Cardiovascular Examination Findings

Peripheral Vascular Examination

• A peripheral vascular examination assesses the blood vessels outside the heart.
• General inspection involves checking for missing limbs or digits, potentially due to amputation or critical ischaemia.
• Scars may indicate past surgeries (e.g., bypass surgery) or healed ulcers.
• Medical equipment like dressings and prosthetics offer clues about a patient's history.
• Mobility aids (wheelchairs, walkers) indicate current mobility.
• Vital signs (e.g., blood pressure, heart rate) track a patient's current and changing physiological status.
• Prescriptions provide information about recent medications.

Upper Limbs

• Inspection: Inspect and compare upper limbs for abnormalities.
• Finger tip necrosis: A sign of Buerger's disease.
• Tar staining: Indicates smoking, a major risk factor for cardiovascular issues.
• Tendon xanthomas: Raised yellow cholesterol deposits, linked to hyperlipidaemia.
• Limb pallor: Pale skin, indicating poor blood circulation.
• Cyanosis: Bluish discolouration of skin, linked to low blood oxygen levels (SpO2).
• Gangrene: Tissue necrosis (death) due to poor blood circulation, often showing black or red discolouration.

Lower Limbs

• Inspection: Note the lower extremities' colour, including potential pallor.
• Peripheral pallor: Pale skin color, indicating poor perfusion.
• Peripheral cyanosis: Blue discoloration, showing low blood oxygen.
• Ischemic rubour: Dusky-red discoloration, seen with dependent limbs.
• Venous ulcers: Large, shallow, irregular borders that are moderately painful.
• Arterial ulcers: Small, well-defined, deep ulcers that are severe and typically occur in distal areas.
• Gangrene: Tissue death, marked by changes in skin color (red, black).
• Missing limbs/toes/fingers: Secondary to critical ischaemia.
• Scars: Previous surgical procedures (e.g., bypass surgery or healed ulcers).
• Hair loss/Muscle wasting: Indicators of chronic, peripheral vascular disease (PVD).
• Xanthomata: Raised yellow deposits, associated with hyperlipidaemia.
• Paralysis: Severe limb ischaemia may cause weakness and paralysis.

Temperature and Capillary Refill Time (CRT)

• Temperature: Assess upper and lower limbs' temperature using the dorsal aspect of hands.
• Healthy limbs are typically symmetrical and warm, suggesting adequate perfusion.
• A cool and pale limb indicates poor arterial perfusion.
• CRT: Applying five seconds of pressure to a finger or toe, then releasing, to see how quickly colour returns.
• Normal CRT returns to normal colour in under 2 seconds.
• A slow CRT suggests poor perfusion.

Pulse Character

• Rate: Number of pulses per minute (bpm). Normal resting rate is 60-90 bpm.
• Rhythm: Regular, evenly spaced pulses. Irregular rhythm can indicate a problem with the heart's electrical system.
• Volume: Strength of the pulse; strong pulses indicate good blood flow, while weak ones suggest poor flow or decreased cardiac output.
• Character: Shape and duration of the pulse wave. A regular shape and duration are characteristic of a normal pulse. Irregular shapes/durations can indicate problems with heart structure or function.

Pathological Pulses

• Waterhammer pulse: Sharp upstroke, increased amplitude, usually due to aortic regurgitation.
• Slow-rising/Anacrotic pulse: Gradual upstroke, reduced amplitude, characteristic of aortic stenosis.
• Pulsus bisferiens: Two prominent peaks during systole, suggesting mixed aortic stenosis and regurgitation.
• Pulsus alternans: Alternating strong and weak pulses, indicative of left ventricular systolic impairment.
• Double impulse apex beat: Two palpitations during the single heartbeat, indicating hypertrophic obstructive cardiomyopathy.
• Pulsus paradoxus: Pulse decreases during inspiration, associated with conditions like cardiac tamponade, constrictive pericarditis, and severe asthma.

Absent Radial Pulse

• A radial pulse that is missing or cannot be palpated, possible causes include post-catheterization, congenital absence, aortic dissection involving the subclavian artery, peripheral artery embolism, compression by the cervical rib, and Takayasu's arteritis.

Buerger's Test

• Buerger's test assesses arterial supply to the legs.
• Patient lies supine, and legs raised to 45 degrees, for 1-2 minutes.
• Observe limb colour changes; pallor indicates poor arterial perfusion.
• A Buerger's angle below 20 degrees shows significant ischaemia.

Further Assessments and Investigations

• Measure blood pressure in both arms to look for discrepancies indicative of aortic dissection.
• Assess the cardiovascular system.
• Complete ankle-brachial pressure index (ABPI) measurement.
• Conduct a neurological examination of the upper and lower limbs.

Instrumental Methods for Exam of Arterial Perfusion

• Blood tests assess conditions like high cholesterol, triglycerides, or diabetes.
• Ultrasound of the legs and feet to visualise blood flow.
• Angiography (using X-rays, MRI scans or CT) helps to identify blockages in arteries using dye (contrast).