Video

Note: Mitral Stenosis causes a diastolic murmur, not a systolic murmur.

Exam Summary


1. Introduction

  • Introduce yourself and the exam
  • Ask the patient to expose their chest
  • Wash hands
  • Angle bed at 45º

2. Observations

  • Temperature
  • Oxygen saturations
  • Heart Rate
  • Respiratory Rate

3. General Inspection

  • Alertness
  • Supplementary Oxygen
  • Fluid and Diet Restrictions
  • Cardiac Monitoring
  • Breathing
  • Cachexia - cancer
  • Body Habitus
  • Deformity
  • Scars - chest, arms and legs - previous surgery or vessel harvest
  • Gait aid

4. Hands

a. Nails

clubbing.jpg
clubbing
220px-Splinter_hemorrhage.jpg
Splinter Haemorrhages

Koilonychia.jpg
Koilonychia

b. Fingers

  • Capillary refill - The time taken for the external capillary bed under the nail to return to colour after pressure is applied. It should take no longer than 2 seconds. A prolonged refill time is indicative of poor perfusion which may be due to shock, hypovolaemia or peripheral vascular disease.
  • Peripheral cyanosis - Blue or purplish colouration of the hands due to low oxygen saturation.
  • Nicotine stains - yellow stains on fingers due to chronic smoking.
  • Janeway lesions - non-tender erythematous maculopapular lesions on palms/fingers due to infective endocarditis
  • Osler's nodes - painful, palpable, red lesions which can be found on the fingers and toes. They are due to immune complex deposition or infective endocarditis.
Capillary Refill.jpg
Capillary Refill








Cyanosis.JPG
Peripheral cyanoisis
Nicotine_stains10.JPG
Nicotine Stains

Janeway lesion.png
Janeway Lesion
Osler_Nodules_Hand.jpg
Osler's Nodes














c. Palms
palmar_erythema.jpg
Palmar Erythema


d. Dorsum

Hand Xanthomata.jpg
Hand Xanthomata

5. Arms

a. Radial Pulse

radialpulse.jpg
Radial Pulse

The radial pulse is taken on the flexor side of the forearm, just below the wrist on the radial side. Check rhythm, rate and volume. A normal heart rate is between 60 and 100 beats per minute. A fast rate is called a tachycardia and a slow rate is called a bradycardia.

b. Radial-radial delay

Measure both radial pulses simultaneously. If there is a time delay it suggests large arterial occlusion, large arterial stenosis or aortic dissection.

c. Radiofemoral delay

Measure the radial pulse simultaneously with femoral pulse. A radiofemoral delay in a young patient with hypertension could be caused by aortic coarctation, a congenital narrowing of the aorta.

d. Collapsing Pulse

A collapsing pulse can be felt in Aortic Regurgitation by raising the patient's arm up while simultaneously feeling their pulse.

e. Blood Pressure

Measure blood pressure while sitting and while standing. Normal blood pressure in 120/80. A BP higher than 140/90 is considered hypertension. A BP below 90/60 is hypotension. Remember that a single BP cannot be used to make a diagnosis. BP must be repeated if there is an abnormal finding.

f. Postural Blood Pressure

Blood pressure should be repeated while the patient is standing. A systolic drop of more than 15mmHg and a diastolic drop of more than 15mmHg is considered abnormal and is most commonly due to antihypertensive medication (particularly alpha-blockers), Hypovolaemia, Addison's Disease or Autonomic Disorders.

6. Face

a. Eyes

  • Xanthelasmata - cholesterol deposits (see dyslipidaemia)
  • Conjunctival Pallor - a sign of anaemia
  • Arcus Senilis - a gray ring (or incomplete ring) around the eye which suggests hypercholesterolaemia in young people. It is very common in the elderly.
  • Request Fundoscopy looking for Roth Spot's - a sign of infective endocarditis.
Xanthelasma_wiki.jpg
Xanthelasmata
conjunctivapallor.jpg
Conjunctival Pallor
Arcus_Senilis.jpg
Arcus Senilis

b. Mouth and Tongue

  • Dry Mucous Membranes - Dehydration
  • Tongue - Central cyanosis
  • High Arched Palate - Marfan's Syndrome which is associated with aortic regurgitation, congenital heart disease, mitral regurgitation and aortic dissection.
  • Pharyngeal Petechiae - This is a sign of Streptococcal pharyngitis or infective endocarditis
  • Angular Stomatitis - or angular cheilitis is inflammation of the corners of the mouth. It is often due to immunosuppression.
  • Dental Health - Teeth can be a source of organisms which cause Infective endocarditis.
Streptococcal_pharyngitis_wiki.jpg
Pharygeal Petechiae
Angular_Cheilitis_wiki.JPG
Angular Stomatitis

