A printer friendly checklist can be found here.
Examination of any system should start with inspection. The patient should be sitting comfortably at 45° with adequate exposure of the praecordium. The room should be quiet and warm. Stand on the patient’s right hand side and, when palpating, use your right hand.
A. Wash hands with water or alcohol gel.
B. Introduce self and seek permission to examine the cardiovascular system.
C. Confirm patient’s name and date of birth.
D. Ask if patient is currently in any pain.
E. Position patient at 45 degrees with chest adequately exposed.
2. GENERAL INSPECTION
A. Look for signs of breathlessness, discomfort or pain.
B. Examine face, eyes and mouth for signs of clinical anaemia, cyanosis, xanthelasmata, corneal arcus and malar flush.
C. Examine hands to assess circulation for warmth and capillary refill. Look for evidence of peripheral cyanosis, nicotine staining, clubbing, splinter haemorrhages, koilonychia (nail spooning.)
Observe patient generally for breathlessness (tachypnoea suggests heart failure), peripheral cyanosis and evidence of pain or discomfort.
Observe face for colour. Is he unduly pale or highly coloured? Consider if he could be anaemic or polycythaemic. Is there a malar flush (indicative of mitrial stenosis)?
Observe eyes. Look for corneal arcus and xanthelasmata (sign of hyperlipidaemia). Is he anaemic? Turn down lower eyelid and look at colour. It should be pink.
Observe mouth. Look at colour of lips. Look under tongue for central cyanosis.
Feel hands to assess circulation, warmth, filling of veins. Check capillary refill time. Is there any peripheral cyanosis?
Look for evidence of anaemia - pallor of palmar creases, pallor under lower eyelids, koilonychia (nail spooning). Palpate the nail bed and assess for finger clubbing by opposing the dorsal surfaces of two nails. The diamond shaped window is absent if the nails are clubbed (a sign of anaemia).
Look for evidence of infective endocarditis – splinter haemorrhages.
Look at hands for evidence of long term smoking -nicotine staining.
A. Palpate both radial pulses and assess rate and rhythm. Assess for collapsing pulse.
B. Palpate right carotid pulse and assess volume and character.
- Rate (normal is 60-100 bpm)
- Collapsing pulse
The radial pulse is felt between the radial styloid and the tendon of flexor carpi radialis. Feel with two or three fingers (not the thumb) – use one hand to steady the patient’s hand and the other to palpate. Check both radial pluses simultaneously to make sure that they are equal (unequal pulses can indicate atherosclerosis or aortic dissection), and then concentrate on the right radial pulse.
Count the rate per minute. (Count for 15 seconds and multiply by four. You will require a second hand on your watch)
Assess the rhythm: Is it regular? If it is not, is it occasionally irregular, as when an ectopic heart beat occurs, or is it totally irregular as in atrial fibrillation?
ASSESSMENT OF CAROTID PULSE
Feel for the carotid pulse, which is found at the anterior border of sternomastoid muscle, at the level of the angle of the mandible. Get the patient to relax their neck by lying back and turning to one side. Use your index and middle fingers, not your thumb. (Many textbooks show pictures using the thumb.) Never feel both carotids simultaneously but it may be useful to feel them independently to compare both sides.
Check the volume. A large volume suggests a hyperdynamic circulation; small volume suggests a low cardiac output.
Assess the character or shape of the pulse. Does it rise slowly as in aortic stenosis when it is called an anacrotic pulse? Or does it fall away quickly, as does the collapsing pulse of aortic regurgitation? Slow rising pulses are less obvious in the peripheral pulses, hence the need to assess character at the carotid. A double-impulse pulse is indicative of mixed aortic valve disease.
Collapsing pulse. Another way to check for a collapsing pulse is to hold up the patient’s right arm and let his radial pulse beat against the flat of your hand. If present, a slapping sensation caused by a collapsing pulse can be noted.
4. JUGULAR VENOUS PULSE ASSESSMENT
A. Assess right internal jugular vein with patient at 450. Check for hepatojugular reflux.
The JVP correlates with the right atrial pressure and hence an elevated JVP may indicate right heart failure. It may also give valuable clues in the assessment of valvular lesions. Thus assessment of the JVP is part of the evaluation of the right side of the heart.
Visual assessment of the pressure within the right internal jugular vein gives an indication of right atrial pressure (RAP). This in turn reflects right atrial filling and emptying, and gives a useful indicator of cardiac disease.
JVP assessment is an important but difficult skill to master. We need to be able to imagine or “visualise” the internal jugular vein.
Although the external jugular veins are fairly readily seen, they do not give reliable information. One problem is that we cannot actually see the internal jugular vein itself and we therefore require to visualise the vein. However, although the lower part of the internal jugular vein itself lies deep between the clavicular and sternal heads of sternocleidomastoid muscle, its pulsations can be seen in a normal person lying at 450 (degrees). The pulsation does not arise from the vein but reflects changes in pressure within the right atrium.
