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Cardiovascular System Examination
GEP Year 1 2014-2015
Lead Lecturer: Dr Hamed Khan
Tutor notes
Tutors - The PBL case is Sally Thompson who has hypertension
Students have already covered:
 The principles of systematic examination
 Palpation of the radial and carotid pulses, measurement of pulse rate, respiratory rate and blood
pressure
 Peripheral vascular examination
There is a section devoted to relevant surface anatomy which you need to demonstrate (on a
volunteer) in the context of why it is important for the examination.
They then have an exercise to do in order to listen to normal heart sounds
During the session they need to spend as much time as possible practicing the examination so
timekeeping is essential. Do not go through the physiology.
Time
(Session 1)
13.30– 13.35
(5 mins)
13.35- 14.00
(25 mins)
14.00– 14.20
(20 mins)
14.20– 15.00
(40 mins)
15.00
Activity
Setting the stage
 Introductions
 Clinical relevance
 Explain objectives for session
o Recognise and describe normal heart sounds
o Carry out a CVS examination on a colleague.
 Stimulate prior recall:
o Principles of systematic examination
o Palpation of the radial and carotid pulses,
o Measurement of pulse and blood pressure
o Palpation of manubriosternal angle and 2nd ICS
 Go through relevant surface anatomy as in the handout using a volunteer
and the skeleton.
 Exercise. Listening to normal heart sounds
Core learning activity – stages 2 & 4 as per handouts
You will need to use one of the men in the group as a model but make sure he gets
to practice on one of the others.
 Stage 2 – run through the examination explaining what you are doing and
describe any findings (positive or negative)
 Stage 4 – get the students to do the examination – they can do one bit
each to break it up.
Practice with feedback
 Break into two groups using both cubicles for practice.
Encourage ongoing practice and transfer
 Reminder about ongoing practice
Learning outcomes
By the end of this session you should be able to:
o Recognise and describe normal heart sounds
o Carry out an examination of the cardiovascular system on a colleague
1
Time
(Session 2)
15.30 – 15.35
(5 mins)
15.35- 16.00
(25 mins)
16.00– 16.20
(20 mins)
16.20– 17.00
(40 mins)
17.00
Cardiovascular System Examination
GEP Year 1 2014-2015
Lead Lecturer: Dr Hamed Khan
Tutor notes
Clinical relevance
The cardiovascular (CVS) examination is an essential part of a patient’s assessment.
 A large number of people suffer from cardiovascular conditions such as heart failure, ischaemic
heart disease or arrhythmias.
 Cardiovascular problems are one of the top causes of death in the UK.
 Although there are various investigations which allow you to assess the state of the patient’s
heart, the CVS exam still provides information which helps in diagnosis and both the
monitoring of the condition and the effects of therapeutic interventions.
Links with other learning
In this session we are mainly concentrating on the examination of the heart and general signs of
cardiovascular disease.
You have already covered
 The principles of systematic examination and the principles of cardio-respiratory
examination
 Palpation of the manubriosternal angle and 2nd ICS – essential surface anatomy landmarks
used in the CVS examination
 Palpation of the radial and carotid pulses
 Measurement of pulse rate and blood pressure
 Peripheral vascular examination – considered part of a full cardiovascular examination.
You will learn later about diabetes (a major risk factor for cardiovascular disease) and how aspects
of CVS and peripheral vascular examinations are integrated into the annual diabetic check.
Related Basic Science
There is a lot to cover in this session – in order for you to achieve the objectives it is
essential that you prepare by reading and understanding the relevant physiology below
We will cover the essential surface anatomy during the session.
Physiology
Jugular venous pressure (JVP)
As a pump, the heart normally has an inflow pressure and there is an equal “back pressure” of
blood in the great veins as they enter the right atrium. The jugular vein therefore acts like a
manometer and indicates the filling pressure of the right side of the heart. If the left ventricle is
unable to pump effectively (ie if there is left sided heart failure), the height of the JVP increases.
Conversely the pressure will drop if there is insufficient circulating blood in a patient who is
bleeding.
In an intensive care situation the pressure can be formally measured by putting an intravenous
catheter into the superior vena cava via the internal jugular or subclavian vein, and attaching a
manometer. This records the central venous pressure (CVP).
Laminar v turbulent flow.
Sounds heard from the vascular system indicate turbulent flow – normal smooth laminar flow is not
audible.
Heart sounds
The normal heart sounds come from the heart valves closing.
 The 1st heart sound (S1) is due to the closure of the mitral and tricuspid valves at the start of
systole (when the ventricular myocardium contracts to pump blood out of the heart). The mitral
and tricuspid valves close to ensure that blood does not flow back from the ventricles into the
atria.
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Cardiovascular System Examination
GEP Year 1 2014-2015
Lead Lecturer: Dr Hamed Khan
Tutor notes

