Cardiovascular examination


Before starting
  • Introduce yourself to the patient.
  • Confirm his name and date of birth.
  • Explain the examination and obtain his consent.
  • Position him at 45 degrees, and ask him to remove his top(s).
  • Ensure that he is comfortable.
  • Wash your hands.
The examination (IPPA)
General inspection
  • From the end of the couch, observe the patient’s general appearance (age, state of health, nutritional status, and any other obvious signs). Is he breathless or cyanosed? Is he coughing? Does he have the malar flush of mitral stenosis?
  • Observe the patient’s surroundings, looking in particular for items such as a nitrate spray, an oxygen mask, ECG electrodes, and IV lines and infusions.
  • Inspect the chest for any scars and the precordium for any abnormal pulsation. A median sternotomy scar could indicate coronary artery bypass grafting (CABG), valve repair or replace- ment, or the repair of a congenital defect. A left submammary scar most likely indicates repair or replacement of the mitral valve. Do not miss a pacemaker if it is there!
Inspection and examination of the hands
  • Take both hands noting:
    • –  temperature: feel with the back of your hand
    • –  colour, in particular the blue of peripheral cyanosis and the orange of nicotine stains
    • –  nail bed capillary refill time: press the nail for 5 seconds; it should refill within 2 seconds
    • –  any presence of clubbing (endocarditis, cyanotic congenital heart disease)
    • –  any presence of Osler nodes and Janeway lesions (subacute infective endocarditis)
    • –  any presence of splinter haemorrhages (subacute infective endocarditis)
    • –  any presence of koilonychia or ‘spoon nails’ (iron deficiency)
  • Determine the rate, rhythm, volume, and character of the radial pulse. A regularly irregular rhythm suggests second degree heart block, whereas an irregularly irregular rhythm suggests atrial fibrillation or multiple ectopics.
  • Raise the patient’s arm above his head to assess for a collapsing/water hammer pulse (aortic regurgitation). Ask the patient whether he has any shoulder pain first.
  • Simultaneously take the pulse in both arms to exclude radio-radial delay (aortic arch aneurysm). Indicate that you would also exclude radio-femoral delay (coarctation of the aorta).
  • As you move up the arm, look for bruising, which may indicate that the patient is on an anti- coagulant, and for evidence of intravenous drug use, which is a risk factor for acute infective endocarditis.
  • Indicate that you would like to record the blood pressure (see Station 12). A wide pulse pressure is typically seen in aortic regurgitation; a narrow pulse pressure in aortic stenosis.
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Clinical Skills for OSCEs
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Station 13 Cardiovascular examination
Inspection and examination of the head and neck
  • Inspect the eyes, looking for peri-orbital xanthelasma and corneal arcus, both of which indicate hyperlipidaemia.
  • Gently retract an eyelid and ask the patient to look up. Inspect the conjunctivus for pallor, which is indicative of anaemia.
  • Ask the patient to open his mouth, and look for signs of central cyanosis, dehydration, poor dental hygiene (subacute bacterial endocarditis), and a high arched palate (Marfan’s syndrome).
  • Palpate the carotid artery and assess its volume and character. A slow-rising pulse is suggestive of aortic stenosis, a collapsing pulse of aortic regurgitation. Never palpate both carotid arteries
simultaneously.
  • Assess the jugular venous pressure (see Figure 6) and, if possible, the jugular venous pulse form:
ask the patient to turn his head slightly to one side, and look at the internal vein medial to the clavicular head of sternocleidomastoid. Assuming that the patient is reclining at 45 degrees, the vertical height of the jugular distension from the angle of Louis (sternal angle) should be no greater than 4 cm: if it is greater than 4 cm, this suggests right heart failure, fluid overload, or tricuspid valve disease.
Palpation of the heart
Ask the patient if he has any chest pain.
  • Determine the location and character of the apex beat. It is normally located in the fifth inter- costal space at the midclavicular line. The apex may be:
    • –  impalpable: obesity, dextrocardia, situs inversus...
    • –  displaced, suggesting volume overload (mitral or aortic regurgitation)
    • –  heaving, suggesting pressure overload and left ventricular hypertrophy (aortic stenosis)
    • –  ‘tapping’, suggesting mitral stenosis
  • Place the flat of your hands over either side of the sternum and feel for any heaves and thrills.
