STANDARDS FOR PATIENT EXAMINATION FROM THE POINT

FROM A CARDIOVASCULAR VIEWPOINT

The following data constitutes a series of suggestions that are

They apply for the study of the patient with cardiovascular problems. It is
it's important to mention that this is a way to study the patient with
cardiovascular problems and does not constitute everything that
what needs to be done to reach the cardiovascular diagnosis, but from the opinion of
there are many questions and many data that can be obtained from a
patient with cardiovascular problem, we must reach a situation where
we can ask a limited number of questions and practice a number
limited maneuvers in the physical examination to obtain a diagnosis in the
patient with cardiovascular problem.

CLINICAL HISTORY

The medical history from a cardiovascular perspective must include

starting with personal background, which is relevant for study
the cardiovascular problem, recognizing that any pathological condition that
Here, the patient is important, in this section of the study of the patient with
cardiovascular problem we will only consider the following
medical history: high blood pressure, diabetes mellitus
history of lung diseases, obesity, history of fever
rheumatic, history of central ischemic disease for example: angina
heart attack, history of claudication, cerebrovascular disease.

Of the so-called non-pathological antecedents that could be described

As habits and customs, the following are data that should always be
to ask: Smoking, how much does the patient smoke?, this should be expressed
in cigarettes per day and for how many years have you been doing it?, consumption of
alcohol, it should also specify which drink and in what quantity and by
how much time, coffee intake, also how many cups and for how long
he has been doing it, excessive salt consumption, a way to ask it
it's that if the patient, in addition to the salt contained in food, uses the salt shaker to
season your food. Type of patient life, determine if practice
some sport or ask if they are subjected to some type of exercise with
regularity.

The following are data that should always be asked to the

patient, chest pain, dyspnea, palpitations, syncope, cyanosis, claudication and
edema of the lower limbs. It is the ordered and semiological study of each
one of the symptoms and signs mentioned above what at a given moment
they guide the diagnosis.

Regarding pain, the following are the characteristics that should be considered.
study, since when do you have pain, in which region, with what
how often does this pain occur, how many times a week, per day, or per month,
under what conditions does the pain occur, at rest, during exercise, during
emotional states of anxiety, anguish, fear, anger, how long does it last
pain, where does this pain radiate to, what factors precipitate it, increases with
Exercise decreases with rest, have you had the opportunity to use isosorbide?
How long does the pain subside after taking sublingual nitroglycerin?
Isosorbide or nitroglycerin, have you ever been awakened by this pain? What?
symptoms are associated with the pain?, at the moment you are having
pain feels difficulty breathing, feels nauseous, vomits when he has the
pain?

The importance of pain semiology in cardiovascular pathology

it is very large. Since various pathologies are expressed by pain that in a
given moment; only semiological study can indicate to us the
diagnostic possibilities. As a reference, we can establish that the
the following pathologies are expressed by chest pain, angina, myocardial infarction,
pericarditis, pulmonary embolism, dissecting aortic aneurysm, hernia
theoretically 10 to 15 more pathologies can manifest as pain
chest pain similar to angina and the most important thing is that there is no exam
from the laboratory that tells us which organ is sick, only
The semiological study is the one that can guide us towards the diagnosis.
correct.

Regarding dyspnea, these are the key questions: Have you experienced difficulty?
to breathe, under what conditions, sitting, standing or walking, can we
establish that dyspnea can be divided into exertional dyspnea, orthopnea, and
paroxysmal nocturnal dyspnea, the three varieties of dyspnea usually involve
condition or failure of the left ventricle, in the absence of disease
pulmonary, obesity or emotional problems. To study dyspnea of
effort should be established at how many blocks the patient starts to
experience difficulty breathing, terms such as dyspnea should not be used
of small, medium, or large efforts, since this is completely
irrelevant, exertional dyspnea should be referred to as dyspnea that occurs during effort
presents when walking 6 to 8 blocks, it is important to establish since when the
the patient presents effort dyspnea and after how many blocks did it start
present it and currently establish how much exercise is needed to
to manifest Disney-like.