The 2nd heart sound (S2) is due to the closure of the aortic and pulmonary valves. This
occurs at the start of diastole (which is when the atrial myocardium contracts and the
ventricular myocardium relaxes) pushing blood from the atria into the ventricles. The aortic and
pulmonary valves need to close to ensure that blood does not flow back from the atria into the
ventricles.
Abnormal sounds
Most abnormal heart sounds are either murmurs or additional sounds:
Murmurs
 Murmurs arise due to turbulence of blood flow, which could be due to a number of reasons,
such as reduction of blood flow through a valve which is stenosed with a narrow valvular
space, or regurgitation of blood ‘backwards’ across a valve which is not fully closed when it
should be.
Additional sounds
 In many normal young subjects you can hear a soft sound after the second heart sound. This is
a physiological third heart sound reflecting rapid ventricular filling during diastole.
 A fourth heart sound can occur in late diastole just before the first heart sound. It is produced
during atrial contraction when a bolus of blood suddenly hits a stiff, non-compliant ventricle. It is
pathological.
Anatomy
It is essential to know and understand the reasoning behind the surface anatomy
Your tutor will go through this with you.
Tutors – use a volunteer and skeleton – include identifying the auscultation areas including demo
palpating the apex beat and describing the position – line and space.
The internal jugular vein / sternocleidomastoid muscle
The vein descends in the neck in the carotid sheath postero-medially to the sternocleidomastoid
muscle (SCM).
Just above the clavicle it lies between the two heads of the SCM - the joint action pulls the
mastoid process of the same side down towards the sternum. Turning the head away from the side
of the muscle will clearly show the head attaching to the sternum. This is sufficient a manoeuvre in
order to look at the JVP. The other head attaches more laterally to the clavicle.
When assessing the JVP you need to look for a pulsation between the heads of SCM, ie just lateral
to the sternal head.
The common carotid artery and pulse
This artery runs upwards and backwards through the neck from the sternoclavicular joint to the
upper border of the thyroid cartilage where it divides into the external and internal carotid arteries.
The pulse can be palpated by pressing in a posterior direction just lateral to the upper border of the
thyroid cartilage (“adam’s apple”) medial to the SCM.
You need to auscultate over the carotids for bruits and radiation of aortic valve murmurs
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Cardiovascular System Examination
GEP Year 1 2014-2015
Lead Lecturer: Dr Hamed Khan
Tutor notes
Gross anatomy of the heart and chest wall
Picture representation of
the heart in the thoracic cavity
Accessed 13/9/10
http://www.nottingham.ac.uk/nursing
/practice/resources/cardiology/imag
es/cut_away_chest.gif
Sternum
The sternocostal surface of the heart is formed mainly by the right atrium and right ventricle. The
right atrium is located right of the sternum. The right ventricle sits under the sternum and slightly to
the left of the sternum

When palpating to the left of the sternum for “heaves”, a positive finding is suggestive of right
ventricular hypertrophy.
The apex of the heart
The left ventricle is directed downward, forward, and to the left. As the heart beats it rotates slightly
and in doing so the apex of the left ventricle can be felt through the chest wall.
The point furthest inferiorly and laterally where this beat can be felt is the position of the
apex beat and is described in terms of the intercostal space (ICS) and vertical anatomical
line as described below:
Mid clavicular - from the midpoint of the clavicle
Anterior axillary - from the anterior axillary fold - edge of the pectoralis major
Posterior axillary - from the posterior axillary line - edge of the latissimus dorsi
Mid axillary line - from midway between the anterior and posterior folds.



