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Cardiovascular exam – detailed

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June 9, 2015

Examination of the Cardiovascular System – detailed

Cardiovascular examination and questions for medical student exams, finals, OSCEs and
MRCP PACES

Introduction
Preparation
Start by washing your hands
Introduce yourself to the patient and obtain informed consent.
Check the patient is not in any pain or discomfort and ensure he/she is
positioned correctly, ideally with the chest fully exposed (this may cause
embarrassment in female patients so one can try and access the auscultation
points without full exposure but this may compromise the accuracy of the
examination).
The patient should be lying in bed with their upper body at 45 degrees and a
pillow supporting the head.
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General Inspection
Begin the examination at the end of the bed with an inspection of the patient’s
general condition and their surroundings.
Explain to the patient what you are doing to avoid embarrassment. Although
each anatomical area will be examined in detail later in the examination it is
important to note signs such as dyspnoea, pallor or cyanosis which may be
detectable at this stage.
Note any medical equipment attached to the patient or in the bedspace

The Hands
Move to the left-hand side of the bed (the patient’s right side) and examine their hands.

Begin by inspecting the finger nails for splinter haemorrhages and clubbing.
Splinter haemorrhages are reddish-brown linear haemorrhages lying parallel to
the long axis of the nail. They are a sign of previous trauma (classically
gardening or mechanical work) or pathologically of infective endocarditis
Clubbing is an enlargement of the soft tissue of the distal phalanges resulting in
an exaggerated nail curvature, nail-fold bogginess and an angle of greater than
180° between the nail and nail-fold.
Examine each of the fingers of each hand for these signs.
Clubbing is an important sign but evidence suggests that it has poor precision.
Schamroth’s sign may be a more reliable way to diagnose clubbing.
Try to elicit Schamroth’s sign by asking the patient to curl the fingers of both
hands towards the palms and then bring their hands together so the nails and
distal interphalangeal joints of the two middle fingers touch.
If clubbing is absent there should be a diamond shaped gap between the two
nails. The loss of this gap is Schamroth’s sign and is an indicator of clubbing.
Clubbing also occurs in the toe-nails but the toes are not routinely examined as
part of the examination of the cardiovascular system.

Finger clubbing

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Examining for Schamroth’s sign when looking for clubbing

Examine the dorsum of the hands.

Inspect along the extensor tendons for cholesterol deposits called xanthomata.
These are irregularly-shaped, yellowish nodules on the skin.
Then ask the patient to turn their hands over and examine the finger pulps for
painful, red, raised nodules known as Osler nodes and the palms for flat, red
macules known as Janeway lesions. These are both highly specific signs of
infective endocarditis but they tend to present in the later stages of the disease
and so are not commonly seen in the developed world.
Note the temperature of the hands and the colour of the skin.
Assess the patient’s peripheral perfusion by squeezing the fingertip firmly for
five seconds then letting go and recording the time taken for normal colour to
return. This is the capillary refill time and should be less than three seconds. A
delay indicates poor perfusion of the extremities which may be caused by
hypovolaemia, hypothermia, peripheral vascular disease or just cool
peripheries (with associated vasoconstriction).

