CHAPTER 1 The Cardiovascular Examination KEY POINTS • The cardiovascular examination lends itself to a systematic approach. • The examination should be thorough but should be directed by the history to areas likely to be relevant. • Certain cardiovascular signs are quite sensitive and specific. • When the examination is well performed, many unnecessary investigations can be avoided. CASE 1 SCENARIO: TARA WITH 3. Pick up the patient’s hand. Feel the radial pulse. DYSPNOEA Inspect the patient’s hands for clubbing. Demon- strate Schamroth’s sign (Fig. 1.1). If there is no 34-year-old Tara was referred to the hospital by her general clubbing, opposition of the index finger (nail to practitioner. She presented with increasing dyspnoea for the nail) demonstrates a diamond shape; in clubbing last 2 weeks. She has found it difficult to lie flat in bed and this space is lost. Also look for the peripheral has been waking up frequently feeling breathless. She also stigmata of infective endocarditis. Splinter haemor- has a dry cough and has felt extremely tired for weeks. She rhages are common (and are usually caused by also has high fever with a shake. She is an intravenous drug trauma), whereas Osler’s nodes and Janeway lesions user and her general practitioner (GP) found a loud murmur (Fig. 1.2) are rare. Look quickly, but carefully, at on auscultation. each nail bed, otherwise it is easy to miss key signs. Please examine the cardiovascular system. Note the presence of an intravenous cannula and, if an infusion is running, look at the bag to see The cardiovascular system should be examined in what it is. There will usually be a peripheral or all patients who present with cardiac symptoms. A routine central line in situ if the patient is being treated for for this examination should be very familiar to students infective endocarditis. Note any tendon xanthomata and registrars. (type II hyperlipidaemia). The history should help to direct the examination. 4. The pulse at the wrist should be timed for rate and For patients with possible heart failure there are certain rhythm. Pulse character is poorly assessed here. This important signs that support the diagnosis. is also the time to feel for radiofemoral delay (which occurs in coarctation of the aorta) and radial–radial inequality. AN OUTLINE OF THE CARDIOVASCULAR 5. Next inspect the face. Look at the eyes briefly for EXAMINATION jaundice (valve haemolysis) and xanthelasma (type 1. Make sure the patient is positioned at 45 degrees II or III hyperlipidaemia) (Fig. 1.3). You may also and that the chest and neck are fully exposed. For notice the classic ‘mitral facies’ (owing to dilation a woman, the requirements of modesty dictate of malar capillaries associated with severe mitral that you cover her breasts with a towel or loose stenosis and caused by pulmonary hypertension garment. and a low cardiac output). Then inspect the mouth 2. While standing back, inspect for the appearance of using a torch for a high-arched palate (Marfan Marfan, Turner or Down syndrome. Also look for syndrome and the possibility of aortic regurgitation dyspnoea and cyanosis. It is also worth looking at and mitral valve prolapse), petechiae and the state the neck from a distance. Big v waves are sometimes of dentition (endocarditis). Look at the tongue or more obvious from a distance lips for central cyanosis. 1 2 Problem Based Cardiology Cases A C B D FIG. 1.1 Lateral views of the index finger and Schamroth’s sign in a healthy individual (A and B), and in an individual with severe clubbing (C and D). (From Taussig LM, Landau LI. Pediatric respiratory medicine. 2nd ed, Fig. 10-3. Mosby, Elsevier, 2008, with permission.) FIG. 1.2 Janeway lesions. (Based on Mandell GL, Bennett JA, Dolin R. Mandell, Douglas, and Bennett’s FIG. 1.3 Xanthelasma. (From Yanoff M, Duker JS. principles and practice of infectious diseases. 7th ed, Fig Ophthalmology. 3rd ed. Fig. 12-9-18. Mosby, Elsevier, 195-15. Churchill Livingstone, Elsevier, 2009, with 2008, with permission.) permission.) CHAPTER 1 The Cardiovascular Examination 3 by a submammary or lateral thoracotomy approach. BOX 1.1 These patients slowly redevelop mitral stenosis over Jugular Venous Pressure (JVP) many years. Inspect for deformity, the site of the CAUSES OF AN ELEVATED CENTRAL VENOUS apex beat and visible pulsations. Do not forget about PRESSURE (CVP) pacemaker and cardioverter–defibrillator boxes (see Right ventricular failure Fig. 1.4). Tricuspid stenosis or regurgitation 9. Palpate for the apex beat position. Count down the Pericardial effusion or constrictive pericarditis correct number of intercostal spaces. The normal Superior vena caval obstruction position is the fifth intercostal space, 1 cm medial Fluid overload to the midclavicular line. The character of the apex Hyperdynamic circulation beat is important. There are a number of types. a. A pressure-loaded (hyperdynamic, systolic- WAVE FORM overloaded) apex beat is a forceful and sustained Causes of a Dominant a Wave impulse (e.g. in aortic stenosis, hypertension). Tricuspid stenosis (also causing a slow y descent) b. A volume-loaded (hyperkinetic, diastolic- overloaded) apex beat is a forceful but unsus- Pulmonary stenosis tained impulse (e.g. in aortic regurgitation, mitral Pulmonary hypertension regurgitation). 