The Cardiovascular Examination

Introduction

• Introduce yourself to the patient
• Wash your hands
• Briefly explain to the patient what the examination involves
• Position the patient at 45^o
• Assess the patient from the end of the bed
  • Look for obvious distress or shortness of breath in the patient
  • Comment on any items of clinical note around the bed

Always start with the hands and proceed as below unless instructed otherwise; be prepared to be instructed to move on quickly to certain sections by any examiner.

The Hand and Arm

• Begin with the nails:
  • Capillary refill time (should be less than 2 seconds)
  • Clubbing
  • Splinter haemorrhages*

• Tar staining
  • This is typically seen between the 2^nd and 3^rd digits and is indicative of long smoking history

• Hands
  • Oslers nodes*: painful nodules on the finger pulps
  • Janeway Lesions*: painless macules on the palm
  • Pale palmar creases (sign of anaemia)

• Radial pulse
  • Rate
  • Rhythm – regular, regularly irregular (e.g. Type I Mobitz / ‘Wenckebach’), or irregularly irregular (e.g. atrial fibrillation)
    • If irregularly irregular (suspected AF), pulse must be assessed from the apex beat and not from the radial pulse

Offer to take a blood pressure reading at the arm, yet this is commonly suggested for the end of the examination

*Peripheral stigmata of infective endocarditis

The Neck and Face

• Feel the carotid pulses (assess for character and volume)
  • Aortic stenosis has a slow rising pulse with a narrow pulse pressure
  • Aortic regurgitation has a rapidly rising pulse with a large pulse pressure

• Assess the Jugular Venous Pressure
  • Affected by fluid status and contractility of the heart
  • Allow patient to relax their head back onto the pillow and turn their head to the left
  • Look between the two heads of the sternocleidomastoid for the double peak of the JVP
    • If unsure between carotid pulse and JVP, press gently over the region; if the pulsations disappear, likely to be JVP
  • Measure the height of the JVP from the sternal angle vertically upwards

• Assess the patients eyes
  • Check for corneal arcus or xanthalasma, both signs of hyperlipidaemia*

• Ask the patient to pull their eyelid down
  • Assess for pale conjunctivae (suggests possible anaemia)

• Look for signs of flushing of the cheeks
  • Sign of mitral stenosis

• Check around the lips for any peripheral cyanosis

• Ask the patient to open their mouth wide
  • Check dental hygiene, as this is a risk factor for infective endocarditis

• Ask the patient to put their tongue in to the roof of their mouth
  • Look under the tongue for central cyanosis

*Senile arcus is commonly seen in elderly patients and may be confused with corneal arcus

Examining the Precordium

• Expose the patient’s chest (any bra present can be left on throughout the examination)
• Look for any scars or chest wall deformity

• Feel for the apex beat, assessing for strength and position
  • Strong apex beat suggests LVH
  • Apex beat becomes laterally displaced following RVH or LVF
  • If cannot feel apex beat, ask patient to roll onto their left side (yet you are unable to comment on its displacement)

• Feel for any parasternal heaves with the palm
• Feel for valvular thrills over the four valve areas

• Auscultate over the 4 valve areas
  • Aortic valve heard 2^nd intercostal space, right sternal edge
  • Pulmonary valve heard 2^nd intercostal space, left sternal edge
  • Tricuspid valve heard 4^th intercostal space, left sternal edge
  • Mitral valve heard 4^th intercostal space, left mid-clavicular line
• Accentuate any murmurs present
  • Mitral regurgitation is a pan-systolic murmur heard over the mitral valve, radiating to the axilla
  • Mitral stenosis is a diastolic murmur, heard best over the apex with the patient rolled on to their left side with the stethoscope bell
  • Aortic stenosis is an ejection systolic murmur that radiates to the neck
  • Aortic regurgitation is a diastolic murmur, best heard in the left sternal edge with the patient sat forward and in expiration
• Auscultate over the carotids
  • Assess for any carotid bruits

The Rest of the Examination

• Listen to the lung bases
  • Assesses for any fluid overload
• Check for sacral oedema
• Assess for peripheral oedema over the ankles
  • If any peripheral oedema found, move up the leg to assess severity of oedema
• Assess for vein graft harvest scars
• Check the peripheral pulses
  • Dorsalis pedis can be felt between the EHL and EDL tendons
  • Posterior tibial can be felt behind the medial malleolus

Completing the Examination

Remember, if you have forgotten something important, you can go back and complete this. To finish the examination, stand back from the patient and state to the examiner that to complete your examination, you would like to perform a:

• Peripheral vascular examination
• Temperature measurement
• Urinalysis
• Fundoscopy