The Radial Pulse

Palpate the right radial pulse by placing the tips of your index, middle and ring fingers
over the radial artery, usually situated just medial to the radius.
You should assess the rate, the rhythm and the character of the pulse.
Establish the rate in beats per minute by counting the number of beats over a
15 second period and multiplying by four.
The normal resting heart rate should be between 60 and 100 beats per
minute.
Then analyse the rhythm of the pulse and decide if it is regular, irregularly
irregular, or regularly irregular.
A regular pulse is at a constant frequency with a constant interval
between the beats.
If it is not of a constant frequency it is irregular.
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 Irregular pulses are conventionally divided into ‘regularly irregular’
and ‘irregularly irregular’.
A regularly irregular pulse has a repeating pattern – for example two beats
close together, then a gap and then another two beats close together.
If there is no repeating pattern and the beats seem to arise randomly
then the pulse is said to be irregularly irregular.
A correlation of pulse character and underlying cardiac rhythm is beyond the scope of
this article but one of the most common abnormalities of pulse rhythm is atrial
fibrillation (AF) which gives an irregularly irregular pulse.
The character of the radial pulse should also be assessed, although it is more
accurate to do this in large volume central pulses such as the carotids.
A ‘slow-rising’ pulse has a delayed up-stroke and occurs in aortic stenosis.
A pulse is described as ‘bounding’ if it has an increased up-stroke and down-
stroke. This may be a sign of CO2 retention.
A ‘jerky’ pulse is characteristic of hypertrophic cardiomyopathy, but this is
unlikely to be detected peripherally.
Proceed to palpate both radial pulses simultaneously to detect any inequality in
timing.
This is known as radio-radial delay and is a sign of aortic coarctation.
Check for inequality in the strength of the radial pulses.
Strength inequality of arm pulses has been shown to be a highly sensitive
sign in diagnosing aortic dissection.
Examine for a collapsing pulse by placing your fingers across the anterior
aspect of patient’s forearm and applying just enough pressure to occlude the
radial pulse.
Confirm that the patient has no pain in their shoulder, and then elevate
their arm above their head whilst maintaining the position of your hand.
You are feeling for a forceful knocking sensation that is typical of aortic
regurgitation, commonly known as the ‘collapsing’ or ‘water-hammer’
pulse.
Radio-femoral delay is the sign that is present if the femoral pulse comes after the
radial pulse. The two pulses should occur at the same time and radiofemoral delay is
a sign of coarctation of the aorta.
The difficulty exposing the femoral artery means that this part of the
examination is not included in routine cardiovascular examinations.
In OSCEs you should simply indicate to the examiner that at this point you
would like to palpate for radio-femoral delay. See Examination of the Peripheral
Arterial System.

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Examining for a collapsing pulse

Blood Pressure
Measure the patient’s arterial blood pressure using a spyhgnomanometer. In an
OSCE, it is unlikely you will have the time to actually measure it but it is an essential
part of the cardiovascular examination and you must indicate this to the examiner at
this point.
Ensure the cuff is the appropriate size for the patient. An undersized cuff will
overestimate the ABP and vice versa.
Ensure the patient is comfortable and support their arm at around heart level.
Wrap the cuff around the upper arm, palpate the radial artery and then inflate
the cuff until the radial pulse can no longer be detected. The pressure at which
the pulse is lost gives a rough estimate of the systolic blood pressure.
Deflate the cuff and place your stethoscope over the brachial artery which is
situated in the antecubital fossa, just medial to the biceps tendon, midway
between the medial and lateral epicondyles of the humerus.
Reinflate the cuff to around 20mmHg above the estimated systolic blood
pressure and then deflate it slowly (2-3mmHg per second) until a sound is
first heard over the artery (Korotkoff 1). The pressure at which this occurs is the
systolic blood pressure.
Continue to deflate the cuff until the sounds disappear (Korotkoff V). The
pressure at which this occurs is the diastolic blood pressure.
Normal arterial blood pressure is defined as systolic blood pressure of less than
140mmHg and diastolic blood pressure of less than 90mmHg.
Having measured the arterial blood pressure go on to
calculate the pulse pressure which is the difference between the systolic blood
pressure and the diastolic blood pressure. The pulse pressure may be narrow
in aortic stenosis and wide in aortic regurgitation.

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Postural Blood Pressure
A full examination of the cardiovascular system should include lying and standing
blood pressure to see if there is a postural drop in blood pressure. But this should not
be done at this stage in a medical school examination because there is not sufficient
time. Simply indicate to the examiner that you would like to perform it and mention it
again at the end of your examination.
To measure the postural blood pressure, position the patient lying supine, wait two
minutes then measure the blood pressure as described above.
Then stand the patient up, wait a further minute and repeat the blood pressure
reading.
A postural drop in blood pressure is defined as a fall on standing of greater than
15mmHg in systolic BP or 10mmHg diastolic.

