Cardiovascular exam

～～心血管系の身体診察法～

Patient positioning

Basic Exam

• Supine, head elevated 30 degrees

Left lateral decubitus
Sitting, leaning slightly forward

Inspection and Palpation

Inspection of PMI (apical impulse)
Palpation of thrill
Palpation of retrosternal heave
Palpation of PMI

Lateral displacement

CHF, cardiomyopathy, ischemic heart disease

Increased amplitude

Hyperthyroidism, severe anemia,
pressure or volume overload of LV

Once you have found the apical impulse, make finer assessments with your fingertips, and then with one finger

Auscultation

Listen for rhythm and rate.
Listen to at least two of the four cardiac areas

 for murmurs, rubs, gallops. 

Listen to the mitral area with the patient on his left side.
Auscultate the apex with the bell of the stethoscope.

Listen to the base of the heart with the patient leaning forward.

<Systolic murmur>

AS (--> carotids)

• PS (--> back)

MR/MVP (-->axilla)

• TR

<Diastolic murmur>

MS , TS
AR , PR

<Extra sounds>

S3

(flabby ventricle-->dilated cardiomyopathy)

S4
(stiff ventricle -->LVH)

Opening snap (-->MS)
ejection sounds (-->AS, PS)
systolic clicks (-->MVP)

<Split S2>

Physiologic Splitting
accentuated by inspiration
usually disappears on expiration

Pathologic Splitting

• Wide splitting (-->MR, PS)
• Fixed splitting (-->ASD)
• Paradoxical or reversed splitting (-->CLBBB, AS)

Vascular

Listen to the carotids for bruits
(use the bell of the stethoscope).
Look for JVP (45-degree, use light)

Identify the highest point of pulsation in the right internal jugular vein.
Measure the height of venous pressure from sternal angle.

more than 4 cm above the sternal angle is elevated

Right-sided HF, constrictive pericarditis,
TS, SVC obstruction

Check for pedal edema
Check the peripheral pulses

dorsalis pedis pulse / posterior tibial pulse

Decreased or absent

often seen in diabetes mellitus.

Check for cyanosis/peripheral bloodflow
(palm color)