Regarding orthopnea, which means resting dyspnea, one way of

Interrogating her is asking how many pillows the patient uses to sleep,
Some people use more than one pillow for comfort, and then if the
patient says two or three pillows to sleep, the next question is
What happens if you sleep without pillows? If the patient uses pillows because
a failure of the left ventricle, will manifest that it wakes up due to lack of
breathing.

Regarding paroxysmal nocturnal dyspnea, which is the expression of

sudden left heart failure, it manifests itself as its name suggests
indicate, during the night and usually two to four hours after the
the patient went to sleep, the explanation of paroxysmal nocturnal dyspnea is
that manifests in patients with marginal cardiovascular reserve,
this is that they are on the sidelines of heart failure, they have from 1 to 3 liters
of circulating volume more, this circulating volume is found
"kidnapped" by default of atmospheric gravity in the members
lower, so that when the patient is going to lie down, they eliminate that
defect of atmospheric gravity and "suddenly" that excess of liquid is
free from the lower limbs and 'floods' the lungs.

Trepopnea is the term that identifies the discomfort of sleeping on the

left side, it can be associated with cardiomegaly.

Regarding the palpitations, you should ask: Have you felt any
Do you see like earrings in your heart? Like something beats out of rhythm? Since
when?, how long does that sensation last?, what discomfort do they cause you?, (could it
produce dizziness or angina-like pain) what conditions have you noticed that
This situation is precipitated by: emotions?, excessive consumption of alcohol, coffee or
of tobacco. Usually, the presence of palpitations indicates alterations in the
conduction system and the most common causes may be extrasystoles
ventricular or atrial extrasystoles, episodes of atrial fibrillation
paroxysmal, episode of supraventricular tachycardia, here it is important
establish that the electrocardiographic study is what provides the diagnosis
about the type of arrhythmia that is causing this symptom.

Syncope in cardiology usually expresses the following conditions:

aortic stenosis, severe arrhythmias mainly advanced degrees of
atrioventricular block, extreme bradycardias, and finally alterations in
the extracranial vessels. Syncope is defined as the sudden loss of
knowledge in such a way that the patient can injure themselves when falling, since
falls without me being able to take any protective measures, which is
completely different from the case of the patient who experiences dizziness, in the
the patient always tries to protect themselves and not fall and get injured. To this
Symptom should undergo semiology, since when did this loss present itself?
of knowledge, how many times he has presented it, what factors precipitate it,
How long does the loss of consciousness last, when you wake up you do so completely
using their mental faculties, recognizes the people around them, feels
Do you get up by yourself on all fours or do you need help?
Usually, syncope caused by aortic stenosis occurs during or
immediately after exercise, the syncope caused by problems of
Conduction can occur either during exercise or at rest and syncope.
produced by extracranial disease can present with changes
exaggerated in the neck position, either in flexion or extension.

Limping, in relation to this symptom, one should ask if

presents pain in their lower extremities, usually at the level of the
calves, this pain usually occurs during exercise of such
how many blocks you need to walk.
start to manifest the pain, how long does the pain last, ask
whether it is at both ends or at just one, whether it is in the calves or in
what other region of the lower limbs does the pain occur, it is
it is extraordinarily rare for peripheral vascular insufficiency to manifest
at rest and this only occurs in very advanced stages. A third
Some of the patients who exhibit claudication have coronary disease.
severe even in the absence of precordial pain.

Edema of the lower limbs, from a cardiovascular perspective

it is interpreted as a sign of heart failure, the causes do not
cardiovascular conditions that most frequently cause edema are failure
renal, liver diseases, states of hypoproteinemia (loss of proteins due to the
urine, gastrointestinal tract, states of malnutrition), one should ask
since when have you noticed the presence of swelling, how far does the swelling go,
if it is bilateral, if it is more pronounced during the afternoon.