Face, Eyes and Mouth

Look around the eyes for yellow cholesterol deposits known as xanthelasma.
These are sharply demarcated, yellow plaques, usually around 1-2mm and
most commonly found on the upper and lower eyelids.
Examine the iris for senile arcus, a grey or white arc visible around the cornea.
These are signs of hyperlipidaemia.
Ask the patient to look up, and retract the lower eyelid to inspect for
conjunctival pallor which is a sign of anaemia.
Use a pen-torch to examine the inside of the mouth. Inspect below the tongue and
the lips for central cyanosis, a blue discolouration of the skin and mucous
membranes as a result of hypoxia.
Inspect the mucosa for petechiae which can be caused by infective endocarditis and
note the patient’s dental hygiene. Poor dental hygiene is a risk factor for
infective endocarditis.

The Neck
Examination of the neck includes assessment of the jugular pulse and the carotid
pulse.

The Jugular Venous Pulse

The jugular venous pulse (JVP) provides an estimate of the central venous pressure
(CVP) and hence the patient’s volume status and heart function. Although it is an
important part of the examination, clinical assessment of CVP using the JVP has
poor sensitivity.
To assess the JVP, ask the patient to turn their head to the left and extend their neck
directly backwards. It may be helpful to gently move the patient’s head into the
correct position.

Video on how to examine the JVP

First measure the height of the JVPs highest point in centimetres. This is the vertical
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 height above the sternal angle at which a pulsation is observed in the internal jugular
vein.
It is very important that the patient is positioned at 45° because this
angle directly influences the height of the JVP for any given CVP.
Look for the JVP along the course of the vein which travels from the earlobe,
down the neck and into the chest, between the two heads
of sternocleidomastoid. A JVP of greater than 4cm is said to be elevated.
It may be difficult to distinguish the JVP from the carotid pulse but there are a
number of differentiating features that will help you make the distinction.
Make an assessment of the waveform of the JVP. Figure 1 of Levick & Dwight shows
the normal waveform.
Simultaneously palpating the contralateral carotid may help you in identifying
its different components.
The a-wave coincides with the first heart sound and precedes the carotid pulse.

Go on to try and elicit hepatoojugular reflux. Ensure the patient has no abdominal
pain and press firmly on their right upper quadrant for 15-30 seconds and inspect the
JVP.
A sustained increase of 4cm or greater throughout the compression is a sign of
right ventricular failure.
Ask the patient to breathe slowly through the mouth, then look for the presence of
Kussmaul’s sign: a paradoxical increase in the JVP with inspiration.
This can occur in any condition where right ventricular filling is restricted such
as constrictive pericarditis or cardiac tamponade.

The Carotid Pulse

Palpate the carotid artery, medial to the sternocleidomastoid, paying particular

attention to its character and volume, as well as the rate and rhythm. Palpate each
side in turn, never simultaneously as this may compromise the cerebral blood supply.

Video on how to assess the carotid pulse

The Precordium
Inspect

Begin by inspecting for scars.

Look at the midline of the chest for a median sternotomy scar which would indicate
previous valve surgery or a coronary artery by-pass graft.
Examine the mid-axillary lines for a lateral thoracotomy scar indicating previous
thoracic surgery.
Look under the clavicles for a cardiac pacemaker or defibrillator.
Look for visible cardiac impulses.

Palpate

Palpate the apex beat first.

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 The apex beat is defined as the most lateral and inferior point on the chest wall
at which a cardiac impulse can be felt.
To locate it, identify the sternal angle found at the junction of the sternum and
second rib, move your fingers laterally and inferiorly to the second intercostal
space, then count down the intercostal spaces in the midclavicular line.
The apex beat should be situated in the fifth intercostal space along the
midclavicular line.
If the apex beat is impalpable here, move inferiorly and laterally.
Displacement of the apex in this direction suggests cardiomegaly.

Go on to assess the character of the apex beat.

Decide if it is normal, pressure-overloaded or volume-overloaded.
A pressure-overloaded apex is heaving, sustained and forceful, and
develops as a result of aortic stenosis or hypertension.
A volume-overloaded apex is diffuse and displaced laterally and/or
inferiorly.
This may be a feature of aortic or mitral regurgitation, dilated
cardiomyopathy or ventricular damage due to ischaemic heart disease.
A ‘tapping’ apex beat is a palpable first heart sound and a sign of mitral
stenosis.
A ‘double impulse’ apex (two beats per cardiac cycle) is a sign
of hypertrophic cardiomyopathy.
Place the heel of your hand over the lower left sternal edge and feel for a
right ventricular heave as a push against your hand. This is a sign of
right ventricular hypertrophy.
Then feel for thrills by systematically placing the flat of your hand over the
apex (mitral valve area), lower left sternal edge (tricuspid valve area),
right 2nd intercostal space (aortic valve area) and left 2nd intercostal
space (pulmonary valve area).

