Give me in detail explanation of cardiovascular system examination with which conditions contain which type of signs and symptoms in order wise and differentiation between diseases if any diseases are similar

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Cardiovascular System Examination - Complete Guide

Sources: Harrison's Principles of Internal Medicine 22E (2025), Goldman-Cecil Medicine

ORDER OF EXAMINATION

The cardiovascular exam follows a structured sequence:

General Appearance
Vital Signs (BP, HR, RR)
Ophthalmologic Exam
Jugular Venous Pressure (JVP)
Carotid Pulse
Precordial Inspection and Palpation
Cardiac Auscultation
Abdominal and Peripheral Exam

1. GENERAL APPEARANCE

Before touching the patient, observe for features pointing to specific diagnoses:

Finding	Associated Condition
Tachypnea, labored breathing	Heart failure, pulmonary edema
Cheyne-Stokes respirations	Advanced heart failure
Exophthalmos, stare	Hyperthyroidism (atrial fibrillation, high-output failure)
Ptosis, expressionless face	Myotonic dystrophy (AV block, arrhythmia)
Tall, thin build with arm span > height	Marfan syndrome (aortic root dilation, MVP)
Blue sclerae	Osteogenesis imperfecta (aortic dilation, MVP)
Webbed neck, low hairline	Turner syndrome (coarctation, bicuspid aortic valve)
Short stature, flat face	Down syndrome (ASD, VSD, AV canal)
Malar rash, joint swelling	SLE, rheumatoid arthritis (pericarditis, endocarditis)
Tight skin, sclerodactyly	Scleroderma (pulmonary hypertension)
Skin bronzing	Hemochromatosis (cardiomyopathy, heart block)

2. VITAL SIGNS

Blood Pressure

Technique: Seated, arm at heart level, 5-10 min rest, appropriately sized cuff. Cuff bladder length 80%, width 40% of arm circumference.

BP Finding	Interpretation
BP difference >10 mmHg between arms	Subclavian artery atherosclerosis/inflammation, aortic dissection, supravalvular aortic stenosis, coarctation
Arm BP >> leg BP	Normal: leg systolic is ~20 mmHg higher; reversed ratio suggests coarctation of the aorta
Very low diastolic (near 0)	Chronic severe aortic regurgitation (AR) or large arteriovenous fistula
Wide pulse pressure	Severe AR, hyperthyroidism, fever, anemia, high-output states
Narrow pulse pressure	Severe aortic stenosis (AS), cardiac tamponade, severe LV dysfunction

Pulsus Paradoxus

A fall in systolic BP >10 mmHg with inspiration.

Cause	Key Distinguishing Feature
Pericardial tamponade	Most classic cause; also has elevated JVP, muffled heart sounds
Massive pulmonary embolism	Tachycardia, hypoxia, pleuritic chest pain
Severe obstructive lung disease	Wheeze, prolonged expiratory phase
Tension pneumothorax	Absent breath sounds, tracheal deviation
Hemorrhagic shock	Hypotension, bleeding source

Pulsus Alternans

Beat-to-beat variability of pulse amplitude at regular rhythm. Indicates severe LV systolic dysfunction. Every other Korotkoff sound is audible as cuff deflates.

3. OPHTHALMOLOGIC EXAM

Finding	Associated Condition
Diabetic retinopathy	Ischemic cardiomyopathy
Hypertensive retinopathy	Hypertensive heart disease, LVH
Roth spots (white-centered hemorrhages)	Infective endocarditis
Beading of retinal arteries	Severe hypercholesterolemia
Retinal artery occlusion	Embolus from left atrial thrombus, myxoma, aortic atheroembolism

4. JUGULAR VENOUS PRESSURE (JVP)

Measurement: Vertical distance from sternal angle (angle of Louis) to top of jugular pulsation at 30-45 degrees. Normal <4.5 cm at 30°; add 5 cm to get central venous pressure in cm H₂O. Normal CVP = 5-10 cm H₂O. Pulsations above the clavicle in the sitting position are always abnormal.