Finally, cyanosis is a sign that one can usually detect when

While interviewing the patient, cyanosis in cardiology means the presence of
a short circuit from right to left, this means that there is venous blood that
it is starting to contaminate the arterial blood, for example: Tetralogy of Fallot,
interventricular communication with reversal of flow. Cyanosis is usually
it is more observed in children and has the connotation of revealing the
presence of a short circuit from right to left. Cyanosis also is
it can present in adults with a low cardiac output expression and in
a pronounced peripheral vasoconstriction such as that seen in patients with
cardiogenic shock. The other important cause of cyanosis is the
pulmonary diseases.

All the information that has been given so far must be applied to the
patient we are studying, regardless of what the reason is
of consultation or admission to this hospital. As an example, we will
expose the following case: Once personal background has been established
pathological, the habits and customs and if we know that the reason for admission is
precordial pain and syncope, we will now proceed to carry out the semiological study
of both, with all the characteristics mentioned above.

Once this is done, we should ask at this very moment and in

that same section the presence or absence of the missing data, that is
ask about dyspnea and conduct the semiology of this symptom, inquire about
palpitations, claudication, edema, dyspnea, cyanosis.

The following is an example of a medical history according to the information

what was given above.

IDENTIFICATION SHEET

________________________________________
Sex: _____
PATHOLOGICAL PERSONAL HISTORY: It is diagnosed
systemic arterial hypertension for 5 years, diabetes mellitus is
negative, there are no antecedentes of lung disease, there are no antecedentes
of rheumatic fever. There have been no previous episodes of angina-like pain or
heart attack or claudication.

HABITS AND CUSTOMS: He/She started smoking at the age of 18.

average pack per day to date, consumes 2 to 3 beers per day
For about 20 years, I have been consuming 2 to 3 cups of coffee a day.
For the past 15 years, he/she states that he/she does not consume excessive salt. He/She does not practice.

no sport, does not usually exercise in a methodical way.

REASON FOR ADMISSION: Precordial pain and syncope.

PRINCIPLE AND EVOLUTION OF THE AILMENT: This is about a patient.

a 55-year-old male enters today after experiencing
suddenly and during the night pain in the precordial region that
accompanied by loss of consciousness. The patient reports that today in the
night approximately at 3 in the morning woke up due to the
presence of pain in the precordial region, this pain was of intensity
severe, it radiated to the left upper limb and to the side
left side of the neck, the pain lasted approximately an hour, was accompanied
of nausea and the patient reports having vomited on 3 occasions a material of
light yellow, during the painful episode the patient reports having
experienced extreme difficulty breathing, as well as profuse sweating, the
the pain was not intensified by breathing but prevented him from walking, already
the pain increased in intensity when he tried to walk; he sought help from the
Red Cross in which a medication injection was administered not
specified without the intensity of pain having diminished, is transferred to
this hospital, where 10 mg of morphine sulfate was administered intravenously
and the patient states that approximately 10 minutes after the
the pain decreased significantly in intensity.

During the journey from the Red Cross to this hospital, the ambulances give the
information that the patient suddenly lost consciousness,
experiencing a period of convulsions characterized by movements
clonic-tonic seizures of the four extremities, this episode lasted
approximately 45 seconds the patient regained consciousness and upon arrival
no neurological deficit was found at this hospital.

The patient claims that this has been the first painful episode they have had.
experienced, denies having suffered from exertional dyspnea, orthopnea, dyspnea
nocturnal paroxysms, likewise denies having suffered from palpitations,
claudication, edema of the lower limbs, cyanosis and does not remember having
presented the episode of syncope previously described.
 PHYSICAL EXAMINATION OF THE CARDIOVASCULAR PATIENT

The characteristics of a proper physical examination to establish the

Diagnosis in a cardiovascular patient is as follows: It must be the most
complete possible, it must always be done in the same way and it must be
always follow the same order. The physical examination that will follow is
Detailing is one of the ways to obtain information; it aims to be
eminently practical and seeks to set aside considerations
theories that could complicate the analysis of the data from the physical examination.