Video on how to examine the apex beat, heaves and thrills

Auscultate

Positions
Begin auscultation of the heart by listening over the four valve areas shown in
the figure below with the diaphragm of the stethoscope.
Auscultate in the following order:
mitral
tricuspid
aortic
pulmonary
Then auscultate over both carotid arteries and the left axilla to detect the
radiating murmurs of aortic stenosis and mitral regurgitation respectively.
Listen over each carotid using the bell whilst the patient comfortably
holds a breath.
Auscultation over the carotids also allows for the detection of a stenotic
carotid bruit which can be distinguished from a radiating murmur by
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 identifying the site of the sound’s maximal intensity; the former heard
loudest above the thyroid cartilage, the latter over the precordium.

The four auscultatory areas

Heart Sounds
During auscultation you should listen for the following at each valve position:
first and second heart sounds (S1 and S2), added heart sounds and murmurs.
S1 and S2
When auscultating the valve areas, start by identifying the first (S1) and second
(S2) heart sounds which are caused by the closure of the atrioventricular and
semi-lunar valves respectively.
Simultaneously palpating a peripheral pulse (the radial is often the most
convenient) will help to distinguish systole and diastole.
S1 marks the start of systole and coincides with the peripheral pulsation.
Physiological splitting of S2 is common, and characteristically increases
at end-inspiration but wide splitting (exaggerated physiological splitting),
fixed splitting (unaffected by respiration) and reverse splitting (widens in
expiration) all have underlying pathologies.
Added Sounds
Now listen between S1 and S2 for added heart sounds.
The 3rd heart sound (S3) is a low-pitched extra heart sound that occurs
in early diastole, just after S2, and is best heard over the apex.
It produces a ‘gallop’ rhythm often compared to the cadence of the word
‘Kentucky’ with the syllables ‘ken’, ‘tuc’ and ‘ky’ representing S1, S2 and
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 S3 respectively.
The presence of the third heart sound may indicate left ventricular
failure, mitral regurgitation or high output cardiac states, but it
can be physiological in the young.
Listen for a fourth heart sound (S4), which is slightly higher-pitched and
occurs in late-diastole, immediately before S1. It produces a ‘gallop’
rhythm often compared to the cadence of the word ‘Tennessee’ with the
syllables ‘ten’, ‘nes’ and ‘see’ representing S4, S1 and S2 respectively.
A fourth heart sound is indicative of a poorly compliant ventricle
and is always pathological, associated with aortic
stenosis, hypertension and left ventricular failure.
Go on to auscultate for other abnormal sounds. First, listen for an
ejection click, a high-pitched ringing sound heard in early systole shortly
after S1. This is a feature of aortic or pulmonary stenosis and is thought
to be caused by the sudden opening of the deformed valve. Listen for a
mid-systolic click, a sound most often associated with mitral
valve prolapse which may be accompanied by a late systolic murmur.
Listen in early diastole for an opening snap heard in mitral stenosis. This
is best heard over the lower left sternal edge and is caused by the rapid
opening of a stenosed but pliable mitral valve under high left atrial
pressure.
Finally, listenthroughout the cardiac cycle for the ‘walking on snow’ sound
of a pericardial friction rub, caused by pericarditis.
Murmurs
Murmurs should be considered in terms of timing, site of greatest intensity,
character, loudness, and
radiation.
The intensity of a murmur does not really help in assessing the severity of the
valve lesion, but a change in intensity may be of importance. Murmur intensity
can be quantified using Levine’s grading system. Of all the features of a
murmur, its timing is most important diagnostically.