10. Don’t miss the tapping apex beat of mitral stenosis Causes of Cannon a Waves (a palpable first heart sound) or the dyskinetic apex Complete heart block beat caused by a previous large myocardial infarction. Paroxysmal nodal tachycardia with retrograde atrial The double or triple apical impulse in hypertrophic conduction cardiomyopathy is very important too. Feel also for Ventricular tachycardia with retrograde atrial an apical thrill and time it. conduction or atrioventricular dissociation 11. Palpate with the heel of your hand for a left parasternal impulse, which indicates right ventricular Causes of a Dominant v Wave hypertrophy or left atrial enlargement. Feel at the Tricuspid regurgitation base of the heart for a palpable pulmonary com- ponent of the second heart sound (P2) and aortic x Descent thrills. Percussion is usually unnecessary. Absent: atrial fibrillation 12. Auscultation begins with listening in the mitral area Exaggerated: acute cardiac tamponade, constrictive with both the bell and the diaphragm. Spend most pericarditis time here. Listen for each component of the cardiac cycle separately. Identify the first and second heart y Descent sounds (see Fig. 1.4) and decide whether they are Sharp: severe tricuspid regurgitation, constrictive of normal intensity and whether they are split. Now pericarditis listen for extra heart or prosthetic heart sounds and Slow: tricuspid stenosis, right atrial myxoma murmurs. Mechanical valves include bileaflet, ball- in-cage and tilting-disc types. Ball-in-cage valves have (From Talley N, O’Connor S, Clinical examination. 8th ed, vol. 1, p. 92, with permission.) a sharp opening sound and may rattle. Tilting-disc valves have soft opening sounds and sharp closing sounds. 6. The neck is very important, so take time to examine 13. Repeat the approach at the left sternal edge and here. The jugular venous pressure (JVP) must be then at the base of the heart (aortic and pulmonary assessed for height and character (see Box 1.1 and areas). Time each part of the cycle with the carotid Fig. 1.4). Use the right internal jugular vein to assess pulse. Listen below the left clavicle for a patent this. Normally the JVP falls with inspiration; eleva- ductus arteriosus murmur, which may be audible tion during inspiration is called Kussmaul’s sign. here and nowhere else. 7. Now feel each carotid pulse separately. Assess the 14. It is now time to reposition the patient, first in pulse character (see Box 1.1). the left lateral position. Again feel the apex beat 8. Proceed to the chest. Look everywhere for scars. for character (particularly tapping). Auscultate Previous mitral valvotomy may have been performed carefully for mitral stenosis with the bell. Next sit 4 Problem Based Cardiology Cases S1 S2 Atrial contraction a Atrial filling c v Tricuspid valve closure x Atrial relaxation y Repid ventricular filling FIG. 1.4 The JVP and its relationship to the first (S1) and second (S2) heart sounds. (From Talley N, O’Connor S, Examination medicine. 8th ed, p. 394, fig 16.4, with permission.) the patient forward and feel for thrills (with the failure. Feel for splenomegaly (endocarditis) and patient in full expiration) at the left sternal edge an aortic aneurysm. Palpate both femoral arteries. and base. Then listen in those areas, particularly Then examine all the peripheral pulses. Look par- for aortic regurgitation. ticularly for peripheral oedema, clubbing of the toes, 15. Dynamic auscultation should always be done if Achilles tendon xanthomata (Fig. 1.5), signs of there is any doubt about the diagnosis. The Val- peripheral vascular disease and the stigmata of salva manoeuvre should be performed whenever infective endocarditis. there is a systolic murmur, otherwise hypertrophic 18. The results of the urine analysis (haematuria) and cardiomyopathy is easily missed the temperature chart (fever) and examination of 16. The patient is now sitting up. Percuss the back the fundi (for Roth’s spots (Fig. 1.6)) are necessary quickly to exclude a pleural effusion (e.g. due to if endocarditis is a possibility. The fundi should left ventricular failure) and auscultate for inspiratory also be examined for hypertensive changes. crackles (left ventricular failure). If there is radiof- Certain symptoms and signs are quite sensitive and emoral delay, also listen for a coarctation murmur specific for the diagnosis of heart failure. When a patient here. Feel for sacral oedema and note any back presents with possible heart failure (often with problems deformity (ankylosing spondylitis is associated with with dyspnoea) the history and examination will often aortic regurgitation).