Although technology has a high profile in cardiology, clinical examination remains a central tool, especially for the generalist.
Many clues to the cardiac condition can be detected with a simple visual inspection. In the acutely unwell patient, cyanosis, pallor, and sweatiness can all be signs of impending danger – does the patient "look" ill? In nonacute patients, cachexia is perhaps the most important feature to note on general inspection since it is an important prognostic sign in heart failure. Palpation is essential to confirm that girth is excess fluid (pitting edema). Certain physical appearances should always prompt an awareness of cardiac abnormalities (see Table 1). Facial signs for which there is evidence of an association with cardiac conditions are shown in Table 2. Finally, it is important to document the condition of a potential cardiac patient's teeth.
Cardiac manifestations of genetic disorders.
Facial signs associated with cardiac conditions.
Taking the pulse
Taking the pulse is one of the simplest, oldest, and yet most informative of all clinical tests. As you pick up the patient's hand, you should check for clubbing and any peripheral signs of endocarditis (see Table 3). Note the rate and document the rhythm of the pulse. The character and volume of the pulse can also be useful signs and traditionally it is believed that these are easier to detect in larger arteries such as the brachial and the carotid (see Table 4).
Peripheral signs associated with infective endocarditis.
Checking both radials simultaneously is important in all cases of chest pain as a gross screening test for aortic dissection. Adding radiofemoral delay (or radiofemoral difference in volume) may alert you to coarctation as a rare cause of hypertension.
Peripheral pulses should also be documented, as peripheral vascular disease is an important predictor of coronary artery disease:
femoral – feel at the midinguinal point (midway between the symphysis pubis and the anterior superior iliac spine, just inferior to the inguinal ligament)
popliteal – feel deep in the center of the popliteal fossa with the patient lying on their back with their knees bent
posterior tibial – feel behind the medial malleolus
dorsalis pedis – feel over the second metatarsal bone just lateral to the extensor hallucis tendon
This is described in Chapter 6, Hypertension.
Jugular venous pressure
Of all the elements of clinical examination, the jugular venous pressure (JVP) is the most mysterious. It is highly esoteric, and whilst some people wax lyrical about the steepness of the "y" descent, others will feel grateful to be convinced they see it at all. Two things are very clear: (1) the JVP is a very useful clinical marker in many situations, and (2) the exact height of the JVP is a poor guide to central venous pressure. Taken together, this suggests that noting whether the JVP is "up" or "down" is good practice in every cardiac patient. In particular, it can be very useful in diagnosing right-sided heart failure and in differentiating a cardiovascular cause of acute shortness of breath (right ventricular failure, pulmonary embolism) from an intrinsic pulmonary cause (asthma, chronic obstructive pulmonary disease). For the general physician, the waveform of the JVP (see Figure 1) is, for most purposes, only of academic significance.
Waveforms of the jugular venous pressure (including a brief explanation for each wave). The "c" wave represents right ventricular contraction "pushing" the tricuspid valve back into the right atrium. Reproduced with permission from Oxford University Press (more...)
The JVP should be assessed with the patient reclined at a 45° angle (see Figure 2). Accepted practice is that only the internal jugular vein should be used, as only this vessel joins the superior vena cava at a 180° angle. The JVP is defined as the height of the waveform in centimeters above the sternal angle (<4 cm is normal). Abnormalities of the JVP are described in Table 5.
The jugular veins. The patient is lying at a 45° angle, thus revealing the surface markings of the neck.
Abnormalities of the jugular venous pressure (JVP).
Before auscultation, inspection of the precordium can be a useful indicator of previous surgery – eg, midline sternotomy suggests previous bypass, lateral thoracotomy suggests previous mitral valve or minimally invasive bypass surgery (left internal mammary artery to left anterior descending coronary artery). Locate the apex beat – the furthest point laterally and inferioraly where you can clearly feel the apex (usually the fifth intercostal space in the midclavicular line). There are many different descriptions for abnormal apex beats. One scheme distinguishes heaving (high afterload, eg, aortic stenosis) from thrusting (high preload, eg, aortic regurgitation). The apex may also be "tapping", but this reflects a loud first heart sound. In addition, you should place your left hand over the sternum and feel for any significant ventricular heave (right ventricular hypertrophy) or thrill (tight aortic stenosis, ventricular septal defect).
Held by many as the key to physical examination, the importance of auscultation remains, but is diminished in an age of increasingly portable echocardiography.
Listen over the aortic (second right intercostal space) and pulmonary (second left intercostal space) areas and at the left lower sternal edge with the diaphragm of your stethoscope (better for higher pitches), then use the bell for the apex (better for lower pitches). If in doubt, use both. Press lightly with the bell. If you hear an abnormality over the aortic or pulmonary areas, you should listen over the carotids. If you hear an abnormality at the apex, listen in the axilla. Listen systematically. Start with the heart sounds – ignore everything else.
Heart sound variations
When listening to heart sounds, note their volume (normal, diminished, loud) and whether physiological splitting is present (see Figure 3).
Relative positions of heart sounds and added sounds in auscultation. Sounds in red are high pitched. A2: aortic component of second heart sound; EC: ejection click; MSC: mid systolic click; OS: opening snap; P2: pulmonary component of second heart sound; (more...)
Physiological splitting of the second heart sound is when the sound of aortic valve closure (A2) occurs earlier than that of pulmonary valve closure (P2). It occurs in inspiration and is more common in the young. It is caused by increased venous return and negative intrathoracic pressure. This delays right ventricular emptying and pulmonary valve closure, at the same time that pooling of blood in the pulmonary capillary bed hastens left ventricular emptying and aortic valve closure. Reverse splitting of the second heart sound can occur in conditions where aortic valve closure is delayed, such as left bundle branch block or paced right ventricle, or where pulmonary valve closure occurs early, such as in the B form of Wolff–Parkinson–White syndrome. Wide fixed splitting of the second heart sound occurs in atrial septal defect.
A third heart sound may be heard soon after the second heart sound. It is thought to be due to rapid, high-volume filling of the left ventricle. As such, it is found in pathological (left ventricular failure) as well as physiological (athletic heart, pregnancy) states.
A fourth heart sound may be heard just before the first sound. This is caused by atrial contraction filling a stiff left ventricle, eg, hypertensive heart or diastolic heart failure.
When you have considered these heart sound variations, move on to consider the gaps between the heart sounds. If you hear a murmur, first establish whether it occurs in systole or diastole (time against the carotid pulse if necessary). Then determine its length and, if short, its exact position (early, mid, or late; systole or diastole) (see Figure 3).
An opening snap occurring after the second heart sound represents a diseased mitral valve opening to a stenotic position. An ejection click soon after the first heart sound occurs in aortic stenosis and pulmonary stenosis. A mid systolic click is heard in mitral valve prolapse.
After listening to the heart
Listen to the base of the lungs for the fine inspiratory crackles of pulmonary edema. If you suspect right-sided cardiac pathology, palpate the liver, which will be enlarged, congested, and possibly pulsatile in cases of right ventricular failure or tricuspid valve disease. Also, check the patient's ankles for swelling.
Table 6 outlines common associations in cardiovascular clinical examination.
Common associations in cardiovascular clinical examination.
A careful clinical examination can reveal much about the condition of your patient's heart. In addition, noting the findings of a full examination will greatly facilitate specialist referral. In an age of high technology, skilled clinical examination has yet to be surpassed in terms of convenience, safety, and value for money.
Bickley LS, Hoekelman RA, editors. Bates' Pocket Guide to Physical Examination and History Taking, 3rd edn. Lippincott Williams & Wilkins, 2000.
Gleadle J. History and Examination at a Glance. Blackwell Science, 2003.
Perloff JK. Physical Examination of the Heart and Circulation, 3rd edn. WB Saunders, 2000.(Video) Cardiovascular Examination - OSCE Guide (Old Version)
Turner RC, Blackwood RA. Lecture Notes on Clinical Skills, 3rd edn. Blackwell Science, 1997.
The cardiovascular examination consists of assessing the vital signs, jugular venous pulse (JVP), chest inspection, palpation of the chest and peripheral pulses, and auscultation of the heart. It should also include a fundoscopic exam to evaluate for retinopathy in patients with diabetes or hypertension.What is the first step in examination of the cardiac system? ›
Position the patient correctly, with the bed angled at 45 degrees. Ensure that the bed is at a comfortable height in order to avoid an awkward examination. Always stand on the right side of the bed during the cardiovascular examination.
A thorough cardiovascular assessment will help to identify significant factors that can influence cardiovascular health such as high blood cholesterol, cigarette use, diabetes, or hypertension (CDC, 2011).What are 3 cardiac tests? ›
the Astrand treadmill test. the 2.4 km run test. the multistage bleep test.What are 4 tests to diagnose cardiovascular diseases? ›
- Blood tests. ...
- Electrocardiogram (ECG) ...
- Exercise stress test. ...
