CVS Examination Dr Amr Khayat MBBS Member of
CVS Examination Dr. Amr Khayat, MBBS Member of Saudi General Surgery Society Member of Saudi Society for Vascular Surgery Member of Saudi Association for Plastic Surgery
CVS Examination • General appearance The hands The face The neck The praecordium Inspection • Palpation Auscultation
Apex beat The Praecordium Visible pulsations Scars Palpation Apex beat Parasternal heave Palpable thrills
1 - General Appearance • Look for: (ABCDE) Respiratory distress Cachexia Dysmorphic features
Patient Position in CVS Examination
2 - The Hand • Look For : Clubbing Cyanosis Splinter hemorrhage Osler nodes (tender) Janway lesions (not tender) Muscle Wasting.
2 - The Hand • Radial pulse: Rate Rhythm: [regular, irregular (irregularly irregular, regularly irregular)] Character and volume (collapsing, alternans) Radio-radial delay Radiofemoral delay Condition of the vessel wall Blood pressure
3 - The Face • Eye’s : Pallor , Jaundice, Xanthelasma. Mitral features (rosy cheeks, bluish tinge). Central cyanosis in the tongue
4 - The Neck • Palpate the carotid artery medial to sternomastoid muscle for character (bisferience, collapsing, alternans, jerky) Inspect the height of the JVP by inspecting the internal jugular vein
4 - The Neck • Jugular pulse can be distinguished from arterial pulse by: It is a complex wave (flicker twice) Jugular is visible but not palpable JVP decreases with inspiration It is filled from above after removing pressure applied to the base of the neck.
5 - The Precordium • By INSPECTION: Scars Skeletal abnormalities (pectus excavatum, kyphoscoliosis) Visiable Apex beat Other visible pulsations
• By PALPATION: 5 - The Precordium ➡Apex beat: Site (the most lateral and most inferior; normally in the 5 th left intercostals space in the mid clavicular line) Displaced or not Character (heaving, double impulse, tapping) ➡Parasternal impulse: • By the heel of the hand rested just to the left of the sternum. ➡Palpable murmurs (thrills):
5 - The Precordium • By AUSCULTATION: ➡Start in the mitral area with the bell to hear low pitch sounds like in mitral stenosis then use the diaphragm. ➡Then move to the tricuspid area (5 th Lt. intercostal) ➡Then to pulmonary area (2 nd Lt. intercostal) ➡Then to aortic area (2 nd Rt. intercostal) ➡On auscultation listen to: Heart sounds (S 1, S 2) Abnormalities in heart sounds (loud, soft, increased splitting, fixed splitting, reversed splitting) Additional sounds (S 3, S 4) Heart murmurs
What to look for in murmurs • Site Intensity ( 6 grades ) Time (systole , diastole) Duration (early , pan , late) Radiation (axilla , carotid) Pitch (High, Low) Special character
6 - The Back • Percussion and auscultation of the lung bases looking for signs of pulmonary edema like: Crepitation Dull percussion , decrease air entry (pleural effusion ) In the back look for sacral edema as well
7 - The Abdomen • Look for Ascitis Hepatomegaly
8 - The Lower Limbs • Palpate the: Femoral artery (below inguinal ligament 1/3 of the way up from the pubic tubercle) Popliteal artery (behind the knees) Post. tibial (below medial malleolus half the way between the calcaneus and medial malleolus) Dorsalis pedis (between the 1 st and 2 nd metatarsal bone lateral to flexor hallosis longus) Then look for lower limb edema.
THANK YOU
• 1. A 45 year old man comes into your office complaining of heart palpitations. You listen at his heart apex with the diaphragm of the stethoscope and hear a mid systolic click (an extra beat in between the 1 st and 2 nd heart sound). What is the likely diagnosis? • A-Mitral stenosis B-Aortic regurgitation C-Mitral valve prolapse D-Mitral regurgitation
• 2. A 50 year old woman comes into your office citing exercise intolerance. You listen to her heart at the lower left sternal border with the bell of the stethoscope and hear an S 3 sound (an extra, low frequency heart beat occurring after the 2 nd heart sound). What is the likely diagnosis? • A-Patent ductus arteriosis B-Aortic stenosis C-Congestive heart failure D-Mitral stenosis
• 3. If a patient has atrial fibrillation (the atria no longer respond to heart pace-making cells) an S 4 heart sound (an extra, low frequency beat occurring before the first heart sound) will not exist. • A-True B-False
• 4. A 10 year old boy comes into your office with no symptoms or complaints. When listening with the bell of the stethoscope at the apex, you hear an S 3 heart sound. What is the diagnosis? • A-Chronic heart failure B-Pulmonic Stenosis C-Tricuspid Stenosis D-Normal heart sound
• 5. A 40 year old man comes into your office complaining of exercise intolerance. You listen to his heart at the 3 rd left intercostal space with the diaphragm and hear a murmur that is saw-like in quality that begins after S 1 (first heart sound) and ends before S 2 (2 nd heart sound) during systole (while the heart is contracting). What is a likely diagnosis? • A-Aortic regurgitation B-Tricuspid stenosis C-Mitral stenosis D-Aortic Stenosis
