1. Cardiovascular Examination
Deling Zou

2. Anatomy

4. Inspection 1 Precardial projection and excavation 2 Apical impulse
3 Abnormal pulsations of precardium

5. Inspection 1 Precardial projection and excavation
congenital heart disease: tetralogy of Fallot
Valvular heart disease MS,PS
pericardial effusion (large , childhood)

6. The second right intercostal space(2nd ICS-RS)
aneurysm of aortic arch
dilatation of ascending aorta
2) flat chest
3) pigeon chest/funnel chest

7. Inspection 2 Apical impulse *Normal:
position—the fifth left intercostal space cm medial to the midclavicular line range— cm in diameter

8. *Abnormal 1) Location #diaphragm:
“transverse position” upper,outward
obesity ,child, pregnacy;
ascites; tumor of abdominal cavity
“vertical position” (thin, high, emphysema) inferior,inner

10. #mediastinum:
one side pleural effusion or pneumothorax—to the healthy side
one side atelectesis or pleural adhesion—to the affected

11. #enlargement of the heart
right ventricular dilatation –left or slightly upper
left ventricular dilatation—left inferior
LV &RV dilatation –left inferior (both side dilatation)

13. #Posture: recumbent position—upper
left lateral position—to the left 2-3cm
right lateral position—to the right cm
Dextrocardia: 5-ICS—RS

14. Inspection-
apical impulse - abnormal
2)Intensity and extent changes

15. -apical impulse - abnormal
Inspection
-apical impulse - abnormal
3)Inward impulse:
apex excavation in the systole
seen: adhensive pericarditis prominent RV hypertrophy

16. Inspection Abnomal pulsations of percardium
1)left third-forth intercostal space lateral to the sternum(3,4ICS-LS)
seen: RV hypertrophy

17. 2)hypoxiphoid process
seen:
difference deep inspiration
RV hypertrophy ↑ abdominal aorta (aneurysm) ↓

18. 3)basal part of the heart
2 ICS-LS: dilatation of the pulmonary artery or pulmonary hypertensin, occasionally healthy young man
2 ICS-RS: aneurysm of aortic arch or dilatation of ascending aorta

19. Palpation 1 Apical impulse and pulsation of precardium 2 Thrill
3 Pericardial friction rub

20. 1 Apical impulse and pulsation of precardium
Palpation
1 Apical impulse and pulsation of precardium
Exact position of apex
The beginning of systole of ventricle first sound
Heaving apex impulse: reliable of LV hypertrophy

21. 2 Thrill One of characteristic signs of organic heart disease.
Mechanism : the flow of blood→narrowed orifice→vortices→ vibration→chest wall
thrill-high frequency murmurs-low frequency
Method:position,phase of cardiac cycle,clinical significance
seen: CHD or valvular stenosis ,
occasionally insurficiency

22. CHD:congenital heart disease

23. 3 Pericardil friction rub
1)Precardium-4th ICS-LS
2) both phases of the cardiac cycle
3) systolic period, sitting erect and leaning forward, the end of expiration
4)mechanism: rub of the visceral and parietal layers of pleura
5)seen:acute pericarditis

24. Percussion Aim:to determine the size and shape of the heart .
Absolute dullness: contain no gas Relative dullness : real size

25. 1 murneuver of percussion
patient in erect position –the pleximeter is vertical with the intercostal space
patient in the recumbent position –the pleximeter is parallel with the intercostal space

26. 2 order : left—right ; upwards ; inward
left margin : from 2-3 cm lateral to the apex beat up to the 2nd ICS
right margin : one intercostal space higher than the border of liver dullness up to the 2nd ICS
size: vertical distance from margin to the anterior midline

28. Percussion

29. Percussion

30. (2)The upper border –the lower border of the anterior end of the third rib↑
(3)The basal part —the second intercostal space upward
left: aortic node and PA
(4)Concave part –between the aorta and the left ventricle

31. 5 Changes in the area of cardiac dullness and its significance
Percussion
5 Changes in the area of cardiac dullness and its significance
Cardiac factors :
1)LV enlargement: “boot shape” Seen:aortic valvular disease ,
hypertension heart disease

32. 2)RV enlargement : slightly↑--absolute dullness↑ Prominent↑--relative dullness↑ to the left side prominently Seen:PHD, MS
3)Two ventricle ↑:
“generally enlarged heart” seen:DCM , Kashan cardiomyopathy

33. 4)LA and/or pulmonary artery: LA:concave part disappear LA+PA:2,3 ICS-LS outwards
“pear shape” Seen: MS--- “mitrial type”

34. 5)pericardial effusion: enlargement of both sides of the border
body’s position:
recumbent position：widening of base of the heart
erect position:“triangular shape”

35. 6)dilatation of the aorta /ascending aortic aneurysm:
widening if the dull area of first and second intercostal space (with systolic pulsation)

