Cardiovascular examination

Introduction

Introduce yourself, confirm the patient's name and date of birth. Explain the examination and obtain consent from the patient. Offer a chaperone and then proceed to wash hands. Adjust the bed to a 45o angle.

General inspection

Begin the examination by inspecting the patient from the end of the bed. The patient should be exposed from the waist up. Offer a blanket to maintain the patient's dignity and inform women that they may keep their undergarments on. Ask the patient to expose their legs as well, as there may be some obvious oedema or venous ulceration.

Ask the patient if they are in any pain and are comfortable. Check for any increased work of breathing, pallor or cyanosis as this will give you a good indication of the state of the patient at rest. Note any paraphernalia around the bedside, looking for clues such as oxygen and/or ECG leads. Patients with angina may have a glyceryl trinitrate (GTN) spray.

Do look for more subtle signs which may give clues to the patient's pathology. For example, a patient with cardiac failure may be using a large number of pillows, fluid restricted and fitted with a catheter to monitor urine output.

Increased work of breathing can be due to several cardiac pathologies ranging from pericarditis to congestive heart failure.

Cyanosis suggests low tissue oxygen saturation and needs to be promptly addressed. Cardiac causes of cyanosis are usually congenital in nature (due to right-to-left cardiac shunting) or a result of abnormal haemoglobin.

Pallor suggests anaemia or reduced perfusion, although it may just be the natural complexion of the patient.

Hands

Inspection of the hands should be done in an intentional and noticeable way. Well perfused hands will be symmetrically warm and of a similar colour. Look at the nails carefully for clubbing, which could be a sign of congenital cyanotic heart disease, infective endocarditis or atrial myxoma (CIA). Inspect the hand for stigmata of endocarditis, such as splinter haemorrhages on the nails, Osler's nodes on the fingers, and Janeway lesions on the palms.

Examine the fingers, as long fingers (arachnodactyly) can be a sign of Marfan's syndrome, a risk factor for aortic dissection. Inspect the joints and palm for xanthomas (yellow cholesterol-rich deposits), which are indicative of familial hypercholesterolaemia.

Next assess distal perfusion by recording the capillary refill time. Apply pressure to the distal phalanx of the patient's index finger for five seconds. The finger should turn pale but revert back to its normal colour within less than two seconds. Poor perfusion is a sign of shock.

When assessing the palm for pallor, a good tip is to compare the patients palm to your own.
Temperature can be crudely assessed by placing the dorsal aspect of your hand on theirs and comparing.

Infective endocarditis is an inflammation of the endocardium of the heart due to an infectious cause. It presents with the following hand signs:

Arm

Radial pulse

Palpate the right radial pulse at the wrist to assess rate and rhythm. An irregular rhythm is commonly due to atrial fibrillation or the presence of ectopic beats. Rarer causes include bundle branch blocks or re-entrant tachycardias.

Palpate the left radial pulse to compare and check for radio-radial delay, which could be a sign of aortic coarctation. Offer to check for radio-femoral delay, which would indicate either aortic coarctation or dissection.

When assessing rate, measure for 15s and multiply by 4.

Aortic coarctation: This is when there is congenital narrowing of the descending aorta near the ductus arteriosis. Hence blood is delayed in reaching the right arm and lower limbs.

Aortic dissection: This is where there is a tear in the aortic intima creating a false lumen for blood to flow through. This can also delay the flow of blood.

Collapsing pulse

Ask the patient if they have any pain in their right shoulder. With your left hand, hold their right elbow and feel for the brachial pulse (medial to the distal tendon of the biceps brachii), and with your right hand, feel for the radial pulse. Lift their arm briskly (but gently) above the level of their heart and hold it. If a sudden, gushing, "waterhammer" retraction of blood can be felt, this is a collapsing pulse and is indicative of aortic regurgitation.

A collapsing pulse is a sign of blood rushing back towards the heart during the diastolic phase. In aortic regurgitation, this occurs due to a leaky aortic valve.

Blood pressure

Check the patient's blood pressure. Ideally you would want to do this in both arms, as aortic dissection would present with a difference in blood pressure, and also when patient is both sitting and standing, as a difference would be found in postural (orthostatic) hypotension.

Aortic dissection: This can present with a blood pressure discrepancy of >20mmHg between each arm.

Postural hypotension: A decrease of >20mmHg in systolic, or >10mmHg in diastolic blood pressure when standing for more than 3 minutes when compared to rest. It is usually due to dysfunction of the autonomic nervous system.

Face

Inspect the eyes for pallor (anaemia), corneal arcus (dyslipidaemia), xanthelasma (dyslipidaemia) and Kayser–Fleischer rings (Wilson's disease). The eyes may also appear sunken in a dehydrated patient. Check the mouth for dental hygeine, as poor hygiene is a risk factor for infective endocarditis.

