The Cardiovascular Exam
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Examination of the cardiovascular system is easy to learn but difficult to master. Careful inspection and palpation for peripheral findings, coupled with attentive auscultation of the praecordium, may allow for clinical diagnosis of a patient's cardiac pathology prior to any further investigations.
When performing a cardiovascular examination, always try to get to the chest as quickly as possible.
Before commencing the cardiovascular exam, wash your hands, introduce yourself to the patient and gain consent.
Position the patient correctly, with the bed angled at 45 degrees. Ensure that the bed is at a comfortable height in order to avoid an awkward examination.
Always stand on the right side of the bed during the cardiovascular examination.
Inspect the RoomLook around the room, as this can provide clues regarding the patient's diagnosis:
- Cigarrettes are a sign of smoking, a significant cardiovascular risk factor.
- Oxygen delivery suggests that the patient is hypoxic; this may for several reasons including pulmonary oedema or pulmonary hypertension.
- GTN spray suggests that the patient has ischaemic heart disease.
- Intravenous antibiotics in a patient with a murmur suggest infective endocarditis.
- Any other medications that the patient may be taking, including intravenous infusions, puffers or tablets, may provide additional information.
Generally inspect the patient, taking note of their age, gender and general comfort.
Assess Body Habitus
- Obesity is associated with multiple conditions including diabetes, ischaemic heart disease, stroke and obstructive sleep apnoea.
- Measures of body habitus include:
- The body mass index (BMI) - assesses the patient's weight in the context of their height, allowing for a more accurate measurement (with several limitations).
- The waist circumference and waist-hip ratio are markers of central obesity, with evidence to support their use in estimating cardiovascular risk.
Look for obvious dysmorphic facies - signs suggestive of congenital syndromes such as Marfan syndrome, Down syndrome and Turner's syndrome - as these conditions are associated with cardiovascular disease.
- Look at the colour of the patient's skin for pallor or cyanosis.
Skin pallor is classically a sign of anaemia, though may also occur due to low output or peripheral shutdown.
Cyanosis is a blue discolouration of the skin and mucous membranes - this may be either peripheral or central and suggests either severe hypoxia, or severe peripheral shutdown.
- Assess whether the patient is dehydrated, euvolaemic or fluid overloaded.
Dehydration occurs in the setting of poor oral intake or fluid loss (e.g. due to diarrhoea, vomiting, sweating or diuresis). Signs of dehydration include tachycardia, poor urine output, dry mucous membranes and reduced skin turgor.
Fluid overload may occur in the context of several conditions including, heart failure, renal failure, liver cirrhosis, SIADH, pregnancy or simply due to excessive IV fluid administration. Signs of fluid overload include bounding pulses, raised JVP, pulmonary crepitations and pitting oedema.
- Look at the digits for evidence of clubbing, or enlargement of the distal segments of the fingers / toes. This is classically associated with respiratory pathology such as cancer or chronic lung infection, though may also occur with cyanotic congenital heart disease and liver cirrhosis.
The Nail Beds
- Look at the nails for splinter haemorrhages (a sign of endocarditis), pallor or nail bed cyanosis.
- Press on the patient's nail and count how long it takes for colour to return to the nail. A prolonged capillary refill time of <2 seconds is classically a marker of poor perfusion, however this test is highly variable in adults.
- Look for pallor of the palmar creases; signs of endocarditis such as Osler's nodes (painful nodules) or Janeway lesions (flat macules); and xanthomata (lipid-filled nodules).
- Track marks on a patient's arm suggest IV drug use, which is a strong risk factor for bacterial septicaemia and infective endocarditis.
- Palpate the patient's radial pulse for heart rate and rhythm. Count the heart rate over at least 30 seconds and multiply to estimate beats per minute.
Note whether the pulse is regular, regularly irregular or irregularly irregular. The implication of an irregularly irregular pulse is likely atrial fibrillation; remember that this is associated with valvular (particularly mitral) pathology.
Radial Pulse Delay
- Next, palpate both radial pulses at once to assess for radio-radial delay. If the left radial pulse is slightly later than the right, then this suggests aortic coarctation. Radio-femoral delay may also be assessed for, though ensure that you ask the patient and examiner prior to testing for this.
- While ostensibly still measuring the pulse, count the patient's respiratory rate over 30 seconds. Resp rate is a sensitive marker of deterioration in hospitalised patients and both tachypnoea (fast resp rate >20) and bradypnoea (slow resp rate <12) are concerning signs.
- Always offer to measure the patient's blood pressure.
The cuff should measure ~80% of the patient's arm circumference; inflate the cuff to 30mmHg beyond where the pulse is no longer palpable, then slowly deflate until the beating sound is first heard (this is the systolic blood pressure). Then deflate until the beating sound disappears entirely (this is the diastolic blood pressure). Never check the blood pressure on an arm with an AV fistula or axillary clearance for breast cancer.
Hypertension (increased BP >140/90) may have primary or secondary causes, and is associated with increased risk of both acute and chronic cardiovascular complications. Hypotension (reduced systolic BP <100mmHg) is associated with postural hypotension, cardiac disease, hypovolaemia and shock.