In a normal person (allowing for some variation) the apex beat is usually felt in the left 5th
ICS, mid-clavicular line. If it is displaced laterally and /or inferiorly from the normal position
then it usually indicates dilatation of the heart.
The apex beat may also be displaced by other conditions including pleural or pulmonary
diseases and deformities of the chest wall or the thoracic vertebra.
You also need to be able to locate the position of the apex beat in order to listen to the mitral
valve
Manubrio-sternal angle and intercostal spaces
The manubrio-sternal angle is formed by the articulation of the manubrium with the body of the
sternum and can be recognised by the presence of a transverse ridge on the anterior aspect of the
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Cardiovascular System Examination
GEP Year 1 2014-2015
Lead Lecturer: Dr Hamed Khan
Tutor notes
sternum. It lies at the level of the second costal cartilage, the point from which costal cartilages,
ribs and intercostal spaces are counted (the second intercostal space lies just below this angle).

It is important to remember that when auscultating the heart we do not listen over the
anatomical position of the valves but in the following areas where the heart sounds and
murmurs are traditionally considered to be best heard




Mitral area
Tricuspid area
Pulmonary area
Aortic area

It is important to listen at the bases of the lungs for fine crackles/crepitations associated with
pulmonary oedema secondary to heart failure.
– 5th ICS, mid-clavicular line / position of apex beat
–lower left sternal edge at medial aspect of 4th IC space
– 2nd left intercostal space
nd
– 2 right intercostal space
Exercise
Using surface anatomy listen to the heart sounds in a colleague.
1. Familiarization with stethoscope
The traditional stethoscope has a bell and a diaphragm
 The bell is designed as a resonation chamber and is better for listening to low pitched
sounds.
 The diaphragm is used for listening to higher pitched sounds.
2. Identify the position of the apex beat by palpation
Position your colleague at 45 degrees. Feel initially with the flat of the hand with your fingertips in
the mid axillary line over the 5th and 6th ribs. Then move medially and localise the beat with one or
two fingers. The point furthest down and laterally at which the beat can be felt is the position
of the apex beat.
Describe the position in relation to the intercostal spaces and anatomical lines
3. Listen over the four auscultation areas for S1 and S2
Listen whilst your colleague holds their breath in and then whilst holding it out (remember that right
sided heart sounds are louder during inspiration and left sided during expiration).
Keep one finger on the carotid pulse to relate the sounds to the cardiac cycle. When listening to
the heart you need to be able to simultaneously palpate the carotid artery in order to relate the
sounds to the cardiac cycle.
 The pulse wave under your finger is systole. It is after S1 and before S2
 The pulseless period is diastole. It is after S2 and before S1
The 1st heart sound (S1)
 Is produced by the closure of the mitral and tricuspid valves.
 Marks the start of systole
 Just before the carotid pulse
The 2nd hear sound (S2) “dupp”
 Is produced by the closure of the aortic and pulmonary valves.
 Marks the start of diastole
 Just after the carotid pulse
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Cardiovascular System Examination
GEP Year 1 2014-2015
Lead Lecturer: Dr Hamed Khan
Tutor notes
Because systole is shorter than diastole S1 is heard as the first of two grouped beats and S2 is
heard as the second one - “lubb (S1) dupp (S2) lubb (S1) dupp (S2) lubb (S1) dupp (S2)’’ and
so on. Normally you should be able to hear the first and second heart sounds in all areas.
Each of these two normal heart sounds actually consists of two sounds very close together
because the two sets of valves (mitral+tricuspid and aortic+pulmonary) do not close
simultaneously. The left sided mitral and aortic valves close slightly before their corresponding right
sided tricuspid and pulmonary valves. This is termed physiological splitting of the heart sounds.


It is extremely difficult to hear the physiological splitting of S1.
S2 splitting is easier to hear especially during deep inspiration. This is because during
inspiration a decrease in thoracic pressure increases venous return to the right side of the
heart. This results in the right side taking longer to fill and contract which delays closure of the
pulmonary valve resulting in a wider gap.
Do not worry if you cannot hear the physiological splitting of the heart sounds at this stageoften the two sounds are extremely close together, and can be very difficult to distinguish.
You maybe able to hear that the second sound “split” in the pulmonary area. Ask your colleague to
take deep breaths and see if you can hear the physiological splitting vary with breathing (wider gap
in inspiration).
General points


When reporting your findings describe what you see not what you are “looking for”.
Remember to include the relevant negatives. Eg “The hands are warm and well perfused,
there is no peripheral cyanosis or tar staining”
Chaperones and supervision
In cardiovascular examination the chest does need to be exposed and the breasts may need to be
touched (eg palpation of the apex beat or when listen to the mitral valve). Hence, a chaperone
should be offered during a cardiovascular examination, and as with all intimate
examinations, you should make it clear to the patient that they will be examined again by
your clinical supervisor.
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Cardiovascular System Examination
GEP Year 1 2014-2015
Lead Lecturer: Dr Hamed Khan
Tutor notes
Examination of the Cardiovascular System- STEPS
INTRODUCTION AND PREPARATION











