Cardiovascular System Examination

Cardiovascular Exam

• Includes:
  • Appropriate history
  • Vital Signs: Blood pressure, Pulse (rate, rhythm, volume)
  • Assessment of distal vasculature (legs, feet, carotids)

Respectful and Effective Exam

• Keys to performing a respectful and effective exam:
  • Explain what you're doing and why before doing it
  • Expose minimum amount of skin necessary
  • Enlist patient's assistance
  • Don't rush
  • Don't examine through clothing

Observation

• Pay attention to:
  • Chest shape
  • Shortness of breath (at rest or walking)?
  • Sitting upright?
  • Able to speak?
  • Visible impulse on chest wall from vigorously contracting ventricle (rare)

Surface Anatomy

• Finding the sternal manubrium junction (angle of Louis)
• Identifying valve areas

Palpation Technique

• Fingers across chest, under breast (explain first)
• Point of Maximal Impulse (PMI)
  • Apex ventricle that pinpoints with finger tip
  • ~70% of patients - if not palpable, repeat with patient on L side
• Size of LV – increased dimension if PMI shifted to L of mid-clavicular line
• Vigor of contraction
• Palpable thrill (rare) - associated with regurgitant or stenotic murmurs

Auscultation

• What are we listening for?
  • Normal valve closure creates sound
  • First Heart Sound (S1) - closure of Mitral, Tricuspid valves
  • Second Heart Sound (S2) - closure of Pulmonic, Aortic valves
• Systole - time between S1 & S2; Diastole - time between S2 & S1
• Physiologic splitting of S2 - two components of second heart sound (Aortic & Pulmonic valve closure) audible with inspiration

Auscultation Technique

• Patient lying @ 30-45 degree incline
• Chest exposed (male) or loosely fitted gown (female)
• Stethoscope must contact skin
• Stethoscope with diaphragm (higher pitched sounds) engaged

Murmurs

• Murmurs: Sound created by turbulent flow across valves:
  • Leakage (regurgitation) when valve closed
  • Obstruction (stenosis) to flow when normally open
• Systolic murmurs:
  • Aortic stenosis
  • Mitral regurgitation
• Diastolic murmurs:
  • Aortic regurgitation
  • Mitral stenosis

Extra Heart Sounds & S3-S4

• Ventricular sounds, occur during diastole
• Normal in young patient (~ < 30 yo)
• S3 - follows S2, caused by blood from LA colliding with "left over" blood in LV; associated with heart failure
• S4 - precedes S1, caused during atrial systole when blood squeezed into non-compliant LV; associated with HTN

Carotid Arteries

• Anatomy
• Palpation (each side separately)
• Rhythm
• Fullness
• Auscultation
• Radiation of murmurs

Jugular Venous Pressure (JVP)

• Anatomy of Internal Jugular Vein
• Straight line with RA
• Manometer - reflecting Central Venous Pressure (CVP)

Lower Extremity Vascular Exam

• General observation including femoral region
• Expose both legs, noting:
  • Asymmetry
  • Muscle atrophy
  • Joint (knee, ankle) abnormalities
• Focus on Femoral Area:
  • Inspect - ?Obvious swelling - femoral hernia v large lymph nodes (rare)
  • Palpate lymph nodes
  • Identify femoral pulse
  • Listen over femoral artery with diaphragm stethoscope for bruits

Feet and Ankles

• Observe:
  • Swelling (edema)
  • Discoloration
  • Ulcers
  • Nail deformities
• Palpation:
  • Temperature: Use back of examining hand - warm - inflammation; cool - atherosclerosis &/or hypoperfusion
  • Capillary refill: push on end of toe or nail bed & release - color returns in < 2-3 seconds; longer - atherosclerosis &/or hypoperfusion