Physical examination of the cardiovascular system is mainly discussed under four headings i.e., itlspection, palpation, percussion and auscultation like any other systemic examination. Ausculation is discussed separately in section.
Inspection
Cardiac exaniinatio~l begins with inspection of the chest, which is best carried out with the examiner standing by the side or at the foot end of the bed.Respiratory rate, regularity and pattern (abdon~inothoracic or thoracic) should be noted Clleyne Stokes respiration suggests low cardiac outI;ut. Precordial bulge suggests cardiac enlargement having been developed before puberty.Dcfornrities of tlre Cliest FYall Sltorrld be Noted
a) Pectus carinatum (pigeon chest): may be associated with Marfan syndrome.
b) Pectus excavatum: commonly seen in Marfan syndrome, and in small fraction of patients with MVP. An ASD should also be suspected. Lack of normal thoracic kyphosis (straight back syndrome) may also be associated with pectus excavatum.
c) Shield chest: (Broad chest with greater angle than usual between manubriun~ and body of sternum along with widely separated nipples) suggests Turners syndrome in a female and concomitant coarctation of aorta. In males, it suggests Noonan's syndrome and is comnlonly associated with pulmonary stenosis.
d) Kypl~oscoliosis may be responsible for cor pulmonale.
Pulsatiorrs
1) Apex impulse; lowest and outernlost point of definite cardiac pulsation.
2) Pronlinellt pulsations in left parastelnal region suggest RV enlargement, in 3rd left ICS suggest pulmonary artery enlargeinent and in 2nd right ICS suggest,aortic enlargement.
3) Other pulsations:
Suprasternal notch suggests aneurysm of arch of aorta.Over the scapulae as in coarctation of aorta.Cardotid pulsations in neck in patients with hyperdynamic circulation ,e.g., tl~yrotoxicosis, AR.In epigastriunl where it could be normal aortic pulsations as in thin persons or due to aortic aneurysm or it could be hepatic pulsation from TR.
Palpation
Teclzri iques
Examincr should use the fingertips or the part just proximal to them for palpation.The chest should be completely exposed and elevated to 30 degree the patient should be examined both in supine and in left lateral position (heart moves laterally, and hence is better palpable).should be tiined with carotid pulse or auscultated heart Prccordial n~oven~ents,
sounds.
a)Left Verztricular Itl~pulse (Apex beat)
This is the lowest and the outennost point on the chest at which cardiac impulse call be palpated. Normally it is felt in the 5th intercostal space, medial to midclavicular line, occupying an area of 2.5 cm2.It is palpable as a single, brief outward motion. It may not be palpable in persoils with thick chest wall, or when it is hidden behind the rib. If not palpable in supine position, turning the patient to left lateral position may help.
Abnormal Apical, Impulse
i)Site: Displacement of the apex beat lateral to mid-clavicular line or beyond 10 CIIIS lateral to Inidsternal line is a sensitive but not specific sign of left velitricular enlargemellt. 111 left lateral decubitus, if apical impulse is more than 3 cms in diameter, it is an accurate sign of left ventricular enlargement.In absence of cardionlegaly the apical impulse may be displaced to the left in patients with pectus excavatum or congenital complete absence of pericardium. In patients with Dextrocardia: apex beat will be palpable on the right hemi thorax.
ii) Character: Heaving apex impulse as in patieiits with concentric LVH where the apical irnpulse is sustained and displaced laterally and downwards.Hypcrkiiietic apex inipulse as in patieiits with volume overload where it is brisk and larger. Hyperkinetic apex impulse as in patients with low cardiac output. Tapping apical impulse as in patients with MS.
iii) Other Co~~ditions:
Double apical impulse as in patieiits with HOCM when a wave (palpable atrial hump) is present, as in sevcre HOCM, a triple outward
movement (triple ripple) can be palpated.Constrictive pericarditis is usually associated with systolic retraction of chest, especially of ribs in left axilla (Brodbent sign).
b)Right Verltl-icular hvpulse
Normally it is not palpable except in first few months of life. Systoilc outward motion in the left parasternal area suggests RV enlargemenllhypertrophy. A sustained lcft parastcrnal impulse suggests RVH due to pressure overload as in PS or PH.On placing the pad of right thumb pointing upward just below the xiphoid process, if an impulse can be palpated hitting the thunib pad, it indicate RV inflow cnlargeinent. In left lateral position RV enlai.genient is suggested by a doniinant lateral retraction.
Prominent systolic pulsation of pulmonary artery in 2nd ICS just to the left of sternum suggests pulmonary hypertension and or increased pulnionary blood flow. It is often associated with prominent left parastenial pulsatioii of RV enlargement. Normal puliilonary trunk can sonietinles be palpablc in patients with narrow aiiteroposterior diameter.Systolic bulging of LA is transmitted through the RV and it begins and terminates after the LV impulse. Left parasteinal nlovellleiit can occur in absence of RV enlargement in patients with dilated LA as in severe MR.
There are palpable manifestations of loud, harsh murmur having low medium frequency components and is classically described as the purring of a cat. These are best felt with flat of the hand or fingertips. High-pitched muiniurs, as those produced by valvar regurgitation are not usually associated with thrills, even when loud.
Percussion
Palpation is more helpful than percussion in deternlining cardiac size. Percus'sion aids in detennining visceral situs. Percussion of 2nd left ICS is important as a dull, note signifies dilatation of large arteries as in pulmonary artery or aneurysm of ascending aorta.