36. Extacardial factors : 1)large pleural effusions and pneumothorax → to the healthy side 2)atelectasis /pleural pachynsis →to the affected 3)a large amount of ascites or big abdominal tumor: diaphragm elevated→transverse position →left side enlargement

37. Ausclutation

38. 1 Ausclutatoty valve areas
1)ausclutatory mitral area: apical area 2)ausclutatory pulmonary area:2 ICS-LS 3)ausclutatory aortic area: 2 ICS-RS 4)second ausclutatory aortic area: 3rd ICS-LS—Erb area 5)tricuspid area :4,5 ICS-LS

40. 2 Order:
MV---PV---AV1---AV2---TV
3 Contents : 1) rate 2)rhythm 3)heart sound 4)extra heart sound 5)murmurs 6)pericardial friction sound

41. 1)heart rate:
60~100bpm F＞M
child (＜3 years) ＞ 100bpm
tachycardia: normal adult ＞100bpm child(＜3 years) ＞150bpm
bradycardia: HR ＜60 bpm

42. Ausclutation
heart rate:60-100bmp

43. 2)cardiac rhythm:. sinus arrythmia—affected by breath
2)cardiac rhythm: *sinus arrythmia—affected by breath *premature beat: classification:atrial~ ventricular ~
junctional ~
frequently:＞6 bpm
occasionally: ＜6 bpm
bigeminy trigeminy

44. *atrial fibrillation: absolute irregular rhythm S1 intensity inequality Pulse deficit seen:MS,CHD,hyperthyroidism,
PHD,DCM

45. Ausclutation
atrial fibrillation

46. 3) cardiac sound

47. Ausclutation
content
cardiac sound
S1：
S2：

49. 4)Abnormal cardiac sound *Intensity:
position of the atrioventricular valve
Ventricular contractility and output
Valvular integrity and activity

50. S1: Accentuation: MS
HR↑contractility↑ fever,anemia,hyperthyroidism
complete AVB →cannon sound

52. S1 attenuation : MI
P-R interval enlong AI
myocarditis,myopathy,MI,HF inequality: af, III°AVB

54. S2---A2,P2
S2 ↑ ---pressure and flow of
blood ↑ A2 : hypertensin, arterisclerosis P2 : PHD,CoHD(L--R),LVF
S2 ↓ ---pressure↓ flow ↓ Seen:hypotension,AS/AL,PS/PI

56. *Quality mono rhythm
pendular rhythm---embryocardia
*Splitting of heart sound S1 splitting:
seen—RBBB, right heart failure Ebetein malformation ,MS LA myxoma

58. S2 splitting: (1)physiological splitting :end of inspiration (2)general splitting : most commonly seen: CRBBB, PS, MS,MI ,VSD (3)fixed splitting :ASD (4)paradoxical splitting(reversed splitting) :pathological seen: CLBBB ,AS, hypertension

60. 5)extra cardiac sound Diastolic period 1)gallop rhythm: --protodiastolic gallop: S1+S2+S3 the third sound gallop (sign of organic heart disease) seen : HF（AMI, severe myocarditis , myopathy etc.） -- late diastolic gallop: atrial gallop S1+S2+S4 seen : HBP ,HCM ,AS ,CHD -- summation gallop: quadruple rhythm
seen:HF,cardiomyopathy

63. 5) extra cardiac sound Diastolic period
2)opening snap:MS 3)pericardial knock: constrictive pericarditis 4)tumor plop: LA myxoma

65. Ausclutation
CONTENT
Tumor plop

66. S1----mid＜0.08″ late＞0.08″ seen: mitral prolapse
Systolic period (1)early systolic ejection sound(click) pulmonary :pulmonary hypertension; pulmonary artery dilatation PS, ASD, VSD Aortic: hypertension, aneurysm ,
AS, AI ,aorta constriction (2)mid and late systolic click:
S1----mid＜0.08″ late＞0.08″ seen: mitral prolapse

69. iatrogenic (1)prosthetic valvular sound (2)pacemaker

70. 6)cardiac murmurs

72. *characterization of murmur and ausclutatory key points (1)location:L3,4 –VSD L2,3—PDA (2)transmission:
MI ---left axilla AS---neck (3)phase: systolic murmurs diastolic ~ continuous ~
biphasic ~
early,mid,late,whole murmurs

73. (4)quality: blowing—MI rumbling—MS sighing--AI machinery--PDA
(5)intensity :Levine 6 grade classification shape: crescendo---MS decrescendo---AI crescendo-decrescendo---AS continuous---PDA regular---MI
murmurs

74. (6) others:
body position: MS--left lateral position AI--sitting erected and forward MI,TI,PVS--lie on one’ back Lie → stand: HCM
breath:expiration--LV murmurs inspiration --RV murmurs valsalva--HCM
exercise: HR↑--murmurs ↑
murmurs

