1. Examination of CVS
*General examination regarding CVS
1.Anaemia-Angina
2.Breathlessness
3.Clubbing with cyanosis-Right to left shunt
4.HyperlipidaemiaXanthroleshma
Archus cornea-Creamy yellow discoloration at the
boundary of iris due to cholesterol precipitation
5.Splinter hemorrhage-(SBE)-Small linear hemorrhage under nail
6.Ostler’s nodes-Painful erythematous swelling in finger pulp(SBE)

2. Examination of CVS
*Arterial pulsation examination
1.Radial pulse(RRV_CC)
Rate , rhythm , volume , condition of vessel wall , character ,radio radial
delay , radio femoral delay(Coarctation of aorta)
**Volume and character better by carotid pulse
2.Brachial pulse-Medial to biceps at antecubital fossa
3.Carotid pulse-Angle of jaw just anterior to sternocleidomastoid muscle
4.Popliteal-Popliteal fossa
5.Posterior tibial-2cm below and behind the medial malleolus between
flexor digitorum and flexor hallucics longus
6.Dorsalis pedis-Just lateral to extensor hallucis longus in 1st inter
metatarsal space most proximally

3. Pulse rate
1.Bardycardia(Heart rate below 60 beats/min)
Sinus bradycardia: When SA node produces impulse <60 beats/min
2.Tachycardia(Heart rate >100beats/min)
Sinus tachycardia: When SA node produces impulse 100 beats/min
**Causes of sinus bradycardia
Physiologic—Athlets ,sleep
Pathologic—MI ,hypothermia , hypothyroidism
**Causes of sinus tachycardia
Physiologic—Exercise , emotion , excitement
Pathologic—CCF ,anaemia , hyperthermia ,hyperthyroidism
**Causes of tachycardia
AF ,VF ,VT , VF +Flutter
**Causes of hyperdynamic circulation/increased pulse volume
Exercise , fever , pregnency , hyperthyroidism , anemia
**Irregular pulse
AFF ,heart block

4. Character of pulse
1.Normal/catacrotic
2.Low volume pulse
Shock ,pericardial effusion , aortic stenosis
3.High volume pulse
4.Collapsing pulse/water hammer pulse
AR ,PDA ,Hyperdynamic circulation
5.Pulsus bisferiens(Double peak)
Combined AR and AS
6.Pulsus alternans(Altered strong and weak pulse)
LVF
7.Pulsus paradoxas(Decreased volume in inspiration)
Constrictive pericarditis , pericardial effusions , severe asthma
8.Pulsus deficit(Difference in H.R and P.R)
AF
9.Dicrotic pulse: Fever
10.Plateau: AS

5. Examination of CVS
*Examination of BP
*JVP examination
a.45 degree lying
b.Opposite sided face
c.Relaxed neck muscle
d.Observe along medial border of sternocleidomastoid muscle
e.If not found , then do abdomino jugular reflux to confirm highest limit of pulse
f.Measure from sternal angle which is normally 4cm indicating 6mmHg pressure of right atrium. In Kussmaul’s sign there
is paradoxical rise in JVP in inspiration indicating constrictive pericarditis due to less accommodation of increased
venous return during inspiration--1.a wave peak: Right Atrial contraction(Giant in TS , absent in AF)
2.x descent: Tricuspid ring descent/fall in g atrial pressure during ventricular systole(Rapid descent in Constrictive peri.)
3.c wave peak: Tricuspid closure
4.v wave peak: Atrial filling/ventricular contraction(Giant in TR)
5.y descent: Opening of tricuspid(Rapid descent in Pericardial effusion)
**Raised JVP: CCF , TR ,constrictive pericarditis , pericardial temponade , sup.venacaval obstruction

6. Impalpable apex beat
Obese
Athletes
Asthma
Emphysema
CCF
Dextrocardia
Pericardial effusion

7. Examination of CVS
*Precordium examination
Area of heart that lies on the anterior chest wall is precordium
Inspection:
1.Shape of the chest/precordium
2.Visible pulse
3.Engorged vein
4.Scar marks
Palpation:
1.Loacte apex and measure from left sternal edge along midclavicular line(Minorly check for any swelling/tenderness)
If not found/obese person make left lateral position to confirm(Normal , Thrusting in right ventricular hypertrophy , Tapping in MS , Thrilling in
VSD)
2.Check for thrill(Palpable vibration on chest wall) by flat of the fingers at apex(mitral area) , 3 rd/4th space(tricuspid area) , aortic and pulmonary
area , below the clavicle(PDA) ,above tricuspid area(VSD)
3.Left parasternal heave( Systolic thrust in right ventricular hypertrophy) by heel of the hand with fingertips right angle to sternum
4.Pulmonary component of 2nd heart sound(Palpable P2) at left 2nd space with finger tips(Use index , middle , ring finger tips)
Percussion: 1.Locate apex and upper border liver dullness and join the line which is inferior border of heart
2.Draw clinical base of heart ;RnL 2nd space 1.25cm from each sternal edge ,on left space along upper border of 3rd rib and on right space along
lower border of 2nd rib
3.Mark multiple point along right and left margin of heart where dullness is found by percussing from shoulders ,lateral chest wall ,and join the
point to indicate the borders/margin of heart