Inspection
Cardiac exaniinatio~l begins with inspection of the chest, which is best carried out with the examiner standing by the side or at the foot end of the bed.Respiratory rate, regularity and pattern (abdon~inothoracic or thoracic) should be noted Clleyne Stokes respiration suggests low cardiac outI;ut. Precordial bulge suggests cardiac enlargement having been developed before puberty.Dcfornrities of tlre Cliest FYall Sltorrld be Noted
a) Pectus carinatum (pigeon chest): may be associated with Marfan syndrome.
b) Pectus excavatum: commonly seen in Marfan syndrome, and in small fraction of patients with MVP. An ASD should also be suspected. Lack of normal thoracic kyphosis (straight back syndrome) may also be associated with pectus excavatum.
c) Shield chest: (Broad chest with greater angle than usual between manubriun~ and body of sternum along with widely separated nipples) suggests Turners syndrome in a female and concomitant coarctation of aorta. In males, it suggests Noonan's syndrome and is comnlonly associated with pulmonary stenosis.
d) Kypl~oscoliosis may be responsible for cor pulmonale.
Pulsatiorrs
1) Apex impulse; lowest and outernlost point of definite cardiac pulsation.
2) Pronlinellt pulsations in left parastelnal region suggest RV enlargement, in 3rd left ICS suggest pulmonary artery enlargeinent and in 2nd right ICS suggest,aortic enlargement.
3) Other pulsations:
Suprasternal notch suggests aneurysm of arch of aorta.Over the scapulae as in coarctation of aorta.Cardotid pulsations in neck in patients with hyperdynamic circulation ,e.g., tl~yrotoxicosis, AR.In epigastriunl where it could be normal aortic pulsations as in thin persons or due to aortic aneurysm or it could be hepatic pulsation from TR.
Palpation
Teclzri iques
Examincr should use the fingertips or the part just proximal to them for palpation.The chest should be completely exposed and elevated to 30 degree the patient should be examined both in supine and in left lateral position (heart moves laterally, and hence is better palpable).should be tiined with carotid pulse or auscultated heart Prccordial n~oven~ents,
sounds.
a)Left Verztricular Itl~pulse (Apex beat)
This is the lowest and the outennost point on the chest at which cardiac impulse call be palpated. Normally it is felt in the 5th intercostal space, medial to midclavicular line, occupying an area of 2.5 cm2.It is palpable as a single, brief outward motion. It may not be palpable in persoils with thick chest wall, or when it is hidden behind the rib. If not palpable in supine position, turning the patient to left lateral position may help.
Abnormal Apical, Impulse
i)Site: Displacement of the apex beat lateral to mid-clavicular line or beyond 10 CIIIS lateral to Inidsternal line is a sensitive but not specific sign of left velitricular enlargemellt. 111 left lateral decubitus, if apical impulse is more than 3 cms in diameter, it is an accurate sign of left ventricular enlargement.In absence of cardionlegaly the apical impulse may be displaced to the left in patients with pectus excavatum or congenital complete absence of pericardium. In patients with Dextrocardia: apex beat will be palpable on the right hemi thorax.
ii) Character: Heaving apex impulse as in patieiits with concentric LVH where the apical irnpulse is sustained and displaced laterally and downwards.Hypcrkiiietic apex inipulse as in patieiits with volume overload where it is brisk and larger. Hyperkinetic apex impulse as in patients with low cardiac output. Tapping apical impulse as in patients with MS.
iii) Other Co~~ditions:
Double apical impulse as in patieiits with HOCM when a wave (palpable atrial hump) is present, as in sevcre HOCM, a triple outward
movement (triple ripple) can be palpated.Constrictive pericarditis is usually associated with systolic retraction of chest, especially of ribs in left axilla (Brodbent sign).
b)Right Verltl-icular hvpulse
Normally it is not palpable except in first few months of life. Systoilc outward motion in the left parasternal area suggests RV enlargemenllhypertrophy. A sustained lcft parastcrnal impulse suggests RVH due to pressure overload as in PS or PH.On placing the pad of right thumb pointing upward just below the xiphoid process, if an impulse can be palpated hitting the thunib pad, it indicate RV inflow cnlargeinent. In left lateral position RV enlai.genient is suggested by a doniinant lateral retraction.
Prominent systolic pulsation of pulmonary artery in 2nd ICS just to the left of sternum suggests pulmonary hypertension and or increased pulnionary blood flow. It is often associated with prominent left parastenial pulsatioii of RV enlargement. Normal puliilonary trunk can sonietinles be palpablc in patients with narrow aiiteroposterior diameter.Systolic bulging of LA is transmitted through the RV and it begins and terminates after the LV impulse. Left parasteinal nlovellleiit can occur in absence of RV enlargement in patients with dilated LA as in severe MR.
There are palpable manifestations of loud, harsh murmur having low medium frequency components and is classically described as the purring of a cat. These are best felt with flat of the hand or fingertips. High-pitched muiniurs, as those produced by valvar regurgitation are not usually associated with thrills, even when loud.
Percussion
Palpation is more helpful than percussion in deternlining cardiac size. Percus'sion aids in detennining visceral situs. Percussion of 2nd left ICS is important as a dull, note signifies dilatation of large arteries as in pulmonary artery or aneurysm of ascending aorta.
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