Cardiovascular System Examination

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I. Preparation & General Inspection

1. Wash hands
→ Maintain hygiene and infection control.

2. Introduce yourself and obtain consent

3. Position the patient
→ Supine at 45° with chest exposed appropriately.

4. General observation from end of bed:

• Cyanosis (bluish discoloration — indicates hypoxia)
• Pallor (pale skin — suggests anemia)
• Dyspnea (difficulty breathing — seen in heart failure)
• Use of accessory muscles (suggests respiratory distress often due to left heart failure)
• Edema (swelling — usually pedal; suggestive of right heart failure)
• Cachexia (wasting — occurs in chronic heart failure)

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II. Hands and Arms

1. Look at the hands:

• Clubbing (bulbous fingers — seen in infective endocarditis, congenital heart disease)
• Splinter hemorrhages (linear bleeding under nails — seen in infective endocarditis)
• Osler’s nodes (tender nodules on fingers — due to immune complex in infective endocarditis)
• Janeway lesions (painless red macules on palms/soles — septic emboli from endocarditis)
• Palmar crease pallor (suggests anemia)

2. Capillary Refill Time (CRT)
→ Press the fingernail bed for 5 seconds and release.
→ Refill time >2 seconds = poor perfusion.
(CRT: delayed refill shows reduced cardiac output or shock)

3. Assess the pulse

• Rate (Normal: 60–100 bpm)
• Rhythm
  • Regular
  • Irregularly irregular (Atrial fibrillation — no consistent rhythm)
  • Regularly irregular (e.g., sinus arrhythmia — natural variation with breathing)
• Character
  • Bounding pulse (strong, forceful — seen in aortic regurgitation)
  • Collapsing pulse (sharp upstroke, rapid fall — "water hammer pulse", in aortic regurgitation)
  • Pulsus parvus et tardus (slow rising, weak — typical of aortic stenosis)

4. Blood Pressure

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III. Face and Neck

1. Face:

• Malar flush (rosy cheeks — seen in mitral stenosis)
• Conjunctival pallor (anemia)
• Xanthelasma (lipid plaques near eyes — seen in hyperlipidemia)

2. Eyes:

• Arcus senilis (white ring — hypercholesterolemia in young)
• Roth spots (retinal hemorrhages — infective endocarditis)

3. Mouth:

• Central cyanosis (bluish tongue)
• High-arched palate (Marfan syndrome — predisposes to aortic dissection, MVP)

4. Neck:

• Jugular Venous Pressure (JVP)
  • Raise head to 45°, observe internal jugular vein pulsations.
  • Use right side.
  • Measure from sternal angle — normal <4 cm.
  • Raised JVP → seen in right heart failure, fluid overload, constrictive pericarditis.
  • Prominent 'v' wave → tricuspid regurgitation.
    (JVP reflects right atrial pressure; unlike carotid pulse, it is non-palpable)

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IV. Precordium (Chest) Examination

1. Inspection:

• Scars (CABG, pacemaker)
• Visible pulsations
• Chest wall deformities
• Apex beat — visible in thin individuals

2. Palpation:

• Apex Beat Location:

  • Normally at 5th intercostal space, mid-clavicular line
  • Thrusting apex (forceful & sustained — volume overload as in aortic regurgitation)
  • Heaving apex (sustained, forceful — pressure overload like aortic stenosis)
  • Displaced apex (seen in cardiomegaly/heart failure)

• Parasternal Heave (sustained lift felt along left sternal edge — indicates right ventricular hypertrophy)

• Thrills (palpable murmurs — turbulent blood flow as in severe valvular disease)

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V. Auscultation

Valves:

1. Aortic — 2nd Right ICS
2. Pulmonary — 2nd Left ICS
3. Tricuspid — 4th Left ICS
4. Mitral — 5th Left ICS MCL (Apex)

Murmurs:

• Pan-systolic murmur (murmur throughout systole — seen in mitral regurgitation, tricuspid regurgitation, VSD)
• Ejection systolic murmur (crescendo-decrescendo — seen in aortic or pulmonary stenosis)
• Mid-diastolic murmur (seen in mitral stenosis — due to turbulent filling)

Manoeuvres:

• Valsalva maneuver (forced expiration against closed glottis — reduces venous return)
  → Helps identify murmurs like HOCM and MVP
• Squatting and standing → Used to differentiate murmurs by affecting venous return and afterload

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VI. Back, Abdomen, Legs

Back:

• Listen for basal crackles (pulmonary edema — left heart failure)
• Sacral edema (seen in right heart failure or immobile patients)

Abdomen:

• Hepatomegaly (congestive hepatomegaly — right heart failure)
• Ascites (fluid accumulation — right heart failure)
• Abdominal aortic aneurysm (AAA) — palpate above umbilicus

Legs:

• Pedal edema (pitting swelling — right-sided heart failure)
• Calf tenderness (DVT — risk of embolism)

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VII. Special Conditions & Their CVS Findings

Condition	Key Signs
Heart Failure	Raised JVP, displaced apex, pedal edema, crackles
Mitral Stenosis	Malar flush, tapping apex beat, mid-diastolic murmur
Infective Endocarditis	Fever, murmur, Osler’s nodes, Janeway lesions, splinter hemorrhages
HOCM (Hypertrophic Obstructive Cardiomyopathy)	Ejection murmur ↑ with Valsalva
MVP (Mitral Valve Prolapse)	Mid-systolic click, murmur ↑ on standing
Aortic Dissection	Sudden chest pain, pulse deficit, unequal BP
Coarctation of Aorta	Radiofemoral delay, HTN in upper limbs, weak lower limb pulse
Atrial Fibrillation	Irregularly irregular pulse, loss of 'a' wave in JVP
Sinus Arrhythmia	Pulse varies with respiration (normal in youth)
Bounding Pulse	Wide pulse pressure — aortic regurgitation
Collapsing Pulse	Water-hammer pulse — aortic regurgitation
Pulsus Parvus et Tardus	Weak & slow — aortic stenosis

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