Examination

By
Assist Prof. Maged Albasmi, MSc, MD, PhD
Cardiovascular Medicine
 Cardiovascular Examination
• W - Wash your hands.
• I - Introduce yourself to the patient.
• P - Permission. Explain that you wish to examine their heart.
Obtain consent for the examination. Pain. Ask the patient if
they are in any pain and to tell you if they experience any during
the examination. E - Expose the necessary parts of the patient.
Ideally the patient should be undressed from the waist up
taking care to ensure the patient is not cold or unnecessarily
embarrassed.
• R - Reposition the patient. In this examination the patient
should be supine and reclined at 45 degrees.
• In the cardiovascular examination a lot of information can be
obtained by looking for peripheral signs of cardiovascular
disease. The examination is therefore split into a peripheral
examination and then examination of the precordium.
 Peripheral Examination
• End of the Bed
• Look at the patient at the end of the bed for signs of breathlessness or distress.
• It is also important to look at the surrounding environment for oxygen, fluid restriction signs .
• Hands
• Take the patient’s hand and assess warmth, sweating and whether there is peripheral cyanosis.
• Check the capillary refill (press the end of the finger for 5 seconds, release and see how long it
takes the colour to return. It should be less than 2 seconds)
• Examine the nails for clubbing or signs of infective endocarditis (splinter haemorrhages, Osler’s
nodes and Janeway lesions).
• Palpate the radial pulse and assess the rate and rhythm.
• Locate and palpate the brachial pulse and assess its character.
• Measure the blood pressure. If the blood pressure is raised compare both arms
• Face
• Check eyes for corneal arcus and per-orbital region for xanthelasma.
• Inspect the conjunctiva for pallor (which can be a sign of anaemia)
• Look at the lips and tongue for central cyanosis. (please note that you do not have to check
under the tongue)
• Assess the jugular venous pressure height and wave form. The height of the JVP is the vertical
height above the sternal angle (see figure 1)
• Palpate the carotid pulse and assess its character.
 Tips for assessing the JVP
• This is an area that many students struggle with.
• Firstly, it is important to remember the anatomy : the
internal jugular vein tracks from beneath the mastoid
process down to between the sternal and clavicular
heads of the sternocleidomastoid, always deep to
the sternocleidomastoid, so if the patient’s neck is
not relaxed, you will struggle to see the JVP. Another
consequence of the internal jugular vein lying deep,
is that you will never see a clear outline of the JVP,
only a diffuse pulsation. Remember that the external
jugular vein is more superficial and can be easily
visualized, but this should not be routinely used to
assess the JVP as it is prone to kinking which may
give misleading results.
• To examine the JVP, the patient must be lying at 45° and in
good light. Ensure that the patient’s neck muscles are relaxed
(you may want to have the patient’s head turned slightly to the
left).
• The height of the JVP is directly related to the right atrial
pressure, since there are no valves between the atrium and the
internal jugular vein. It is measured as the vertical height above
the sternal angle with the patient lying at 45°. A normal
patient’s right atrial pressure should be less than 9cmH2O,
which corresponds to less than a 4cm vertical distance above
the sterna angle (since at 45° the right atrium is approximately
5cm below). Note that it is therefore often very difficult to see
in normal patients. To practise, you may want to experiment
with the bed flatter than 45°, since this will make the JVP more
easily visible (remember though that you are then unable to
quote the height of it as you have changed the angle).
• Differentiating the carotid pulse from the
JVP The JVP :
• has a double waveform
• is impalpable
• varies with position of the patient
• height of pulstaion varies with
respiration
• rises with increased abdominal pressure
Examination of the precordium
• Inspection
• Inspect the chest wall for
• Previous scars Pacemaker Abnormal pulsations A visible
apex beat
• Palpation, Palpate for:
• Apex beat, note the location and assess the quality of impulse felt.
Is it forceful, diffuse, tapping?
• Heaves. Heaves are forceful ventricular contractions. Heaves
represent ventricular hypertrophy and feel as if your hand is being
lifted of patient’s chest. This should be performed close to the left
sternal border and towards the apex.
• Thrills. Thrills are ‘palpable murmurs’ that can be present over
any area of heart. They feel like ‘stroking a purring cat’. If present
there should be an easily audible murmur present on auscultation.
• Percussion
• This is not normally performed in this examination.
• Auscultation
• Listen with diaphragm and the bell of your stethoscope at the apex, base,
aortic and pulmonary regions. (see Figure 2 below)
• Start by listening to the heart sounds.
• To help you differentiate between the heart sounds they should be timed against
the carotid pulse.
• The first heart sound is principally the sound of the mitral valve closing. It is the
sound immediately before the main apical impulse and carotid pulsation. It is
usually loudest at the apex or between the apex and the lower left sternal border.
• The second heart sound is due to closure of the aortic and pulmonary valves. It
is the sound which follows the apical impulse and carotid pulsation. It is usually
best heard at the upper left sternal edge using the diaphragm of the
stethoscope.
• If you hear any murmurs these should also be timed with the carotid pulse to
determine whether they are systolic (with carotid pulse) or diastolic. Also listen
to whether the murmur is louder in inspiration or expiration.
• Ask your patient to hold their breath and auscultate over the carotid arteries
for bruits.
• Systolic murmurs Aortic stenosis is an
ejection systolic murmur best heard at the
apex and upper right sternal edge. It often
radiates to neck. Mitral regurgitation is a
pansystolic murmur best heard at the
apex. It radiates to the axilla. Diastolic
murmurs These are often more difficult to
hear and require the patient to be moved
into the best position to hear them
• Mitral Stenosis is best heard with the patient
rolled on to their left side using the bell of the
stethoscope to auscultate at the apex. The
murmur is low pitched and rumbling and
often localised.
• Aortic Regurgitation is best heard with the
patient sitting up, leaning forward and
breathing out.
• (NB left sided murmurs are quieter on
inspiration and louder on expiration).It is
heard at the left sternal edge using the
diaphragm
Finishing Off
• State that you would complete the examination by:
• Auscultating the lung bases posteriorly for
pulmonary oedema
• Checking for sacral and ankle oedema
• Checking the peripheral pulses – femoral,
popliteal, posterior tibial & dorsalis pedis.
• Check for an abdominal aortic aneurysm
Finally explain to the patient that your examination
has been completed, thank them for their
cooperation and help them to get dressed.
Thank you