Distinguishing JVP from carotid:

JVP: biphasic (two peaks), not palpable, changes with posture and respiration
Carotid: monophasic, palpable, does not change with respiration

JVP waveforms: normal (A), tricuspid regurgitation mild/severe (B), constrictive pericarditis (C) with prominent Y descent and pericardial knock

JVP Waveform Components and Their Abnormalities

Wave/Descent	Normal Meaning	Abnormality	Disease
a wave	RA presystolic contraction (after P wave, before S1)	Prominent a wave	Reduced RV compliance (pulmonic stenosis, pulmonary hypertension, RV hypertrophy)
		Cannon a wave	AV dissociation (VT, complete heart block) - RA contracts against closed tricuspid valve
		Absent a wave	Atrial fibrillation
x descent	Fall in RA pressure after tricuspid opening	Absent/blunted	Atrial fibrillation, tamponade
v wave	Atrial filling during ventricular systole	Accentuated v wave (cv wave)	Tricuspid regurgitation - waveform becomes "ventriculized"
y descent	After v peak, tricuspid valve opens	Blunted/prolonged y descent	Tricuspid stenosis, pericardial tamponade
		Rapid, prominent y descent	Constrictive pericarditis, severe TR

Elevated JVP: Differential Diagnosis

JVP Pattern	Diagnosis
Elevated JVP + blunted/absent y descent + pulsus paradoxus + quiet heart	Cardiac tamponade - echocardiography urgently needed
Elevated JVP + sharp prominent y descent + Kussmaul sign + quiet precordium	Constrictive pericarditis - CT/MRI/catheterization needed
Elevated JVP + sharp brief y descent + Kussmaul sign + evidence of pulmonary hypertension + TR	Restrictive cardiomyopathy
Elevated JVP without y descent	Right heart failure of any cause
Prominent a wave (no elevated mean JVP)	Tricuspid stenosis, pulmonic stenosis, pulmonary hypertension
Prominent v wave + sharp y descent	Tricuspid regurgitation

Kussmaul's sign (JVP rises or fails to fall with inspiration): Constrictive pericarditis (classic), restrictive cardiomyopathy, massive PE, RV infarction, advanced LV systolic failure.

Abdominojugular (hepatojugular) reflux: Firm pressure over RUQ for >15 seconds; positive = sustained JVP rise >3 cm. Indicates volume-overloaded state; predicts pulmonary artery wedge pressure >15 mmHg in heart failure.

5. CAROTID PULSE (CHARACTER OF PULSE)

Best assessed at the carotid artery. Describes pulse volume and contour.

Carotid pulse waveforms: A=Normal, B=Anacrotic (Aortic Stenosis), C/D=Bisferiens (AR, HOCM), E=Dicrotic (sepsis/severe HF)

Pulse Character	Description	Disease(s)
Pulsus parvus et tardus	Weak, delayed upstroke to a small peak	Severe Aortic Stenosis
Anacrotic pulse	Slow notched upstroke, peak near S2	Severe Aortic Stenosis
Corrigan's (water-hammer) pulse	Sharp rapid rise, collapsing fall	Chronic severe Aortic Regurgitation
Bisferiens pulse (two systolic peaks)	Percussion wave + tidal wave	Severe AR; HOCM; combined AS+AR with dominant AR
Dicrotic pulse (one systolic + one diastolic peak)	Exaggerated dicrotic wave	Sepsis, severe heart failure, hypovolemic shock, tamponade, after AVR
Hyperkinetic pulse	Increased amplitude and frequency	AR, AV fistula, hyperthyroidism, fever, anemia
Normal contour, reduced amplitude	Normal shape but weak	Any cause of reduced stroke volume

Differentiating Aortic Stenosis vs Aortic Regurgitation by Pulse

Feature	Aortic Stenosis	Aortic Regurgitation
Pulse character	Parvus et tardus (weak, delayed)	Water-hammer (sharp rise, collapsing)
Pulse pressure	Narrow	Wide
BP diastolic	Normal/elevated	Low (near 0 in severe)
Systolic murmur	Ejection (crescendo-decrescendo), midsystolic	None (unless combined lesion)
Diastolic murmur	None	Decrescendo, high-pitched, early diastolic