Introduce yourself by giving your full name and role
Check the patient’s name
Explain the examination using non-technical language. Explain that you will need to examine
their hands, face, neck and chest- and that they will need to be expose their chest but can keep
it covered until they are examined.
Explain that your supervisor will also examine the patient afterwards.
Obtain consent
Offer a chaperone (and ensure that they are present)
Document the above in the notes
Ask if the patient has any pain, and if so to describe where it is.
Ask the patient to report any pain when you are examining them
Clean your hands
Position your patient on the bed inclined at 45 degrees
INSPECTION FROM THE END OF THE BED
Bedside

Any equipment eg ECG monitor

Any medication eg oxygen, GTN spray
Patient
 Do they look well?
 Is their colour pale or cyanosed?
 Are they sweating profusely?
 Are they in pain?
 Are they breathless?
HANDS AND NAILS
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




Temperature – abnormally cool hands could represent reduced cardiac output due to shock
Moisture – sweaty clammy hands may be caused by a myocardial infarction (due to
sympathetic activation)
Peripheral cyanosis - deoxygenated blood due to decreased peripheral circulation (patients
with central cyanosis will usually also be peripherally cyanosed)
Tar stains - smoking
Osler’s nodes, Janeway lesions - infective endocarditis
Nails
 Clubbing - congenital heart disease, infective endocarditis, atrial myxoma
 Splinter haemorrhages - infective endocarditis
 Capillary refill. Squeeze the finger nail firmly for 2-3 secs and then release it, how quickly
does it go pink again? ≤2sec is regarded as normal at room temp - slow return is
consistent with reduced peripheral circulation
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Cardiovascular System Examination
GEP Year 1 2014-2015
Lead Lecturer: Dr Hamed Khan
Tutor notes
ARMS

Scars
Look specifically over the anterior aspect of the forearm for a scar. Many patients who have
undergone coronary artery by bass grafting (CABG) will have scars from radial artery grafts.

Radial pulses
Palpate one wrist first for the following:
 Rate- 15 sec and multiply by 4
 Rhythm- regular or irregular
 Volume- normal or thread (low volume)
 Character
o Slow rising pulse- this is a sign of aortic stenosis. A normal pulse will be felt as an
immediate bounding sensation. A slow rising pulse will be felt hitting your finger tips
and rising more slowly against it.
o Collapsing pulse- Feel for a “knocking” associated with aortic regurgitation. The
‘leaky’ incompetent valve will let the arterial pressure fall markedly in diastole, which
is the ‘collapse’ in a collapsing pulse (and which causes a wide pulse pressure). The
rapid downstroke can make each pulsation feel like a sudden ‘tap’ which can
sometimes even be palpated through the muscle bulk around the wrist.
 Radio-radial delay – check for this by palpating both wrists together and seeing if the
pulse is palpated at the same time on both wrists. If they cannot be palpated at the same
time, there is a radio-radial delay. This may indicate an aortic dissection.

Respiratory rate
Count the respirations for 15 sec and multiply by 4 to determine the rate- the normal respiratory
rate is 12-16 breaths a minute. Tachypnoea could be caused by severe hypoxeamia or
metabolic acidosis

Blood pressure
 High- eg hypertension
 Low- shock, aortic stenosis, heart failure
 Pulse pressure- the pulse pressure is the difference between the systolic and diastolic
blood pressures. A normal pulse pressure is 30-40mmHg, and an abnormal pulse pressure
can be a sign of valvular pathology.
o Wide pulse pressure (>40)- aortic regurgitation (caused by a low diastolic pressure
as blood regurgitates back in the aorta in diastole). Usually the diastolic blood
pressure is half of the systolic blood pressure in aortic regurgitation.
o Narrow pulse pressure (<30)- aortic stenosis (caused by a low systolic pressure
as blood flow is reduced)
FACE
Look for the following:
 Skin
 Malar flush - this is a “plum”/dark red discolouration over the cheekbones associated with
mitral stenosis.
 Eyes
 Xanthalasma - small fatty deposits around the eyes which may be seen in hyperlipidaemia.
 Corneal arcus - a white ring around the iris of the eye which may be seen in
hyprlipidaemia
 Conjunctival pallor – anaemia
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Cardiovascular System Examination
GEP Year 1 2014-2015
Lead Lecturer: Dr Hamed Khan
Tutor notes

Mouth
 Central cyanosis - ask your patient to touch the roof of their mouth with their tongue to that
you can see under the tongue for a bluish discolouration. This is due to desaturation of
central arterial blood resulting from cardiac and respiratory disorders associated with
shunting of deoxygenated venous blood into the systemic circulation. Patients who are
centrally cyanosed will usually have a dangerously low pO2 and will also be peripherally
cyanosed (as peripheral cyanosis occurs before central cyanosis)
 Dental hygiene (using a pen torch) Poor dental hygiene is a risk factor for endocarditis in
patients with abnormalities of one or more of the heart valves, congenital heart abnormalities
and artificial heart devices
 Dehydration causing hypotension
NECK

JVP
When examining from the right, ask the person to turn their head to the left.
It helps to get down to “gaze” across the SCM rather than looking down at the neck.
The internal JV can often be confused with the carotid artery. Although there are various ways
of distinguishing between the two, the simplest and most effective is to remember that the
carotid pulse is palpable, whereas the JVP is not (it can only be examined visually).
 Measure the height of the JVP
With the patient lying at 45 degrees, draw an imaginary horizontal line across the top of the
pulsation and measure the vertical distance from the manubriuo-sternal angle to this line.
The JVP is recorded as this height. The JVP is raised if it is over 3cm. A normal JVP is
less than this, and is often not visible at all.

Carotid pulses.
 Palpation: palpate one at a time- DO NOT EVER palpate both together as this could
occlude the brains arterial blood supply.
 Volume – eg normal, increased, low.
 Character – eg normal, slow rising
 Auscultate for a carotid bruit over each carotid with the bell.
Ask the patient to breathe in and hold their breath (don’t let the patient hold their breath
for too long).
9
Cardiovascular System Examination
GEP Year 1 2014-2015
Lead Lecturer: Dr Hamed Khan
Tutor notes
CHEST

Close inspection - look for:
 Scars eg midline sterniotomy
 Visible pacemaker under the skin
 Apex beat – in thin people this may be visible

Listen for mechanical sounds of an artificial metallic valve, which will be audible from the end
of the bed.

Palpation
 Apex beat. Feel initially with the flat of the hand with your fingertips in the mid axillary line
at the level of the 5th intercostal space. The point furthest down and laterally at which the
beat can be felt with one finger is the position of the apex beat. If it is hard to palpate ask
the patient to lean forward.
 Describe the character eg:
- Normal
- Tapping - mitral stenosis
- Double impulse- HOCM
- Heaving – LV hypertrophy
 Describe the position in relation to the spaces and lines
- Normal - left 5th ICS, mid-clavicular line.
- Displaced - lateral +/- inferior displacement suggests enlargement
 Heaves. Place your outstretched right hand just to the left of the sternum vertically (fingers
pointing upwards)
 A left parasternal heave will lift the heel of your hand with each heart beat. It is
suggestive of right ventricular hypertrophy.
 Thrills. Place the flat of your hand at the apex and the upper part of the precordiumwhat you will feel is a palpable murmur.
 Palpate all 4 areas of the praecordium using the centre of your palm
o Mitral area- start here, placing your palm horizontally on the chest
o Tricuspid area- place your palm vertically over this area
o Pulmonary area- place your palm diagonally with your finger pointing roughly
towards a 2’o’clock position
o Aortic area- place your palm diagonally at 45 degrees pointing roughly towards
a 10’o’clock position
 The commonest cause of a thrill is aortic stenosis.
 An alternative technique is place your palm in the following positions:
o Mitral area- palm horizontal
o Tricuspid area- palm vertical
o Pulmonary and aortic area- palm placed horizontally at the superior border of
the sternum, and then vertically at the right sternal edge
Your tutors will demonstrate both techniques- both are perfectly valid.
Tutors: please ensure that you watch this part carefully during your briefing, and demonstrate it to
your students
10
Cardiovascular System Examination
GEP Year 1 2014-2015
Lead Lecturer: Dr Hamed Khan
Tutor notes

