Complete Guide for CVS Examination

CVS Examination

A. Inspection

I. Precordium

II. Apex Impulse

  • Normal Location: 5th left intercostal space near the midclavicular line.
  • May be absent/not visible in:
    • Emphysema
    • Pericardial effusion
    • Behind a rib (may appear in anterior axillary line in left lateral position)

III. Pulsations

IV. Dilated Chest Wall Veins

V. Scars and Sinuses

  • Surgical Scars: Indicate previous heart or thoracic surgeries
  • Sinuses: May result from conditions like spinal tuberculosis

B. Palpation

CVS Examination

I. Apex Beat

  • Definition: The lowermost and outermost point on the chest wall where the maximum cardiac impulse is felt. It gives a gentle thrust to the palpating finger.
  • Normal Location and Characteristics:
    • 5th left intercostal space, at or just medial to the mid-clavicular line
    • Diameter: < 2.5 cm, confined to one intercostal space
    • Duration: < 50% of systole
  • Abnormalities of the Apex Beat:
    • Tapping Apex: Short, sharp systolic tap → Loud S1 due to mitral stenosis, often with RV enlargement.
    • Hyperdynamic Apex: High amplitude, < 2/3 of systole.
      • Causes: AR, MR, high-output states (e.g., anemia, thyrotoxicosis), PDA, VSD, AV fistulas, thin chest wall.
    • Heaving Apex: High amplitude, > 2/3 of systole, well-sustained.
      • Causes: AS, HOCM, coarctation of aorta, systemic hypertension.
    • Double Apical Impulse: LV aneurysm, HOCM, LBBB.
    • Diffuse Apex: > 3 cm diameter or involving > one intercostal space → LV aneurysm, severe LV dysfunction, LV dilatation (e.g., AR).
    • Triple or Quadruple Impulse: HOCM.
    • Retractile Impulse (Broadbent’s Sign): Systolic retraction of apex → Constrictive pericarditis.
    • Absent Apex Beat (Left Side):
      • Non-cardiac Causes: Obesity, thick chest wall, emphysema, left pleural effusion (with mediastinal shift to right)
      • Cardiac Causes: Dextrocardia, pericardial effusion, dilated cardiomyopathy, severe LV dysfunction (e.g., CAD)

II. Parasternal Heave

  • Definition: A systolic impulse felt in the left parasternal region, usually due to RV hypertrophy/enlargement.
  • Assessment:
    • Place ulnar border of hand vertically over left parasternal area with the patient in supine position.
    • Feel for lifting/thrusting movement during systole.
  • AIIMS Grading:
    • Grade I: Just touches the hand.
    • Grade II: Palpable and compressible.
    • Grade III: Palpable and not compressible.
  • Other Causes (without RV Enlargement):
    • Enlarged left atrium pushing RV forward
    • Aortic aneurysm displacing RV

III. Diastolic Shock

  • Definition: Palpable second heart sound (S2) – either P2 or A2.
  • Clinical Significance:
    • Loud P2: Pulmonary hypertension
    • Loud A2: Systemic hypertension or aortitis (e.g., syphilitic or Takayasu arteritis)

IV. Thrills

  • Definition: Palpable vibrations on the chest wall due to turbulent blood flow (feels like a purring cat).
  • Detection: Use palm of the hand over the precordium; best felt in:
    • Thin chest wall
    • Superficial murmurs
    • High flow states
  • Clinical Importance: Always indicates organic heart disease.

V. Timing and Sites of Thrills

  • Mitral Stenosis (MS): Presystolic → Apex
  • Mitral Regurgitation (MR): Systolic → Apex
  • Aortic Stenosis (AS): Systolic → Aortic area or Neoaortic area
  • Aortic Regurgitation (AR): Diastolic → Aortic area or Neoaortic area
  • Pulmonary Stenosis (PS): Systolic → Pulmonary area
  • Aortic Stenosis (Carotid Radiation): Systolic → Carotid arteries (carotid shudder)
  • Patent Ductus Arteriosus (PDA): Continuous → Pulmonary area or below left clavicle
  • Ventricular Septal Defect (VSD): Systolic → 3rd–4th left intercostal space (Neo-aortic or Erb’s area)
  • AV Communications: Continuous → Site of AV communication

C. Percussion

Purpose

  • To determine cardiac borders.
  • Less useful for heart size due to overlying lung resonance.
  • More useful in detecting:
    • Pericardial effusion
    • Aortic aneurysm

Limitations

  • Lung resonance often obscures heart borders.
  • Great vessels cause dullness similar to the heart, making distinction difficult.
  • Lower border of the heart cannot be assessed due to liver dullness.

I. Left Border of the Heart

  • How to Percuss:
    • Begin at the 4th and 5th intercostal spaces in the mid-axillary line.
    • Move medially toward the apex.
    • Note where resonance changes to dullness (heart border).
  • Normal Finding: Left border aligns with the apex beat.
  • Abnormal Finding: Dullness outside the apex beat suggests pericardial effusion.

