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Examination of the Cardiovascular system
Tutors:
Students saw a demo of a cardio respiratory examination and covered the principles of
systematic examination in the introductory session.
They have also already done BP, pulses and respiratory rate
Time
5 min
15 min
Activity
Setting the stage
 Introductions
 Motivation (Clinical relevance) –essential skill, CVD is common
 Explain objectives for session
 Stimulate prior recall – Introduction – systematic examination and Vital Signs


Exercise 1 – Surface anatomy
Exercise 2 – Apex beat and listening to normal heart sounds (working in threes
using the other cubicle.)
30 min
Core learning activity –
4 stage teach as per handout
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 1 – Perform examination without talking
 Stage 2 – run through the examination explaining what you are doing and
describe any findings (positive or negative).
 Stage 3 – ask the students to guide you through the examination.
 Stage 4 – get the students to do the examination – they can do one bit each to
break it up.
35 min
Practice with feedback
 Break into two groups using both cubicles for practice.
5 min
Encourage ongoing practice and transfer
 Encourage on-going practice,
 Self directed learning JVP and murmurs in preparation for T-year
 Remind re SDL room/Harvey/discs
1
Examination of the Cardiovascular system
Learning outcomes
By the end of this session you should be able to:
 Apply the principles of systematic examination to the cardiovascular system
 Carry out a competent examination of the cardiovascular system on a colleague
 Recognise and describe normal heart sounds
Dress Code
Policy
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 useful 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 learned how to palpate the radial and carotid pulses, measure
the pulse rate and take blood pressure – essential components of the CVS
examination.
 The peripheral vascular examination is also considered part of a full
cardiovascular examination. This will be covered in a separate session.
Related Basic Science
Please prepare for this session by understanding the relevant physiology and
learning the relevant anatomy below.
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 heart fails and is unable to pump effectively, 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 a line
into the superior vena cava via the internal jugular or subclavian vein, and attaching a
manometer. This records the central venous pressure (CVP).
2
Examination of the Cardiovascular system
Laminar v turbulent flow, heart sounds.
Sounds heard from the vascular system indicate turbulent flow – normal smooth
laminar flow is not audible. The normal heart sounds reflect the turbulence created
as valve cusps abruptly close.
The first sound (S1) comprises closure of the mitral and tricuspid valves.
The second sound (S2) comprises closure of the aortic and pulmonary valves.
Each of these two normal heart sounds actually consist of two sounds very close
together because the two valves do not close simultaneously- the left sided mitral
and aortic valves close slightly ahead of their corresponding right sided valves.
It is extremely difficult to hear the physiological splitting of the first heart sound.
Physiological splitting of the second sound 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. The results in the right side
taking longer to fill and contract which delays the closure of the pulmonary valve
resulting in a wide gap.
Because of the nature of the sounds we use the diaphragm of the stethoscope to
listen with apart from at the apex when we use the bell.
 In a normal subject you should be able to hear the first and second heart sounds
in all areas. In at least the pulmonary area you should be able to hear that the
second sound is “split” and that this splitting varies with inspiration.
 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.
 Sounds from the apical region can be accentuated by rolling the patient partially
onto their left side and listening round towards the axilla with the bell of the
stethoscope.
 Aortic sounds can be accentuated by sitting the subject up, leaning them
forwards and listening whilst holding the breath in expiration.
 To avoid being confused by breath sounds you can ask the patient to hold their
breath whilst listening in all areas – but remember to hold yours as the same time
so that you can tell them to start breathing again in time to stop them getting
uncomfortable.
Additional and abnormal sounds arise when flow is rapid or when it is constricted.
Examples:
 Rapid flow of blood, through a stenosed valve, for example, will give rise to a
murmur and the timing of this will depend on when blood is flowing through it
in the cardiac cycle.
 A fourth heart sound can occur in late diastole just before the first heart
sound. It is produced during atrial contraction when a sudden bolus of blood
hit a stiff, non-compliant ventricle. It is pathological.
