Cardiovascular Clinical Examination HD

Introduction
Wash hands
Introduce yourself
Confirm patient details – name / DOB
Explain the examination
Gain consent
Position the patient at 45° with their chest exposed
Ask if the patient currently has any pain

General inspection
Bedside – treatments or adjuncts? – GTN spray / O2 / medication / mobility aids

Check the patient is comfortable at rest

Malar flush – plum red discolouration of cheeks – may suggest mitral stenosis

Inspect chest – scars or visible pulsations? (remember to look underneath arms for thoracotomy scars and for small scars from minimally invasive surgery)

Inspect legs – scars from saphenous vein harvest for CAGB / peripheral oedema / missing limbs or toes

Hands
Hands out with palms facing downwards

Splinter haemorrhages – reddish/brown streaks on the nail bed – bacterial endocarditis

Finger clubbing:

• Ask the patient to place the nails of their index fingers back to back
• In a healthy individual, you should be able to observe a small diamond shaped window (Schamroth’s window)
• When finger clubbing is present this window is lost
• Finger clubbing has a number of causes including infective endocarditis and cyanotic congenital heart disease

Hands out with palms facing upwards

Colour – dusky bluish discolouration (cyanosis) suggests hypoxia

Temperature – cool peripheries may suggest poor cardiac output/hypovolaemia

Sweaty/Clammy– can be associated with acute coronary syndrome

Janeway lesions – non-tender maculopapular erythematous palm pulp lesions – bacterial endocarditis

Osler’s nodes – tender red nodules on finger pulps/thenar eminence – infective endocarditis

Tar staining – smoker – risk factor for cardiovascular disease

Xanthomata – raised yellow lesions – often noted on tendons of the wrist – caused by hyperlipidaemia

Capillary refill time – normal is <2 seconds – if prolonged may suggest hypovolaemia

Pulses
Radial pulse – assess rate and rhythm

Radio-radial delay:

• • Palpate both radial pulses simultaneously
  • They should occur at the same time in a healthy adult

• • Radio-radial delay can be associated with subclavian artery stenosis (e.g. compression by a cervical rib) or aortic dissection

Collapsing pulse – associated with aortic regurgitation

• First, ensure the patient has no shoulder pain
• Palpate the radial pulse with your hand wrapped around the wrist
• Raise the arm above the head briskly
• Feel for a tapping impulse through the muscle bulk of the arm as blood empties from the arm very quickly in diastole, resulting in the palpable sensation
• This is a water hammer pulse and can occur in normal physiological states (fever/pregnancy), or in cardiac lesions (e.g. AR/PDA) or high output states (e.g. anaemia/AV fistula/thyrotoxicosis)

Brachial pulse – assess volume and character

Blood pressure:

• Measure blood pressure and note any abnormalities – e.g. hypertension/hypotension
• Narrow pulse pressure is associated with aortic stenosis
• Wide pulse pressure is associated with aortic regurgitation
• Often you won’t be expected to actually carry this out (due to time restraints) but make sure to mention that you’d ideally like to measure blood pressure in both arms

Carotid pulse:

• Assess character and volume – e.g. slow rising character in aortic stenosis
• It’s often advised to auscultate the carotid artery for a bruit before palpating, as theoretically palpation may dislodge a plaque which could lead to a stroke
• However, if you perform carotid auscultation at this point, remember that the ‘bruit’ may actually be a radiating murmur!

Jugular venous pressure (JVP)
1. Ensure the patient is positioned at 45°

2. Ask patient to turn their head away from you

3. Observe the neck for the JVP – located inline with the sternocleidomastoid

4. Measure the JVP – number of centimetres from the sternal angle to the upper border of pulsation

Raised JVP may indicate – fluid overload / right ventricular failure / tricuspid regurgitation

Hepatojugular reflux:

• Apply pressure to the liver
• Observe the JVP for a rise
• In healthy individuals, this should last no longer than 1-2 cardiac cycles (it should then fall)
• If the rise in JVP is sustained and equal to or greater than 4cm this is a positive result
• A positive hepatojugular reflux sign is suggestive of right-sided heart failure and/or tricuspid regurgitation
• This is very uncomfortable to perform correctly – an examiner will often prevent you performing it but remember to mention it!

Face
Eyes
Conjunctival pallor – anaemia – ask the patient to gently pull down their lower eyelid

Corneal arcus – yellowish/grey ring surrounding the iris – hypercholesterolaemia

Xanthelasma – yellow raised lesions around the eyes – hypercholesterolaemia

Mouth
Central cyanosis – bluish discolouration of the lips and/or the tongue

Angular stomatitis – inflammation of the corners of the mouth – iron deficiency

High arched palate – suggestive of Marfan syndrome – ↑ risk of aortic aneurysm/dissection

Dental hygiene – important if considering sources for infective endocarditis

Close inspection of the chest
Scars:

• Thoracotomy – minimally invasive valve surgery
• Sternotomy – CABG / valve surgery
• Clavicular – pacemaker (can be either side, so remember to check both)
• Left mid-axillary line – subcutaneous implantable cardioverter defibrillator (ICD)

Chest wall deformities – pectus excavatum / pectus carinatum

Visible pulsations – forceful apex beat may be visible – hypertension/ventricular hypertrophy

Palpation
Apex beat:

• Located at the 5th intercostal space / midclavicular line
• Palpate the apex beat with your fingers (placed horizontally across the chest)
• Lateral displacement suggests cardiomegaly

Heaves:

• A parasternal heave is a precordial impulse that can be palpated
• Parasternal heaves are present in patients with right ventricular hypertrophy
• Place the heel of your hand parallel to the left sternal edge (fingers vertical) to palpate for heaves
• If heaves are present you should feel the heel of your hand being lifted with each systole

Thrills:

• A thrill is a palpable vibration caused by turbulent blood flow through a heart valve (the thrill is a palpable murmur)
• You should assess for a thrill across each of the heart valves in turn
• To do this place your hand horizontally across the chest wall, with the flats of your fingers and palm over the valve to be assessed

Auscultation
Auscultate the four valves
A systematic routine will ensure you remember all the steps whilst giving you several chances to listen at each valve area. Your routine should avoid excess repetition whilst each step should ‘build’ upon the information gathered by the previous steps.

1. Palpate the carotid pulse to determine the first heart sound.

2. Auscultate ‘upwards’ through the valve areas using the diaphragm of the stethoscope:

• Mitral valve – 5th intercostal space – midclavicular line (apex beat)
• Tricuspid valve – 4th or 5th intercostal space – lower left sternal edge
• Pulmonary valve – 2nd intercostal space – left sternal edge
• Aortic valve – 2nd intercostal space – right sternal edge

3. Repeat auscultation across the four valves with the bell of the stethoscope.

4. Auscultate the carotid arteries with the patient holding their breath to check for radiation of an aortic stenosis murmur (this is known as an accentuation manoeuvre).

5. Sit the patient forwards and auscultate over the aortic area during expiration to listen for the murmur of aortic regurgitation (this is known as an accentuation manoeuvre).

6. Roll the patient onto their left side and listen over the mitral area with the bell during expiration for mitral murmurs (regurgitation/stenosis).

To complete the examination
Auscultate lung bases:

• Crackles may suggest pulmonary oedema (e.g. secondary to left ventricular failure)
• Consider chronic lung diseases if the patient has no other signs of fluid overload (e.g. pulmonary fibrosis)

Sacral oedema/pedal oedema – may indicate right ventricular failure

Thank the patient

Wash hands

Summarise findings