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 the aorta

Arm:

Brachial pulse character: slow rising in aortic stenosis
Check BP: Check both arms in a new patient, 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 indicator 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 that wells up from the root the of the 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 the patient at 45° – is normal

Head:

Closer inspection of the chest:

Chest wall deformities: Pectus excavatum: known as “sunken” or “funnel” chest, Pectus carinatum: known as “pigeon” chest, Poland syndrome, Jeune syndrome, Slipping rib syndrome
Scars e.g. thoracotomy
Pacemaker lumps

Palpation

Apex beat:

Feel for it with the right, then count down it from the 2nd intercostal with the left
Should be in the left 5th intercostal
Describe the size, location, and waveform
If it can’t be felt, tilt the 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 maybe 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 the 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 on 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 breathe again when done
Have the 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 breathe 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 the base of lungs, asking the patient to breathe in and out deeply
Crackles may indicate pulmonary edema from heart failure

Completing the exam

To complete the examination: