Medicine Notes - Clinical Examination - General Cardiovascular Examination

Cardiovascular physical examination
General examination
The first step is to comment on the patient general health (, pale, coughing, shortness of breath) and the surrounding ( ECG, ventilator,nebulizer, oxygen, medication, IV drips.).
Hand and pulse examination
Next inspect the hand of the patient. Look for any evidence of clubbing ( mostly due to congenital heart disease or infective endocarditis.) Then, look for the stigmata of infective endocarditis such as Osler’s nodes, Janeway lesions and splinter hemorrhage. Look also for any pale or bluish disoloration of the fingers which are suggestive of peripheral cyanosis. Feel the patient’s hand and assess for any evidence of retention of carbon dioxide ( warm clammy and red palms). Spoon shaped nail is the common term used to describe the present of anemia. Spoon shaped nail is also known as koilonychia. There will also be wasting of thenar eminence.
After that, the pulse is felt. Three tips of fingers are used to feel the radial pulse. Assess the rate and rhythm of the pulses. Bradycardia if the rate is less than 60 and tachycardia if the rate is more than 100 beats per minutes. Assess the rhythm. The rhythm may be regular, regularly irregular and irregularly regular. Regularly irregular is associated with heart block while irregularly regular is associated with atrial fibrillation.
Special test is performed to identify any collapsing pulse. Four fingers are placed across the wrist. The patient ‘s arm is then raised above the head to illicit the sign. Collapsing pulse is associated with aortic regurgitation. In aortic regurgitation, there will be backflow of blood into the left ventricles which reduce the diastolic pressure and lead to wide pulse pressure.
Any radial radial pulse delay is associated with coarctation of the subclavian artery while radial femoral delay is commonly occur due to coarctation of the aorta.
blood pressure measurement is considered while the patient standing and lying to identify the present of postural hypotension.
Carotid pulse and Jugular venous pressure examination
Feel/palpate the carotid pulses. Carotid pulse is palpate by using the thumb. It is important not to palpate both sides of carotid pulses at the same time as the patient may collapse. The purpose of palpating carotid pulse is to assess the character and volume of the carotid pulse. Large carotid volume is an indication of fluid overload or diastolic overload. Mostly mitral regurgitation and aortic regurgitation may lead to large carotid volume. Small carotid volume is due to low output condition such as peripheral vascular disease, mitral stenosis, aortic stenosis and pericardial effusion. Slow rising carotid pulse is associated with aortic stenosis. Carotid volume may raise during expiration and fall during inspiration by more than 15 mmHg ( pulsus paradoxus) due to constrictive pericarditis, asthma and cardiac tamponade.
Jugular venous pressure located less than 4 cm up the neck. Jugular venous pressure is more clear by applying pressure to the abdomen. Jugular venous pressure is an indication of pressure of the right atrium. Jugular venous pressure consists of double pulse wave. The ‘a’ wave is an indication of atrial contraction/ atrial systole while ‘v’ wave is just before the opening of the tricuspid valve. Raised jugular venous pressure is associated with fluid overload, constrictive pericarditis, pericardial effusion and right heart failure. Absent of ‘a ‘wave is due to atrial fibrillation while the raised of ‘a ‘ wave is due to tricuspid stenosis. Raised ‘v’ wave is due to tricuspid regurgitation.
Eyes inspection may reveal pallor of the conjunctiva which is a sign of anemia. Besides that, there will be corneal arcus which is yellow/ white band around the iris that is an indication of hyperlipidemia. Yellow skin around the eyes is known as xanthelasma.
Blue lip is an indication of central cyanosis. Assess the patient’s dental hygiene and look for any evidence of Marfan syndrome such as high palate beside aortic regurgitation. Rosy cheeks with blue tinge is also known as malar flush which is associated with mitral stenosis and pulmonary hypertension.
Chest Examination
Initially comment on the present of any scars. Then palpate the apex beat which is at the fifth intercostal space at mid clavicular line. Palpate for any thrill. Thrill is also known as palpable murmur which is identify by placing the palm of the hand over the area of the valve such as the aortic valve, pulmonary valve, tricuspid valve and mitral valve.
Listen to each valve by feeling the pulse at the same time. Listen to first heart sound which is due to the opening of the ventricle valve ( aortic valve). First heart sound is best heard at the apex. Second heart sound is due to the closure of the aortic valve. Listen also for any additional heart sound such as third heart sound and fourth heart sound, murmurs, clicks, snaps
Any evidence of mitral stenosis is best identify by asking the patient to roll on the left sides breath out and hold breath on expiration. Using the bell of the stethoscope ( low pitched sound is best detected with the bell) listen at the apex. Mitral stenosis is presented with mid diastolic murmur in the apex.
Aortic regurgitation is best detected by asking the patient to sit forward and hold on expiration. Using the diaphragm of the stethoscope listen at the aortic valve. Aortic regurgitation will be heard as early diastolic murmur at the aortic valve.
Lung is auscultated for any evidence of crackles at the base of the lung and look for any evidence of sacral edema.
Additional examination include palpate the abdomen and inspect for any evidence of abdominal aortic aneurysm. Leg is inspected and palpated for any evidence of pitting edema, ulcers, varicose veins, ulcers and deep vein thrombosis. Feel the pulses at the foot which include popliteal pulses, posterior tibial pulses and dorsalis pedis pulses.
