Cardiovascular Examination

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Cardiovascular Examination
Procedure and what to be looking for at each stage
Observation

? Marfan's -> aortic regurgitation

? Rheumatological disorders eg ank. spond -> aortic regurgitation
? Down's -> ASD or VSD
? Turner's -> coarctation of aorta
? Thyrotoxic -> predisposed to AF and high output heart failure
? Alcoholism -> dilated cardiomyopathy
Hands

Clubbing
Cyanotic congential heart disease
Infective endocarditis
Peripheral cyanosis and Perfusion
Endocarditis is suggested by
Splinter haemorrhages
Osler's nodes = tender lumps in pulp of fingertips
Janeway lesions = red macules on wrist and hand
Nicotine stains - peripheral vascular disease
Radial pulse - for rate and rhythm

Irregularly irregular = atrial fibrillation (or multiple ectopics)

Regularly irregular = 2nd degree heart block
Water hammer pulse (= Collapsing)
strong radial pulse that taps hand on lifting of arm
indicates wide pulse pressure of aortic regurgitation
Bounding pulse
CO2 retention
Liver failure
Sepsis
Small volume thready pulse = shock
Radio-radial delay - suggests coarctation or dissection
Arterio-venous fistulae - buzzing - for dialysis
Carotid pulse - for character

Normal
Small volume - in low output states eg heart failure, shock, mitral stenosis
Small Volume And Slow Rising pulse = aortic stenosis
Collapsing (rapid up and rapid down) in aortic regurgitation (also AV fistula or hyperdynamic
cicrulation)
Bisferiens = collapsing and slow rising occurring in mixed aortic disease
Pulsus alternans - LVF
Jerky - hypertrophic cardiomyopathy
Pulsus Paradoxus - pulse weakens in inspiration - indicates tamponade or constrictive pericarditis

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Face

Malar flush = mitral stenosis (also present in mixed mitral disease)

? Jaundice - poss. prosthetic valve causing mild haemolysis
Eyes

Argyll-Robertson pupil
pupil constricted, does not react to light but does to accomodation
"the prostitute's pupil accomodates but does not react"
think of syphilitic aortic regurgitation & poss. aneurysm
Xanthelasmata or corneal arcus = hyperlipidaemia
Mouth

Cyanosis
High arched palate of Marfan's -> aortic regurgitation
Mucosal petechiae -> infective endocarditis
JVP
Inspection of precordium

Scars
Deformity
Pulsation
Pacemaker boxes
Palpation

Thrills
Heaves
parasternal heave of RVH
apex beat may be
tapping (quick and light) - mitral stenosis
thrusting (diffuse and long) - mitral regurgitation
heaving (sharp and firm) - LVH & aortic stenosis
Apex beat should be 5th intercostal space mid-clavicular line
Auscultation

Remember to roll into left lateral position and to sit forwards

Remember to listen on inspiration and on held expiration
Chest

Listen at lung bases for fine inspiratory creps of pulmonary oedema (LVF)
Sacral oedema
Abdomen

Hepatomegaly - RVF

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Cardiovascular Examination

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Pulsatile hepatomegaly - tricuspid regurgitation

Splenomegaly - endocarditis
Pulsatile mass (not liver) - abdominal aneurysm
Femoral arteries, radio-femoral delay (coarctation of aorta) and femoral bruits
Also can listen for renal bruits
Peripherally

Peripheral pulses
Pitting oedema
Peripheral vascular disease - cold feet, gangrene
Varicose veins
Finally

BLOOD PRESSURE
narrow pulse pressure indicates aortic stenosis
wide pulse pressure indicates aortic regurgitation
drop of > 10mm Hg in inspiration indicates pulsus paradoxus and either tamponade or
constrictive pericarditis
Fundi
hypertensive change
grade I copper wiring of arteries
grade II arteriovenous nipping
grade III flame or blot haemorrhages, cotton wool exudates
grade IV papilloedema
Roth' spots = retinal vasculitis indicative of endocarditis
Urine - haematuria may indicate endocarditis
Temperature chart - endocarditis

The Signs of Different Conditions

Aortic Stenosis (Uncomplicated)

Observation - more likely to be male

Hands - nil
Radial pulse
normal
AF (irregularly irregular)
Carotid pulse - slow rising pulse
Face - nil
JVP - normal
Thrills
aortic areas
2nd R intercostal space (classical aortic area)
4th L intercostal space/sternal edge whch is along the line of LV ejection
over apex (along line of LV ejection)
Apex
normal position 5th intercostal space in mid-clavicular line
heaving character due to LVH
Auscultation
1st HS normal
Ejection systolic click may precede murmur
Ejection systolic murmur

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loudest sitting forward

loudest in expiration
radiates to carotids and apex
2nd HS
may be soft or absent
paradoxical splitting may occur during expiration such that P2 occurs before A2 but
A2 may not be audible anyway
No diastolic murmurs
4th HS may be present just before 1st HS
Peripherally nil of note
Blood pressure
narrow pulse pressure eg 120/80 or 110/80
Mitral Regurgitation (Uncomplicated)

Observation - nil
Hands
look for signs of endocarditis ie splinter haemorrhages (transilluminate them), Osler's nodes,
Janeway lesions
Radial pulse - may find AF
Face - normal in uncomplicated mitral regurgitation (but malar flush of mitral stenosis if mixed
mitral disease)
Carotid
usually normal character
in severe disease may get a small volume jerky pulse due to shortened ejection volume and
time
JVP
usually normal
raised if subsequent pulmonary hypertension
Thrill possible in mitral area
Heaves
in severe regurgitation may develop a parasternal heave due to left atrium enlargement
may also have RV Heave if pulmonary hypertension has developed
Apex
displaced laterally and down
thrusting
Auscultation
1st HS - soft or normal
Pan-systolic murmur
loudest at apex in left lateral position
radiates to the axilla
may obscure aortic component of 2nd HS
2nd HS may be obscured (but if there is pulmonary hypertension it could be loud and late)
3rd HS often present

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