Auscultation
Listen to the four main valve areas whilst palpating the carotid pulse to time the heart sounds (if
you are unable to palpate the carotid pulse, the brachial pulse could also be used although the
central pulses are more reliable). Listen with the patient holding their breath in inspiration and
then in expiration (don’t let the patient hold their breath for too long!)
 Listen specifically to S1 then S2
 Are there any added sounds or murmurs?
 Determine the timing of any added sound or murmur in relation to the cardiac cycle.
o Murmurs audible at the same time as when the pulse is palpable are systolic
murmurs
o Murmurs audible between pulsations are diastolic murmurs
 If anything abnormal is found, move the stethoscope around until the abnormality is heard
most clearly and explore where it radiates to.
Positioning and areas to be auscultated:
 Four areas of the heart corresponding to the valves as below. (Mitral/ Tricuspid/
Pulmonary/ Aortic)
 Lying on their left side (mitral stenosis)
 Sitting forwards (aortic regurgitation)
Mitral area – position of apex beat
 Listen initially with the diaphragm. If you hear a systolic murmur at the apex it is
important to listen around the chest wall laterally towards the axilla and listen there too.
Although systolic murmurs of all types might be heard here, the pansystolic murmur of
mitral regurgitation is loudest at the apex and radiates into the left axilla.
 Then roll the patient onto their left and listen again with the BELL at the apex: S3 and S4
are best heard here and it is the ideal position for auscultating the low-pitched middiastolic murmur of mitral stenosis.
Tricuspid area – 4th intercostal space, left sternal edge
 Ask the patient to roll back to the straight position, listen with the diaphragm
Pulmonary area – 2nd intercostal space, left sternal edge
 In the same straight position listen with the diaphragm
Aortic area – 2nd intercostal space, right sternal edge
 In the same straight position listen with the diaphragm – this is the best place to listen for a
systolic aortic murmur. If you hear a systolic murmur, listen over the carotid arteries on
both sides of the neck between the thyroid cartilage and the angle of the jaw for radiation
of this murmur. The systolic murmur of aortic stenosis often radiates to the carotids
 Then sit the patient up leaning forwards. This position is best for listening for the diastolic
murmur of aortic regurgitation. Listen with the diaphragm in the aortic area and then in
the third/fourth intercostal space at the left sternal edge. The murmur is best heard when
the patient is holding their breath in expiration.
Posterior aspect of chest (the patient should now be sitting up)


Auscultate for fluid in the base of the lungs.
 Mild pulmonary oedema will give rise to fine crackles/crepitations.
Palpate for sacral oedema
 Press gently with your thumb for a few seconds over the sacrum
11
Cardiovascular System Examination
GEP Year 1 2014-2015
Lead Lecturer: Dr Hamed Khan
Tutor notes
LEGS

Palpate for ankle oedema.
 Press gently with your thumb for a few seconds over the ankle.
 Residual indentation when you remove your finger indicates oedema
Consider other examinations depending on the clinical scenario:
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Radio-femoral delay (coarctation of the aorta)
Peripheral vascular examination
Abdomen - enlarged liver (in heart failure)
Fundoscopy (flame shaped haemorrhages in infective endocarditis)
Temperature (pyrexia in infective endocarditis)
CLOSURE

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Thank the patient, tell them they may get dressed and ensure comfort
Clean your hands and your stethoscope.
Report or record your findings.
Common valvular conditions found on cardiovascular examination
(Reproduced with permission of Wiley-Blackwell from 'OSCE's for Medical Finals' by H Khan et al)
12
Cardiovascular System Examination
GEP Year 1 2014-2015
Lead Lecturer: Dr Hamed Khan
Tutor notes
CARDIOVASCULAR EXAMINATION- SUMMARY
INTRODUCTION
 Name/role
 Check patients name
 Explain examination and exposure
 Explain that they will be examined again by supervisor
 Consent
 Offer Chaperone
 Document
 Ask about pain
 Clean your hands
 Position at 45 degrees
 Ensure adequate exposure
INSPECTION
 Bedside
o Equipment (ECG, GTN spray)
 Patient
o Distress/Pain/Pallor/Cyanosis/Sweating/Breathless
HANDS
 Nails
o Clubbing (congenital heart disease, atrial myxoma, endocarditis)
o Splinter haemorrhages (infective endocarditis)
o Capillary refill time (2-3s)
o Tar stains (smoker)
 Sweaty/clammy (eg MI)
 Oslers nodes (endocarditis)
 Peripheral cyanosis
 Janeway lesions (endocarditis)
RADIAL PULSE
 Rate (15s X 4 normal is 60-100)
 Rhythm (regular, irregular)
 Character (slow rising = AS, collapsing = AR)
 Volume (hypovolaemic/’thready’  MI/heart failure/AS))
 Radial-radial delay (aortic dissection)
RESPIRATORY RATE
 15s X 4  N = 12-16
ARMS
 Blood pressure
o Pulse pressure (wide/>40 = AR, narrow/<40 = AS)
 Scars
o CABG graft from radial artery
FACE
 EYES
o Xanthalasma (hyperlipidaemia)
o Corneal arcus (hyperlipidaemia)
o Conjunctival pallor (anaemia)
13
Cardiovascular System Examination
GEP Year 1 2014-2015
Lead Lecturer: Dr Hamed Khan
Tutor notes