The cardiovascular physical examination begins with the examination of the neck, which is
considered as an extension of the cardiovascular system, because in
In this region are the arteries that carry the blood that nourishes the
brain and the veins that return blood to the heart. In each of
the various sections that will be mentioned will always follow the following
Order: Inspection, palpation, percussion when applicable, and auscultation.
That order is unchangeable.

In the neck to the Inspection, the first data we are going to observe is the
presence of the carotid pulse, normally the carotid pulse is weakly
perceptible, there are occasions when the carotid pulse has characteristics
hyperdynamic, this means that when observing the carotid region, one observes a
pulsating 'jump', one of the most common causes of circulation
hyperdynamic states include: aortic insufficiency, anemia, pregnancy,
hyperthyroidism, fever, and exercise. At the time of inspection as
We said it will be determined whether or not the carotid pulse is visible in form
bilateral. The following characteristics will be determined by palpation of the
carotid pulse, frequency, is it regular or irregular, intensity, (to assess the
the intensity of the carotid pulse the student will touch their own carotids taking
they are normal, if the carotid pulse of the patient is less intense than
the student's, then it will be the case of a diminished carotid pulse of
intensity and if the carotid pulse is stronger than that of the student, it will be a
case in which the carotid pulse is more intense than that of the student will be a
case in which the carotid pulse is increased in intensity. The
the assessment of the intensity of the carotid pulse is of great importance due to
which indirectly reflects the quality of this patient's cardiac output, is
to say that in those cases where cardiac output is decreased,
for example: In heart failure, the carotid pulses will be diminished
of intensity, an example of unilateral decrease in carotid pulse
it is generally that of a patient who has a carotid obstruction,
usually due to a process of arteriosclerosis. It is important to establish
if the amplitude of the carotid pulse is equal in both carotids.

Here, the percussion maneuver is not applicable and we move on to auscultation, which is
will be done with the bell of the stethoscope gently applied over the area in the
how to feel the carotid pulse, this maneuver will only be noted if it
find or not the presence of murmurs, which are usually only
systolic, rarely will they be systolic and diastolic. At the moment of
The auscultation of the neck is also important to auscultate over the hollow.
suprasternal, as well as auscultating below the two subclavians. From this
We finished the physical examination of the arterial system in the neck.

Regarding the venous system, the following are the data that should be
obtain. The inspection will note whether or not there is engorgement of the veins
external jugular veins, it is essential that the patient is in
supine position with the head of the bed elevated at 45 degrees, in that
The position will be noted if there is or is not jugular distention.

Normally, in the previously described position, it should not be observed

external jugular distention, in case there is jugular distention this
will indicate that there is an increase in intrathoracic pressure and by extension
it will serve as evidence in favor of the diagnosis of insufficiency
right heart, not forgetting that there are various pathologies that can
increase intrathoracic pressure and produce jugular engorgement without causing
due to right heart failure. A means to assess the degree of
Intrathoracic pressure is to admit that when engorgement is not observed
Jugular above the clavicles, the intrathoracic pressure can range from 0 to
10 cms. of water. For each centimeter of jugular engorgement above
the clavicles will add one centimeter to the number 10, so that
if the swelling reaches 4 centimeters above the collarbones, the
Intrathoracic pressure will be 14 cm of water and will therefore be increased.
the normal range of intrathoracic pressure is from 4 to 10 cm. It is important
also establish whether there is venous pulse or not, normally upon inspection
clinic only, two waves can be seen which are the 'a' wave and the 'v' wave.
The wave "a" manifests as a pulse of the vein that coincides with the
carotid pulse, represents the right atrial contraction and is
manifestation of hypertension in the right cardiac circuit. Embolism
pulmonary, COPD, pulmonary stenosis, complete AV block are examples of
the prominent 'a' wave. The 'v' wave represents the relaxation of the atrium
right (auricular filling) and is identified as a collapse or a depression of
venous pulse, characteristically the prominent 'v' waves are produced
due to tricuspid insufficiency.