cyanosistongue.jpg
Central Cyanosis












7. Neck

  • Carotid Arteries - feel for volume and character
  • Jugular Venous Pressure (tutorial) - Measure with the patient's head at 45º and assess height. Also test the Hepatojugular Reflex. In a normal individual the JVP will rise and fall or not rise at all. A positive test occurs when the JVP remains higher while pressure is applied to the liver. An abnormally high JVP indicates Right Heart Failure.
Elevated_JVP.JPG
Elevated JVP

8. Chest

a. Inspection

  • Scars - past surgery or trauma
  • Skeletal abnormality - A kyphosis (excessive outward curvature of the spine) may displace the heart or cause pulmonary hypertension. It may also be a sign of Marfan's Syndrome.
  • Pacemakers

b. Palpitation

  • Apex beat - feel for the apex beat in the 5th intercostal space, mid-clavicular line. (Note that the apex beat is only palpable in 50% of adults. In left ventricular hypertrophy the apex beat may be displaced more laterally. Other abnormal apex beats include:
    • A pressure loaded apex beat (heaving, forceful) due to aortic stenosis or hypertension
    • A volume loaded apex beat (thrusting) that is displaced and diffuse due to advanced mitral regurgitation or dilated cardiomyopathy
    • A dyskinetic apex beat that is uncoordinated due to left ventricular dysfunction
    • A double impulse apex beat where there are two apex beats for every systole indicating hypertrophic cardiomyopathy
    • A tapping apex beat where the first heart sound is also palpable. This indicates mitral stenosis or tricuspid stenosis (very rare).
  • Thrills - feel for thrills with the palm of the hand in the apical region. A thrill is a palpable murmur and may be due to mitral regurgitation. Also feel in the precordial region. Here Systolic thrills may be due to Aortic Stenosis, a diastolic thrill may be due to Aortic Regurgitation.
  • Heaves (Parasternal Impulse) - Felt by placing the palm of the hand on the left sternal edge. If a force is felt it is indicative of Righ Ventricular Hypertrophy.

c. Auscultation

  • Listen to the four regions using the bell to hear low-pitched murmurs and the diaphragm to hear high-pitched murmurs. Remember to listen for radiation of murmurs towards the axilla. Heart sounds recordings.
  • Listen to the left axilla (mitral regurgitation) and carotid arteries (aortic stenosis) for radiation of murmurs.
  • Heart Sounds tutorial (Blaufuss)

d. Return to neck

Listen for radiation of murmurs or bruits at the bifurcation of the carotid artery. If a noise is heard auscultate down the carotid to distinguish between a bruit (noise disappears) and a murmur (can be heard all the way down the common carotid artery.

e. Left Lateral Position

Auscultate the mitral region with the patient on their left side, this will make mitral valve murmurs more pronounced. Listen to the apex with the bell.

f. Dynamic Manoeuvres

Sit the patient forwards.

i. Respiration

Right sided murmurs become louder due to increased venous return.

ii. Deep expiration

Allows aortic regurgitation and pericardial rubs to be heard more easily

iii. Valsava manoeuvre

Expiration against a closed glottis makes mitral valve regurgitation and hypertrophic cardiomyopathy louder.

iv. Standing to squatting

Increases the intensity of most murmurs except mitral murmurs and hypertrophic cardiomyopathy

9. Back

  • Lung Bases - percuss the lung bases for signs of effusion and listen for crackles which can be due to Left Heart Failure or Congestive Heart Failure.
  • Sacrum - check for sacral oedema

10. Abdomen

11. Lower Limb

a. Inspection

  • Amputation, scars, deformities
  • Ulcers - ulcers may be due to venous insufficiency, ischaemia or diabetes complications
  • Erythema
  • Varicosities
  • Atrophy
  • Discolouration - including venous staining
  • Hair loss
  • Swelling - which may be pitting oedema.
Diabetic_Wound_121.jpg
Diabetic Ulcer
Venous Ulcer.jpg
Venous Ulcer

Arterial Ulcer.jpg
Arterial Ulcer


b. Palpation

  • Temperature
  • Pitting Oedema - may be a sign of Right Heart Failure (but may also be due to hypoproteinaemia due to liver failure or renal failure). If there is unilateral swelling then a Deep Vein Thrombosis must be ruled out.
  • Capillary Refill of Great Toe should be less than two seconds
  • Venous filling of dorsal arch - Occlude the venous arch with two fingers then remove the distal finger. If there is no refilling then it is suggestive of poor arterial supply.
  • Pulses - posterior tibial, dorsalis pedis.
Piting_Oedema wiki.jpg
Pitting Oedema
Pulses.png
Pulses of the Cardiovascular exam
toe refill.jpg
Toe Capillary Refill














c. Auscultation

Listen for abdominal, renal and femoral bruits

12. Other Examinations

Request:

13. Conclusion

Thank the patient and offer assistance.