FACE
o Malar flush (MS)
MOUTH
o Central cyanosis
o Dental hygene
o Dehydration
NECK
 JVP (>3cm = R heart failure, TR)
 Carotid pulse
o Volume
o Slow rising
o Auscultate
CHEST
 INSPECTION
o Scars (eg midline sternotomy)
o Pacemaker
o Apex beat
 Metallic heart valve (audible without stethoscope)
 PALPATION
o Apex beat
o Heaves (L parasternal heave = RVH)
o Thrills
 AUSCULTATION
o HS 1+2  time with carotid pulse
o Murmurs + added sounds
 Time with carotid pulse
 Inspiration (to accentuate R sided sounds) and expiration (accentuate
L sided sounds)
 Apex/mitral (5th ICS mid-clavicular line)
o Bell and diaphragm
 Tricuspid (4th ICS L sternal edge)
 Pulmonary (2nd ICS L sternal edge)
 Aortic (2nd ICS R sternal edge)
 Special positions
o Left lateral position  MS murmur
o Sitting up leaning forward  AR murmur
o Lung bases (crackles- pulmonary oedema)
ANKLES/SHINS
 Peripheral oedema
CONSIDER OTHER EXAMINATIONS
 Radio-femoral delay (coarctation of the aorta)
 Peripheral vascular examination
 Abdomen - enlarged liver (in heart failure)
 Fundoscopy (flame shaped haemorrhages in infective endocarditis)
 Temperature (pyrexia in infective endocarditis)
CLOSURE
 Thank the patient
 Help them get dressed
 Clean hands and stethoscope
14
Cardiovascular System Examination
GEP Year 1 2014-2015
Lead Lecturer: Dr Hamed Khan
Tutor notes
Self Directed Learning
JVP
It is difficult to see the JVP in a normal person - it is easier to see if it is abnormal.
It can also be difficult to distinguish between the JVP and the carotid pulsation.
With practice it will become easier. You may find the following table helpful.
Mnemonic “POLICE”
Palpability
Occludability
Location
Inspiration
Contour
Erect position
JVP
Normally not palpable
Pulsations eliminated by light
pressure
Pulsation between heads of
SCM
Level of pulsation descends
with inspiration
Rapid,
two
waveforms
(elevations)
Decreases in erect position
Carotid pulse
Palpable
Not occludable
Medial to SCM
Level of pulsation unaffected
Single elevation
Unaffected
The most important of these is the ability to palpate the carotid artery- the jugular vein, in
contrast, cannot be palpated.
Once you can see the JVP try
to assess the wave form.
There are normally two
components.
Feel the carotid pulse on the
other side to determine which
is the “v” wave of ventricular
contraction during systole and
which the “a” wave of atrial
contraction during diastole.
Heart murmurs
In T-year you will be examining real patients who may have heart murmurs.
Please prepare for this in advance. Resources inc- Harvey, heart sound simulators
How to describe a heart murmur.
As junior doctors you should be able to recognise common murmurs. However, you will hear
murmurs that you do not recognise. This is not important, provided you are able to describe it
accurately in a systematic way so that a more senior colleague will be able to make a diagnosis.
The following system is commonly used to assess heart sounds and murmurs:
1. Sounds. Assess S1 and S2 - is S2 splitting physiological, fixed or paradoxical?
15
Cardiovascular System Examination
GEP Year 1 2014-2015
Lead Lecturer: Dr Hamed Khan
Tutor notes
Normally the splitting of the second sound widens during inspiration. In certain pathological
conditions the splitting does not vary at all during breathing (fixed), and may even be wider during
expiration (paradoxical).
2. Position in the cardiac cycle: Is it occurring in systole or diastole?
Keep your finger on a carotid artery and orientate yourself in the cardiac cycle.
3. Point of maximum intensity Where is the murmur heard the loudest?
It is important to listen all over the precordium.
4. Radiation: axilla, carotids, sternum.
5. Intensity: How loud is the murmur? Use the 1 - 6 grading to describe this.
Grade 1 - the faintest murmur that can be heard under optimal conditions (very quiet room, relaxed
patient etc...)
Grade 2 - a soft but readily audible murmur
Grade 3 - loudness equal to normal heart sounds – this grade is easy to hear.
Grade 4 - a very loud murmur that is palpable (thrill)
Grade 5 - louder still (thrill)
Grade 6 - a murmur heard without a stethoscope + thrill
Recording 3/6 means that in this 6-grade scale, the patient's murmur intensity is 3 which is the
same loudness as normal heart sounds.
6. Character:
 loud or soft – this is not the same as intensity, it is a more qualitative description which you
will learn with experience.
 pitch - squeaking, rumbling, "scratchy"
 duration
 pansystolic - you can hear it throughout the systole, all the way from S1 to S2
 early diastolic/systolic - just after S2/S1
 mid-diastolic/systolic - halfway between S2 and S1/S1 and S2
 late-diastolic/systolic - just before S1/S2
 continuous - begins with S1 and continues through S2 into diastole
 shape:
 crescendo
 decrescendo
 crescendo-decrescendo
 decrescendo-crescendo
7. Relation to posture:
 sit forward- aortic incompetence louder
 lie left side – mitral stenosis louder
8. Relation to respiration:
 inspiration increases the murmur of a right heart lesion
 expiration increases the murmur of a left heart lesion
16
Cardiovascular System Examination
GEP Year 1 2014-2015
Lead Lecturer: Dr Hamed Khan
Tutor notes
A murmur description – example aortic stenosis.
1. Sounds
Sound S1 unremarkable
Sound S2: A2 (aortic component of second sound) soft or absent (P2 can be mistaken for A2
because it sounds louder!) PLUS paradoxical splitting.
Other sounds: may include S4 and aortic ejection sound
2. Position in the cardiac cycle: Early-mid systolic
3. Maximum: aortic area (2nd right intercostal space)
4. Radiates upward to both carotids and downward to the left and the apex
5. Intensity: >3/6
6. Character
 loud
 rough, grunting
 increases with disease progression
 crescendo-decrescendo
7. Posture - best heard in the patient sitting forward
8. Not relevant
You need to be familiar with the following murmurs.