General examination
The first step is to comment on the patient general health (, pale, coughing, shortness of breath) and the surrounding ( ECG, ventilator,nebulizer, oxygen, medication, IV drips.).
Hand and pulse examination
Next inspect the hand of the patient. Look for any evidence of clubbing ( mostly due to congenital heart disease or infective endocarditis.) Then, look for the stigmata of infective endocarditis such as Osler’s nodes, Janeway lesions and splinter hemorrhage. Look also for any pale or bluish disoloration of the fingers which are suggestive of peripheral cyanosis. Feel the patient’s hand and assess for any evidence of retention of carbon dioxide ( warm clammy and red palms). Spoon shaped nail is the common term used to describe the present of anemia. Spoon shaped nail is also known as koilonychia. There will also be wasting of thenar eminence.
After that, the pulse is felt. Three tips of fingers are used to feel the radial pulse. Assess the rate and rhythm of the pulses. Bradycardia if the rate is less than 60 and tachycardia if the rate is more than 100 beats per minutes. Assess the rhythm. The rhythm may be regular, regularly irregular and irregularly regular. Regularly irregular is associated with heart block while irregularly regular is associated with atrial fibrillation.
Special test is performed to identify any collapsing pulse. Four fingers are placed across the wrist. The patient ‘s arm is then raised above the head to illicit the sign. Collapsing pulse is associated with aortic regurgitation. In aortic regurgitation, there will be backflow of blood into the left ventricles which reduce the diastolic pressure and lead to wide pulse pressure.
Any radial radial pulse delay is associated with coarctation of the subclavian artery while radial femoral delay is commonly occur due to coarctation of the aorta.
blood pressure measurement is considered while the patient standing and lying to identify the present of postural hypotension.
Carotid pulse and Jugular venous pressure examination
Feel/palpate the carotid pulses. Carotid pulse is palpate by using the thumb. It is important not to palpate both sides of carotid pulses at the same time as the patient may collapse. The purpose of palpating carotid pulse is to assess the character and volume of the carotid pulse. Large carotid volume is an indication of fluid overload or diastolic overload. Mostly mitral regurgitation and aortic regurgitation may lead to large carotid volume. Small carotid volume is due to low output condition such as peripheral vascular disease, mitral stenosis, aortic stenosis and pericardial effusion. Slow rising carotid pulse is associated with aortic stenosis. Carotid volume may raise during expiration and fall during inspiration by more than 15 mmHg ( pulsus paradoxus) due to constrictive pericarditis, asthma and cardiac tamponade.
Jugular venous pressure located less than 4 cm up the neck. Jugular venous pressure is more clear by applying pressure to the abdomen. Jugular venous pressure is an indication of pressure of the right atrium. Jugular venous pressure consists of double pulse wave. The ‘a’ wave is an indication of atrial contraction/ atrial systole while ‘v’ wave is just before the opening of the tricuspid valve. Raised jugular venous pressure is associated with fluid overload, constrictive pericarditis, pericardial effusion and right heart failure. Absent of ‘a ‘wave is due to atrial fibrillation while the raised of ‘a ‘ wave is due to tricuspid stenosis. Raised ‘v’ wave is due to tricuspid regurgitation.
Eyes inspection may reveal pallor of the conjunctiva which is a sign of anemia. Besides that, there will be corneal arcus which is yellow/ white band around the iris that is an indication of hyperlipidemia. Yellow skin around the eyes is known as xanthelasma.
Blue lip is an indication of central cyanosis. Assess the patient’s dental hygiene and look for any evidence of Marfan syndrome such as high palate beside aortic regurgitation. Rosy cheeks with blue tinge is also known as malar flush which is associated with mitral stenosis and pulmonary hypertension.
Chest Examination
Initially comment on the present of any scars. Then palpate the apex beat which is at the fifth intercostal space at mid clavicular line. Palpate for any thrill. Thrill is also known as palpable murmur which is identify by placing the palm of the hand over the area of the valve such as the aortic valve, pulmonary valve, tricuspid valve and mitral valve.
Listen to each valve by feeling the pulse at the same time. Listen to first heart sound which is due to the opening of the ventricle valve ( aortic valve). First heart sound is best heard at the apex. Second heart sound is due to the closure of the aortic valve. Listen also for any additional heart sound such as third heart sound and fourth heart sound, murmurs, clicks, snaps
Any evidence of mitral stenosis is best identify by asking the patient to roll on the left sides breath out and hold breath on expiration. Using the bell of the stethoscope ( low pitched sound is best detected with the bell) listen at the apex. Mitral stenosis is presented with mid diastolic murmur in the apex.
Aortic regurgitation is best detected by asking the patient to sit forward and hold on expiration. Using the diaphragm of the stethoscope listen at the aortic valve. Aortic regurgitation will be heard as early diastolic murmur at the aortic valve.
Lung is auscultated for any evidence of crackles at the base of the lung and look for any evidence of sacral edema.
Additional examination include palpate the abdomen and inspect for any evidence of abdominal aortic aneurysm. Leg is inspected and palpated for any evidence of pitting edema, ulcers, varicose veins, ulcers and deep vein thrombosis. Feel the pulses at the foot which include popliteal pulses, posterior tibial pulses and dorsalis pedis pulses.