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Cardiovascular examination

 

  • Inspection

    End of bed:

    • Have patient lying at 45°.
    • Expose to waist if male, but keep female patients covered until closer inspection.
    • General comments: well, comfortable at rest, body habitus.
    • Cardiorespiratory status: respiratory distress, cyanosis, pallor.
    • Pitting oedema at ankle: press for 5 seconds.

    Hands:

    • If normal: "hands feel warm and well perfused".
    • Capillary refill: squeeze nailbed for 5 seconds. Should refill in ≤2 seconds.
    • Signs of infective endocarditis (IE): splinter haemorrhages, Osler's nodes, Janeway lesions.
    • Clubbing: cyanotic congenital heart defect, IE, axillary artery aneurysm, atrial myxoma.
    • Tar stains.

    Wrist:

    • Take radial pulse for 15 seconds and multiply by 4.
    • Report rate, rhythm, and volume.
    • Check for collapsing pulse by lifting arm up, asking first if they have right shoulder pain. A sign of hyperdynamic circulation, seen in aortic regurgitation, anaemia, pregnancy, hypertension, exercise, PDA, AV fistula, and thyrotoxicosis.
    • Feel radial pulse on both sides. Radio-radial delay in coarctation of aorta.

    Arm:

    • Brachial pulse character: slow rising in aortic stenosis .
    • Check BP. Check both arms in a new patient with suspected ↑BP, or any patient in which you suspect coarctation or dissection of the aorta.

    Look at jugular venous pressure (JVP) in the neck:

    • Ask patient to look up and to the left while lying at 45°.
    • Elevation in the JVP suggests raised right atrial pressure.
    • The external jugular vein (EJV) can be directly visualised and is a fairly good indicator of cardiac pressure; in general, inspecting this is sufficient. The internal jugular vein (IJV) is a more accurate indictor – since there are no valves between it and the right atrium – but cannot be directly visualised. However, one can see impulses from it in the triangle formed by the clavicle and two heads of the SCM.
    • The venous wave form is a double wave which wells up from root the of neck and varies with respiration, and can be obliterated by occluding the vein at the base. It can thus be distinguished from carotid arterial pulsation, which is a single wave which pulses outwards and does not vary with respiration.
    • If it is hard to see, use the hepato-jugular reflex by pressing the liver up.
    • Causes of ↑JVP: heart failure, valve disease, PE, tamponade.
    • Up to 4-5 cm above sternal angle – with patient at 45° – is normal.

    Head:

    • Eye: jaundice, pallor.
    • ↑Cholesterol: xanthelasma – lipid lumps around eyes – and corneal arcus.
    • Mouth: central cyanosis (lift tongue), dentition (IE risk factor).

    Closer inspection of the chest:

    • Chest wall deformities.
    • Scars e.g. thoracotomy.
    • Pacemaker lumps.

    Palpation

    Apex beat:

    • Feel for it with right, then then count down it from the 2nd intercostal with left.
    • Should be in the left 5th intercostal.
    • Describe the size, location, and wave form.
    • If it can't be felt, tilt patient away.
    • If impalpable, think COP3D: COPD, Obesity, Pleural or Pericardial effusion, Pneumothorax, Dextrocardia.

    Abnormal apex beats:

    • Left displacement of apex: LVH, mitral regurgitation (plus AF, while mitral stenosis would be AF without apex displacement), right pleural effusion.
    • Sustained apex beat (aka LV heave, heaving apex): forceful and sustained (>50% of systole) apex beat due to pressure overload from sustained pushing against resistance. Can be displaced – due to wall hypertrophy – or non-displaced. Seen in aortic stenosis, systemic HTN, HCM, and coarctation of the aorta.
    • Hyperdynamic apex beat (aka hyperkinetic, thrusting, forceful): forceful and non-sustained (<50% of systole) apex beat due to volume overload, resulting in a dilated ventricle but not necessarily wall hypertrophy. The large volume creates a forceful impulse, but it is non-sustained as it is not pushing against resistance. It is displaced, diffuse (>2 rib spaces), and may be visible. Seen in aortic and mitral regurgitation, dilated cardiomyopathy, and VSD.
    • Tapping apex: mitral stenosis.

    Heaves and thrills:

    • Parasternal heave (aka RV heave): base of hand at left parasternal edge to feel for the right ventricle pushing against resistance; you feel it 'in your joints'. Seen in RVH and pulmonary HTN.
    • Thrills are palpable murmurs. Place flat fingers horizontal at apex, then vertical either side of the sternum.

    Auscultation

    Heart:

    • Check while palpating the carotid pulse, which pulsates during systole (between S1 and S2). Systolic murmurs are heard with it, and diastolic after.
    • Listen at aortic (2nd right intercostal), pulmonary (2nd left intercostal), tricuspid (4th left intercostal), and mitral (5th left mid-clavicular) valve areas.
    • Listen at the carotids for radiation of atrial stenosis, and at the apex for radiation of mitral regurgitation.

    Further manoeuvres for heart auscultation:

    • Left sided murmurs (aortic or mitral) are louder on expiration, while right sided murmurs (tricuspid and pulmonary) are louder on inspiration.
    • Have patient roll on their side and hold their breath in exhalation. Listen at the apex with the bell (gentler pressure) for the low-intensity sound of mitral stenosis. Tell the patient to breath again when done.
    • Have patient sit forward, hold their breath in inhalation, and listen at the left sternal edge (tricuspid valve) and left 2nd intercostal space (pulmonary valve). Have them breath again. Now have them hold their breath in exhalation and listen at the 2nd right intercostal (aortic valve) and carotids (radiation of aortic stenosis).

    If heart auscultation normal: "heart sounds 1 and 2 are present, with no additional sounds".

    Lungs:

    • Listen on back at base of lungs, asking the patient to breath in and out deeply.
    • Crackles may indicate pulmonary oedema from heart failure.

    Completing the exam

    To complete the examination:

    • Check BP (if not yet done).
    • Check the peripheral pulses, for signs of PVD.
    • Perform fundoscopy and dip the urine, for signs of hypertension and IE.
    • Get an ECG.

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