Examination of the patient, cardiovascular system

General inspection

  • Does the patient look well or ill?
  • Are they lying flat?
  • Are they cachectic (cardiac cachexia)?
  • Is there evidence of a congenital syndrome associated with cardiac abnormalities such as Marfan’s syndrome or Down’s syndrome?

Position

Help the patient to adopt a comfortable position at 45° with the chest exposed. In women, cover the chest until ready to examine the praecordium.

Hands

  • Clubbing: subacute bacterial endocarditis (SBE) and congenital cyanotic heart disease.
  • Cyanosis: peripheral vasoconstriction, pulmonary edema and right-to-left shunt.
  • Splinter hemorrhages: SBE.
  • Janeway’s lesions: non-tender macules in the palms due to SBE.
  • Osler’s nodes: painful nodules on the pulps of the fingers due to SBE.
  • Quincke’s sign: aortic regurgitation.
  • Xanthomata: hypercholesterolemia (vascular disease).

Radial pulse

  • Rate: normally between 60 and 100 bpm.
  • Rhythm: regular or irregular.
  • Radioradial delay: dissecting thoracic aortic aneurysm.
  • Radiofemoral delay: coarctation of the aorta.
  • Character: best determined by palpation of a larger artery (e.g. brachial or carotid arteries).

Blood pressure

  • Level: hypertension is a risk factor for vascular disease.
  • Lying and standing: postural hypotension.
  • Right and left: left may be lower than right in aortic dissection.
  • Wide pulse pressure: in the elderly and aortic regurgitation.
  • Narrow pulse pressure: aortic stenosis.
  • Pulsus paradoxus: exaggerated fall in pulse pressure during inspiration resulting in a faint or absent pulse in inspiration; caused by severe asthma or cardiac tamponade.

Jugular venous pressure

When assessing JVP, the patient should be at 45° with their head resting on a pillow (this relaxes the sternocleidomastoid muscles). Pulsation should be up to 3 cm above the sternal angle (8 cm above right atrium). JVP acts as a manometer for right atrial pressure and is raised when right atrial pressure is raised. Abnormalities in the waveform result from specific underlying pathologies. Restrictive cardiomyopathy, constrictive pericarditis and pericardial tamponade are all associated with Kussmaul’s sign (JVP rises during inspiration).

Face

  • Central cyanosis: right-to-left shunt.
  • Anaemia: possible high-output cardiac failure.
  • Malar flush: mitral valve disease.
  • Jaundice: haemolysis due to mechanical valves.
  • Xanthelasmata: hypercholesterolaemia (vascular
    disease).
  • Mouth: high-arched palate in Marfan’s syndrome.
  • De Musset’s sign: head nodding due to aortic
    regurgitation.
  • Roth’s spots in the retina: bacterial endocarditis.

Precordium

  • Sternotomy scar: arterial bypass grafts and valve replacements.
  • Mitral valvotomy scar under the left breast: always look for it, as it indicates a previously closed mitral valvotomy.
  • Skeletal deformities: can cause an ejection systolic flow murmur.

Apex beat

  • Lateral displacement: left or severe right ventricular dilatation. Lung pathology may also cause displacement.
  • Impalpable: obesity, pleural effusion, pericardial effusion, chronic obstructive airways disease and dextrocardia (palpable on the right!).
  • Tapping: mitral stenosis (palpable first heart sound).
  • Heaving: ‘pressure overload’ in aortic stenosis or hypertension.
  • Thrusting: ‘volume overload’ in aortic regurgitation, mitral regurgitation (ventricle usually markedly displaced).
  • Diffuse: left ventricular dilatation.
  • Double impulse: left ventricular aneurysm or hypertrophic cardiomyopathy.

Palpation

Parasternal heave is caused by the enlargement or hypertrophy of the right ventricle. A thrill is a palpable murmur and indicates significant valve disease; it can be systolic or diastolic and therefore its position in the cardiac cycle should be assessed by timing its relation to a central pulse.

Auscultation

  • Listen in all four areas with the bell and diaphragm
  • Roll the patient to the left-hand side to listen with the bell at the axilla for mitral stenosis.
  • Sit the patient forward to listen with the diaphragm at the left sternal edge in expiration (with breath held) for aortic regurgitation.
  • Listen to the first and second sounds, then for third and fourth sounds.
  • Are there any murmurs?
  • Listen for additional sounds including opening snap, ejection click, pericardial knock or rub, and mechanical valves.
  • Time any abnormalities against the carotid pulsation.
  • Listen to the carotid arteries for bruits (atheroma) or radiation of aortic stenotic murmur.

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