Aortic stenosis
Aortic regurgitation
Pulmonary stenosis
Mitral regurgitation
What exactly is happening in the heart to generate these murmurs?
What conditions predispose to these murmurs?
What other clinical signs might you elicit?
Note on stethoscopes:
The skills department can only afford basic stethoscopes for large groups. These will allow you to
hear all normal physical signs but are clearly not as good as the more expensive models,
particularly once you reach the wards and are trying to hear quieter sounds and more subtle
differences.
You will probably want to have your own stethoscope. It may be worth getting it sooner so that you
get used to it.
17
Cardiovascular System Examination
GEP Year 1 2014-2015
Lead Lecturer: Dr Hamed Khan
Tutor notes
References and Further Reading




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

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Khan, H et al. (2013) OSCE’s For Medical Finals, Blackwell, Oxford
Hansen J, Lambert D (2005) Netter’s Clinical Anatomy, Icon Learning Systems, New
Jersey
Moore K L, Dalley A F (2006) Clinically Oriented Anatomy 5th Edition, Lippincott, London
Talley J N, O’Connor S (2006) Clinical Examination, Churchill Livingstone, London
Cox N L T, Roper T A (ed.) (2006) Clinical Skills, Oxford University Press, Oxford
Bickley L S, Hoekelman R A (1999) Bates’ Guide to Physical Examination 7th Edition,
Lippincott Hurley K F (2005) OSCE and Clinical Skills Handbook Elsevier Saunders,
Canada
Welsby P D (2002) Clinical History Taking and Examination 2nd Edition, Churchill
Livingstone
Douglas G. Nicol F. Robertson C. (ed) (2005) Macleod’s Clinical Examination 11th Edition,
Churchill Livingstone
Acknowledgements
Special thanks to Dr Rajan Sharma (Consultant in Cardiology) and Dr Iqbal Khan (Clinical Fellow
in ITU) for his valuable contribution to this handout.
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