenosis,
PDA with large L  R shunt,
AR, left bundle branch block
and LVF

23. Abnormalities of pulmonic
component
 Intensity – Accentuated or diminished or
absent
 Timing – Delayed
Pulmonary arterial hypertension
Pulmonic stenosis
Pulmonary valvar atresia
• Pulmonic stenosis
• ASD
• Right bundle branch block
• Total anomalous pulmonary venous congestion
• Type A WPW syndrome

24. Abnormalities in splitting of S2
 Wide splitting of S2 splitting during expiration
 If interval increases during inspiration  Wide variable
split
 If interval increases in both inspiration and expiration 
Wide and fixed second sound
Early A2
Late P2
A2 – P2 interval ≥ 0.03 sec during expiration

25. Wide variable splitting of S2
 Pulmonic stenosis due to delay in
P2
 Mitral regurgitation
 VSD
due to early A2

26. Wide and fixed splitting of S2
 ASD
 Right bundle branch block
 Total anomalous pulmonary venous
connection
* In these conditions, splitting is due to
delay in P2

27.  Delay in A2 results in closely split, single or
paradoxically split S2.
 In paradoxically split S2, the split is wide in
expiration, but narrows during inspiration

28. A single second sound
 Either A2 or P2 or a combination of both
 The decision whether it is aortic or pulmonary
or a combination is based on clinical profile
 Tetrology of fallot  A2
 VSD with pulmonary hypertension 
Combination
* Interpretation of single second sound is not
dependant on auscultation alone

29. Third heart sound (S3)
 Protodiastolic sound or ventricular gallop,
produced by intial passive filling of ventricles
 Heard best with bell at the apex
 Normally present in children and athletes
 Pathological causes :
• High output states
• Congenital heart diseases
• Regurgitant lesions
• HOCM
• Systemic hypertension

30. Fourth heart sound (S4)
 Presystolic gallop/atrial gallop, produced by
rapid emptying of atrium into a non-compliant
ventricle
 Confused with ejection click
 Always pathological :• HOCM
• Systemic hypertension
• Ventricular failure
• Pulmonary hypertension

31. Added sounds
 Gallop rhythm
 Opening snap
 Ejection click
1. Triple rhythm
2. Quadruple rhythm
3. Summation gallop

32. Murmurs
 Turbulence caused by increased flow through
normal/stenosed valve or a normal flow
through a stenosed valve/orifice
 Ausculation should be done over precordium,
back and over the carotids
 Note :
 Changing murmurs
• Various charecteristics of the murmer
• Position of the patient in which the murmur is best
heard

33. Site
 Note the site of maximum intensity of murmur
 VSD – Murmur best heard in left 3rd and 4th
ICS
 Pulmonary ejection systolic murmur – left 2nd
ICS

34. Timing
 Timing of the murmur in relation to ventricular
activity noted
 Appreciated by palpating the carotid artery
while auscultating the precordium
1.Systolic
2.Diastolic
3.Continuous

35. Systolic murmurs
 Heard during systole
1. Regurtitant systolic murmurs
• Start immediately after 1st heart sound and may
continue to 2nd sound
• Usually pansystolic or holosystolic
• Intensity is uniform throughout
• Causes : VSD
Tricuspid regurgitation
Mitral regurtitation
1. Regurtitant systolic murmur
2. Ejection systolic murmur

36. 2. Ejection systolic murmur
• Due to the blood flow in pulmonary or aortic
outflow tracts
• There is gap b/n first heart sound and murmur
• Intensity of murmur follows a diamond shaped
configuration with midsystolic peak
• Causes : Pulmonary stenosis
Aortic stenosis
Pulmonary hypertension
Tetrology of fallot

37. Diastolic murmurs
 Heard in diastolic phase of cardiac cycle
 Three mechanisms
 According to timing
a) Semilunar valve regurgitation
b) Atrioventricular valve stenosis
c) Increased blood flow through AV valve
1. Early diastolic
2. Mid diastolic
3. Presystolic

38. Early diastolic mumur
 Decresendo murmur starts immediately after
second heart sound
 Causes :
• Aortic regurgitation
• Pulmonary regurgitation

39. Mid diastolic murmur
 Starts after the second heart sound
 Clear gap present between second sound and murmur
 Occcurs due to functional or anatomic stenosis of AV
valves
 Causes :
Due to MITRAL valve Due to TRICUSPID
valve
• Mitral stenosis
• Mitral regurgitation
• VSD
• PDA
• Tricuspid stenosis
• Tricuspid regurgitation
• ASD
* Presystolic murmur occurs in mitral and tricuspid stenosis