6. PRECORDIAL INSPECTION AND PALPATION

Inspection

Finding	Meaning
Visible apex beat at 5th ICS mid-clavicular line	Normal in thin adults
Apex beat displaced leftward/downward	LV enlargement
Visible sternal/parasternal pulsation	RV enlargement
Right upper parasternal pulsation	Ascending aortic aneurysm
Epigastric pulsation	Cardiac impulse displaced (COPD, emphysema) vs. pulsatile liver
Unilateral left chest asymmetry	RV hypertrophy developing before puberty

Palpation (Technique: supine at 30°, left lateral decubitus to enhance)

Finding	Meaning	Disease
Normal apex (<2 cm, brief outward movement)	Normal LV	-
Sustained (heaving) apex	Pressure overload	AS, chronic hypertension
Displaced, enlarged apex	Volume overload + LV dilation	Severe MR, severe AR, DCM
Palpable S4 (presystolic impulse)	Reduced LV compliance	LV hypertrophy, active ischemia, AS
Palpable S3	Rapid early filling (advanced HF)	Dilated cardiomyopathy, severe MR
Ectopic dyskinetic impulse (separate from apex)	LV aneurysm	Post-MI aneurysm
Triple cadence at apex (S4 + bisferiens)	Very rare	HOCM
Sternal/parasternal lift	RV pressure or volume overload	Pulmonary hypertension, RV failure, ASD
Loud palpable P2	Pulmonary hypertension
Systolic thrill	Turbulent flow	Grade ≥4 murmur: severe AS, VSD, MR
Diastolic thrill	Turbulent diastolic flow	Severe MS

7. CARDIAC AUSCULTATION

Heart Sounds

First Heart Sound (S1)

Produced by mitral and tricuspid valve closure.

S1 Character	Disease
Loud S1	Early rheumatic mitral stenosis (leaflets pliable but narrowed), hyperkinetic states, short PR interval
Soft S1	Late MS (leaflets rigid/calcified), after beta-blockers, long PR interval, LV contractile dysfunction
Variable S1	Complete AV block, atrial fibrillation
Wide splitting of S1	RBBB (delayed tricuspid closure)

Second Heart Sound (S2)

A2 (aortic closure) + P2 (pulmonic closure). Normally A2 before P2. Splitting increases with inspiration.

S2 Pattern	Cause	Disease
Fixed splitting (A2-P2 gap same in inspiration and expiration)	Equalization of RV/LV filling	Atrial Septal Defect (ASD)
Wide splitting (physiologic, inspiratory increase)	Delayed P2	RBBB, idiopathic PA dilation
Paradoxical (reversed) splitting (splits on expiration, closes on inspiration)	Delayed A2	LBBB, severe AS (mechanical delay), HOCM
Close fixed splitting	Loud P2 + fixed gap	Pulmonary hypertension
Single S2	Only one valve audible	Severe AS (A2 absent/inaudible), severe pulmonary hypertension (P2 overwhelms A2)
Loud A2	Increased aortic pressure	Systemic hypertension
Soft A2	Reduced aortic valve excursion	Aortic stenosis
Loud P2	Increased pulmonary artery pressure	Pulmonary hypertension, large ASD

Third Heart Sound (S3) - Early Diastolic Gallop

Low-pitched sound after S2, in early diastole (rapid ventricular filling phase).

Context	Significance
In patient <40 years	Often normal (physiologic)
In adults with dyspnea + dilated LV	LV systolic failure - high sensitivity for elevated wedge pressure
After MR	Chronic severe Mitral Regurgitation
Right-sided S3 (louder with inspiration)	RV failure, severe TR

Fourth Heart Sound (S4) - Presystolic Gallop

Low-pitched sound before S1 (late diastole), due to atrial contraction into non-compliant ventricle. Not present with atrial fibrillation.