Note the patient's pulse pressure, or the difference between the systolic and diastolic blood pressure. A narrow pulse pressure is a sign of severe aortic stenosis, severe mitral stenosis or hypovolaemia. A widened pulse pressure (often along with a collapsing pulse) is a sign of aortic regurgitation or patent ductus arteriosis.
- Next, feel for collapsing pulse. This can be thought of as palpably widened blood pressure, in the context of aortic regurgitation or patent ductus arteriosis. First ask the patient if they have any pain in their left shoulder, then lift their left shoulder up while palpating the radial pulse. Feel for a strong pulse with sudden drop in intensity following its peak.
- Look at the patient's face for evidence of mitral facies: a rosy complexion of the cheeks with patches of blue discolouration, - a classical sign of mitral stenosis.
- Look at the patient's eyes for xanthelasma (yellowish plaques) or conjunctival pallor.
FundoscopyWhen performing the cardiovascular exam, always offer to perform fundoscopy - though recognise that the yield will likely be low in a patient without a dilated pupil. Look for:
- Hypertensive eye changes such as silver wiring, arteriovenous nicking, flame-shaped haemorrhages, cotton wool spots and papilloedema.
- Roth spots - pale patches on the retina with a ring of surrounding haemorrhage, and are a sign of infective endocarditis.
Or, at least, mention that you would look for those things.
- Look in the patient's mouth. Note their dentition (the condition of their teeth), as poor dentition is associated with risk of bacteraemia and infective endocarditis. Look for the high-arched palate of Marfan syndrome.
- Finally, ask the patient to lift their tongue to the roof of the mouth and assess for cyanosis of the tongue. This suggests significant hypoxia - such as due to pulmonary disease or congenital cyanotic heart disease.
Jugular Venous Pressure
- Visualise the patient's jugular venous pulsation (JVP) between the sternal and clavicular heads of the sternocleidomastoid. With the bed at 45 degrees, ask the patient to turn their head away from you. Look for the highest level of the jugular venous pulsation, and measure the vertical distance between the sternum and this pulsation. This is elevated if greater than 4cm, which suggests fluid overload, right ventricular failure or pulmonary hypertension.
If the jugular venous pulsation is difficult to visualise, assess for hepatojugular reflux. Ask the patient if they have any pain in their abdomen, then gently press over the right upper quadrant for 10-15 seconds - this temporarily increases venous return, making the JVP more pronounced.
- Palpate the carotid pulses one at a time, within the anterior neck medial to the sternocleidomastoid. This is mainly to assess the character of the pulse - a pulses tardis and parvis (late and weak) is suggestive of aortic stenosis, while a waterhammer pulse (strong with sudden collapse) suggests aortic regurgitation.
Auscultate the carotid arteries for the presence of a bruit, which suggests carotid artery stenosis. You may also hear the transmitted murmur of aortic stenosis.
Chest Inspection & Palpation
Inspect the chest wall both anteriorly and posteriorly for thoracic scars, which may suggest previous chest surgery or trauma. A midline scar (sternotomy) suggests past cardiac surgery (bypass graft or valve replacement), while a scar over the left or right upper chest suggests an implantable device.
- Next, palpate for the patient's apex beat. This is the most inferior and lateral point at which the patient's cardiac impulse is palpable: this is normally in the fifth intercostal space in the midclavicular line (make a show of palpating the ribs down the chest). Feel for displacement, and whether the apex is pressure-loaded or volume-leaded.
- Palpate the chest for parasternal heave (over the left side of the sternum) and thrills (palpable murmurs).
When auscultating the heart, systematically listen to each of the cardiac regions for a heart sounds, murmurs or a rub. If added heart sounds or a murmur are noted, determine which area the extra sound is loudest in, and then perform manoeuvres to further isolate the added sound. You may find it useful to start at the left sternal edge (tricuspid area) as an initial screening test, and then listen to the other areas.
- AAortic area - the second intercostal space at the right sternal border
- PPulmonary area - the second intercostal space at the left sternal border
- TTricuspid area - the fifth intercostal space at the left sternal border
- MMitral area - the fifth intercostal space in the midclavicular line
- Left axilla - the fifth intercostal space in the midaxillary lineListen to each of the areas with the diaphgram of the stethoscope, and also listen to the apex of the heart with the bell - this makes the lower-pitched murmur of mitral stenosis easier to appreciate.
- First, listen for the heart sounds.
The first heart sound (S1) indicates closure of the mitral and tricuspid valves, and is normal heart best over the apex. Listen for presence of S1, and whether it is loud or soft.
The second heart sound (S2) indicates closure of the aortic (A2) and pulmonary (P2) valves. Normally on expiration, S2 splits into separately audible A2 and P2 sounds. Note whether the second heart sound is loud or soft.
The third heart sound (S3) is a pathological finding associated with rapid ventricular filling. This is a gallop rhythm, with an extra heart sound heard just after S2.
