2. • A careful and detailed clinical assessment is
essential in order to assess the likely cause and
severity of symptoms, arrange appropriate
investigations and referral, avoid unnecessary
investigations, and to assess individual risk of
cardiovascular disease or cardiomyopathy.
3. ARTICLES REQUIRED
• A watch with a second hand
• Stethoscope with diaphragm & bell
• Centimeter ruler, Penlight
• Tape measure
• Sphygmomanometer
8. PAST HISTORY
• Rheumatic fever
• Recurrent attacks of lower respiratory infections
since childhood
• Enquire about dental carries, the recent dental
extraction
• Previous history of DM & HTN
• Previous history of angina ,MI,CABG
9. FAMILY HISTORY
• Marriage : Consanguineous
• History of coronary artery disease,HTN,DM
• Sudden cardiac death in family
12. Differentiating points Central cyanosis Peripheral cyanosis
Site Skin & mucous membrane
: tongue, lips
Only skin
On breathing 100 % O2 Cyanosis reveres if due to lung
disease : not if due to right to left
shunts
No effect at all
Warming the limb No effect Cyanosis decreases
Clubbing Usually associated Not associated
Periphery Warm Cold
13. • central cyanosis is seen in the following
cardiac condition
• cyanosis congenital heart disease
• reversal of left to right shunt
• Pulmonary edema
peripheral cyanosis occur in
• peripheral vascular disease
14. • Pedal edema
• Clubbing
Clubbing is caused by prolonged hypoxemia of
the extremities. Hypoxemia causes structural changes in
the distal phalanges over time.
• Cyanotic Congenital heart disease
• Reversal of left to right shunts
• Infective endocarditis
15. Inspection...
• Inspect nails. Splinter hemorrhages are
associated with infective endocarditis
• Inspect the face. People with supravalvular
aortic stenosis have wide-set eyes, low-set
ears, upturned nose, hypoplasia of the
mandible
• Moon face suggests pulmonic stenosis
16. More inspection...
• Expressionless face with puffy eyelids and
loss of the outer 1/3 of the eyebrow is seen in
hypothyroidism
• Inspect eyes. Yellow plaques on eyelids
(xanthelasma) may be due to
hyperlipoproteinemia
17. Assessment of Blood Pressure
• Always measure in both arms
sitting, standing,lying down
Normal-15 mg reduction of systolic from lying to standing
HR- should not increase 20 b/min from supine to standing
18. Jugular Venous Pulse
• Assesing the internal jugular vein provides
information about right atrial pressure
• The pulsation of the internal jugular vein are
beneath the sternocleidomastoid muscle and are
visible as they are transmitted through surrounding
tissue
• The vein itself cannot be seen
• JVP> 4cm from sternal angle at 45’ patient position
is said to be raised
21. Heapatojuglar reflex
• patient in 45 degree inclination .
• The examiner standing on the right side of the patient
should apply firm pressure over the mid abdomen for 20
seconds
• Patient should be asked to breathe normally (not to strain .
In normal individual JVP rise is not more than 4 cm it is not
sustained .
• In RH sustained elevation of more than 4 cm is noted .
22. EXAMINATION OF THE
PRECORDIUM
Inspection
• The heart and chest develop at the same time in
embryo, so anything that interferes with
development of the chest may interfere with the
heart
• Pectus Excavatum (caved-in chest) is seen in
Marfan’s syndrome and sometimes MVP
• Pectus Carinatum (pigeon chest) also seen in
Marfan’s syndrome
23. Palpation
• a. Apical impulse
• b. Pulsation
• Heaves-Sustained lifts of chest wall in precordial area
• c. Thrills
- Thrills – vibratory sensations
- Thrills are best palpated with head of
metacarpal bones
• - Thrills suggest presence of a murmur
• - Thrills are common with obstructive lesion with narrow orifice
• - Diastolic thrills – MS
• - Continuous thrill – PDA
24.
25. • Percussion
The right and left sides of the heart can be
estimated by percussion.The curve of the rib in the
fourth and fifth intercoastal space starting at
midaxillary line is percussed
26. Auscultaion
• Auscultatory areas :
• Aortic area - Right of the sternum (in the 2nd intercostal
space )
• Pulmonary area – left of the sternum (2nd intercostal space )
• Erb’s point—3rdintercostal space to the left of the sternum
• tricuspid area—fourth intercostal spaces to the left of the
sternum
• mitral area—the PMI, 5th intercostal space midclavicular
location on the chest where heart contractions can be
palpated
27.
28. Principles of Auscultation
• Normally only the closing of valves can be heard.
• Closure of the tricuspid and mitral valves (AV valves)
produce the 1st heart sound.
• Closure of the aortic and pulmonic valves produce the 2nd
heart sound.
• Opening of valves can only be heard if they are very
damaged (opening “snap” “click”)
29. Third Heart Sound
• When AV valves open, the period of rapid filling of
ventricles occurs. 80% of ventricular filling occurs now.
At the END of rapid filling, a 3rd heart sound may be
heard
• S-3 is normal in children and young adults, but not in
people over age 30. It means there is volume overload
of ventricle
30. Fourth Heart Sound
• At the end of diastole, atrial contraction contributes
to the additional 20% filling of the ventricle
• If the left ventricle is stiff and non-compliant, you
will hear an S4.
• It sounds like this: a-STIFF-wall, a-STIFF-wall, a-
STIFF-wall Or sounds like TEN-ne-see
31. Murmurs
• They are produced when there is turbulent blood flow
within the heart
• Turbulence may be due to a narrowed opening of a
valve (stenosis) or a valve that does not close
completely, allowing blood to slosh backwards
(regurgitation or insufficiency)
32. The Intensity of Murmurs
• Grade I = lowest intensity, not heard by
inexperienced listener
• Grade II = low intensity, usually audible to everyone
• Grade III = medium intensity but no palpable thrill
• Grade IV = medium intensity with a thrill
33. Intensity of murmurs, con’t
• Grade V = loudest murmur audible when stethoscope is on
the chest. Has a thrill
• Grade VI = loudest intensity, audible when stethoscope is
removed from the chest. Has a thrill
34. Systolic Murmurs
• These are ejection murmurs
• May be caused by turbulence across the aortic or pulmonic
valves if they are stenosed
• May be caused by turbulence across the mitral or tricuspid
valves if they are incompetent (regurgitant)
• The murmur falls between S1 and S2
• Sounds like, LUB-shhh-dub
35. Diastolic Murmurs
• Mitral and tricuspid stenosis can cause a diastolic murmur
• Aortic or pulmonic regurgitation can cause a diastolic
murmur
• Sounds like this: Lub-dub-shhh
36. Pericardial Friction Rub
• These are extra-cardiac sounds of short duration that have
a sound like scratching on sandpaper
• May result from irritation of the pericardium from infection,
inflammation, or after open heart surgery
• Best heard when patient sits and holds breath