Cause	Disease
Reduced LV compliance	LV hypertrophy, hypertensive heart disease, AS
Active myocardial ischemia	Acute MI, angina
Hypertrophic cardiomyopathy	HOCM
Right-sided S4	RV hypertrophy (pulmonary hypertension, pulmonic stenosis)

Differentiating S3 vs S4

Feature	S3	S4
Timing	Early diastole (after S2)	Late diastole (before S1)
Mechanism	Rapid filling into diseased ventricle	Atrial kick into non-compliant ventricle
Present in AF	Yes	NO
Implies	LV systolic dysfunction / volume overload	Reduced compliance / pressure overload
Pitch	Low (bell)	Low (bell)

Additional Sounds

Sound	Timing	Disease
Ejection click (early systolic)	Just after S1	Bicuspid aortic valve, mobile aortic valve in congenital AS; pulmonic valve stenosis (click disappears with inspiration); pulmonary hypertension with forceful valve opening
Mid-late systolic click	Variable during systole	Mitral Valve Prolapse (MVP) - moves toward S1 with standing/Valsalva; moves toward S2 with squatting
Opening snap (OS)	Early diastole (after A2)	Mitral Stenosis - shorter A2-OS interval = more severe MS
Pericardial knock	Early diastole	Constrictive pericarditis - high-pitched, occurs at the nadir of Y descent
Tumor plop	Early diastole	Atrial myxoma (movement of tumor through mitral valve)
Pericardial friction rub	Two or three component (systolic + diastolic) scratching sound	Pericarditis - best heard with patient leaning forward; may disappear with effusion

Heart Murmurs

Graded 1-6 (thrill present at grade 4+).

SYSTOLIC MURMURS

Holosystolic (Pansystolic) Murmurs

Persist throughout systole (S1 to S2), flat or decrescendo.

Disease	Location	Radiation	Character	Key Signs
Mitral Regurgitation (MR)	Apex	Left axilla (anterior leaflet to back; posterior leaflet to base - can mimic AS)	Holosystolic blowing	Displaced apex, S3, reduced S1
Tricuspid Regurgitation (TR)	Left lower sternal border	None	Holosystolic, increases with inspiration (Carvallo sign)	CV waves in JVP, pulsatile liver, peripheral edema
Ventricular Septal Defect (VSD)	Left sternal border 3rd-4th ICS	Right sternal border	Holosystolic harsh	Thrill common; if large: signs of pulmonary hypertension

Midsystolic (Ejection) Murmurs

Crescendo-decrescendo, begin after S1, end before S2.

Disease	Location	Radiation	Key Signs	Differentiation
Aortic Stenosis (AS)	Right 2nd ICS (aortic area)	Carotids (Gallavardin - to apex, can mimic MR)	Parvus et tardus pulse, sustained apex, soft/absent A2, paradoxical S2 split, S4	Late-peaking murmur = more severe
Pulmonary Stenosis	Left 2nd ICS (pulmonic area)	Left shoulder	Loud P2 if mild (soft if severe), ejection click (decreases with inspiration)	Right-sided signs; no carotid radiation
Hypertrophic Obstructive Cardiomyopathy (HOCM)	Left lower sternal border	Does NOT radiate to carotids well	Bisferiens pulse, S4, dynamic murmur	Increases with Valsalva/standing; decreases with squatting/hand-grip
ASD (relative pulmonic stenosis)	Left 2nd ICS	-	Fixed split S2	Soft murmur (flow); fixed S2 splitting
Benign flow murmur	Left sternal border/pulmonary area	None	No abnormal signs	Grade 1-2, vibratory (Still's murmur in children)

Differentiating AS vs MR vs HOCM (all are systolic murmurs)

Feature	AS	MR	HOCM
Timing	Midsystolic (ejection)	Holosystolic	Mid-late systolic
Location	Right 2nd ICS	Apex	Left lower sternal border
Radiation	Carotids	Axilla	Not carotids
Pulse	Parvus et tardus	Normal or hyperdynamic	Bisferiens
S2	Soft A2, paradoxical split	Wide physiologic split (early A2)	Normal
Valsalva	Decreases	Decreases	Increases
Squatting	Increases	Increases	Decreases
Standing	Decreases	Decreases	Increases
Handgrip	Increases	Increases	Decreases

