CARDIOVASCULAR EXAMINATION

CARDIOVASCULAR EXAMINATION

I. LOOK

Clinical signs

Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive
of underlying pathology:

1- Cyanosis: a bluish discolouration of the skin due to poor circulation (e.g. peripheral
vasoconstriction secondary to hypovolaemia) or inadequate oxygenation of the blood (e.g.
right-to-left cardiac shunting).

2- Shortness of breath: may indicate underlying cardiovascular (e.g. congestive heart

failure, pericarditis) or respiratory disease (e.g. pneumonia, pulmonary embolism).

3- Pallor: a pale colour of the skin that can suggest underlying anaemia (e.g. haemorrhage,
chronic disease) or poor perfusion (e.g. congestive cardiac failure). It should be noted that a
healthy individual may have a pale complexion that mimics pallor, however, pathological
causes should be ruled out.

4- Malar flush: plum-red discolouration of the cheeks associated with mitral stenosis.

5- Oedema: typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen
(i.e. ascites). There are many causes of oedema, but in the context of a cardiovascular
examination OSCE station, congestive heart failure is the most likely culprit.

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A. Hand
I. LOOK

General observations

Inspect the hands for clinical signs relevant to the cardiovascular system:

1- Color: pallor suggests poor peripheral perfusion (e.g. congestive heart failure) and
cyanosis may indicate underlying hypoxaemia.

2- Tar staining: caused by smoking, a significant risk factor for cardiovascular disease (e.g.
coronary artery disease, hypertension).

3- Xanthomata: raised yellow cholesterol-rich deposits that are often noted on the palm,
tendons of the wrist and elbow. Xanthomata are associated with hyperlipidaemia (typically
familial hypercholesterolaemia), another important risk factor for cardiovascular disease (e.g.
coronary artery disease, hypertension).

4- Arachnodactyly (‘spider fingers’): fingers and toes are abnormally long and slender, in
comparison to the palm of the hand and arch of the foot. Arachnodactyly is a feature of

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Marfan’s syndrome, which is associated with mitral/aortic valve prolapse and aortic
dissection.

5- Finger Clubbing: Finger clubbing involves uniform soft tissue swelling of the terminal
phalanx of a digit with subsequent loss of the normal angle between the nail and the nail
bed. Finger clubbing is associated with several underlying disease processes, but those most
likely to appear in a cardiovascular OSCE station include congenital cyanotic heart disease,
infective endocarditis and atrial myxoma (very rare).

To assess for finger clubbing:

Ask the patient to place the nails of their index fingers back to back.
In a healthy individual, you should be able to observe a small diamond-shaped
window (known as Schamroth’s window)
When finger clubbing develops, this window is lost.

Signs in the hands associated with endocarditis

There are several other signs in the hands that are associated with endocarditis including:

1- Splinter haemorrhages: a longitudinal, red-brown haemorrhage under a nail that looks

like a wood splinter. Causes include local trauma, infective endocarditis, sepsis, vasculitis and
psoriatic nail disease.

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2- Janeway lesions: non-tender, haemorrhagic lesions that occur on the thenar and
hypothenar eminences of the palms (and soles). Janeway lesions are typically associated with
infective endocarditis.

3- Osler’s nodes: red-purple, slightly raised, tender lumps, often with a pale centre, typically
found on the fingers or toes. They are typically associated with infective endocarditis.

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II. FEEL(PALPATE)

1- Temperature

Place the dorsal aspect of your hand onto the patient’s hand to assess temperature:

a. In healthy individuals, the hands should be symmetrically warm, suggesting

adequate perfusion.
b. Cool hands may suggest poor peripheral perfusion (e.g. congestive cardiac failure,
acute coronary syndrome).
c. Cool and sweaty/clammy hands are typically associated with acute coronary
syndrome.

2- Capillary refill time (CRT)

Measuring capillary refill time (CRT) in the hands is a useful way of assessing peripheral
perfusion:

1- Apply five seconds of pressure to the distal phalanx of one of a patient’s fingers and
then release.

2- In healthy individuals, the initial pallor of the area you compressed should return to
its normal colour in less than two seconds.

3- A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g.
hypovolaemia, congestive heart failure) and the need to assess central capillary refill
time.

II. Pulses and blood pressure

1- Radial pulse
2- Brachial pulse

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B. Face, Eyes and Mouth

I. LOOK

Inspect the mouth for signs relevant to the cardiovascular system

Inspect Eyes for Pallor

1- Central cyanosis: Use a pen-torch to examine inside the mouth. bluish discolouration of
the lips and/or the tongue associated with hypoxaemia (e.g. a right to left cardiac shunt)

2-Petechiae: Inspect the mucosa for petechiae which can be caused by infective
endocarditis.

3- Dental hygiene: note the patient’s dental hygiene. Poor dental hygiene is a risk factor for
infective endocarditis.

4- Angular stomatitis: a common inflammatory condition affecting the corners of the

mouth. It has a wide range of causes including iron deficiency.

5- xanthelasma: Look around the eyes for yellow cholesterol deposits known as
xanthelasma. These are sharply demarcated, yellow plaques, usually around 1-2mm and most
commonly found on the upper and lower eyelids.

6- Senile arcus: Examine the iris for senile arcus, a grey or white arc visible around the
cornea.
These are signs of hyperlipidaemia.

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7- High arched palate: a feature of Marfan syndrome which is associated with mitral/aortic
valve prolapse and aortic dissection.

8- Pallor: Ask the patient to look up, and retract the lower eyelid to inspect for conjunctival
pallor which is a sign of anaemia.

C. NECK

1- Carotid pulse

I. FIRST: Listen

Prior to palpating the carotid artery, you need to auscultate the vessel to rule out the
presence of a bruit. The presence of a bruit suggests underlying carotid stenosis, making
palpation of the vessel potentially dangerous due to the risk of dislodging a carotid plaque
and causing an ischaemic stroke.

Place the diaphragm of your stethoscope between the larynx and the anterior border of the
sternocleidomastoid muscle over the carotid pulse and ask the patient to take a deep breath
and then hold it whilst you listen.

Be aware that at this point in the examination, the presence of a ‘carotid bruit’ may, in fact,
be a radiating cardiac murmur (e.g. aortic stenosis).

II. Then: FEEL(PALPATE)

If no bruits were identified, proceed to carotid pulse palpation:

1- Ensure the patient is positioned safely on the bed, as there is a risk of inducing reflex
bradycardia when palpating the carotid artery (potentially causing a syncopal episode).

2- Gently place your fingers between the larynx and the anterior border of the
sternocleidomastoid muscle to locate the carotid pulse.

3- Assess the character (e.g. slow-rising, thready) and volume of the pulse.

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2- Jugular venous pressure (JVP)

1- Position the patient in a semi-recumbent position (at 45°).

2- Ask the patient to turn their head slightly to the left.

3- Inspect for evidence of the IJV, running between the medial end of the clavicle and the ear
lobe, under the medial aspect of the sternocleidomastoid (it may be visible between just
above the clavicle between the sternal and clavicular heads of the sternocleidomastoid. The
IJV has a double waveform pulsation, which helps to differentiate it from the pulsation of the
external carotid artery.

4. Measure the JVP by assessing the vertical distance between the sternal angle and the top
of the pulsation point of the IJV (in healthy individuals, this should be no greater than 3 cm).

Causes of a raised JVP

A raised JVP indicates the presence of venous hypertension. Cardiac causes of a raised
JVP include:

1- Right-sided heart failure: commonly caused by left-sided heart failure. Pulmonary

hypertension is another cause of right-sided heart failure, often occurring due to
chronic obstructive pulmonary disease or interstitial lung disease.

2-Tricuspid regurgitation: causes include infective endocarditis and rheumatic heart

disease.