II. Upper Border of the Heart

  • How to Percuss:
    • Percuss the 2nd and 3rd left intercostal spaces in the parasternal line (midway between mid-clavicular and lateral sternal lines).
  • Normal Finding: Resonant note in 2nd space; dull in 3rd space.
  • Dullness in 2nd Space Suggests:
    • Pericardial effusion
    • Aortic aneurysm
    • Pulmonary hypertension
    • Left atrial enlargement
    • Mediastinal mass

III. Right Border of the Heart

  • How to Percuss:
    • Start in the mid-clavicular line on the right side.
    • Percuss downward until liver dullness is found.
    • Move one intercostal space above and percuss medially toward the sternal border.
  • Normal Finding: Right border is retrosternal and not percussible.
  • Parasternal Dullness Suggests:
    • Pericardial effusion
    • Aneurysm of ascending aorta
    • Right atrial enlargement
    • Dextrocardia
    • Mediastinal mass
    • Right lung base pathology

To Determine Situs (Organ Position)

  • Situs Solitus (Normal):
    • Liver dullness on the right
    • Stomach tympany on the left
  • Situs Inversus:
    • Liver dullness on the left
    • Stomach tympany on the right

D. Auscultation

Stethoscope Components

  • Bell: Low-frequency sounds (80–150 Hz)
    • S3
    • S4
    • Mid-diastolic murmur of mitral stenosis (MS)
  • Diaphragm: High-frequency sounds (>300 Hz)
    • S1, S2
    • Opening snap (OS)
    • Clicks
    • Systolic and early diastolic murmurs
  • Length: Tubing is usually 12 inches long.

Purpose of Auscultation

  • To assess:
    • Heart sounds
    • Murmurs
    • Other sounds (clicks, snaps, rubs, plops, knocks)

I. Heart Sounds

  • S1: Closure of mitral (M1) and tricuspid (T1) valves
    • High frequency, single sound
    • Best heard at the mitral area with the diaphragm
    • Timed with carotid pulse
    • Marks onset of systole
  • Abnormal S1:
    • Loud S1: MS, TS, tachycardia, short PR, high output states, L–R shunts
    • Soft S1: MR, TR, pericardial effusion, obesity, prolonged PR, MI, calcified valves
    • Variable S1: Atrial fibrillation, complete heart block
    • Widely Split S1: RBBB, TS, Ebstein’s anomaly
    • Reverse Split S1: LBBB, severe MS, LA myxoma
  • S2: Closure of aortic (A2) and pulmonary (P2) valves
    • High frequency, normally split (A2 before P2)
    • Best heard in aortic and pulmonary areas
  • Abnormal Splitting of S2:
    • Wide Split: RBBB, ASD, PS, MR
    • Reverse Split: LBBB, AS, HOCM, LV failure
    • Single S2: AS, PS, TOF, truncus arteriosus
    • Narrow Split: Pulmonary hypertension
  • Intensity Changes:
    • Loud P2: Pulmonary hypertension, ASD
    • Soft P2: PS, TOF
    • Loud A2: Hypertension, aortic aneurysm
    • Soft A2: AS, AR
  • S3: Early diastolic, low frequency
    • Normal in youth, pregnancy, athletes
    • Pathologic in MR, TR, MI, CCF, VSD, high output states
    • Heard with bell, best in left lateral (LV) or supine (RV)
    • Disappears on standing, appears on passive leg raising
  • S4: Late diastolic, low frequency
    • Heard with bell, best at apex or LLSB
    • Seen in MI, LVH, HOCM, hypertension
  • Gallops:
    • Triple rhythm: S1 + S2 + S3 or S4
    • Quadruple rhythm: All 4 sounds
    • Summation gallop: S3 and S4 merge at HR > 100 bpm
  • Palpable Heart Sounds:
    • S1: Tapping apex (MS)
    • S2: Pulmonary hypertension
    • S4: Double apex beat (HOCM, severe AS)

II. Murmurs

  • Types:
    • Systolic (S1–S2)
    • Diastolic (S2–S1)
    • Continuous (through S2 into diastole)
  • Grading (Systolic Murmurs): Levine Scale
    • I: Very faint
    • II: Faint but audible
    • III: Moderately loud
    • IV: Loud, thrill present
    • V: Very loud, heard with stethoscope half lifted
    • VI: Audible without stethoscope contact
  • Diastolic Murmurs: Only Grades I–IV
  • Innocent Murmurs: No pathology
    • Soft, systolic, blowing, no thrill
    • Vary with posture
    • Normal heart sounds
  • Organic Murmurs:
    • Systolic:
      • Mid-systolic: AS, PS, HOCM
      • Late systolic: MVP, papillary muscle dysfunction
      • Pansystolic: MR, TR, VSD
      • Early systolic: Acute MR/TR, small VSD
    • Diastolic:
      • Early: AR, PR
      • Mid: MS, TS, Carey Coombs, Austin Flint
      • Late: MS, TS, atrial myxoma
    • Continuous:
      • PDA
      • AP window
      • Ruptured sinus of Valsalva
      • AV fistulas
      • Venous hum, mammary souffle

III. Other Auscultatory Sounds

  • Opening Snap: MS, TS
    • High-pitched, early diastole, best at apex
    • Short A2–OS interval = severe MS
  • Clicks:
    • Systolic ejection clicks: AS, PS, aortic aneurysm
    • Mid-systolic click: MVP, TVP
  • Pericardial Rub: Frictional, leathery
    • Best heard leaning forward
    • Seen in MI, Dressler, rheumatic fever, uremia
  • Pericardial Knock: Constrictive pericarditis
  • Tumor Plop: Atrial myxoma

IV. Dynamic Auscultation

  • Respiration:
    • ↑ Right-sided murmurs with inspiration
    • ↓ Left-sided murmurs with inspiration
  • Valsalva (Strain):
    • ↓ Most murmurs
    • ↑ MVP and HOCM murmurs
  • Handgrip:
    • ↑ MR, AR, VSD murmurs
    • ↓ HOCM, MVP murmurs
  • Passive Leg Raising: ↑ Right-sided murmurs
  • Squatting: ↑ Most murmurs, ↓ MVP and HOCM
  • Standing: ↓ Most murmurs, ↑ MVP and HOCM

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