Cardiovascular System Examination

Presenting complaints

• Chest pain
  • Site
  • Onset: Sudden? Was it preceded by activity?
  • Character: Crushing? Heavy? Burning? (heartburn)
  • Radiation: To the arm, neck, or jaw?
  • Associations: Shortness of breath? Nausea? Vomiting?
  • Timing and Duration
  • Exacerbating and Relieving factors: Worsened by breathing? (less likely to be anginal), Relieved by nitrates? Worsened by breathing but relieved by sitting forward? (pericarditis)
  • Severity: On a numerical scale out of 10
• Palpitations
  • Awareness of the heartbeat
  • Onset and Duration
  • Is the heart going faster?
  • Is there a “tap out” rhythm?
  • Associated with blackouts? (and for how long?)
  • Associated with chest pain?
  • Associated with Dyspnea?
  • Associated with caffeine or other foods?
• Dyspnea
  • Duration?
  • Is there dyspnea at rest?
  • Is there dyspnea on exertion?
  • NYHA classification?
  • Is it worse on lying flat? (how many pillows does the patient sleep with? → Orthopnea)
  • Do they wake up in the night gasping for breath? (And how often do they wake up? → PND)
  • Is there swelling in the ankles?
• Dizziness or Blackouts
  • How long did they blackout?
  • Were there warning symptoms? (presyncope)
  • What was the patient doing at the time?
  • Onset: Sudden or gradual?
  • Associated symptoms: Tongue biting, Seizure, Incontinence
  • Residual symptoms: Confusion, memory loss e.t.c
  • How long did it take until the patient returned to normal?
• Claudication
  • SOCRATES
  • Site: is it at the foot, calf, thigh or buttock?
  • How long can they walk before the onset of pain? “Claudication distance””
  • Is there pain at rest?
• Risk factor
  • Vascular risk factors: Hypertension, Diabetes, Smoking
  • MI risk factors: Nausea, Shortness of body, Vomiting, Heart racing?
  • VTE risks factors: Calf swelling, recent surgery or long-travel, OCPs, recent calf-swelling
  • Infective endocarditis risks: Recent dental work, Intravenous Drug Use
• Review
  • Cardiovascular: SOB, Heart racing, ankle swelling, leg pain on walking, dizziness or loss of consciousness
  • Constitutional: Fever, weight loss, tiredness, loss of appetite

Physical Examination

Introduce yourself, obtain consent to examine and position the patient recumbent at 45 degrees. Expose to the waist and explain what you’re doing.

Inspection

General inspection

Is the patient in pain or respiratory distress? Assess their general state (sick looking or in fair general condition)

Inspection of the hands

Inspection of the face, eyes and mouth

Inspection of the Neck (Jugular Venous Pulse)

The JVP approximates pressure in the Right atrium. Important to assess it. Needs lots of practice. Always try to assess the JCP and confirm with hepatojugular reflex. In healthy individuals it can be visualized at the level of the clavicle between the heads of the SCM. An elevated JVP is visible higher up in the neck.

Inspection of the chest and precordium

Note the activity of the precordium as either hyperactive or hypoactive

Palpation

Palpate pulses for Rate, Rhythm, Volume and Character. Best to check for rate and rhythm at the radial artery and character at the carotid artery. Don’t forget to measure blood pressure.

Radial pulse rate

Normal pulse rate should be 60 – 100 bpm

Radial Pulse Rhythm

Note whether the rhythm is regular, regularly irregular or irregularly irregular

Radial Pulse Volume

Carotid pulse character

Abnormal pulse character generally indicates a valvular diseases or Hypertrophic Obstructive Cardiomyopathy (HOCM)

Blood Pressure

Apex beat

Usually at the 5ICS MCL. Note the character and placement of the apex beat. A displaced beat is not always significant for CVS disease (can have pulmonary and MSK causes).

Thrills

Thrills are rare. They are the result of a murmurs producing a palpable sensation (like a cat’s “purrrr”). Feel with the palms of your hand over the 4 valve areas.