8. Examination of CVS
Auscultation
1.Locate apex and at apex with diaphragm
2.On left lateral position then with diaphragm at apex and bell at apex in breath
holding expiration and radiation to axilla(Maneuver for MS)
3.Return to 45 degree angle
4.At tricuspid , pulmonary , aortic area with diaphragm
5.Sit and Lean a bit forward and auscultate with diaphragm at left parasternal
edge(Think Tricuspid area but never say it) with breath holding
inspiration(Maneuver for AR) and at pulmonary-aortic area in breath holding
expiration
6.Over carotid arteries by diaphragm and radiation in neck
**During auscultation of CVS always check coincidation with carotid artery with
thumb and during thrill palpation do only if murmur found

9. Apex beat
1.Position
2.Character
Normal
Tapping(MS)
Heaving(LVH)
Double apical(Hypertrophic cardiomyopathy)
Diffuse (Dilated cardiomyopathy)
Thrills
PS ,AS-Systolic
TS ,MS-Diastolic
Left parasternal heave
RVH

10. About murmurs
Systolic murmurs
Diastolic murmurs
Continuous murmurs
PASs+ASD
(Mid systolic/ejection
systolic)
PARd
(Early diastolic)
PDA
Arteriovenous shunt
TMR+VSD
(Pansystolic)
TMS
(Mid diastolic)
MP
(Late systolic)

11. About heart sounds
Heart
sounds
Reasons of producing
S1
TM(Closure)---TMSS is only one(S1) medical college in BD
S2
(Single in
expiration
and splits in
inspiration)
AP(Closure)---Many (S2) students PASS in TMSS medical college
S3
Abrupt cessation of ventricular filling
S4
Stiff ventricle
Systolic click
PASS
Opening
snap
Opening of stenosed mitral valve

12. About different murmurs
MS:
Low pitched localised , rough rumbling , mid diastolic murmur in mitral area best heard with bell of stethoscope in left lateral position with
breath hold after expiration with presystolic accentuation
Cause: Chronic rheumatic fever
MR:
S1 soft
Pansystolic murmur radiating towards left axilla
MP:
Mid systolic click
Late systolic murmur
VSD:
Pansystolic murmur
Normal S1 and S2
ASD:
Fixed splitting S2
Mid systolic murmur
Mid diastolic murmur

13. AR:
3 pulses:
1.High volume pulse(Collapsing pulse/Water hammer pulse)
2.Carotid dense pulse
3.Capillary pulse: Pressure on nail tips initiates blood column flickering under nail
Slide on tongue to see capillary pulse
3BP:
1.High systolic
2.Low diastolic
3.Wide pulse pressure
3 murmurs:
1.Early diastolic(Classical murmur)
2.Mid systolic
3.Soft mid diastolic(Austin flint murmur)

14. TR:
Pansystolic murmur
Normal S1 and S2
TS:
Mid diastolic murmur
PR:
Early diastolic/Graham steel murmur
PS:
Ejection systolic murmur
PDA:
Continuous murmur(Both in systolic and diastolic phase , Ruptured sinus valsalva)

15. AS:
Ejection systolic click
Ejection systolic murmur radiating towards
neck

16. Symptoms analysis
Chest pain(SOCRATES ;any pain)
Breathlessness
Palpitation
Syncope
Oedema

17. Symptoms analysis
Chest pain
Pericardium ,heart ,pleura ,lung ,trachea
,larynx,oesophagus ,musculoskeletal causes

18. Traits
Angina
MI
Oesophageal
pain
Site
Retrosternal
Same
Retrosternal or
epigastric
Radiation
Arm ,neck
,epigastrium
Same
Arm ,back
Precipitated by
Exercise
Spontaneous
Often present
Relieved by
Rapidly by rest
/nitrates
Not by
rest/nitrates
Relieved by
rest/nitrates but
not rapidly
Wakes from sleep
No
No
Often
Hurt burn
No
No
Sometimes
Vomit/nausea
No
Common
No

19. Symptoms analysis
Palpitation
Awareness of heart beat
Syncope
Loss of consciousness due to inadequate cerebral perfusion
Causes—Postural hypotension(HANDI)
hypovolaemia
hypopituitarism
addison’s disease
neuropathy
drugs(vasodilators and anti HTN drugs)