Inspect the tongue and palate. Macroglossia can be cause of amyloidosis whereas an atrophic, red tongue can occur in iron deficiency. A high arched palate can occur in Marfan's syndrome.

Central cyanosis can be observed on the lips or on the underside of the tongue. Finally check the cheeks for a malar flush, a sign of mitral stenosis.

Corneal arcus: A crescentic opacity of the eyes, which can be blue or white. This may occur in early childhood but it will eventually fade. It is also common in the elderly and is a sign of dyslipidaemia.

Kayser–Fleischer rings: These occur due to a hereditary condition known as Wilson's disease, in which copper deposition leads to dark circles encircling the iris.

Xanthelasma: Yellow deposits of fat under the skin near the eyelids. Associated with dyslipidaemia.

Neck

Assess the carotid pulse. The character of the waveform should be considered. A visible carotid pulse in the neck is Corrigan's sign, which is indicative of aortic regurgitation.

Ask the patient to turn their head to the left and observe their jugular venous pressure (JVP). In healthy patients, this should be no greater than 4 cm. This is measured as the vertical height from the angle of Louis (sternal angle) to the highest visible point where the JVP can be seen. If the JVP cannot be observed, pressure can be applied to the liver to elicit a hepatojugular reflux, however it may not be apparent in healthy individuals.

Character is best assessed by more experienced individuals. It could be described as normal, bounding (aortic regurgitation), thready (circulatory shock), or slow-rising (aortic stenosis).

When assessing the JVP it is important that the patient does not turn their head completely to the left nor tense their neck muscles. This could obscure visibility of the vein.
The JVP can be distinguished from the carotid pulse by its double pulsation.

A raised JVP is a sign of venous hypertension. Three common causes are:

Praecordium

Inspection

Inspect the praecordium (chest area over the heart) for anterior scars, chest wall deformities (e.g. pectus carinatum/excavatum) or visible pulsations. Common scars include:

Chest showing common scars following cardiothoracic surgery.

Common scars following cardiothoracic surgery.

Palpation

Palpate for the apex beat. This is usually found in the left 4th or 5th intercostal space in the midclavicular line. A displaced apex beat could be a result of ventricular hypertrophy. Palpate the areas of the four heart valves for thrills (palpable murmurs, which feel like soft vibrations). The location of each valve is as follows:

Areas for palpation on the chest.

Areas for palpation on the chest.

Finish palpation by checking for a left parasternal heave, as this is a sign of right ventricular hypertrophy.

It is good practise to localise the apex beat after having palpated it. This is done by keeping your right hand on the area of the apex beat and using your left hand alone to count the ribs from the angle of Louis.

Auscultation

Auscultate the four valves using the same landmarks as above with the diaphragm of the stethoscope (used to detect high-frequency murmurs). Be sure to palpate the carotid pulse whilst doing so in order to time any audible murmurs. Listen for the 1st and 2nd heart sounds and for any additional abnormalities. If you hear a murmur, determine if it is systolic or diastolic by timing it with the carotid pulse.

Performing the following manoeuvres can help accentuate certain left-sided heart murmurs. Auscultation of these murmurs is preferably performed on end expiration (ask the patient to breath out and hold their breath).

It is absolutely vital that you only auscultate whilst palpating for the carotid pulse. This way you can easily determine if a murmur is systolic (in time with the pulse), or diastolic (immediately after the pulse).

Carotid bruits: After auscultating the neck for radiation of an ejection systolic murmur, it may be worth auscultating the carotids once again, but this time using the bell of the stethoscope. This will check for any carotid bruits, a low-frequency, whooshing sound which presents with turbulent blood flow. Carotid bruits in younger patients are often "innocent," but if found in an older patient they usually suggest carotid artery stenosis.

The diaphragm of the stethoscope is best at detecting high frequency sounds. These include most murmurs and vesicular breath sounds. Pansystolic, early diastolic and ejection systolic murmurs are all most audible with the diaphragm.

The bell of the stethoscope is better at detecting low frequency sounds. These include a few murmurs, such as a mid-diastolic murmur in mitral stenosis, and vascular bruits. Vascular bruits will present with a systolic, low frequency, "whooshing" sound on auscultation. They can be due to a very high rate of blood flow or otherwise turbulent blood flow as a consequence of partial obstruction of an artery.

Back

Complete inspection of the thorax by examining the back for posterior and lateral scars. Ask the patient if they have pain in their lower back. If not, gently palpate the sacrum for sacral oedema. Sacral oedema is more common in patients who have been lying flat for a long period of time or are immobile. Finally, auscultate the lung bases for crepitations. Both sacral oedema and crepitations are present in left-sided heart failure.

It is good practise to move onto the back immediately after auscultating the carotids, as the patient will already be sitting up. You do not want the patient to be constantly changing position as this is both uncomfortable and unnecessary.

Ankles

Check the patient's ankles for pitting oedema, which is a sign of right-sided heart failure. Patients may also have peripheral vascular disease, particularly if they are known diabetics, so note any ulcers and offer to check for peripheral pulses.

If the patient has a midline sternotomy scar, this could be a result of a coronary artery bypass graft. Therefore be sure to check the entire knee, leg and ankle for scars due to saphenous vein harvesting.

Completion

Complete the examination by offering to obtain a full history, perform basic observations including temperature and oxygen saturation, carry out a urine dipstick (to look for microscopic haematuria, which may present in infective endocarditis), and (if appropriate), perform a 12-lead electrocardiogram and carry out fundoscopy (a "silver-wiring" effect and microaneurysms may be seen in hypertension and Roth's spots may be seen in infective endocarditis).

A pulsatile liver can be a sign of tricuspid insufficiency, and splenomegaly can occur in endocarditis. Also, if you suspect that the patient may have an abdominal aortic aneurysm, and an abdominal examination may be indicated.

Key

Headings - items highlighted in green are important headings to cover.

Definitions

Stigmata - a clinical sign relating to a particular condition. E.g. clubbing and infective endocarditis.

Paraphenalia - equipment the patient may have by the bedside.

Presentation

Thank you for allowing me to conduct a cardiovascular examination on [patient's name], a [age] year old [male/female]. On general inspection, there were no paraphenalia to suggest disease, and the patient appeared comfortable and well at rest. The patient's hands were warm and well perfused. The pulse was regular at [x beats per minute], with no radio-radial delay. I would like to formally assess blood pressure and radio-femoral delay. On examination of the head, there were no stigmata of anaemia, and dentition appeared normal. In the neck, the jugular venous pressure was normal (below 4cm).

On closer inspection of the chest, there were no scars to suggest previous surgery. The apex beat was palpable in the fifth intercostal space, in the mid-clavicular line. There were no heaves or thrills. Heart sounds SI + SII were present, with no added sounds. There was no peripheral oedema. To conclude, this was a normal cardiovascular examination .

Interactive markscheme


When assessing each other, click on each list item as you go along. Doing so will turn the list item green. Make careful note of any steps missed at the end. We recommend completing any examination or procedure in under 10 minutes, but you can adjust the timer to suit your needs.
:

  1. Introduction: “Hello, I’m SimpleOSCE and I am a medical student. I need to examine your heart and chest today, would that be okay? Can I confirm your name and DOB? Thank you.”
  2. "For the purpose of this examination the examiner will act as a chaperone."
  3. Wash hands.
  4. Position the bed at a 45o angle and ensure adequate exposure.
  5. Ask about pain and discomfort.
  6. Inspect the patient (work of breathing, pallor, cyanosis) and their surroundings (ECG leads, oxygen).
  7. Inspect the hands for: warmth, clubbing, peripheral cyanosis, stigmata of endocarditis (splinter haemorrhages, Janeway lesions, Osler’s nodes).
  8. Check capillary refill.
  9. Test for radial-radial delay AND offers to test for radio-femoral delay.
  10. Take the pulse for 15 seconds (assess for rate and rhythm).
  11. Enquire about shoulder pain and then assess for a collapsing pulse.
  12. Ask to take the blood pressure in both arms, sitting and standing.
  13. Inspect the face (malar flush), eyes (pallor, corneal arcus, xanthelasma) and mouth (central cyanosis, poor dentition).
  14. Ask the patient to look to the left and assess the JVP. If it cannot be seen, offer to test hepatojugular reflux.
  15. Palpate the carotid pulse on both sides to assess character.
  16. Inspect the precordium again in closer detail for scars and deformity.
  17. Palpate for the apex beat and assess its position.
  18. Palpate for heaves and thrills.
  19. Auscultate all areas of the heart appropriately.
  20. Time auscultation with the carotid pulse.
  21. Perform mitral stenosis manoeuvre (left side on expiration) and listen in the axilla for radiation (mitral regurgitation).
  22. Perform aortic regurgitation manoeuvre (sit up and listen to pulmonary area on expiration).
  23. Auscultate the carotids for any bruits/radiation (aortic stenosis).
  24. Auscultate the lung bases.
  25. Feel for sacral oedema.
  26. Palpate the legs for peripheral oedema/harvesting scars.
  27. Thank and cover up the patient.
  28. "To conclude, I would like to take a full history, assess the peripheral pulses, look at any old ECGs, and carry out a urine dipstick/fundoscopy to look for signs of infective endocarditis.”
  29. Present findings.
Overall: 0/28