- Echocardiogram (ultrasound) ...
- Nuclear cardiac stress test. ...
- Coronary angiogram. ...
- Magnetic resonance imaging (MRI) ...
- Coronary computed tomography angiogram (CCTA)
The test takes about one hour, including prep time and actual test time. The cardiac stress test itself only lasts around 15 minutes. During your test, you may walk on a treadmill or pedal a stationary bicycle.What are the 5 cardiac landmarks? ›
What are the 5 points of auscultation of the heart? The 5 points of auscultation of the heart include the aortic, pulmonic, tricuspid, and mitral valve as well as an area called Erb's point, where S2 is best heard.How long does a cardiac exam take? ›
A health care provider monitors the heartbeat while the person walks on a treadmill or pedals a stationary bike. A stress test usually takes about an hour, including both prep time and the time it takes to do the actual test. The actual exercise test takes only around 15 minutes.What should be included in a cardiovascular assessment? ›
- Vital Signs.
- Chest Inspection and Palpation.
- Lung Examination.
- Abdominal and Extremity Examination.
- Point-of-Care Ultrasonography (POCUS)
- Lowered risk of disease. Aerobic exercise reduces your risk of developing many diseases, including:
- Better strength and stamina. Your heart and lungs will get stronger as you exercise. ...
- A more active immune system. ...
- Managed weight. ...
- Stronger bones. ...
- Better mood.
A coronary angiogram is a type of X-ray used to examine the coronary arteries supplying blood to your heart muscle. It's considered to be the best method of diagnosing coronary artery disease - conditions that affect the arteries surrounding the heart.What is the main test for heart? ›
An electrocardiograph is the most common test for heart conditions. An electrocardiograph machine records your heart's rhythm onto paper through sticky electrodes which are placed on your chest, arms and legs. The recording will show if the heart muscle is damaged or short of oxygen.What are the major test for heart? ›
- Lipid profile test: ...
- High-sensitivity C-reactive protein test (hs CRP test) ...
- Natriuretic peptides test. ...
- Troponin (T) Test for Heart Attack.
Heart (cardiac) CT scan.
A CT scan of the heart can show calcium deposits and blockages in the heart arteries. Calcium deposits can narrow the arteries. Sometimes dye is given by IV during this test. The dye helps create detailed pictures of the heart arteries.
High blood pressure, high blood cholesterol, and smoking are key risk factors for heart disease.Can a stress test show a blockage? ›
A cardiac stress test can reveal blockages in your arteries through the various types of information it collects. If your blood oxygen level is below normal, the test reveals that your blood flow is partially blocked.When should you start cardiovascular screening? ›
The American Heart Association (AHA) states that cardiovascular screening can begin as early as age 20. Even if your screenings do not indicate that you are a high-risk patient, your results can act as an incentive to lead or continue a healthy lifestyle.What are the 4 sounds of the heart? ›
- S1 – “lub” caused by the closing of the AV valves.
- S2 – “dub” caused by the closing of semilunar valves.
- S3 – linked with flow of blood into the ventricles.
- S4 – linked with atrial contraction.
A typical heart has two upper and two lower chambers. The upper chambers, the right and left atria, receive incoming blood. The lower chambers, the more muscular right and left ventricles, pump blood out of the heart.Where are the 4 heart sounds? ›
The aortic area, pulmonic area, tricuspid area and mitral area are areas on the surface of the chest where the heart is auscultated. Heart sounds result from reverberation within the blood associated with the sudden block of flow reversal by the valves closing.
There are three main types of stress tests: exercise stress tests, nuclear stress tests, and stress echocardiograms.How do I prepare for my first cardiology appointment? ›
Prepare for Your Cardiologist Appointment
Compile a personal health history and a health history of your family. Gather any recent test results and a list of medications you are taking. Note any symptoms you have been experiencing. Compile a list of questions you want to ask your doctor.