75. clinical significance murmurs: functional and organic 7)pericardial friction sound:
both phases , unaffected by respiration .
seen: pericarditis ,
RHD ,AMI ,renal failure, SLE

76. * clinical significance of cardiac murmurs
systolic murmurs
MV：functional:exercise,fever,anemia,pregnancy,
hyperthyroidism
relative:HBP,CHD,DCM,anemia
organic：MI(RHD),mitral prolapse

78. * clinical significance of cardiac murmurs
systolic murmurs
Aortic area：organic：AS
relative：dilatation of ascending aorta

80. * clinical significance of cardiac murmurs systolic murmurs
pulmonary ：physiology
relative：MS、ASD
organic：PS
TV：relative ：RV enlarged
organic ：rare

81. * clinical significance of cardiac murmurs
Diastolic murmurs
MV:organic:RHD(MS)
relative:AI(severe)
Austin Flint murmur
AV:AI

84. * clinical significance of cardiac murmurs
Diastolic murmurs
PV:organic murmur is rare PI(dilatation of pulmonary artery)
MS+P Graham Steell murmur
TV:rare

85. * clinical significance of cardiac murmurs
continuous murmurs
PDA
innocent murmur

86. Vascular examination
The second clinical hospital of CMU

87. pulse pulse rhythm tensions and state of arterial wall intensity
pulse rate
pulse rhythm
tensions and state of arterial wall
intensity
pulse wave

88. pulse
pulse rate
Atrial fibrillation and frequent premature beat stroke volume peripheral artery no pulse pulse rate less than HR(pulse deficit)

89. pulse pulse deficit； pulse rhythm bigeminal pulse,trigeminal pulse；
dropped pulse

90. pulse tensions and state of arterial wall
Artery tension depending on blood pressure (mainly SBP).
Judge state of artery wall

91. pulse intensity Bownding pulse seen:high fever, hyperthyroidism, AI
Microsphygmia
seen:HF,AS and shock

92. pulse pulse wave normal pulse wave
composed of upstroke（knocking wave）、peak （tide wave）and downstroke（dicrotic wave）

93. pulse
pulse wave
water hammer pulse seen:AI,hyperthyroidism,PDA, severe anemia
pulse tardus seen:AS
dicrotic pulse seen:HCM
pulsus alternans seen:HBP,AMI,AI
paradoxical pulse
seen:cardiac tamponade,constrictive pericarditis
Pulseless
seen:serious shock, arteritis

94. blood pressure method of measurement direct measurement method
indirect measurement method

95. blood pressure standard
definition of Bp level and classification(older than 18 years old)
classification SBP(mmHg) DBP(mmHg)
Ideal BP  80
Normal BP  85
High limit of BP
Grade 1（mild）
subgroup：
boundline hypertension
Grade 2（moderate）
Grade 3（severe） ≥ ≥110
Simple systolic hypertension  90
boundline systolic hypertension 90

96. blood pressure clinical significance of BP changes
hypertension：higher than 140/90mmHg for 3 times not in the same day
hypotension：lower than 90/60-50mmHg
Shock,,MI,acute cardiac tamponade
obvious difference between bilateral upper limbs：more than 10mmHg---arteritis,congenital artery malformation
difference between upper and lower limbs：lower limb BP is 20-40mmHg higher than upper one normally
pathological:constrictive aorta ,arteritis(chest-abdominal aorta)
change of pulse BP：
40mmHg，wide pulse BP---hyperthyroidism,AI
30mmHg，narrow pulse BP---AS,pericardial effusion

97. blood pressure dynamic BP monitoring Average BP for 24h 130/80mmHg;
bright day 135/85mmHg;
night: 125/75mmHg
Peak:6am—10am,4pm—6pm

98. Vessel murmur and peripheral vessel sign
venous murmur
jungular murmur：is caused by the rapid flow of jungular vein into SVC (superior vena cava)

99. Vessel murmur and peripheral vessel sign
artery murmur
Continuous murmur in the lateral lobe of thyroid in the patient with hyperthyroidism
Systolic murmur in the upper abnormal region or lumber region caused by stenosis of renal artery.
Arterio-venous fistula

100. Vessel murmur and peripheral vessel sign
pistol shot sound
Seen:AI,hyperthyroidism,severe anemia
Durozier’s murmur
capillary pulsation

101. The main symptoms and signs of common diseases of circulatory system

102. Mitrial stenosis Causes:
RHD:rheumatic heart disease CHD:congenital heart disease Other reasons: senile retrograde

103. Symptoms: hemoptysis;
cough;
hemoptysis;
dyspnea: dyspnea on exertion→ paroxysmal nocturnal dyspnea → pneumonedema

104. Palpation :diastolic thrill palpable over the apical area
Signs:
Inspection :
mitrial face Apex impulse may be displaced to the left
Palpation :diastolic thrill palpable over the apical area
Percussion : normal heart borders→pear shape heart