Late Systolic Murmur

Disease	Feature
Mitral Valve Prolapse	Preceded by mid-systolic click; click-murmur complex moves toward S1 with standing/Valsalva; moves toward S2 with squatting

DIASTOLIC MURMURS (always pathological)

Early Diastolic (Decrescendo)

Disease	Location	Radiation	Quality	Key Signs
Aortic Regurgitation (AR)	Left sternal border (3rd ICS), also right 2nd ICS if aortic root dilated	Apex	High-pitched blowing decrescendo; best heard with patient sitting forward	Water-hammer pulse, wide pulse pressure, Austin Flint murmur (mid-diastolic low-pitched rumble at apex in severe AR), displaced apex, S3
Pulmonary Regurgitation (Graham Steell murmur)	Left 2nd-3rd ICS	-	High-pitched decrescendo	Loud P2, signs of pulmonary hypertension

Mid-Diastolic (Rumbling)

Disease	Location	Radiation	Quality	Key Clues
Mitral Stenosis (MS)	Apex	None	Low-pitched rumble (use bell); follows opening snap	Loud S1, OS, shorter A2-OS interval = more severe; pre-systolic accentuation in sinus rhythm; AF eliminates presystolic component
Tricuspid Stenosis	Left lower sternal border	None	Rumble; increases with inspiration	Prominent a wave in JVP, hepatomegaly
Austin Flint murmur	Apex	None	Low-pitched rumble	In context of severe AR; no OS; no loud S1

Differentiating MS vs Austin Flint Murmur

Feature	Mitral Stenosis	Austin Flint (AR)
Opening snap	Present	Absent
S1	Loud (early), soft (late)	Normal or soft
AR signs	Absent	Present (water-hammer pulse, wide PP)
Response to amyl nitrite	Louder (MS)	Softer (Flint - less AR)

CONTINUOUS MURMURS (systole + diastole)

Cause	Feature
Patent Ductus Arteriosus (PDA)	Left infraclavicular area; "machinery" murmur; wide pulse pressure
Ruptured sinus of Valsalva aneurysm	Sudden onset, may have thrill
Arteriovenous fistula	Over fistula site
Mammary souffle	Over breast in pregnancy
Combined AS + AR	Can mimic continuous; two separate murmurs

8. ABDOMINAL AND PERIPHERAL EXAMINATION

Finding	Disease
Hepatomegaly	Right heart failure (congestive hepatopathy)
Pulsatile liver	Tricuspid regurgitation
Hepatojugular reflux	Advanced RV failure / obstruction to RV filling
Splenomegaly	Infective endocarditis, portal hypertension from chronic HF
Pulsatile abdominal mass	Abdominal aortic aneurysm
Ascites	Advanced right heart failure, constrictive pericarditis
Peripheral edema (pitting)	Right heart failure
Ankle-brachial index <0.9	Peripheral arterial disease
Femoral/popliteal aneurysm	Associated with AAA
Absent foot pulses	PAD, aortic coarctation (in legs)

DISEASE-BY-DISEASE SUMMARY: SIGNS IN ORDER

Aortic Stenosis

General: symptoms on exertion (angina, syncope, dyspnea = classic triad)
Pulse: parvus et tardus; narrow pulse pressure
JVP: may show prominent a wave (if pulmonary hypertension develops)
Apex: sustained (heaving), not displaced (unless LV dilation in late disease)
Palpation: systolic thrill at 2nd right ICS
S1: normal; S2: single or paradoxically split (P2 soft/absent A2)
S4 gallop present
Murmur: midsystolic ejection crescendo-decrescendo at right 2nd ICS, radiating to carotids

Aortic Regurgitation (Chronic)

Pulse: water-hammer (Corrigan's); wide pulse pressure; bisferiens if severe
BP: high systolic, very low diastolic
Apex: displaced laterally and inferiorly (volume overloaded LV)
S1: normal; early diastolic decrescendo murmur at left sternal border
Austin Flint murmur at apex (in severe AR)
S3 in decompensated AR
Peripheral signs: pistol-shot femoral pulse (Traube's), Duroziez sign, Quincke pulses, de Musset's sign (head nodding)

