Examination and Investigation of The Cardiovascular System (CVS)

EXAMINATION AND INVESTIGATION OF
THE CARDIOVASCULAR SYSTEM(CVS)

INTRODUCTION
• Examination and investigations are essential

part of management of any medical condition.
In order to arrive at a diagnosis of the patient’s
condition, patient must be examined and
investigated.
• after taking a history of patient’s complaints
then a general examination of the various
systems is done while paying attention to the
particular system that is diseased.
• This is followed up by various investigations
then treatment.
• Patient Management is made up of: History-
Examination-Investigation-Treatment.
• General examination of the CVS involves
inspection without touching the patient while
looking out for:
 Features of acute illness
 Features of chronic illness eg wasting or
cachexia.
 Dyspnea: symptom and sign of left heart
failure
 Obesity
 Pain on chest suggesting angina
 Surgical scars on the chest
• Palpation is done next which involves using
the hand to look for:
 Fever as in infective endocardidtis
 Pallor which is sought for on the conjunctiva of the
lower eyelids, tongue and palms particularly in dark
skinned patients. It is a sign of severe congestive
heart failure due to cardiogenic shock and is a
common cause of heart failure in the tropics.
 Cyanosis which may be central or peripheral. It
implies that the arterial blood is unsaturated with
oxygen as a result of cardiac or pulmonary disease
or both.
CVS EXAMINATION PROPER
 The skin of (of the extremities) is dusky blue in
color. At least 5g/dl of hemoglobin is
unsaturated with oxygen or attached to
reduction products of haemoglobin eg
sulhaemoglobin, methaemoglobin.
 Central cyanosis when the tongue is cyanosed
is seen in right to left shunt (cardiac failure),
right sided endomyocardial fibrosis.
 Associated with polycythaemia and finger
clubbing when severe.
 Peripheral cyanosis occurs in the extremities
and is due to venous stasis.
• Finger and toe clubbing
 Stage 1; increased sponginess of the nail bed.
 Stage 2; obliteration of the angle between the
nail bed and nail fold.
 Stage 3; increased convexity of the nail
longitudinally and transversely.
 Stage 4; bulbous swelling of the distal end of
the finger.
• Finger clubbing is seen in
 Heart disease. Cyanotic congenital heart
disease eg fallot’s tetralogy, infective
endocarditis, EMF, atrial myxoma
 Lung disease eg emphyema, bronchiestasis
 Chronic diarrhoea eg crohn’s disease
 Cirrhosis of the liver
 Familial
• Warmth
 Moist, warm palms as seen in thyrotoxicosis.
 Moist, cold palms are seen in anxiety.
• Oedema of cardiac origin is pitting and
dependent and is associated with raised
jugular venous pressure.
• Proptosis (protrusion of the eyeball) may be
found in the patient with chronic severe,
tricuspid regurgitation, thyrotoxicosis, cor
pulmonale, carvenous sinus thrombosis,
orbital tumours.
• Pulse rate (60-100 b/min)
 Below 60/min is called bradycardia.
 Above 100/min is tachycardia.
 It varies with age.
 Sinus bradycardia caused by athletic fitness,
excessive dosage with digitalis, beta blockers,
hypothyroidism, sick sinus syndrome, heart block,
coupled ectopic beats, vasomotor syncope,
hypothermia and raised intracranial pressure.
 Sinus tachycardia caused by exercise, emotional
problems, fever, thyrotoxicosis, anaemia,
excessive fluid or blood loss, administration of
atropine or sympathomimetic drugs.
• Pulse rhythm
 This can be regular or irregular.
 A completely irregular pulse is caused by atrial
fibrillation and worsens by exercise.
 A regularly irregular pulse is caused by ectopic
beats and tends to improve by exercise.
• Pulse equality
 Comparison of two different arterial pulsation for
radio-femoral delay eg coarctation of the aorta.
 Unequal or absent radial pulses may be due to
abnormal position of the radial artery, pressure
over the subclavian artery by an aortic aneurysm,
dissecting aneurysm, atheroma, thrombosis or
embolism.
• Pulse volume
 May be small, normal or large
 Small pulse volume due to obstruction of
blood flow in the heart or within the vessels