3-Constrictive pericarditis: often idiopathic, but rheumatoid arthritis and

tuberculosis are also possible underlying causes.

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3- Hepatojugular reflux test

The hepatojugular reflux test involves the application of pressure to the liver whilst observing
for a sustained rise in JVP.

To be able to perform the test, there should be at least a 3cm distance from the upper margin
of the baseline JVP to the angle of the mandible:

1- Position the patient in a semi-recumbent position (45º).

2- Apply direct pressure to the liver.
3- Closely observe the IJV for a rise.
4- In healthy individuals, this rise should last no longer than 1-2 cardiac cycles (it should then
fall).
5- If the rise in JVP is sustained and equal to or greater than 4cm this is deemed a positive
result.

This assessment can be uncomfortable for the patient and therefore it should only be
performed when felt necessary.

Causes:

1- Constrictive pericarditis
2- Right ventricular failure
3- Left ventricular failure
4- Restrictive cardiomyopathy

D. CHEST

I. LOOK

Look for clinical signs that may provide clues as to the patient’s past medical/surgical history:

1- Scars: suggestive of previous thoracic surgery: see the thoracic scars section below.

2- Pectus excavatum: a caved-in or sunken appearance of the chest.

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3- Pectus carinatum (pigeon chest): protrusion of the sternum and ribs.

4- Visible pulsations: a forceful apex beat may be visible secondary to underlying ventricular
hypertrophy.

II. FEEL(PALPATE)

1- Apex beat

1- Palpate the apex beat with your fingers placed horizontally across the chest.

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2- In healthy individuals, it is typically located in the 5th intercostal space in the

midclavicular line. Ask the patient to lift their breast to allow palpation of the
appropriate area if relevant.
2- Displacement of the apex beat from its usual location can occur due to ventricular
hypertrophy.

2- Heaves

A parasternal heave is a precordial impulse that can be palpated.

1- Place the heel of your hand parallel to the left sternal edge (fingers vertical) to
palpate for heaves.
2- If heaves are present you should feel(palpate) the heel of your hand being lifted
with each systole.
Parasternal heaves are typically associated with right ventricular hypertrophy.

3- Thrills

A thrill is a palpable vibration caused by turbulent blood flow through a heart valve (a thrill is
a palpable murmur).

1- You should assess for a thrill across each of the heart valves in turn.
2- To do this place your hand horizontally across the chest wall, with the flats of your
fingers and palm over the valve to be assessed.

III. Listen

1- Murmurs

A systematic routine will ensure you remember all the steps whilst giving you several chances
to listen to each valve area. Your routine should avoid excess repetition whilst each step
should ‘build’ upon the information gathered by the previous steps. Ask the patient to lift
their breast to allow auscultation of the appropriate area if relevant.

1. Palpate the carotid pulse to determine the first heart sound.

2. Auscultate ‘upwards’ through the valve areas using the diaphragm of the stethoscope
whilst continuing to palpate the carotid pulse:

a. Mitral valve: 5th intercostal space in the midclavicular line.

b. Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge.
c. Pulmonary valve: 2nd intercostal space at the left sternal edge.

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d. Aortic valve: 2nd intercostal space at the right sternal edge.

Bell vs diaphragm

The bell of the stethoscope is more effective at detecting low-frequency sounds, including the
mid-diastolic murmur of mitral stenosis. (MS MID..DI)

The diaphragm of the stethoscope is more effective at detecting high-frequency sounds,

including the ejection systolic murmur of aortic stenosis, the early diastolic murmur of aortic
regurgitation and the pansystolic murmur of mitral regurgitation.

E. SACRAL OEDEMA
Look and feel the sacrum for evidence of pitting oedema.

F. LEGS
Look and feel(palpate) the patient’s ankles for evidence of pitting pedal oedema (associated
with right ventricular failure).

Look the patient’s legs for evidence of saphenous vein harvesting (performed as part of a
coronary artery bypass graft).
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