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Overview:Cardiovascular Examination

Clinical History

Important factors:

§ Breathlessness

§ Chest pain

§ Palpitations

§ Syncope

§ Symptoms of arterial disease

§ Symptoms of venous disease

§ Occupation & family history

Breathlessness

Questions to ask:

§ Do you ever feel short of breath?

§ Does this occur with exertion?

§ Do you wake up gasping for breath?

§ If so, do you have to sit up or get out of bed?

§ How many pillows do you sleep on?

§ Do you cough or wheeze when you are SOB?

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Chest Pain

Most common cardiac symptom

Ask:

§ Do you get the pain on exertion?

§ Where do you feel it?

§ Worse with exercise, cold weather or big meal?

§ Stop you from exercising?

§ Go away at rest?

§ Excitement & or upset?

New York Association of Heart

Failure

Grade 1 – No symptoms at rest , dyspnoea only on vigorous exertion

Grade 2 – No symptoms at rest, dyspnoea on moderate exertion

Grade 3 – may be mild symptoms at rest, dyspnoea on mild exertion, severe dyspnoea on moderate exertion

Grade 4 – Significant dyspnoea at rest, severe dyspnoea on mild exertion. Patient often bed bound.

Cardiovascular ExaminationHistory

Observe patient

Examine hand

Radial Pulse: rate, rhythm, volume, vessel wall, waveform

Blood Pressure: supine and erect

Jugular Venous Pressure: height and waveform

Carotid pulses – character (listen first)

Apex Beat: site and nature

Precordial palpation: thrills, taps, heaves, impulses

Auscultation: heart sounds, added sounds & murmurs

Peripheral vascular system

Test urine

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Physical Examination

While taking history observe for:§ Anxiety & distress

§ Breathlessness

§ Pain

What may you find in the hand?

Splinter Haemorrhage

infective endocarditis -clots shooting off heart

valve affected

Aortic Aneurism

Absence does not rule out

Can be normal

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Clubbing

What other clinical signs may you

find in the hands?

Causes of Finger Clubbing?

Describe

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Hand

Take patients hand & assess:§ Warmth

§ Sweating

§ Peripheral cyanosis

§ Clubbing & splinter haemorrhage

Pulses

Palpate radial pulse for

rate, rhythm and vessel wall

Suspicion of aortic arch problem then palpate both simultaneously.

Femoral / radial

Brachial Pulse

Palpate brachial pulse & assess character

Measure blood pressure

Possibly compare both arms

Lying and standing

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Blood Pressure

Systolic – maximum pressure of the blood against

vessel wall following ventricular contraction.

Diastolic – pressure minimum pressure of the blood

against the vessel wall following closure of the aortic valve

Taken at rest

“normal” 100/60 – 140/90

Hypotension better defined by it consequences

Measured in mm Hg

Assess JVP

Assesses input side of the heart

JV direct communication with RA

RA normal pressure of 10-12cm blood

Standing -JV flat

Lying flat – JV full

Surpine 45 ° - JV pulsation just above clavicle

Assessment of JVP

Mean height of pulsation

above right atrial level

§ Jugular venous pulsation above the manubriosternal angle

¥ Normal considered <4cm

above this point

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Distinction between Jugular Venous

and Carotid Pulse

Venous

§ Two peak per cycle

§ Affected by abdominal compression

§ May displace earlobes

§ Low pressure

Arterial

§ One peak per cycle

§ Not affected by abdominal compression

§ Never displaces earlobes

§ High pressure

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JVP

Causes of ↑ JVP

Common§ Congestive heart failure§ Tricuspid regurgitation

Less common§ Pericardial Tamponade§ Massive PE

Rare§ Superior caval obstruction§ Pericarditis§ Tricuspid Stenosis

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Palpation of Precordium

Lay flat hand on chest wall to the left of the sternum

Locate the apex beat

Normally in 5th or 6th intercostal space in midclavicular line

Palpate for characteristics

Possible to palpate some murmurs as vibrations or thrills

LVH – sustained & forceful

Auscultation of the Heart

Introduced to medicine in 19th Century

Two basic principles:

§ Transmit sound while excluding extraneous sound

§ Selectively emphasises sounds of certain

frequencies

Bell (low pitch) / diaphragm( high pitch)

Ear pieces point forward

Auscultation of the Heart

Easier with good quality stethoscope

As minimum listen to apex; base; aortic and pulmonary areas

Good practice to simultaneously palpate carotid artery

Analyse findings under 3 headings§ 1st & 2nd heart sounds

§ Murmurs

§ Additional heart sounds

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Areas to auscultate

Mitral valve

§ apex (left 5th ICS, mid clavicular line)

Tricuspid area

§ 4th costal cartilage, left side of sternum

Aortic area

§ Right 1st ICS costal margin

Pulmonary area

§ Left 1st ICS costal margin

Closure of Heart Valves makes Heart

Sounds

Inflow

§ Atrioventricular Valves

¥ Tricuspid – right

¥ Mitral – left

Outflow

§ Semi-Lunar

¥ Aortic

¥ Pulmonary

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Normal Heart Sounds

“Lub-dup”

1st sound “Lub”

§ Closure of Mitral & Tricuspid - systole

2nd sound “dup”

§ Closure of Aortic & Pulmonary - diastole

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S3

3rd Heart sounds

§ Abnormal heard in addition to normal sounds

§ 3rd – low pitched thudding in diastole

§ Physiological – young fit adults with increased cardiac output (fever)

§ Pathological – severe impairment of left ventricular function

§ ‘da-da-boom, da-da-boom’ or gallop rhythm

S4

4th – coincides with atrial

contraction

§ Hypertrophied left atrium

§ ‘da-lub-dup, da-lub-dup’

Children & Young Adults

Physiological splitting of second sound can occur

“Lup da-lup”

During inspiration: § ↑ venous filling of right side of heart

§ ↑increase right ventricular stroke volume

§ Delay in pulmonary valve closure

Split sound can be caused by anything that delays ventricular contraction

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Ejection Click

High pitched shortly after S1

§ Aortic or pulmonary valve stenosis

Opening Snap

Diastolic sound in mitral stenosis

§ Best heard to the left of sternum

§ Sounds like widely split S2

Murmurs

Caused by:

§ Leakage through structure normally closed during

phase heard

§ Narrowing of valve normally open during phase

§ Increase blood flow through normal valve

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Murmurs

Musical sounds occurring at various points of

cardiac cycle from turbulent blood flow

Early systolic murmur

Pan systolic murmur

Cardiovascular System & Chest

Examination

B symptoms because of C problems

Examine chest for:

§ Basal crepitations

§ Plural effusions

Respiratory symptoms

Abdominal symptoms

Peripheral Vascular System

Compare two limbs for pallor, cyanosis and evidence of nutritional changes

Compare temperature of limbs

Cap refill of foot and toes

Palpate dorsalis pedis – lat to hallucis longus and prox to 1st metatarsal space

Posterior tibial pulse- behind MM

Popliteal pulse – thumbs on patella, fingers into popliteal fossa

Femoral pulse

Palpate pulses in upper limb and neck

Assess volume and waveform using carotid, brachial or femoral artery

Look for Oedema - Swelling that can be displaced by firm pressure and pits

when finger removed (remember sacrum)

Auscultate carotid, subclavian, abdominal aorta, renal and femoral artery

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Cardiovascular ExaminationHistory

Observe patient

Examine hand

Radial Pulse: rate, rhythm, volume, vessel wall, waveform

Blood Pressure: supine and erect

Jugular Venous Pressure: height and waveform

Carotid pulses – character (listen first)

Apex Beat: site and nature

Precordial palpation: thrills, taps, heaves, impulses

Auscultation: heart sounds, added sounds & murmurs

Peripheral vascular system

Test urine