Cardiovascular System Examination: Inspection & Palpation

• Tomasz Pilecki from the Medical University of Warsaw presents a lesson on the examination of the cardiovascular system
• A physical examination of the CV system should include these steps
• Examine the heart
• Examine the vessels, including the extremities
• Examine the abdomen
• Examine the retina

Precordial Inspection and Palpation

• The cardiac impulse is normally seen or felt at or medial to the left midclavicular line in the fourth/fifth intercostal space
• A systolic lift at the lower left parasternal border is typical of RV hypertrophy
• Thrills are vibrations associated with murmurs
• Systolic thrill at the apex indicates mitral regurgitation (MR)
• Systolic thrill at the base of the heart towards the neck indicates aortic stenosis (AS)

Heart Rate and Pulse

• Heart rate (HR) can be measured by inspection of the thorax looking at the apical impulse, palpation at the apex, or auscultation of the heart
• Pulse can be measured by palpation of the radial, carotid, or femoral artery
• Normally, HR and pulse are the same value in healthy individuals
• Discrepancies between HR and pulse can occur
• Atrial fibrillation (AF) can cause a pulse deficit
• Pulseless electrical activity (PEA) can present with a normal HR but no pulse

Normal Values for Heart Rate and Pulse

• Normal HR/pulse is 60-100/min at rest, and up to 180-200/min during exercise/stress
• Bradycardia is defined as <60/min
• Tachycardia is defined as >100/min

Carotid Pulse Examination

• Carotid pulse should only be assessed unilaterally at any one time.
• Bilateral pressing can cause cardiac arrest.

Rate of Breathing

• Breathing rate can be measured by observing the thorax, nose, and/or mouth, or by touching/auscultating the thorax
• Normal breathing rate is in the range of 12-18 (20)/min
• Bradypnea is defined as <12/min
• Tachypnea is defined as >20/min and is a marker of dyspnea

Heart Sounds

• S1 indicates the first heart sound and results from the closing of the AV valves (mitral and tricuspid); its splitting is only 10-30 ms
• S2 indicates the second heart sound is a result of closing semilunar valves; the aortic component is A2 and pulmonic component P2, and its splitting is audible
• S3 indicates the third heart sound and occurs in the ventricle after S2 at the termination of rapid filling; it is normal in children or with high cardiac output but indicates LV impairment in patients over 40 years
• S4 indicates the fourth heart sound and is presystolic and associated with effective atrial contraction; it is not present in atrial fibrillation (AF)

Factors Affecting Loudness of Heart Murmurs

• Increased intensity murmurs are associated with
• High cardiac output (hyperdynamic) states
• Thin chest wall
• Narrow thoracic diameter (e.g., "straight back," pectus excavatum)
• Anemia (decreased blood viscosity)
• Tortuous aorta (close to chest wall)
• Decreased intensity murmurs are associated with
• Obesity
• Muscular or thick chest wall
• Obstructive lung disease
• Barrel chest (increased anteroposterior diameter)
• Pericardial thickening or fluid
• Decreased cardiac output (congestive heart failure, low ejection fraction)

Cardiac Auscultation Sites

• Mitral valve sounds are best heard at the apex, with additional auscultation in the left axilla if a systolic murmur is found
• Aortic valve sounds are best heard at the second right intercostal space near the sternum; Erb's point (third left intercostal space near the sternum) is an additional point for auscultation in patients with a systolic murmur
• Pulmonic valve sounds are best heard at the second left intercostal space near the sternum
• Tricuspid valve sounds are best heard at the fourth/fifth left intercostal space near the sternum (the lower left sternal border)

Examination of the Upper Extremities

• Palpate the radial pulse
• Check the symmetry of the pulses
• Measure blood pressure (BP) at the brachial artery bilaterally at the first time
• Search for edema, scars, injections, haematomas, venflons, AV shunts, petechiae, and clubbing of fingers

Measuring Blood Pressure Manually

• The patient should be relaxed for at least 30 minutes after consuming tea, coffee, smoking, alcohol, etc. and at least 5 minutes at rest; the arm must be supported
• Ensure no tight clothing constricts the arm
• Place the cuff at the level of the heart and adjust it to the arm circumference
• Inflate to occlude the pulse and deflate at 2-3 mmHg/sec
• Measure systolic blood pressure (SBP) when the first sound is heard and diastolic blood pressure (DBP) when the sound disappears

Examination of the Lower Extremities

• Inspection should be performed to assess
• Edema
• Inflammation
• Skin ulcers
• Varicose veins
• Amputations
• Scars from vein removal for artery bypass surgery/knee surgery/hip surgery
• Palpation of arterial pulses should be performed over the
• Femoral artery
• Popliteal artery
• Posterior tibial artery
• Dorsalis pedis arteries

Examination of the Abdomen

• A pulsatile, expandable mass can be palpated in patients with an abdominal aortic aneurysm
• A systolic bruit can be heard over a stenosed renal artery
• A large, tender liver can be palpated in heart failure or constrictive pericarditis
• Systolic hepatic pulsations can be seen in tricuspid regurgitation (TR)
• Ascites can be found in heart failure

Normal Arterial Pressure Pulse

• Palpation of the radial pulse frequently doesn't give as much information as palpation of the carotid pulse.
• The carotid pulse is best examined with the sternocleidomastoid muscle relaxed with the patient's head slightly rotated towards the examiner.
• When palpating the brachial pulse, the examiner can support the patient's relaxed elbow in the right arm while compressing the artery with a thumb.
• A normal arterial pulse is characterized by a fairly rapid rise to a somewhat rounded peak.

Jugular Venous Pulse

• Pulsation of the right internal vein is usually greatest when the trunk is inclined by less than 30 degrees
• JVP consists of 2 or 3 positive waves and 2 negative troughs and assists in estimating the central venous pressure
• The positive presystolic "a" wave is produced by venous distention due to RA contraction and is the dominant wave

Examination of the Retina

• Retinal manifestations of
• Diabetes
• Atherosclerosis
• Arterial hypertension Can be helpful for diagnosis and treatment.