Examination: Cardiovascular

Split the cardiovascular examination into two separate examinations:

1. Peripheral examination
2. Examination of the precordium (chest)

• Inspect generally first
  • Inspect general area (for I.V. drips, catheters, cigarettes, GTN spray, etc.)
  • Inspect patient as a whole (to check they are not in discomfort, are not short of breath, for scars, etc.)
• Examine the peripheral system in a systematic way. Start with the hands (back and front) → wrist (radial pulse) → upper arm (check blood pressure) → head → neck. Do this for the respiratory and abdominal examinations also. See below for details of what to examine in each system.
  • Hands: check for:
    • Clubbing
    • Peripheral cyanosis by compressing fingernails for 5 secs. Normal for blood to return to nails in less than 2 secs.
    • Splinter haemorrhages
    • Osler's nodes
    • Janeway lesions
    • Xanthomata
    • Tar stains (indicative of a smoker)
  • Wrist:
    • Radial pulse:
      • Check RATE and RHYTHM
      • Measure rate for 15 seconds then multiply by 4 to get the beats per minute
  • Arm:
    • Examine for a water hammer pulse from radial to brachial artery:
      • Ask patient if they have any pain in their arm
      • If not, lift up while palpating both radial and brachial pulses
      • Feel for the pulse - if you feel the pulse drop from the brachial to the radial artery, then you have felt a water hammer pulse. This is a peripheral sign indicating possible aortic regurgitation.
    • Examine the patient's blood pressure: see other clinical skills notes for details of how to do this
  • Head:
    • Eyes: corneal arcus and pallor in bottom eyelids, xanthelasma
    • Cheeks and nose: malar flush (occurs in mitral stenosis)
    • Under tongue: central cyanosis
  • Neck:
    • Inspect:
      • The JVP
        • Ask patient to turn head to the left at a 45 degree angle
        • The JVP is visible at the top of the sternal notch between the two sternoclydomastoid muscles.
        • Examine the height of the JVP. It should not be over 4cm above the sternal notch, if the patient is lying at 45°
        • N.B.: sometimes the JVP can be mistaken for the carotid pulse, and vice versa. The JVP is different from arterial pressure as;
          • a) it takes a double wave form
          • b) it is not pulsatile on compression.
          • c) it fills from the bottom
          • d) it is reactive to the hepatojugular reflex (press on patient's liver - this will increase the size of the JVP, but not the carotid)
    • Palpate:
      • The carotid pulse for CHARACTER

• Inspection:
  • Check the patient has no scars.
  • Check for visible apex beat
  • Check for asymmetry on chest
• Palpation:
  • Palpate for the apex beat (should be in the midclavicular line, 5^th intercostal space), for heaves (on the left side of the sternal edge) and for thrills (underneath both clavicles)
• Auscultation:
  • Auscultate 4 areas of the heart, first with the diaphragm and then with the bell. N.B.: Palpate the carotid artery throughout the auscultation process, so you can tell if any murmurs are systolic or diastolic.
  • 4 areas to auscultate:
    • The apex, 5^th intercostal space, mid-clavicular line (for mitral valve sounds)
    • The lower left sternal border, the 4^th intercostal space (for tricuspid valve sounds)
    • The upper left sternal border, 2^nd intercostal space (for pulmonary sounds)
    • The upper right sternal border, the 2^nd intercostal space (for aortic sounds)
  • If you hear a murmur, listen to the axilla and the carotid arteries to see if it radiates (radiation to the axilla may indicate a mitral regurgitation. Radiation to the carotids may indicate an aortic stenosis).
  • Ask patient to move onto their left side and auscultate the apex using the bell (this will increase the sound of the murmur in a mitral stenosis)
  • Ask patient to sit upright and breathe in and out and then hold their breath. Then auscultate the aorta at the right 2^nd intercostal space by the left sternal border (this will increase the sound of the murmur in an aortic regurgitation)
  • To check for carotid artery bruits, hold bell over carotid artery and ask patient to breathe in and out and then hold it

• Auscultate the lung bases for crepitations suggesting pulmonary oedema
• Palpate for pitting ankle oedema
• Thank patient for their time and tell them they may now get dressed
• Tell examiner you would now check the peripheral pulses; measure the temperature (endocarditis), perform a urine dipstick analysis (haematuria in endocarditis) and an ECG.

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