e.g. aortic sternosis and pulmonary embolism,
myocardial failure, excessive fluid or blood
loss (hypovolaemia)
 A large volume pulse is associated with a
collapsing pulse e.g. aortic regurgitation,
arteriovenous fistulae.
• Pulse character
 Pulsus parvus – a small volume pulse
 Pulsus parvus et tardus- pulse is small and the
upstroke is slow
o Seen in aortic stenosis
o Palpable notch on the upstroke (anacrotic
pulse)
 Pulsus bisferiens – double peaked pulse with a
slow upstroke and a fast downstroke.
o Seen in combined aortic stenosis and
regurgitation.
 Collapsing pulse
 Pulsus alternans- alternate pulses are weak
o Indicates severe damage to the heart muscle.
 Pulsus paradoxus
o Taking two systolic blood pressures at full
expiration and at full inspiration. A difference
of 15mm/Hg or more between these two
readings indicates pulsus paradoxus.
o In EMF, constrictive pericarditis, pericardial
effusion.
• Blood pressure:
 Patient lying comfortably or sitting with arm stretched
on a table, the cuff is applied and firmly to the upper
arm and deflated until the pulse can be felt. This is the
systolic blood pressure as determined by palpation
( palpatory method)
 The cuff is reinflated until the radial pulse is
obliterated following which the area over the brachial
artery is auscultated while the cuff is slowly deflated.
The first Korotkoff sound signals
the systolic blood pressure. The diastolic blood
pressure is the point where these sounds
disappear.
• Jugular venous pressure (JVP)- it is the measure
of the end diastolic pressure of the right
ventricle.
• It is raised when the pressure within the right
atrium and right ventricle are raised. Eg right
sided heart failure.
• Except in (a) tricuspid stenosis when only the
pressure in the right atrium is raised and (b)
when the vein is blocked.
• The right internal jugular vein is the best vein
for assessing the height of the venous
pressure.
• The external jugular vein is used when the
internal is not visible.
Location of the Apex beat
• In relation to the mid-clavicular anterior
axillary or mid-axillary line,when it is felt
outside the line, it is displaced.
• The normal apex beat lies within the mid-
clavicular line.
• Displaced apex beat is seen in cardiac enlargement,
deformities of the thoracic cage eg scoliosis.
• The character could be tapping- mitral stenosis; heaving
and localised- left ventricular hypertrophy; heaving and
diffused- dilated hypertrophied left ventricle.
Auscultation of the heart
• Four areas are recognised
1. Mitral area- position of the apex beat.
2. Tricuspid area- low left parasternal area.
3. Aortic area- right of the sternum at the second
intercostal space.
4. Pulmonary area- left of the sternum at the second
intercostal space.
• It should not be confined to these areas.
Heart sounds
• Four well recognised heart sounds- S1, S2, S3,
and S4
• S1 – closure of the mitral and tricuspid valve
• S2 – closure of the pulmonary and aortic valves.
• S3 – vibration of the ventricular wall caused by
the rapid filling of the ventricles. Heard in
normal young people and in pregnancy. It is
pathological in people beyond 50 years.
• S4 heard in normal subject above the age of fifty
years but pathological as a result of stiff
ventricles that are hypertrophied.
• The bell of the stethoscope is for low pitched
sounds. The diaphragm is for high pitched
sounds.
• Other heart sounds eg murmurs
INVESTIGATIONS
• Chest x-ray shows cardiomegaly, aortic knuckle
unfolding, which are all seen in long standing
hypertension.
• Electrocardiogram
i. Rhythm, rate
ii. LVH, RVH
iii. Myocardial ischaemia and infarction
• Echocardiogram (2-D, 3-D)
i. Valvular abnormalities
i.Ejection fraction
ii.
Cardiac wall abnormalities
• Doppler ultrasound scan
 Defect problems with the flow of blood
through the vessels and heart
• CT Scan
 Useful in detecting aneurysms and tumors
• MRI
• Full blood count

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EXAMINATION AND INVESTIGATION OF

THE CARDIOVASCULAR SYSTEM(CVS)

• Examination and investigations are essential

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