Heaves result from right ventricular hypertrophy (cor pulmonale) and thrills from transmitted murmurs.
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Height of jugular
venous distention 4 cm
Angle of Louis (sternal angle)
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45°
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Figure 6. Assessing the jugular venous pressure.
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Cardiovascular and respiratory medicine
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Station 13 Cardiovascular examination
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Auscultation points
C C Mid-clavicular line
AP
T
M
Ax
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Auscultation of the heart
  • Listen for heart sounds, additional sounds, murmurs, and pericardial rub. Using the stetho- scope’s diaphragm, listen in the:
    • –  aortic area
right second intercostal space near the sternum
    • –  pulmonary area
left second intercostal space near the sternum
    • –  tricuspid area
left third, fourth, and fifth intercostal spaces near the sternum
    • –  mitral area (use the stethoscope’s bell)
left fifth intercostal space in the mid-clavicular line
  • Manoeuvres and points to remember:
    • –  ask the patient to bend forward and to hold his breath at end-expiration. Using the stetho- scope’s diaphragm, listen at the left sternal edge in the fourth intercostal space for the mid- diastolic murmur of aortic regurgitation
    • –  ask the patient to turn onto his left side and to hold his breath at end-expiration. Using the stethoscope’s bell, listen in the mitral area for the mid-diastolic murmur of mitral stenosis
    • –  listen over the carotid arteries for any bruits and the radiation of the murmur of aortic
stenosis
    • –  listen in the left axilla for the radiation of the murmur of mitral regurgitation
For any murmur, determine its location and radiation, and its duration (early, mid, late, ‘pan’ or throughout) and timing (diastolic, systolic) in relation to the cardiac cycle. This is best done by palpating the carotid or brachial artery to determine the start of systole. Grade the murmur on a scale of I to VI according to its intensity (see Table 4). Common conditions associated with murmurs are listed in Table 5.
Figure 7. Auscultation points.
Clinical Skills for OSCEs
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Station 13 Cardiovascular examination
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Table 4. Grading murmurs
I
Barely audible murmur
II
Soft and localised murmur
III
Murmur of moderate intensity that is immediately audible
IV
Murmur of loud intensity with a palpable thrill
V
As above, murmur audible with only stethoscope rim on chest wall
VI
As above, murmur audible even as stethoscope is lifted from chest wall
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Table 5. Common conditions associated with murmurs
Aortic stenosis
Slow-rising pulse, heaving cardiac apex, ejection/early-systolic murmur best heard in the aortic area and radiating to the carotids and cardiac apex
Mitral regurgitation
Displaced thrusting cardiac apex, pan-systolic murmur best heard in the mitral area and radiating to the axilla, patient may be in atrial fibrillation
Aortic regurgitation
Collapsing pulse, thrusting cardiac apex, diastolic murmur best heard at the lower left sternal edge
Mitral valve prolapse
Mid-systolic click, late-systolic murmur best heard in the mitral area
RILE: Right-sided murmurs are heard loudest on Inspiration whereas Left-sided murmurs are heard loudest on Expiration
Chest examination
• Percuss and auscultate the chest, especially at the bases of the lungs. Heart failure can cause pulmonary oedema and pleural effusions.
Abdominal examination
  • Palpate the abdomen to exclude ascites and/or hepatomegaly.
  • Check for the presence of an aortic aneurysm.
  • Ballot the kidneys and listen for any renal artery bruits.
Examination of the ankles and legs
  • Inspect the legs for scars that might be indicative of vein harvesting for a CABG.
  • Palpate for the ‘pitting’ oedema of cardiac failure: check for pain and then press for 5 seconds on the patient’s legs. If oedema is present, assess how far it extends. In some cases, it may
extend all the way up to the sacrum or even the torso (‘anasarca’).
  • Assess the temperature of the feet, and check the posterior tibial and dorsalis pedis pulses in
both feet.
Cardiovascular and respiratory medicine
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Station 13 Cardiovascular examination
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After the examination
  • Indicate that you would look at the observation chart, dipstick the urine, examine the retina with an ophthalmoscope (for hypertensive changes and the Roth’s spots of subacute infective endocarditis), and, if appropriate, order some key investigations, e.g. FBC, ECG, CXR, echocar- diogram.
  • Cover the patient up and ensure that he is comfortable.
  • Thank the patient.
  • Summarise your findings and offer a differential diagnosis.