Cardiovascular System (CVS) Examination

Preparation

• Wash hands, introduce yourself, confirm patient identity, explain examination and obtain consent.
• Ensure privacy, adequate lighting, and expose from clavicles to lower chest while maintaining dignity.
• Position patient at about 45°.
• Ask about pain or breathlessness. Examine from the patient’s right side.

1. General inspection

• Dyspnea, cyanosis, pallor, cachexia, sweating
• Peripheral edema
• Oxygen, IV lines, pacemaker scars, medications
• Marfanoid habitus, xanthelasma, tendon xanthomas
• Hands: clubbing, splinter hemorrhages, peripheral cyanosis

2. Hands and arms

• Assess temperature and capillary refill.
• Feel radial pulse:
  • Rate
  • Rhythm
  • Volume/character
  • Compare both sides
• Check for radio-radial delay.
• Measure blood pressure in both arms if indicated.
• Look for collapsing pulse: raise the arm rapidly while palpating the radial pulse.

3. Face

• Eyes: conjunctival pallor, corneal arcus, xanthelasma.
• Mouth: central cyanosis, dental hygiene or infective endocarditis risk.
• Inspect for malar flush in mitral stenosis.

4. Neck

Jugular venous pressure (JVP)

• Turn head slightly left and inspect the right internal jugular venous pulsation.
• Estimate vertical height above the sternal angle.
• Elevated JVP suggests raised right atrial pressure or systemic venous congestion.
• Assess waveform and hepatojugular reflux if needed.

Carotid pulse

• Palpate one carotid artery at a time for volume and character.
• Auscultate for bruit before palpation if vascular disease is suspected.
• Never palpate both carotids simultaneously.

5. Precordial inspection

• Scars: sternotomy, thoracotomy, pacemaker/ICD
• Chest deformity
• Visible apex beat
• Precordial bulge, heaves, or pulsations

6. Palpation

• Locate apex beat: normally at the left 5th intercostal space, midclavicular line.
• Note position, character, and area:
  • Displaced apex: cardiomegaly or mediastinal shift
  • Heaving apex: pressure overload, e.g. hypertension or aortic stenosis
  • Hyperdynamic apex: volume overload
• Palpate for:
  • Parasternal heave: right ventricular hypertrophy
  • Thrills: palpable murmurs
  • Epigastric pulsation

7. Auscultation

• Heart rate and rhythm
• S1 and S2
• Added sounds: S3, S4, clicks, opening snap
• Murmurs: timing, site, radiation, pitch, intensity, and response to maneuvers

• Left lateral position with bell at apex: mitral stenosis and S3/S4.
• Sitting forward in expiration with diaphragm at left sternal edge: aortic regurgitation.
• Inspiration increases right-sided murmurs; expiration tends to accentuate left-sided murmurs.

8. Peripheral examination

• Check sacral edema in bedridden patients and ankle edema in ambulant patients.
• Palpate dorsalis pedis and posterior tibial pulses.
• Check for peripheral cyanosis, ulcers, varicose veins, and signs of peripheral arterial disease.
• Examine lungs for basal crackles, which may indicate pulmonary edema.
• Palpate abdomen for hepatomegaly, ascites, and abdominal aortic aneurysm if indicated.

Completion

• Thank the patient, help them cover up, wash hands.
• Offer to check:
  • ECG
  • Urinalysis
  • Blood pressure
  • Fundoscopy
  • Peripheral pulses and respiratory examination

Apex Beat / Apical Impulse

Normal apex beat

• Site: Left 5th intercostal space, at or just medial to the midclavicular line
• Area: Localized, usually ≤ 2.5 to 3 cm
• Character: Brief, gentle impulse, felt in the first two-thirds of systole
• Best position: Supine. If not palpable, place patient in left lateral decubitus position and ask for held expiration.

1. Site
2. Area
3. Character
4. Duration

Types of Apex Beat

Palpation of the Precordium in CVS Examination

Method

1. Place the patient supine at 30-45° with chest adequately exposed.
2. Inspect first for visible pulsations.
3. Use the whole palm to locate the apex, starting in the left inframammary region.
4. Once located, use finger pads to assess apex beat.
5. If difficult, turn patient to left lateral position and ask them to expire and hold breath.

What to palpate

1. Apex beat

• Site
• Area
• Character
• Duration

2. Parasternal heave

• Place heel of right hand along left sternal border.
• A lifting systolic impulse suggests right ventricular hypertrophy or dilatation.
• In severe LV hypertrophy, a sustained apical thrust is usually more focal at the apex.

3. Thrills

• Site
• Timing: systolic, diastolic, or continuous
• Radiation

• Aortic area / suprasternal notch systolic thrill: severe aortic stenosis
• Pulmonary area systolic thrill: pulmonary stenosis
• Left lower sternal border systolic thrill: ventricular septal defect
• Apex diastolic thrill: mitral stenosis, uncommon

4. Palpable heart sounds

• Palpable S1: tapping apex beat in mitral stenosis
• Palpable S3: may occur in severe volume overload or LV failure
• Palpable S4: may occur with a stiff ventricle, e.g. LV hypertrophy

5. Epigastric pulsation

• Can occur in right ventricular enlargement, abdominal aortic aneurysm, or transmitted aortic pulsation.

“Apex beat is palpated in the left fifth intercostal space at the midclavicular line. It is localized, of normal character, and not sustained. There is no parasternal heave and no palpable thrill.”

“The apex beat is displaced downwards and laterally, diffuse, and hyperdynamic, suggesting left ventricular dilatation with volume overload.”