One essential element is to make sure that the neck is relaxed. Position the patient at 450. Ask the patient to turn his head slightly to the left and let his neck “sink” into the pillow. Look between the heads of sternocleidomastoid just above the clavicle for the pulsations of the right internal jugular vein.
It is worth looking at both sides of the neck for the clearest pulsation, and “sky-lining” the neck sometimes helps. (Stand slightly back from the patient and look across the neck.) Often in young fit subjects, the pressure is low and the vein tends to be empty at 45 degrees. Gentle pressure, just above the clavicle, will fill the vein and it will tend to bulge anterior to sternocleidomastoid and empty on release. Performing the Valsalva manoeuvre (forceful expiration against a closed glottis) may also help to fill the vein.
The double waveform (a and v) of venous pulsation (compared with an arterial pulse) is impalpable and can be stopped by gentle compression. This helps to distinguish it from arterial pulsation which cannot easily be obliterated. Gentle pressure below the right costal margin will elevate the JVP briefly, however it has no effect on arterial pulsations. (Hepatojugular reflux) If this effect lasts longer than 5 seconds, it could be an indicator of right heart failure.
Assess the height of the JVP. It is measured as the vertical height of the highest point of pulsation above the sternal angle, by imagining a horizontal line drawn from the upper level of pulsation to a point vertically above the sternal angle. (Note that this is not the same as the sternal notch. The sternal angle or Angle of Louis is continuous with the second costal cartilage.)
The height of JVP should be less than 4cm vertically above the sternal angle.
To recap, the normal upper limit of height of the JVP is 3cm vertically above the sternal angle. The right atrium lies approximately 5cm below the sternum. So this figure of a maximum height of 3cm corresponds to a right atrial pressure (RAP) of 8cm water. Textbooks may give right atrial pressure in mmHg and cause you some confusion. In order to convert cm of water to mmHg multiply by 0.75.
8cm water x 0.75 = 6mmHg
A RAP greater than 8cm water or 6mmHg may indicate a problem of right heart function, usually right heart failure secondary to left heart failure or pulmonary disease. Other important causes include fluid overload, superior vena caval obstruction, tricuspid regurgitation and conduction blocks and arrhythmias.
A low pressure may indicate that the heart is under filled due to hypovolaemia e.g. dehydration, blood loss.
The waveform of the JVP should also be noted. It has 2 visible peaks, the a and the v wave but don’t worry overly at this stage about visualising them - focus on the height. Click here for more detail.
In practice the JVP takes very little time to assess. However you will require to practise!
It is an important, but difficult skill to master.
5. INSPECTION AND PALPATION OF PRAECORDIUM
A. Inspect praecordium (chest) for shape, respiratory rate, scars and visible apex beat.
B. Palpate praecordium for heaves and thrills. Locate the apex beat and assess character.
The praecordium is the front of the chest overlying the heart.
Look for abnormal chest shape, respiratory rate, operation scars, pacemaker and visible pulsations. In thin people the apex beat may be seen to pulsate. Look for abnormal cardiac pulsations e.g. left ventricular aneurysm.
Brief guide to common scars:
- Midline – sternotomy scar – CABG/valve replacement.
- Left – thoracotomy scar (diagonal from under left breast to left axilla) – mitrial valvectomy for mitrial stenosis.
- Pacemaker – under skin inferior to left clavicle.
- the apex beat
- left parasternal impulse or “heave” and
- aortic and pulmonary “thrills”
Apex beat (defined as the most inferior point where the cardiac impulse is still palpable)
Locate the apex beat accurately with the flat of and fingers of your right hand. Count down the ribs from the sternal angle. The normal apex beat should be in the 5th intercostal space in the mid clavicular line. Decide if the apex beat is normal or displaced. Lateral displacement suggests an enlarged heart. Asking the patient to lean forward may help locate the apex beat if it is hard to palpate.
Character of apex beat. Normal or abnormal? If abnormal, is it tapping (as in mitral stenosis), heaving (aortic regurgitation) or thrusting (left ventricular hypertrophy)?
Left parasternal palpation
Place your outstretched right hand just to the left of the sternum, with your fingers pointing towards the neck. You will feel normal respiration. A left parasternal heave (an abnormal finding) will lift the heel of your hand with each heart beat. This would suggest right ventricular hypertrophy.
A thrill is a palpable vibration caused by turbulent blood flow and is always pathological. Feel for a thrill (rather like a cat purring) at the apex, the upper part of the praecordium and in the sternal notch. The commonest cause of a thrill is aortic stenosis.
6. AUSCULTATION OF PRAECORDIUM
A. (Initially whilst palpating the carotid pulse) auscultate the praecordium, for heart sounds and murmurs in all of the 4 key areas. Use both bell and diaphragm. Position patient on left side and auscultate with bell in expiration.
B. Auscultate in left axilla for radiation of a murmur, and auscultate carotids for radiation and bruits.
C. Sit patient forwards. Auscultate in expiration with diaphragm at lower left sternal edge.
D. Auscultate the lung bases with diaphragm. Feel for sacral oedema.
There is no “correct” or “incorrect” auscultation routine. Find a routine that suits you.