Mitral Stenosis

General: dyspnea, hemoptysis, AF, systemic emboli
Pulse: irregular if AF
JVP: elevated if pulmonary hypertension present
Apex: not displaced; "tapping" quality (palpable S1)
S1: loud (pliable leaflets); S2: loud P2 if pulmonary hypertension
Opening snap (shortly after S2)
Mid-diastolic rumble at apex (bell of stethoscope, left lateral decubitus)
Presystolic accentuation (in sinus rhythm)

Mitral Regurgitation (Chronic)

Pulse: brisk, hyperdynamic
Apex: displaced laterally (volume overload); palpable S3
S1: soft; S2: wide splitting (early A2 due to rapid LV emptying); S3 present
Holosystolic blowing murmur at apex, radiating to axilla
If posterior leaflet: murmur radiates anteriorly to base (mimics AS)

Hypertrophic Obstructive Cardiomyopathy (HOCM)

General: dyspnea, syncope, chest pain, palpitations in young patient; family history of sudden death
Pulse: bisferiens; spike-and-dome character
Apex: triple cadence (S4 + bisferiens); sustained but not displaced
S4 prominent
Midsystolic murmur at left lower sternal border
Dynamic character is key: increases with Valsalva and standing; decreases with squatting and handgrip
Coexistent MR murmur often present

Constrictive Pericarditis

General: fatigue, peripheral edema, ascites - often misdiagnosed as liver disease
JVP: elevated with prominent/rapid y descent; Kussmaul sign (JVP rises with inspiration)
Pulse: may have pulsus paradoxus (mild)
Precordium: quiet precordium (no heave)
S3 equivalent = pericardial knock (high-pitched early diastolic sound; earlier than usual S3, occurs at nadir of rapid Y descent)
Hepatomegaly, ascites, peripheral edema

Cardiac Tamponade

General: Beck's triad - Hypotension + Elevated JVP + Muffled heart sounds
JVP: elevated; blunted/absent Y descent (impaired diastolic filling)
Pulse: pulsus paradoxus >10 mmHg (may be palpable >15 mmHg)
Precordium: quiet, no heave, heart sounds muffled
No Kussmaul sign

Differentiating Tamponade vs Constrictive Pericarditis

Feature	Tamponade	Constrictive Pericarditis
Pulsus paradoxus	Present (prominent)	Mild or absent
JVP Y descent	Absent/blunted	Prominent, rapid
Kussmaul sign	Absent	Present
Heart sounds	Muffled	Normal intensity + pericardial knock
Pericardial knock	Absent	Present
Echo	Pericardial effusion + RV collapse	Thickened/calcified pericardium

Pulmonary Hypertension

Pulse: normal or reduced volume
JVP: elevated; prominent a wave; if TR develops - prominent v wave
RV heave at left parasternal area
Palpable P2 at left 2nd ICS
S2: loud P2, narrow or single splitting
Right-sided S4; then right-sided S3 if RV fails
Ejection click in pulmonic area
TR murmur (holosystolic, left lower sternal border, increases with inspiration) develops late
PR murmur (Graham Steell) - high-pitched early diastolic decrescendo at left 2nd-3rd ICS

Infective Endocarditis

General: fever, weight loss, fatigue, embolic phenomena
Eyes: Roth spots (fundus), petechiae
Hands: Osler nodes (painful tender nodules - fingertips), Janeway lesions (non-tender hemorrhagic macules - palms/soles), splinter hemorrhages (nails)
New or changing murmur (most commonly MR or AR)
Splenomegaly
Signs of heart failure if severe valvular destruction

NYHA FUNCTIONAL CLASSIFICATION (Summary)

Class	Limitation
I	No limitation; ordinary activity does not cause symptoms
II	Slight limitation; ordinary activity causes fatigue/palpitation/dyspnea/angina
III	Marked limitation; less than ordinary activity causes symptoms
IV	Unable to do any activity without discomfort; symptoms at rest

Harrison's Principles of Internal Medicine 22E (2025), Goldman-Cecil Medicine

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