40. Continuous murmurs
 Starts in systole and continue into diastole
 Causes :
• PDA
• Venous hum
• Rupture of sinus of valsalva
• Arteriovenous shunts
• Pulmonary A-V fistula
• Coronary A-V fistula
• VSD with AR
• MR with AR
• AS with AR
• Due to combination of
systolic and diastolic murmur
• Known as to and fro murmur

41. Intensity
 Grading
Grading Character
Grade 1 Very soft (heard in quiet room)
Grade 2 Soft, but easily audible
Grade 3 Moderate – no thrill
Grade 4 Loud with thrill present
Grade 5 Very loud with thrill and murmur heard with
stethoscope barely placed on chest wall
Grade 6 Loud and audible with a stethoscope just
off the chest wall

42.  A cresendo murmur increases in intensity
(MS, PDA)
 A decresendo murmur decreases in intensity
(AR)
 Venous hum has no change

43. Pitch
 High pitched or Low pitched
 See if the murmur is best heard with the bell or
diaphragm of the stethoscope
Low pitched
High pitched

44. Character or Quality
 Soft/harsh/blowing/rough/vibratory or humming
 Rough when obstruction to blood flow (AS,
PS)
 Blowing in case of incompetent valves (MR)

45. Conduction or Transmission
Conducted murmur Transmitted murmur
Same intensity Decreased intensity
Same duration Decreased duration
 Generally, murmurs from aortic and mitral valve may be
conducted to other parts of precordium
 Functional or flow murmurs are heard over wide area of
the precordium
* ESM of AS is loudest in the aortic area and will be radiated to the
axilla and the apex
* Pansystolic murmur of MR is best heard in the mitral area and may
be conducted to axilla or back

46. Variation of murmur with various
Manoeuvres
 Respiration : There is accentuation of right
side murmurs during inspiration and left sided
murmurs during expiration
 Posture : Venous hum murmur varies with
posture
 Certain manoeuvres :

47. Description of murmurs
Condition Murmur Description
Mitral regurgitation Pansystolic High pitched, soft blowing pansystolic
murmur of grade __ best heard with the
diaphragm of the stethoscope,
conducted/transmitted to axilla and back
with the patient lying in left lateral position
with breath held in expiration
Ventricular septal
defect
Pansystolic High pitched, soft blowing pansystolic
murmur of grade 4 best heard with the
diaphragm of the stethoscope in the left
3rd and 4th ICS in parasternal region
Patent ductus
arteriosus
Continuous Grade 4 continuous murmur best heard
with the diaphragm of the stethoscope in
the left 2nd ICS

48. Innocent murmurs
 Functional or benign murmurs
 Occur in the absence of abnormality
 Accentuated during periods of febrile illness or other
high – output states
 Features :
• Asymptomatic
• Normal cardiac silhouette on chest X-ray
• Normal ECG
• Usually systolic, may be continuous
• < grade 3/6 with no radiation or transmission
• No cyanosis
• Normal pulses and heart sounds
* They are usually present in children

50. Common innocent murmurs
 Still’s murmur
 Venous hum
• Low pitched vibratory or musical murmur heard in mid systole
• Soft quality, short in duration
• Best heard in left lower sternal border and apex, no radiation
• Grade 2 – 3/6, common after 3 years of age and rare in infancy
• No cardiac abnormalities present
• Continuous murmur
• Best heard with bell in right supraclavicular region
with head turned to oppoite side in sitting posture
• Disappears on lying down

51. Dynamic auscultation
 Manoeuvres include :
• Inspiration
• Expiration
• Valsalva manoeuvre
• Muller manoeuvre
• Squatting to standing
• Standing to squatting
• Passive leg exercise
• Isometric hand grip
• Transient arterial occlusion
• Administration of amyl nitrate
• Leaning forwards
• Chin turned upwards

52. Valsalva manoeuvre
 This is an attempted forced expiration in
closed glottis when mouth and the nose are
closed
 Significance :• Increases heart rate, BP and then decreases
the heart rate in that order. This sequence will be
absent in CCF
• Ejection systolic murmur in PS will be increased
and that of AS will be decreased
• Murmur of mitral valve prolapse becomes
longer and louder
• HOCM – systolic murmur becomes louder