• 6. The diastolic murmur of tricuspid stenosis (narrowing and hardening of the tricuspid valve cusps) can only be heard with the diaphragm of the stethoscope. • A-True B-False
• 7. A 70 year old man comes into your office complaining of heart palpitations. You listen to his heart at the lower left sternal border with the bell of the stethoscope and hear a rumbling murmur that occurs only during diastole (while the ventricles are filling). What is the likely diagnosis? • A-Mitral stenosis B-Tricuspid stenosis C-Aortic stenosis D-Tricuspid regurgitation
• 8. A 55 year old woman comes into your office complaining of exercise intolerance. You listen to her heart at the 2 nd right intercostal space with the diaphragm of the stethoscope and hear a diastolic murmur of blowing quality. What is the likely diagnosis? • A-Aortic stenosis B-Aortic regurgitation C-Mitral regurgitation D-Tricuspid regurgitation
• 9. A 67 year old man enters your office with no complaints. You listen to his heart at the apex and hear an opening snap when listening with the diaphragm and a rumbling diastolic murmur when listening with the bell. What is the likely diagnosis? • A-Pulmonic stenosis B-Tricuspid stenosis C-Mitral stenosis D-Aortic stenosis
• 10. Now for a whopper: A 60 year old woman enters your office with no symptoms to complain of. You listen to her heart at the 2 nd left intercostal space and hear a mid-systolic murmur accompanied with wide fixed splitting of the S 2 heart sound (Usually the 2 nd heart sound is split and widens with inspiration at the 2 nd left intercostal space). What is the diagnosis? • A-Pulmonic regurgitation B-Mitral regurgitation C-Tricuspid regurgitation D-Atrial septal defect
• 1. A 45 year old man comes into your office complaining of heart palpitations. You listen at his heart apex with the diaphragm of the stethoscope and hear a mid systolic click (an extra beat in between the 1 st and 2 nd heart sound). What is the likely diagnosis? • A-Mitral stenosis B-Aortic regurgitation C-Mitral valve prolapse D-Mitral regurgitation
• 2. A 50 year old woman comes into your office citing exercise intolerance. You listen to her heart at the lower left sternal border with the bell of the stethoscope and hear an S 3 sound (an extra, low frequency heart beat occurring after the 2 nd heart sound). What is the likely diagnosis? • A-Patent ductus arteriosis B-Aortic stenosis C-Congestive heart failure D-Mitral stenosis
• 3. If a patient has atrial fibrillation (the atria no longer respond to heart pace-making cells) an S 4 heart sound (an extra, low frequency beat occurring before the first heart sound) will not exist. • A-True B-False
• 4. A 10 year old boy comes into your office with no symptoms or complaints. When listening with the bell of the stethoscope at the apex, you hear an S 3 heart sound. What is the diagnosis? • A-Chronic heart failure B-Pulmonic Stenosis C-Tricuspid Stenosis D-Normal heart sound
• 5. A 40 year old man comes into your office complaining of exercise intolerance. You listen to his heart at the 3 rd left intercostal space with the diaphragm and hear a murmur that is saw-like in quality that begins after S 1 (first heart sound) and ends before S 2 (2 nd heart sound) during systole (while the heart is contracting). What is a likely diagnosis? • A-Aortic regurgitation B-Tricuspid stenosis C-Mitral stenosis D-Aortic Stenosis
• 6. The diastolic murmur of tricuspid stenosis (narrowing and hardening of the tricuspid valve cusps) can only be heard with the diaphragm of the stethoscope. • A-True B-False
• 7. A 70 year old man comes into your office complaining of heart palpitations. You listen to his heart at the lower left sternal border with the bell of the stethoscope and hear a rumbling murmur that occurs only during diastole (while the ventricles are filling). What is the likely diagnosis? • A-Mitral stenosis B-Tricuspid stenosis C-Aortic stenosis D-Tricuspid regurgitation
• 8. A 55 year old woman comes into your office complaining of exercise intolerance. You listen to her heart at the 2 nd right intercostal space with the diaphragm of the stethoscope and hear a diastolic murmur of blowing quality. What is the likely diagnosis? • A-Aortic stenosis B-Aortic regurgitation C-Mitral regurgitation D-Tricuspid regurgitation
• 9. A 67 year old man enters your office with no complaints. You listen to his heart at the apex and hear an opening snap when listening with the diaphragm and a rumbling diastolic murmur when listening with the bell. What is the likely diagnosis? • A-Pulmonic stenosis B-Tricuspid stenosis C-Mitral stenosis D-Aortic stenosis
• 10. Now for a whopper: A 60 year old woman enters your office with no symptoms to complain of. You listen to her heart at the 2 nd left intercostal space and hear a mid-systolic murmur accompanied with wide fixed splitting of the S 2 heart sound (Usually the 2 nd heart sound is split and widens with inspiration at the 2 nd left intercostal space). What is the diagnosis? • A-Pulmonic regurgitation B-Mitral regurgitation C-Tricuspid regurgitation D-Atrial septal defect
Good Luck
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