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Home , Apex beat, Auscultation, Cannon A waves, Cardiac examination, Gallop rhythm, Heart sounds

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 . 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 (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 . Splinter haemor- has a dry and has felt extremely tired for weeks. She rhages are common (and are usually caused by also has high 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 . 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 should be timed for rate and For patients with possible 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 ) 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 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 and caused by pulmonary garment. and a low ). 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 . It is also worth looking at and 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 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 . 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 (JVP) many years. Inspect for deformity, the site of the CAUSES OF AN ELEVATED CENTRAL VENOUS 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 or constrictive 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 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 , 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 regurgitation). 10. Don’t miss the tapping apex beat of mitral stenosis Causes of (a palpable first heart sound) or the dyskinetic apex Complete heart block beat caused by a previous large . Paroxysmal nodal with retrograde atrial The double or triple apical impulse in hypertrophic conduction cardiomyopathy is very important too. Feel also for 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. is usually unnecessary. Absent: 12. Auscultation begins with listening in the mitral area Exaggerated: acute , constrictive with both the bell and the diaphragm. Spend most pericarditis time here. Listen for each component of the 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 and Slow: tricuspid stenosis, right atrial 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 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 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 . Palpate both femoral . and base. Then listen in those areas, particularly Then examine all the peripheral . 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 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. (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 . 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). help with the diagnosis and in distinguishing heart failure 17. Next lay the patient flat and examine the abdomen from other causes of breathlessness (Box 1.2). for hepatomegaly (e.g. as a result of right ventricular failure) and a pulsatile liver (tricuspid regurgitation). Perform the hepatojugular reflux test. Press over LEFT VENTRICULAR FAILURE (LVF) the upper abdomen for 15 seconds or so and watch • Symptoms: exertional dyspnoea, orthopnoea, for a rise in the JVP. This is a reliable sign of heart paroxysmal nocturnal dyspnoea. CHAPTER 1 The Cardiovascular Examination 5

BOX 1.2 Findings That Favour Heart Failure as the Cause of Dyspnoea • History of myocardial infarction • No • Paroxysmal nocturnal dyspnoea (PND)a • Orthopnoea • Abnormal apex beat • Third heart sound (S3) • Mitral regurgitant murmur • Early and mid-inspiratory crackles • Cough only on lying down

aParoxysmal nocturnal dyspnoea (PND) is a sensation of that awakens the patient, often after 1 or 2 hours of sleep, and is usually relieved in the upright position.

FIG. 1.5 Xanthomata. (From Durrington P. Dyslipidaemia, Lancet 2003;362:717–31, with permission.) Bigeminal rhythm

FIG. 1.7 Pulsus alternans.

• Arterial pulse: , due to increased sympathetic tone; low (low cardiac output); pulsus alternans (alternate strong and weak beats) (Fig. 1.7); it is unlike a bigeminal rhythm caused by regular ectopic beats, in that the beats are regular – this is a rare but specific sign of unknown aetiology. • Apex beat: displaced, with dilation of the left ; dyskinetic in anterior myocardial infarction or ; palpable . The absence of these signs does not exclude left ventricular failure. • Auscultation: left ventricular S3 (an important sign); functional mitral regurgitation (secondary to valve

FIG. 1.6 A retina showing cotton wool spots, retinal ring dilation). haemorrhage and Roth’s spot in a septic bacteraemic • fields: signs of pulmonary congestion (basal cancer patient. (From Celik I, Cihangiroflu M, Yilmaz T. inspiratory crackles) or pulmonary oedema (crackles The prevalence of bacteraemia-related retinal lesions in and throughout the lung fields), due to raised seriously ill patients. J Infect 2006;52(2):97–104, Fig. 1, venous pressures (increased ). The typical with permission.) middle-to-late inspiratory crackles at the lung bases may be absent in chronic, compensated heart failure, and there are many other causes of basal inspiratory • General signs: tachypnoea, due to raised pulmonary crackles. This makes crackles a rather non-specific pressures; central cyanosis, due to pulmonary oedema; and insensitive sign of heart failure. Cheyne–Stokes especially in sedated elderly • Other signs: abnormal Valsalva response; positive patients; peripheral cyanosis, due to low cardiac abdominojugular reflux test; right ventricular failure output; hypotension, due to low cardiac output; may complicate left ventricular failure, especially if cardiac cachexia. this is severe and chronic. 6 Problem Based Cardiology Cases

• Signs of the underlying or precipitating cause: GOOD SIGNS GUIDE 1.1 • Causes of LVF: (1) myocardial disease (ischaemic Left Ventricular Failure in a Patient With heart disease, cardiomyopathy); (2) volume Dyspnoea overload (aortic regurgitation, mitral regurgitation, patent ductus arteriosus); (3) pressure overload General Signs LR+ LR− (systolic hypertension, aortic stenosis). >100 beats per minute 5.5 NS • Signs of a precipitating cause: anaemia, thyrotoxi- at rest cosis, rapid (usually atrial fibrillation). Abdominojugular reflux test 6.4 0.79 (See Good signs guide 1.1.) Crackles 2.8 0.5 RIGHT VENTRICULAR FAILURE (RVF) • Symptoms: , sacral or abdominal swelling, JVP elevated 5.1 0.66 anorexia, nausea. • General signs: peripheral cyanosis, due to low cardiac S4 NS NS output. Apex displaced lateral to 5.8 NS • Arterial pulse: low volume, due to low cardiac output. midclavicular line • Jugular venous pulse: raised, due to the raised S3 11 0.88 venous pressure (right heart preload); Kussmaul’s Any murmur 2.6 0.81 sign, due to poor right ventricular compliance (e.g. right ventricular myocardial infarction); large v waves OTHER FINDINGS (functional tricuspid regurgitation secondary to valve Oedema 2.3 0.64 ring dilation). Wheezing 0.22 1.3 • Praecordial : parasternal impulse (right Ascites 0.33 1.0 ventricular heave). • Auscultation: right ventricular S3; pansystolic murmur THE HISTORY (GOOD SYMPTOMS GUIDE) of functional tricuspid regurgitation (absence of a Paroxysmal nocturnal dyspnoea 2.6 0.7 murmur does not exclude tricuspid regurgitation). Orthopnoea 2.2 0.65 • Abdomen: tender hepatomegaly, due to increased venous pressure transmitted via the hepatic ; Dyspnoea on exertion 1.3 0.48 pulsatile liver (a useful sign), if tricuspid regurgitation Fatigue and weight gain 1.0 0.99 is present. Previous heart failure 5.8 0.45 • Oedema: due to sodium and water retention plus Previous myocardial infarction 3.1 0.69 raised venous pressure; may be manifested by pitting ankle and sacral oedema, ascites or pleural effusions Hypertension 1.4 0.7 (small). COPD 0.81 1.1 • Signs of the underlying cause: • Causes of RVF: (1) chronic obstructive pulmonary COPD = chronic obstructive pulmonary disease; JVP = jugular disease (most common cause of cor pulmonale); venous pressure; LR = likelihood ratio; NS = not significant. (From Talley N, O’Connor S, Clinical examination medicine. 8th ed, (2) left ventricular failure (severe chronic LVF p. 120, with permission.) causes raised pulmonary pressures resulting in secondary right ventricular failure); (3) (, primary tricuspid regurgitation); (4) other causes of pressure over- load (pulmonary stenosis, idiopathic pulmonary hypertension); (5) myocardial disease (right ven- tricular myocardial infarction, cardiomyopathy).