Once the examination of the arterial and venous system in the neck is finished,
we proceed to the examination of the central cardiovascular system, at this moment it is
when blood pressure should be taken in both arms and in two
positions, one of them will be lying down and the other will be any of the
next, either sitting or standing. In optimal conditions, it
you should take the pressure in one of the lower extremities, this is done
placing the Baumanometer above the popliteal fossa and placing the
stethoscope on the popliteal artery.

In the central cardiovascular examination is where concepts that do not prevail.

they adapt to reality, for example: It is thought that in order to hear the noises
For cardiac patients, it is necessary to have a special auditory acuity; any person who
can hear and follow a conversation that takes place in a normal tone of voice,
must be able to hear all heart sounds. It is also believed that
they are a 'large' number of elements that need to be assessed at the
auscultation and in reality there are only a few who are truly
Important, with these clarifications we proceed to the examination of the system.
cardiovascular center. Upon inspection of the chest to find the place in the
How the shock tip looks, it should be noted in the following way: The
The shock point is visible in the sixth intercostal space midline.
clavicular. Another element that should be looked for is the presence or absence
of external lifting, when there is external lifting this is a piece of information
in favor of the diagnosis of right ventricular hypertrophy.

PALPATION. In this section, the location of the impact should be corroborated.

from the tip, the area of the tip's impact will also be determined,
normally the tip shock occupies a space no greater than 2 cm.
the larger the impact area of the tip, the greater the
probabilities of finding valvular insufficiencies in such a way that a
shock area greater than 2 cm is an indicator in favor of mitral insuficiency or
aortic, right there the presence of thrill will be sought, the thrill is systolic or
diastolic, if the thrill coincides when the carotid hits a finger, it will be a
systolic thrill, if it does not match it will be a diastolic thrill, the heel should be placed
from the right hand over the sternum to determine if there is or is not
external lifting; the fact of feeling the heartbeat significantly
cardiac through the sternum, is a sign that favors hypertrophy of the
right ventricle and if there is actually a sternum lift the diagnosis is
almost with complete certainty that there is right ventricular hypertrophy,
Similarly, upon palpation, the presence of thrill in the second will be sought.
right intercostal space, when there is systolic thrill in this area, the
the diagnosis is that of severe aortic valve stenosis. To conclude, we
it will look for the presence of thrill from the second to the fourth intercostal space
left, that's where the thrills caused by the
interventricular communications.

AUSCULTATION. This is where an order must always be followed.

it will be the same, we will proceed to auscultate with the diaphragm of the stethoscope
positioned at the maximum impulse point, this area corresponds to the mitral valve
then the auscultation will continue by placing the diaphragm of the stethoscope on
the second right intercostal space, which is the aortic focus in this way
we will have examined the entrance door of the left ventricle which is the
mitral valve and the outflow door which is the aorta, thus we have examined everything
the arterial system of the heart to continue later with the stethoscope on
on the left side of the xiphoid appendix, which is the tricuspid area for
after putting it in the second or third left intercostal space which is the
pulmonary area, in this way we will have examined the entrance door of the
right ventricle that is the tricuspid and the outflow tract that is from the artery
pulmonary.

The auscultation will be done as follows: With the diaphragm of the

stethoscope placed at the peak of maximum impulse will record the following
data:

1. Heart rate, the heart will be auscultated for a period of one minute and
the heart rate will be recorded.
Is the heart rate regular or irregular?
3. How many heart sounds are heard: Normally, only two are heard.
4. The first and second tone must be identified, for this will be used
on palpation of the carotid the first tone will be the one that coincides with
the carotid pulse that we feel in our finger, usually the first
the tone is more intense than the second when auscultating the area
of the mitral valve, there are cases in which the first tone is
especially increased in intensity such as in stenosis
mitral, anemia, hyperthyroidism, exercise, fever, etc., there are also cases
in which the first tone is noticeably diminished from
intensity, such as in cases of myocarditis or in
cases of mitral insufficiency.
5. Now with the bell of the stethoscope placed at the point of maximum
impulse, it should be investigated whether there are added noises or not. The
auscultatory events necessarily relate to systole or
diastole. In such a way that there are four possibilities of sounds
associated additions with systole: 1) Atrial gallop or S4. 2) Click
the ejection of the latter occurs due to the dilation of the artery
pulmonary or aortic. 3) The systolic click of mitral valve prolapse
which can be late or early in systole. 4) It is the noise that
produced in patients who present incomplete branch block
right. The added sounds that occur during diastole are
three: 1) Sound 3 or ventricular gallop, 2) Opening snap of the
mitral valve, 3) The so-called pericardial knock. (different from the friction
pericardic this noise occurs in constrictive pericarditis). For
identifying which auscultatory event you are auscultating is necessary
relate it to the carotid pulse in such a way that with the finger
palpating the carotid if what we hear matches when the carotid us
take on the finger this is a systolic event. We should look for
within the 4 possibilities of related added noises
with the systole, if the event we are auscultating does not match with the
carotid pulse in the event finger will be diastolic and you
There will only be 3 possibilities that explain that auscultation event.
the way to differentiate the atrial gallop from the ejection click is to know
the characteristics of each of them, for example: The auricular gallop
it is an added sound that coincides with systole (it is not
truly systolic is presystolic). It is a sound that is heard
exclusively with the campaign of this stethoscope, it has an area of
very limited auscultation as is in the tip of the left ventricle,
Sometimes it is only possible to hear it if we put the patient
in left lateral decubitus, when we auscultate that same region with
the diaphragm of the stethoscope that sound is erased, those are the
characteristics of auricular gallop which generally means
loss of elasticity of the left ventricle, such that all
those diseases that cause an increase in connective tissue in
the left ventricle will be the causes of an atrial gallop, such as
example: Heart attack, angina, high blood pressure, advanced age, etc., it is worth
to clarify that an auricular gallop is "never" normal.
The eject click is a high-frequency sound of such
way that it can be heard both with the diaphragm and with the
stethoscope campaign, it has an area of diffuse auscultation, it is
 to say, not only is it heard at the tip of the crash but it can be heard
in almost the entire precordium, such that if at a given moment
we decided that there is an added noise in systole we have elements
clinics at hand to be able to determine if it is an ejection click or not
an auditory gallop. As for the added sounds in diastole,
we said that they are the ventricular gallop and the opening snap and the
pericardial knock, the characterization of these sounds is as follows: The
ventricular gallop is a low-frequency sound as a consequence
listens almost exclusively with the bell of the stethoscope, has a
listening area very limited and almost always nothing is heard
at the tip of the left ventricle or sometimes nothing more
in the left lateral decubitus position, when auscultated with the
the diaphragm of the stethoscope this noise tends to disappear, the
the interpretation of ventricular gallop is that it is a diastolic sound of
low frequency that can normally be heard in children or in the
youths up to the age of 25 or 30 years, after this age the
ventricular gallop presence is synonymous with ventricular failure
left. The opening snap is like the ejection click, a
high-frequency sound, consequently, it is heard with the bell
and with the diaphragm of the stethoscope, you can hear at the tip of the shock
the left ventricle and its best area of auscultation is in a
intermediate pathway between the shock point of the left ventricle and the
tricuspid valve, knowing these characteristics we must admit
that the fundamental problem in detecting aggregated noises is to know if
they are associated with systole or diastole once we decide what they are
systolic we have very reliable clinical data to decide what type of
we are listening to added noise.
6. Now we are going to intentionally look for murmurs or not, the murmurs.
they can be systolic or diastolic, it is worth noting that there are
so much cardiovascular pathology with murmurs as without murmurs. The murmurs
how heart sounds are classified into high, medium, and low murmurs
low frequency; for educational purposes the high frequency blows
they are located in the upper part of the heart, this means that the
high-frequency sounds are produced by alterations in the valve
aortic, pulmonary and in the inter-ventricular communications and
interauricular. As for the low-frequency murmurs, the only
The clinically significant low-frequency murmur is that of stenosis.
mitral and is auscultated in the lower part of the heart, the murmurs of
median frequency identifies mitral and tricuspid insufficiency. Thus
that in the evaluation of murmurs it should be established whether it is systolic
the diastolic and we will again take the carotid as a reference point
to establish at what part of the cardiac cycle this murmur occurs, if
the systolic should be established if it is early in systole, late in
systole, or holosystolic. The degree of intensity of
blowing (Levin classification). Special maneuvers are required.
to hear it example: Place the patient in the left lateral decubitus or
ask him not to breathe. It is clearly heard without resorting to maneuvers.
specials III is an intense breath that has no thrill. IV is a breath
associated with Thrill. It is heard with the stethoscope placed on the side
(on the side). You can hear without the stethoscope making contact with the.
 skin, these last two are very infrequent in clinical practice.
Once all this is done, the stethoscope will be moved from the area.
from auscultation of the mitral valve to the auscultation area of the valve
aortic and in this place only the following will be done:

