Systemic Examination(CVS)

Examination of precordium :

A. Inspection:

• 1. Deformity of the chest wall (kyphosis, scoliosis, lordosis, pectus excavatum or carinatum)
• 2. Visible cardiac impulse (visible apex beat)
• 3. Other impulses: epigastric, suprasternal, supraclavicular
• 4. Any scar mark: in the midline (valve replacement or coronary artery bypass), thoracotomy scar (valvotomy in mitral stenosis)
• 5. Pacemaker or cardioverter defibrillator box may be seen (mention, if any).

B.Palpation:

1. Apex beat:

• a. Site (localize the intercostal space. Beware of dextrocardia)
• b. Distance from the midline (in cm)
• c. Nature (normal, taping, heaving, thrusting, diffuse or double apex beat).

2. Thrill:

• a. Site (apical, basal or any other space)
• b. Nature (systolic or diastolic, by feeling the carotid pulse at the same time. If coincides with carotid pulse, it is systolic and if it does not coincide, it is diastolic).

3. Left parasternal heave: place the flat of right palm in left parasternal area and feel by giving gentle sustain pressure (presence of left parasternal heave indicates RVH)

4. Palpable P2 (in left second intercostal space): It indicates pulmonary hypertension

5. E pigastric pulsation.

C. Percussion:

• Usually not done, may be helpful to diagnose pericardial effusion (area of cardiac dullness is increased)and emphysema (cardiac dullness is obliterated).
  

D. Auscultation:

1. First and second heart sounds in all four areas (mitral, aortic, pulmonary and tricuspid areas). At the same time, palpate the right carotid pulse with thumb simultaneously. 1st heart sound coincides with carotid pulse, but 2nd sound does not (comes before or after). See also other heart sounds, if present (3rd and 4th).

2. Murmur:

• a. Site (apical, parasternal, aortic or pulmonary area)
• b. Nature—systolic (pansystolic or ejection systolic), diastolic (mid diastolic or early diastolic)— by feeling carotid pulse at the same time (systolic coincides with carotid pulse and diastolic does not coincide)
• c. Radiation (pansystolic murmur to left axilla, ejection systolic murmur to neck)
• d. Relation with respiration (right sided murmur increases on inspiration and left sided murmur increases on expiration)
• e. Grading of murmur (e.g. 2/6, 4/6).

3. Added sounds (pericardial rub, opening snap, ejection click, metallic plop.

4. Others:

• a. Auscultate the back of the chest for crepitations (found in pulmonary edema).
• b. Palpate the liver (enlarged tender liver in CCF, pulsatile liver in tricuspid regurgitation) 15
• c. Splenomegaly (may be found in infective endocarditis).