various headings under which cvs examination to be done.

1. CARDIOVASCULAR SYSTEM EXAMINATION
INSPECTION:
1. SHAPE AND SYMMETRY OF CHEST WALL:
NORMAL: bilaterallysymmetrical,anteroposteriordiametertotransverse diameter- 5:7
2. CHEST DEFORMITIES:
-Funnel shapedchest:Marfanssyndrome.
-pigeonshaped chest: Rickets.
3. PRECORDIAL BULGE:
-Chroniccardiomegaly.
4. TRACHEAL POSITION:
-Central/ shifted
5. APICALIMPULSE:
-4TH
intercostal space,justlateral tothe midclavicularline.
6. OTHER VISIBLE PULSATIONS:
- Aorticarea, pulmonaryarea, epigastricregion, suprasternalarea,carotidarea.
7. DILATED VEINS,SCARS and SINUSES.

2. PALPATION
1. JUGULAR VENOUS PULSE (JVP):
-Keepthe patientat45 degree .
-Turnhead to leftside.
-Drawtransverse line overthe upperborderof oscillatorycolumninthe internal jugularveinandatthe level
of Sternal angle.
-Usingcm ruler , vertical distance betweenbothhorizontal linemeasureJVP.
-If distance >3cm (JVPelevated).
-5cm is added toobtainan estimate of meanrightatrial pressure incmsof blood.
-CausesforraisedJVP: rightventricularfailure, tricuspidstenosisorregurgitation, pericardial effusion, fluid
overload.
2.APEX BEAT:
PROCEDURE: Start by doingthiswithentire hand,graduallybecome more specificuntil itisfeltunderone finger.
*palpatingwithhand.
*locatingwithfinger.
*beststudiedinleftlateral positionof the patient.
a) LOCATION: 4th
intercostal space justlateral tomid-clavicularline.
Cause for shiftinapex beat: Leftor right ventricularhypertrophy, Dextrocardia.
b) CHARACTER:
TAPPING APEX BEAT- mitral stenosis(slightincrease inamplitude).
HYPERDYNAMIC APEX BEAT: systemichypertension, aorticstenosis, volume overload.
HEAVING APEX BEAT: (bothamplitude anddurationisincreased).aorticregurgitation, vsd.
DIFFUSE APEX BEAT: leftventricularaneurysms.
DOUBLE APICAL IMPULSE:aortic stenosisorregurgitation.
TRIPLE OR QUADRUPLE APEX BEAT: HOCM.

3. ABSENT APEX BEAT: obese children,impulse behindthe rib
3.TRACHEAL POSITION :
TRAIL’S SIGN: t isthe undue prominence of the clavicularheadof sternomastoidonthe side towhichtracheais
deviated.
4 .PARA STERNAL HEAVE: Palpable thrustwhichliftsthe handinparasternal region.
 Palpatedbyulnaraspectof palm.
 Alsocan be demonstratedbyplacingapenon the leftparasternal region, whichwill moveperpendicular
to chestwall.
 Seeninrightventricularenlargement,leftatrial enlargement.
GRADING OF PARASTERNAL IMPULSE (AIIMSgrading):
GRADE 1: visible butnotpalpable.
GRADE 2: visible andpalpable butobliterable.
GRADE 3: visible andpalpable butnotobliterable.
5. THRILLS/PALPABLE MURMURS:
These accompanyanyorganic murmurof GRADE 3 or more.
TYPES: Aorticthrills,Pulmonarythrills,Leftlowerparasternalthrills,Apicalthrills.
TIMING:systolicthrills,diastolicthrills,continuousthrills.
PERCUSSION:
BORDERS OF HEART: RIGHT , LEFT, UPPER AND LOWER BORDERS.
Helpsinfindingpositionand enlargementof heartas in-