a) Identify the first and second tone

b) Observe which is more intense in this area, here normally the
the second tone is the most intense.
c) Presence of additional noises and here the only possibility is the click of
ejection
d) Presence or absence of systolic or diastolic murmurs. Once done
we move to the auscultation area of the tricuspid valve and
Once again here, the only thing we will do is determine whether there are murmurs or not.
if it is systolic and diastolic, it is worth remembering that the systolic murmur of
tricuspid insufficiency is accentuated with inspiration, so every
once we hear a whisper in this area we should observe if
increases in intensity when the patient inhales.

Now we will place the stethoscope on the pulmonary valve and here normally
three sounds are heard that correspond to the closure of the mitral valve, closure
from the aortic valve, from the pulmonary valve, it is important to determine if
the second tone unfolds in a fixed normal or paradoxical form. Normally
at the moment of inhalation the distance between the closure of the aorta and the pulmonary artery
it is greater, when exhaling this distance decreases, this is called
physiological unfolding. The paradoxical is exactly the opposite and suggests
left bundle branch block of the His bundle, aortic stenosis, acute myocardial infarction
of the myocardium. The fixed splitting is one in which the distance between the
closure of the aorta and pulmonary remains 'wide' both during inspiration
like in expiration and suggests interatrial communication and stenosis of the
pulmonary valve. The assessment of the behavior of the splitting of the
the second tone is of crucial importance especially in congenital pathologies
and the observation of the intensity of the second pulmonary tone is important in
the assessment of cases that present with pulmonary hypertension.

Once the central cardiovascular examination is completed, we must examine the

lungs, from a cardiovascular point of view, we are only interested in
to know whether there are fine crackling rales in the pulmonary bases or not
they only listen during inspiration, it is important to conduct an examination
complete of the lungs to determine if there are or are not pulmonary effusions.

Within the cardiovascular examination, it is important to obtain certain data in the

physical examination of the abdomen, these important data are the presence or
absence of hepatomegaly. Hepatomegaly that is due to congestion is
associates with a systolic murmur in the tricuspid region that increases with the
inspiration, it is common to also detect jugular engorgement with wave
"V" prominent. The other important element in the physical examination of the abdomen.
it is the palpation of the abdominal aorta, in thin individuals and in children it is
it is relatively easy to palpate the abdominal aorta, for this the right hand is
place at the level of the umbilical scar and with the patient's abdomen relaxed
tries to 'grab' the aorta, the hand gradually closes until it
one can palpate the aorta, the significant alteration that can be detected by
this maneuver is the presence of abdominal aneurysms, which
They detect why there is pain on palpation in that area and why the aorta changes.
for configuration and instead of feeling like a tube it will now be felt
as an aneurysmal zone. One way to corroborate this is through
from a lateral abdominal X-ray in which calcium is observed in the wall
from the aorta corroborates the diagnosis of abdominal aortic aneurysm. The
the third important piece of information we must look for in the abdominal exam is the
assessment of the femoral pulses, in this section we are going to qualify the
intensity of the femoral pulses if the intensity is equal bilaterally and if
there is or there is no presence of murmurs.