Heaves

Auscultation

Feel the carotid pulse/apex beat at the same time as auscultating to tell which phase of the cardiac cycle the murmur is heard in.

Valve areas

Heart Sounds

Murmurs

The volume of murmurs does not always correlate to dysfunction!. Left sided murmurs are best heard on Expiration. Right sided murmurs are best heard on Inspiration. Left-sided murmurs are a cause of concern**. Look for your murmur** – auscultate the valve areas with the murmur your looking for in mind…

Grading the intesnsity of heart murmurs

Systolic murmurs

Valve pathologies causing Pan-systolic murmus include mitral regurgitation and aortic stenosis. Both are difficult to tell apart. Aortic stenosis is further classified as an ejection systolic murmur

• Ejection systolic murmur over the aortic area, radiating to the carotid and heard in the neck, crescendo-decrescendo sound
  • Aortic stenosis
  • aortic sclerosis murmur will not radiate to the carotids
• Systolic murmur best heard in the apex radiating to the axilla, S2 may be absent, uniform volume unless caused by prolapse (which has a mid-systolic click)
  • Mitral regurgitation (Rheumatic Heart disease, Infective endocarditis, IHD, post-MI, cardiomyopathy, A-fib, Congenital)
• Innocent flow murmurs (musical tone, pan-systolic, quite quiet
  • Perfectly normal in children and yound adults (musical tone, pan-systolic, quite quiet)

Diastolic murmurs

These are hard to hear.

• Mid-diastolic murmur (click then whoosh) in the mitral area
  • Mitral stenosis
    • Associated with A-fib and mural thrombi → stroke
    • Caused by rheumatic fever
• Early-diastolic murmur, high-pitched (louder then quieter), best heard with pt sitting up in bed at the left-sternal edge, holding their breath at the end of expiration
  • Aortic regurgitation

Extra Heart Sounds

Extra heart sounds produce a triple beat. Triple beat coupled with tachycardia d/t CHF produces a gallop rhythm. Gallop rhythms are difficult to heat. Even cardiologists disagree with their presence.

For S3, listen with the bell (low-pitch) in the mitral area immediately after S2 (for a “double S2 sound). S3 may be heard in healthy individuals.

For S4, listen with the bell (low-pitch) in the mitral area just before S1 (for a “double S1 sound”). S4 is never normal…

• S3heart sound
  • Young fit people
  • Pregnant women (increased stroke volume)
  • Left ventricular failure (non-compliant),
  • Mitral regurditation and aortic regurgitation (increased stroke volume to compensate)
• S4heart sound
  • Aortic stenosis
  • Hypertension
  • CCF
  • HOCM
• Summation gallop
  • S3 + S4

Additional noise

Other signs

• Peripheral oedema – congestive heart failure (measure up to where the edema reaches)
• Peripheral pulses – in reality you will probably just check the posterior tibial and dorsalis pedis
• Sacral oedema – only really caused by heart failure (ankle oedema has several causes)
• Pulsatile liver – In mitral regurgitation superficial palpation of the liver then deep palpation to hear it pulsate

Bonus

• Eponymous signs for aortic regurgitation/hyperdynamic pulse
  1. Corrigan’s pulse: Rapid and forceful distention of arterial pulse with quick collapse
  2. deMusset sign: To and fro head bobbing
  3. Mueller’s sign: visible pulsation of the uvula
  4. Quincke’s sign: capillary pulsation seen on light compression of the nail bed
  5. Traube’s sign: pistol shots (systolic and diastolic sounds) over the femoral artery
  6. Duroriez’s sign: Bruits over the femoral artery on light compression by the stethoscope
  7. Hill’s sign: Popliteal cuff pressure exceeding brachial pulse pressure by 60 mmHg or greater
  8. Becker’s sign: visible pulsations of retinal arteries and pupils
  9. Mayne’s sign: more than 15mmHg decrease in diastolic blood pressure with arm elevation
  10. Rosenback’s sign: systolic pulsations of the liver
  11. Gerhardt’s sign: systolic pulsations of the spleen

Demonstration