The fourth heart sound (S4) is a pathological finding associated with turbulence during atrial systole. This is also a gallop rhythm, with an extra heart sound heard just before S1, usually best heard during inspiration.
- Next, listen for a pericardial rub. This is a superficial, scratching sound present in mid-systole, mid-diastole and late diastole; the presence of a rub suggests pericarditis due to infection, trauma, uraemia, autoimmunity or malignancy.
Listen for Murmurs
- Next, auscultate the chest for cardiac murmurs. If a murmur is present, palpate the carotid pulse while auscultating to determine whether the murmur is systolic, diastolic (between S2 and S1 of the next cardiac cycle) or continuous. Grade the intensity of the murmur from 1 (incredibly faint) to 6 (audible with the stethoscope off the chest).
A systolic murmur is present between S1 and S2. An ejection (or mid) systolic murmur is a classical sign of aortic stenosis, while a pansystolic murmur is associated with mitral regurgitation. Click to read more about murmurs that occur during systole.
A diastolic murmur is present between S2 and S1. An early diastolic murmur is classically a sign of aortic regurgitation, while a mid-diastolic murmur (usually heard with the bell of the stethoscope) suggests mitral stenosis. Click to read more about diastolic murmurs.
Continuous murmurs are uncommon and are associated with rare conditions such as patent ductus arteriosus and AV fistulas.
Listen in Inspiration and ExpirationIt is important to listen to cardiac murmurs in both inspiration and expiration.
- A murmur that is louder on inspiration suggests right-sided (tricuspid or pulmonary) valvular disease
- A murmur that is louder on expiration suggests left-sided (aortic or mitral) valve disease.
A fourth heart sound is also best heard during inspiration.
Left Lateral Position
- Ask the patient to roll to the left lateral position and listen to the cardiac apex with the bell of the stethoscope. The murmur of mitral stenosis is louder in this position, as is a third heart sound.
- Ask the patient to sit forward, breath in deeply and then hold their breath in full expiration. This will make the murmurs of aortic and pulmonary regurgitation louder, and will also accentuate a pericardial rub.
Dynamic ManoeuvresIn patients with suspected hypertrophic cardiomyopathy (i.e. patients with a systolic murmur), offer to perform dynamic manoeuvres:
- Asking the patient to valsalva (breath out hard against a closed mouth and nose) will make the murmur of hypertrophic cardiomyopathy louder, but reducing preload on the heart.
- Asking the patient to squat increases preload, which makes the murmur of hypertrophic cardiomyopathy softer; then asking the patient to stand up acts as a physiologic bolus which increases preload and makes the murmur louder.
- Palpate the lower back for sacral oedema, as often fluid overloaded patients who are lying down with their legs up will accumulate fluid in this area rather than in their feet.
- Auscultate the lung fields, listening for crepitations and wheeze (signs of left ventricular failure / pulmonary oedema) and reduced air entry (a sign of pleural effusions). Often in the cardio exam it is quicker to auscultate only the lung bases to conserve time. Consider percussing the chest for dullness, to prove suspected pleural effusions.
If you are running out of time, skip to the legs at this point as these will provide the highest yield.
- Inspect the abdomen for distension and any abnormal movements. A visible abdominal pulsation is a sign of abdominal aortic aneurym, though this sign can also be normal in thin patients.
- Auscultate for abdominal bruits. Listen for aortic bruits, over the upper abdomen in the midline, and renal bruits, over the upper abdomen on either side of the umbilicus. The presence of bruits would suggest arterial stenosis, due to atherosclerosis or other pathology.
- Palpate the abdomen for a pulsatile abdominal mass, which would suggest an abdominal aortic aneurysm. If you have time, assess for hepatomegaly, splenomegaly and ascites - signs of right-sided or congestive cardiac failure.
- Inspect the legs for skin changes. Chronic changes such as dryness, venous eczema and hyperpigmentation suggest chronic venous insufficiency, while the presence of thin, shiny, cool skin with hair loss suggests partial or complete arterial occlusion. Arterial or venous skin changes may also be accompanied by ulcers.
- Palpate the extremities for temperature, tenderness and pedal oedema.
Cool extremities are a sign of poor perfusion; localised hypoperfusion may occur due to arterial disease or compartment syndrome, while more generalised hypoperfusion is a sign of shock. Warm extremities have a wide variety of causes. Significant unilateral warmth suggests cellulitis or a DVT, while milder warmth suggests fluid accumulation due to venous insufficiency or lymphoedema.
Next, palpate for pedal oedema. Apply pressure to the anterior aspect of the tibia for fifteen seconds and then release, looking for persistence of the depressed area after the finger is removed. If the oedema is pitting, this suggests fluid overload, right ventricular failure, venous pathology or hypoalbuminaemia; non-pitting oedema suggests lymphoedema.
- Palpate the lower limb pulses - dorsalis pedis, posterior tibial and popliteal. Absent pulses are a sign of acute or chronic arterial insufficiency, though patients with shock or severe hypotension may also have absent pulses.
Thank the patient, turn around and present your findings.
Ask for an electrocardiogram (ECG), urinalysis, and fundoscopy to complete your assessment.
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