Reference

Talley and O'Connor - Clinical Examination 7th edition pp57-92

Arcus Senilis image: By Afrodriguezg (Own work) [CC BY-SA 4.0 (http://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons
Capillary refill image:
By Alex Miles - pager Author (Own work)
Venous Ulcer image:
"Úlceras antes da cirurgia" by Nini00 - Own work --> http://www.varizinforma.com/Photo.htm (.jpg). Licensed under CC BY-SA 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:%C3%9Alceras_antes_da_cirurgia.JPG#/media/File:%C3%9Alceras_antes_da_cirurgia.JPG
Arterial Ulcer image:
"Arterial ulcer peripheral vascular disease" by Jonathan Moore - Creating the Ideal Microcosm for Rapid Incorporation of Bioengineered Alternative Tissues Using An Advanced Hydrogel Impregnated Gauze Dressing: A Case Series. The Foot and Ankle Online Journal 1 (9): 2.. Licensed under CC BY 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Arterial_ulcer_peripheral_vascular_disease.jpg#/media/File:Arterial_ulcer_peripheral_vascular_disease.jpg
Diabetic Ulcer image:
By Intermedichbo at sr.wikipedia [CC BY-SA 3.0 rs (http://creativecommons.org/licenses/by-sa/3.0/rs/deed.en) or GFDL (http://www.gnu.org/copyleft/fdl.html)], from Wikimedia Commons
Clubbing image:
"Acopaquia" by Desherinka - Own work. Licensed under GFDL via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Acopaquia.jpg#/media/File:Acopaquia.jpg
Xanthoma image: By Anita A Kumar , Ghanshyam Palamaner Subash Shantha , Yadav Srinivasan , N Senthil , K Rajkumar , Neeta Paunikar and MK Sudhakar [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons
Leukonychia image: "Leukonychia" by Keitei - Own work. Licensed under CC BY 2.5 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Leukonychia.jpg#/media/File:Leukonychia.jpg
Palmar erythema image: https://thebileflow.wordpress.com/2012/03/22/pathology-palmar-erythema/
Conjunctival Pallor image: http://image.frompo.com/4f21b9b2c559bfd71fc1c2f6c49d4c08
Angular Stomatitis image: "Angular Cheilitis" by James Heilman, MD - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Angular_Cheilitis.JPG#/media/File:Angular_Cheilitis.JPG
Pitting Oedema image: "Combinpedal" by James Heilman, MD - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Combinpedal.jpg#/media/File:Combinpedal.jpg
Pulses image - http://intranet.tdmu.edu.ua/data/kafedra/internal/propedeutic_vn_des/classes_stud/en/med/lik/ptn/Nurse%20practice/3/leson_1_Organization%20of%20nurse%20post.htm
Radial Pulse image: "Radial pulse". Licensed under Public Domain via Wikimedia Commons -https://commons.wikimedia.org/wiki/File:Radial_pulse.jpg#/media/File:Radial_pulse.jpg
Scleral Jaundice image: "Jaundice eye" by Photo Credit:Content Providers(s): CDC/Dr. Thomas F. Sellers/Emory University - This media comes from the Centers for Disease Control and Prevention's Public Health Image Library (PHIL), with identification number #2860.Note: Not all PHIL images are public domain; be sure to check copyright status and credit authors and content providers.English | Slovenščina | +/−. Licensed under Public Domain via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Jaundice_eye.jpg#/media/File:Jaundice_eye.jpg
Koilonychia image: from https://yourfingernails.wordpress.com/tag/skin/
Peripheral cyanosis image: "Cynosis" by James Heilman, MD - Own work. Licensed under CC BY-SA 3.0 via Commons - https://commons.wikimedia.org/wiki/File:Cynosis.JPG#/media/File:Cynosis.JPG
"Cynosis" by James Heilman, MD - Own work. Licensed under CC BY-SA 3.0 via Commons - https://commons.wikimedia.org/wiki/File:Cynosis.JPG#/media/File:Cynosis.JPG