In the examination of the lower extremities, we will look for the following
data: presence or absence of edema, determine if there is edema up to
where it extends, if it is bilateral, if it is painful, if there are changes in the
skin temperature, we should also determine if there are any alterations in
the venous system. Finally, we must establish the presence or absence of
the peripheral pulses, this is to look for the anterior dorsal artery and the tibial
afterwards, we must compare the intensity of the beats of these arteries in
bilateral form, It is also important to establish the presence or absence
from the pulse of the popliteal arteries.

These are the guidelines recommended for the physical examination of

patient we are studying from a cardiovascular point of view, are
the maneuvers that must be carried out and with which they must be presented to the
professor at the time of detailing the physical exam, of course any
Another physical examination maneuver that you know of and that is relevant.
the physical examination of a particular patient must be performed and mentioned
in the presentation of the case.

DR. JUAN MANUEL CALDERÓN RAZO

Professor of Cardiology Service
 RULES FOR INTERPRETING THE CHEST X-RAY FROM
THE CARDIOVASCULAR POINT OF VIEW

I. a) Determine if it is a chest X-ray or a portable one. It is a chest X-ray if the tip

The scapulae are outside of the rib cage.
b) If the collarbones are symmetrical.
c) If there is a gastric bubble.

II. X-ray Voltage

It is suitable when you can 'guess' through the silhouette.
cardiac the intervertebral spaces. Pulmonary pattern is observed at
through the cardiac silhouette.
If the vertebrae are visible, it is "over" voltage and this reduces the
signs of heart failure.
If there is a lack of voltage, the intervertebral spaces cannot be 'guessed'.
through the cardiac silhouette, this artificially increases the signs of
heart failure.

III. Whether there is cardiomegaly or not.

There are four degrees of cardiomegaly:
Grade I. The relationship between the thorax and heart is 51%.
Grade II. Intermediate between I and III.
Grade III. When it is "sufficiently" grown but does not do
contact with
the costal wall.
Grade IV. When the left edge of the heart makes contact
with the
costal cartilage.

IV. Define the profiles of the heart.

The structures that make up the edges of the heart are:
On the right side: Right atrium, ascending aorta
There is no radiological criterion for diagnosing growth of the
right atrium, in such a way that the most frequent manner
how the right profile is deformed due to alterations in the aorta
ascending.
The left profile is made up from top to bottom by the following
structures
Aortic button
Pulmonary trunk
Left ventricle

The only pathology that deforms the left profile is the disease of the
mitral valve, mitral stenosis or insufficiency: atrium myxoma
left, Cor triatum. This deformity consists of the presence of
a fourth prominence, which appears between the pulmonary and the ventricle
left; this 4th prominence is the left auricular appendage.
 supposed, alterations of the aorta and the pulmonary alter the morphology of the
left profile, example: aortic stenosis, pulmonary stenosis.

V. Evidence of left atrial enlargement.

Look for the presence of the double image on the right edge of the heart,
horizontalization of the left bronchus, presence of 4 edges in the
left profile.

VI. Look for calcifications.

Fundamentally in mitral valve, aortic valve and aortic button.
the structure of the heart can become calcified; coronary pericardium.

VII. Assess the pulmonary flow.

The right hilum usually measures 16-17 mm in width. Usually
no glasses should reach the outer third of the x-ray; they should not
the thickened pulmonary veins at the apices; there should not be
pleural effusions; these can be bilateral or on the right side.
Never only on the left side. Presence of 'B' lines of Kerley
which are defined as horizontal lines, perpendicular to the pleura,
they are thin and 1-2 cm long. These data describe the degrees
variables of heart failure by X-ray.

DR. JUAN MANUEL CALDERÓN RAZO

Professor of the Cardiology Service