(As a guide for you, auscultation in a routine examination should take approximately 2 minutes. A third of this time should be concentrated on the mitral area. Of course any abnormal findings will increase the time spent on auscultation.)
Initially auscultate whilst palpating the carotid pulse with your left fingers (2nd 3rd and 4th fingers) to distinguish S1 from S2 and therefore assist in identification of systole and diastole.
Listen to each auscultatory component in at least the four classical auscultation areas: -
apex, lower left, upper left and right sternal edges. Known as the:-
- mitral/apex area, (5th intercostal space, ICS, mid clavicular line)
- tricuspid area, (around the 3rd, 4th and 5th left ICSs, at the left sternal edge, LSE)
- pulmonary area (2nd left ICS lateral to sternum, LSE) and
- aortic area (2nd right ICS lateral to sternum).
These areas, although known as the mitral, tricuspid, pulmonary and aortic areas, in fact have no anatomical meaning. They are the key areas where the heart sounds and murmurs radiating from these valves are traditionally considered to be best heard. Be prepared to hunt around slightly to find the optimum position for your stethoscope but don’t move too quickly or you could miss a sound. Generally, you want to move your stethoscope in an S-shape, starting at the apex beat.
Listen systematically to the auscultatory events in the cardiac cycle i.e. 1st and 2nd heart sounds (S1 and 2) and listen in the systolic and diastolic intervals for added sounds and murmurs. Time events with simultaneous palpation of the carotid.
Use both the bell and diaphragm appropriately in the 4 areas – remember that the bell should only be placed lightly on the skin. In particular use the bell at the apex for low frequency sounds (i.e. murmurs) and the diaphragm at the base for high frequency sounds.
Roll your patient slightly onto his left side and listen in the 5th ICS with the bell for the low frequency mid diastolic murmur of mitral stenosis. (Listen in full expiration. This may enhance a murmur.)
Auscultate in the axilla with the diaphragm for radiation and comparative loudness of a systolic murmur. (e.g. the pan systolic murmur of mitral regurgitation radiates to the axilla.)
In addition auscultate with the diaphragm over both carotids for bruits and radiation of murmurs, (the ejection systolic murmur of aortic stenosis radiates to the neck.)
Next sit your patient forwards and listen with the diaphragm at the lower left sternal edge, in expiration, for the high frequency diastolic murmur of aortic regurgitation.
Finally, with the diaphragm, auscultate at the lung bases for the crackles of left ventricular failure.
While your patient is sitting forwards feel for sacral oedema. Press over the sacrum for 10 seconds. Lift thumb and look for indentation.
A summary of the clinical findings of the 4 main valve problems (aortic regurgitation, aortic stenosis, mitral regurgitation, mitral stenosis) may be found at:-
There are several sites on the internet where you can listen to heart sounds and murmurs e.g.
Grading of murmurs
Audible without stethoscope
7. OTHER AREAS
A. Lay patient flat and palpate abdomen for hepato/splenomegaly and aortic pulsation/dilatation. Auscultate for renal and femoral bruits.
B. Assess for radiofemoral delay. Palpate the femoral, popliteal and foot pulses. Feel for ankle oedema.
C. Measure and record BP.
D. Ophthalmoscopic examination. Look for evidence of hypertensive retinopathy.
E. Test urine with dipstix.
F. Examine any observation charts available. Pulse, BP, Temperature, Urine Output.
Assessment of abdomen
Palpate superficially over the nine regions.
Perform deep palpation to assess for an enlarged liver. Start in the right iliac fossa and progress to the right upper quadrant.
Perform deep palpation to assess for an enlarged spleen, again starting in right iliac fossa and then progressing towards the left upper quadrant.
Assess for ascites.
Auscultate for renal and femoral bruits.
Assessment of other pulses and peripheral oedema
- Assess for radiofemoral delay (indicates coarctation of aorta).
- Palpate and compare the femoral (at the midpoint of the inguinal ligament), popliteal (located at the back of the knee with a flexed knee – use both hands pressing towards the lateral aspect) and ankle/foot pulses (posterior tibial (located below the medial malleolus, lateral to the extensor hallucis longus tendon) and dorsalis pedis.)
- Feel for ankle oedema. Press on medial aspect of lower shin – if it is present, find the level at which it stops. Sacral odema may also be present.
Leg ulcers are a good sign of poor peripheral circulation.
Measure and record blood pressure
Measure and record B.P.
Look for evidence of hypertensive retinopathy.
Test urine with dipstix
Examine any observation charts available
- Urine Output
A. Thank patient and wash hands with alcohol gel or water.
B. Summarise and present findings in patient’s notes and orally.
Summarise and present your findings in patient’s notes and orally.
Summary of the clinical findings of the 4 main valve problems:
- aortic regurgitation
- aortic stenosis
- mitral regurgitation
- mitral stenosis
Heart sounds and murmurs