A technician (sonographer) spreads gel on a device (transducer). The sonographer presses the transducer firmly against your skin, aiming an ultrasound beam through your chest to your heart. The transducer records the sound wave echoes from your heart. A computer converts the echoes into moving images on a monitor.What are the 3 circuits of blood flow? ›
The mammalian circulatory system is divided into three circuits: the systemic circuit, the pulmonary circuit, and the coronary circuit. Blood is pumped from veins of the systemic circuit into the right atrium of the heart, then into the right ventricle.What is the largest artery in the body? ›
Your heart pumps oxygen-rich blood into the biggest artery in your body — your aorta.What are the 14 steps of the heart? ›
In summary from the video, in 14 steps, blood flows through the heart in the following order: 1) body –> 2) inferior/superior vena cava –> 3) right atrium –> 4) tricuspid valve –> 5) right ventricle –> 6) pulmonary arteries –> 7) lungs –> 8) pulmonary veins –> 9) left atrium –> 10) mitral or bicuspid valve –> 11) left ...What are the 3 phases of heartbeat? ›
The cardiac cycle has 3 stages: Atrial and Ventricular diastole (chambers are relaxed and filling with blood) Atrial systole (atria contract and remaining blood is pushed into ventricles) Ventricular systole (ventricles contract and push blood out through aorta and pulmonary artery)What are the 2 phases of a heartbeat? ›
The heartbeat consists of two phases: diastole and systole. Diastole is the relaxation phase of the heartbeat. During this phase, the ventricles relax and blood flows through the left and right atria from the vena cava and pulmonary veins. Systole is the contraction phase of the heartbeat.What are the 8 elements of the cardiac conduction system? ›
The cardiac conduction system comprises the following structures in order: SA node, internodal pathway and Bachmann's bundle, AV node, bundle of His, bundle branches, and Purkinje fibers.What are the 7 criteria for ideal cardiovascular health? ›
In brief, the 7 cardiovascular health factors include smoking status, body weight, total cholesterol, blood glucose, physical activity, and diet. Each cardiovascular health factor was categorized into 3 groups (ideal, intermediate, poor).
- Coronary angioplasty. Coronary angioplasty is also known as percutaneous coronary intervention (PCI), percutaneous transluminal coronary angioplasty (PTCA) or balloon angioplasty. ...
- Coronary artery bypass graft. ...
- Heart transplant.
- Start the metronome counter, and set yourself a timer for 3 minutes.
- Step on and off the step one foot at a time (up, up, down, down), stepping at a consistent pace to the beat of the metronome counter.
- Perform this for 3 minutes without stopping. ...
- Once the 3 minutes is up, check your pulse.
About cardiovascular disease
blood clot (thrombosis) build-up of fatty deposits inside an artery, leading to the artery hardening and narrowing (atherosclerosis)
Target heart rate is generally expressed as a percentage (usually between 50 percent and 85 percent) of your maximum safe heart rate. The maximum rate is based on your age, as subtracted from 220. So for a 50-year-old, maximum heart rate is 220 minus 50, or 170 beats per minute.Why is cardiovascular activities important? ›
Getting your heart pumping at faster rates on a regular basis keeps it in shape and healthy, reducing the risk of heart disease. Cardio helps lower your blood pressure by reducing the levels of bad cholesterol and raising levels of good cholesterol.What is the steps of health examination? ›
A physical examination usually includes: Inspection (looking at the body) Palpation (feeling the body with fingers or hands) Auscultation (listening to sounds)What are the steps in a clinical examination? ›
- Inspection. Your examiner will look at, or "inspect" specific areas of your body for normal color, shape and consistency. ...
- Palpation. ...
- Percussion. ...
- Auscultation. ...
- The Neurologic Examination:
The physical examination of the chest is composed of inspection, palpation, percussion, and auscultation.What are the 4 types of physical examination? ›
- 1 Inspection.
- 2 Palpation.
- 3 Auscultation.
- 4 Percussion.
Pre-Employment Medical - Physical Tests 1. Blood Test 2. Urinalysis 3. Chest X-Ray 4.
There are three stages in which witnesses are examined, these are examination in chief, cross examination, re examination under Section137 of Evidence Act. While Section 138 of Evidence Act gives an order of examination in chief, cross examination, re examination.What is a full clinical examination? ›
A clinical examination comprises three components: the history, the examination, and the explanation, where the doctor discusses the nature and implications of the clinical findings. A patient seeks medical help for three main reasons: diagnostic purposes, treatment or reassurance, or a combination of these factors.What are the 5 steps in the patient assessment sequence? ›
These are assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver.What is a normal breath sound? ›
There are two normal breath sounds. Bronchial and vesicular . Breath sounds heard over the tracheobronchial tree are called bronchial breathing and breath sounds heard over the lung tissue are called vesicular breathing.What are 3 procedures used to examine the lungs? ›
Peak flow measurement – Measures air flow from your lungs when you forcefully exhale. Pulmonary function tests – Assesses your breathing and how well your lungs are functioning with normal and deep breathing tests. Pulse oximetry – Measures the oxygen level in your blood by clipping a device on your finger.