105. Auscultation : )the first sound (S1)↑ )diastolic murmur :apical area; localized; mild and late diastolic ;crescendo ;rumbling; more clearly when the patient is lying on his left side ) opening snap may be auscultatory 4)accentuation of second pulmonary sound (P2↑), splitting 5)Graham Steel’s murmur (PV diastolic) 6)Maybe atrial fibrillation(late stage)

106. Mitral Insufficiency RHD / non-RHD ; acute/chronic Symptoms:
fatigue,
palpitations,
dyspnea on exertion,
Left heart failure

107. Signs : Inspection : apex beat is displaced downwards and to the left

108. Palpitation : Percussion :
apical impulse forceful Heaving apex impulse
Severe systolic thrill
Percussion :
the area of dullness to left and downwards

109. Auscultation : 1)S1 ↓(attenuation)
2)murmurs: harsh; pansystolic murmur; blowing; /6 grade ↑ wide spread-transmitted to left axilla left infrascapular angle

110. Aortic Stenosis Causes: RHD Congenital Senile retrograde Symptoms :
palpitation ,dizziness, angina pectoris, syncope, HF-dyspnea

111. Inspection : apical impulse increase Displaced to left and downwards
Signs :
Inspection : apical impulse increase Displaced to left and downwards
Palpation :
apex beat is elevated and forceful
systolic thrill can be palpated over aortic auscultatory valve area
Pulse tardus

112. Percussion: Auscultation :
the area of dullness is normal or to left and downward
Auscultation :
1)murmur:
aortic auscultatory valve area systolic murmur
harsh ,ejection sound ,
3/6 grade ↑(thrill)
transmitted to neck 2)A2 ↓,reversed splitting 3)S4

113. Aortic Insufficiency Causes:
RHD Non-RHD：congenital prolapse syphilis aortitis arteriosclerosis endocarditis acute/chronic

114. Symptoms : Signs Inspection :
palpitation, dizziness, LHF
Signs Inspection :
apical impulse to left and downwards Palpation :
apex impulse to left and downwards Heaving apex impulse

115. Percussion :
the area of cardiac dullness is enlarged downwards and to the left;
the concave part of the heart is not enlarged (boot shape)

116. Auscultation : 1)specific murmur:
diastolic ;
sighing ;
aortic area;
heard clearly sitting erect and forward
2)Austin Flint murmur :relative MS (rumbling mid-diastolic murmur)

117. Peripheral vascular signs
*head bobbing (Musset’s sign):nodding motion of the head with each systole; *signs of capillary pulsation; *water hammer pulse; *pistol shot sounds : esp. Femoral arteries; *Duroziez’s murmur; *Visible pulsation of carotid arteries

118. Pericardial effusion Causes: Symptoms :
infective and non-infective pericarditis
Symptoms :
pain over the pericardial region Dyspnea, cough, fever, lassitude Shock

119. Signs : Inspection :
diminution in strength of the apex beat or absence of the apex beat ;
jugular venous enlargement

120. Palpation :
*diminution in strength of the apex beat or the apex beat palpated uneasily
*paradoxical pulse may be present

121. Percussion :
enlargement of the cardiac dullness bilaterally, changed with posture

122. Auscultation : *pericardial friction sound
*HR↑,diminution of intensity of cardiac sound (S1/S2↓)
*pericardial knock may be heard

123. *Large effusion:
Jugular varicosity
Liver enlargement
Paradoxical pulse
Pulse pressure ↓

124. * Kussmaul sign:
deep inspiration –jugular vein distension
*Ewart sign: left infrascapular region
vocal fremitus↑
dullness -- percussion
bronchovesicular breath sound-- auscultation

125. Causes : Symptoms: Heart Failure myopathy ; ventricular load ↑
promote factors
Symptoms:
1 LHF: fatigue, cough, frothy sputum dyspnea(on exertion → orthopnea → paroxysmal nocturnal ~)
2 RHF: abdominal distension, oliguria, nausea, vomiting

126. Signs : 1 LHF: *Inspection : tachypnea , cyanosis, semireclining/sitting position Acute pneumoedema:
frothy sputum, hyperhidrosis *Palpation :pulse alternans *Percussion : *Auscultation :diastolic gallop rhythm P2↑ Fine rales, rhonchi

127. 2 RHF: *Inspection :Jugular distension Pericardial cyanosis Edema(pitting, pendulous) *Palpation : liver enlargement, tenderness Hepatojugular reflux(+) *Percussion :
pleural effusion (right side)
ascites *Auscultation : RV diastolic gallop rhythm TV systolic blowing murmurs