4.  Dextrocardia.
 Pericardial effusion.
 Dilatedcardiomyopathy.
PROCEDURE:
a) RIGHT BORDER:
Firstpercussfor liverdullness →take1intercostal space above →fromhere gomedially →presence
of dull note atright sternal bordersignifiesrightborderof heart.
b) LEFT BORDER
Localise the apex beat →take 1 intercostal space above →fromhere gomedially → presence of dull
note signifiesleftborderof heart.
AUSCULTATION
AREAS OF AUSCULTATION:
A) MITRAL AREA: 5th
leftintercostal space inthe midclavicularline.
B) TRICUSPID AREA: 4th
leftintercostal space justlateral tolowerendof sternum.
C) 1st
AORTIC AREA: 2nd
right intercostal space, close tosternum.
2nd
AORTIC AREA /ERB’S AREA:3rd
leftintercostal space,close tosternum.
D) PULMONARYAREA: 2nd
leftintercostal space,close tosternum.
E) GIBSON’SAREA: 2nd
leftintercostal areaawayfromsternum.(PDA murmurisbestheardhere)
F) OTHER AREAS: carotid, supraclavicular, axillaryareas.
Back- interscapular, infrascapularareas ( bruitsinthe back).
AUSCULTATE THE AREAS FOR FOLLOWING SOUNDS:
1) HEART SOUNDS-S1,S2, S3 ,S4.
 INTENSITY (soft/loud)
 SLPITTING OF SOUNDS.

a) S1- producedbyclosure of atrioventricularvalves.(M1+ T1)
→ SOFT S1: mitral andtricuspidregurgitation,mitral andtricuspidstenosis.
→ LOUD S1: tricuspidstenosis,highoutputstates.
→ SPLITTING S1: RBBB withpulmonaryhypertension,ebsteinsanomaly.
→ REVERSE SPLITTING:Right ventricularpacing,ectopicbeatsfromRV.
b) S2-Producedbyclosure of aortic and pulmonaryvalves.(A2+P2)

5. → SOFTS2: Aortic/pulmonaryvalve calcification.
→LOUD S2: Systemicandpulmonaryhypertension.
→SPLITS2: Atrial septal defect,pulmonaryembolism, rightventricular
failure.
→REVERSE SPLITTINGS2: LBBB, Aorticstenosis(severe).
c ) S3/PROTODIASTOLIC SOUND/VENTRICULARGALLOP:
Auscultate withbellof stethoscopeatapex.
→ PHYSIOLOGICAL:Childrenandathletes.
→ PATHOLOGICAL:High outputstates ,ASD,VASD,PDA,IHD.
d) S4/PRESYSTOLIC GALLOP/ATRIAL GALLOP:
→ Hypertrophic cardiomyopathy,systemichypertension.
2) ADDED SOUNDS:
a) OPENINGSNAP.
b) EJECTION CLICK.
c) GALLOP RHYTHM.
d) ATRIALGALLOP.
e) VENTRICULARGALLOP.
3) PERICARDIAL RUB:
→ Viral pericarditis, tuberculouspericarditis, acute rheumaticfever, SLE.
4) HEART MURMURS:
→ They are relativelyprolongedseriesof auditoryvibrationsproduceddue toturbulence thatarise
whenbloodvelocityincrease due toincreasedflow ordue toflow througha constrictedorirregularorifice.
Murmurs shouldbe describedinthe following way:
 Areaoverprecordiumwhere murmurisheard.
 Whethermurmurissystolic/diastolic.
 Timingandcharacter of murmur(ESM,PSM,MDM,EDM)
 Intensityof murmur(grading).
 Pitchof murmur(low/high).
 Whethermurmurisbestheardwithbell ordiaphragmof stethoscope.
 Conductionof murmur.

6.  Variationwithrespiration( Ltsidedmurmursbestheardinexpiration&vice versa).
 Posture inwhichmurmurisbestheard.
LEVINE AND FREEMAN’S GRADING OF MURMURS :
SYSTOLIC MURMUR
GRADE:
1.verysoft.(heardinquiet room)
2.soft.
3.moderate.
4.loudwiththrill.
5.veryloudwiththrill (heardwithstethoscope).
6.veryloudwiththrill (evenwhenstethoscope isslightlyawayfromchestwall)
DIASTOLIC MURMURS.
GRADE:
1.verysoft.
2.soft.
3.loud.
4.loudwiththrill.