Auscultate with Manoeuvres

Murmurs are accentuated by the position of the patient during auscultation and the
following manoeuvres should be performed as part of the routine examination.
Ask the patient to turn onto their left hand side. Ensure they are
comfortable then ask them to hold their breath in expiration.
Auscultate the apex with the bell. You are listening for the accentuated mid-
diastolic murmur of mitral stenosis.
Then ask the patient to sit forward. Ensure they are still comfortable and again
ask them to hold their breath in expiration.
Auscultate over the lower left sternal edge with the diaphragm. You
are listening for the accentuated early diastolic murmur of aortic regurgitation.
Whilst expiration accentuates left-sided murmurs, inspiration accentuates right-sided
murmurs. This can be remembered because RIGHT has an ‘I‘ (inspiration) in it and
LEFT has an ‘e‘ (expiration) in it.
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 and this may help in distinguishing the pan-systolic murmurs of mitral and tricuspid
regurgitation. A pansystolic murmur that increases in intensity in expiration is most
likely due to mitral regurgitation whereas one that increases in inspiration is
mostlikely due to tricuspid regurgitation.

The Back, Abdomen and Legs

Ask the patient to lean forwards.
Percuss the lung bases for a pleural effusion and auscultate for fine inspiratory
crackles (signs of heart failure).
Check for sacral oedema by placing one finger firmly on the sacrum for ten seconds
and observing for the persistence of an indentation after release.
Examine the ankles for pedal oedema by placing one finger firmly on the ankle for
five seconds and observing for the persistence of an indentation after release.
If present, repeat the procedure at regular points on the legs moving upwards
towards the knees. Note the point on the leg to which the oedema extends.

Completing the Examination

Thank the patient, help them back into comfortable posture and wash your hands.
Give the patient some privacy to redress.
In an OSCE you should finish by addressing the examiner, stethoscope behind your
back, not looking back at the patient. See here for a summary.
To present, reiterate the manouevres you mentioned during the examination but did
not perform. These will include examination of the toenails, examining for radio-
femoral delay, and measuring postural blood pressure. You should also indicate your
desire to examine the peripheral pulses as detailed in the Examination of
the Peripheral Arterial System and to examine the abdomen for an abdominal aortic
aneurysm and an enlarged liver (heart failure). Go on to explain the special tests and
bedside investigations you would like to undertake, as detailed below.

Pulsus paradoxus
Pulsus paradoxus is usually defined as an inspiratory decline in systolic BP that
exceeds 10mmHg, but a more appropriate threshold may be 12mmHg which has
been shown to be the upper 95% confidence interval for an inspiratory drop in normal
individuals.
It occurs in 98% of patients with cardiac tamponade and is a highly
sensitive and specific sign in identifying the condition in those with known
pericardial effusions.
One should therefore always check for pulsus paradoxus in patients with
suspected pericardial disease and you should indicate this to the examiner.
To measure pulsus paradoxus, begin by measuring the BP as described but
on hearing the first Korotkoff sound, prevent further deflation of the cuff. In patients
with paradox, the sounds are intermittent with respiration. Note this pressure then
continue to deflate the cuff until sounds are heard throughout the respiratory

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 cycle. The amount of paradox in mmHg is the difference between the pressure at this
point and the initial measurement.

Bedside Investigations
Routine observations are an essential part of the cardiovascular exam.
You have already calculated the heart rate and BP. You also need to know
the respiratory rate, the oxygen saturations and the temperature of the patient.
An ECG should be checked for signs of ischaemia or arrhythmia
Uninalysis is indicated if endocarditis is suspected
An echocardiogram is indicated if there is suspicion of structural or valve disease

Questions about the cardiovascular exam

What are the causes of clubbing?
What are the causes of atrial fibrillation?
What are the factors to distinguish the jugular venous from the carotid arterial
pulse?
What are the abnormalities of the waveform of the jugular venous pulsation?
What are the different murmurs and clinical findings in the common valvular
lesions?
What are the abnormalities of the heart sounds (relevance of 1st, 2nd, 3rd and
4th heart sounds)?
What are the grades of murmur intensity (Levine scale)?
What is the differential diagnosis of differently timed murmurs?

Cardiovascular examination evidence

How reliable is the clinical assessment of finger clubbing?

Click here for medical student OSCE and PACES

questions about Examination of the Cardiovascular
System
Common Examination of the Cardiovascular System exam questions for medical
students, finals, OSCEs and MRCP PACES

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