3
Examination of the Cardiovascular system
Anatomy
It is essential to know the following surface anatomy:
Exercise 1
Work through the following landmarks with your tutor using a volunteer.
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.
The internal jugular vein
This 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, and unites with the subclavian vein behind the medial end of
the clavicle to form the brachiocephalic vein.
The sternocleidomastoid muscle
This muscle has two heads. Their 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. For educational reasons identify the other head by
asking your volunteer to tilt the head slightly upwards against resistance (place hand
over mandible) and you will see the head which attaches to the clavicle. If done
correctly the ear on the same side as the muscle being tested should feel as though
it is being pulled down towards the sternum.
Manubrio-sternal angle.
This 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
sternum. The transverse ridge lies at the level of the second costal cartilage, the
point from which costal cartilages, ribs and intercostal spaces are counted.
Mid clavicular line
This runs vertically downwards from the midpoint of the clavicle (in males the line
usually falls just medial to the nipple)
Anterior axillary line
This runs vertically downward from the anterior axillary fold (find the edge of the
pectoralis major muscle)
Posterior axillary line
This runs vertically down from the posterior axillary line (find the edge of the
latissimus dorsi muscle)
Mid axillary line
This runs vertically downwards from a point midway between the anterior and
posterior folds.
Lung bases
The lungs only fill about half the space under the ribcage and extend down to the 89th rib posteriorly. A useful landmark is the tip of the scapula which approximates to
level T6
4
Examination of the Cardiovascular system
Exercise 2
Palpate the apex beat, listen to and recognise normal heart sounds in a colleague.
Gross anatomy of the heart
 The sternocostal surface of the heart is formed mainly by the right atrium and
right ventricle.
 The right border is formed mainly by the right atrium
 The left border is formed by the left ventricle and part of the left auricle.
 The apex of the heart, formed by 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.
In a normal person the apex beat is usually felt in the left 5th ICS, mid-clavicular line.
Auscultation areas
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 (which lie “downstream”
in the direction of flow through the valve concerned):
Mitral area
– apex
Tricuspid area
– lower left sternal edge
Pulmonary area
– 2nd left intercostal space
Aortic area
– 2nd right intercostal space
Work in threes using both cubicles
Identify the following and listen in all the areas.
Use the diaphragm of the stethoscope apart from at the apex when we use the bell
and keep one finger on the carotid pulse for orientation.
Apex beat – Feel initially with the flat of the hand and then localise to the point
furthest down and laterally at which the beat can be felt with one finger. Describe the
position carefully in relation to the intercostal spaces and anatomical lines.
Tutors - Stress that they must find the apex beat by palpation and then work out where
it is (rather than finding the 5th LICS and looking there for the apex beat)
Mitral area
Listen where you have identified the apex beat
Tricuspid area
Listen at the lower left sternal edge
Pulmonary area
Listen in the 2nd left ICS, ask your colleague to take deep breaths and see if you can
hear the physiological splitting vary with breathing (wider gap in inspiration).
Aortic area
Listen in the 2nd right ICS
Then roll your colleague onto their left side, listen again at the apex with the bell and
towards the axilla to accentuate the mitral sounds. You may also be able to hear a
physiological third sound in this position.
Then sit your colleague up leaning forwards and ask them to breathe out and hold
their breath (this position will accentuate aortic sounds) - listen using the diaphragm
again in the aortic area.
5
Examination of the Cardiovascular system
Examination of the Cardiovascular System
General notes
 The order in which an examination is carried out is designed to minimise
discomfort and inconvenience to the patient
 You should communicate with the patient as you go along
 Describe what you find as you go along - it will help you to remember
 You should describe what you see or cannot see rather than what you are
“looking for”.
 In clinical practice an examination is carried out after you have taken the history you may have a possible diagnosis in mind and will be looking for specific signs.
 During your clinical attachments you will learn which signs go with which diseases
 Concentrate now on becoming really familiar with the normal CVS exam.
Introduction and Preparation
 Introduce yourself to the patient and check the patient’s name
 Explain the procedure. Use words that patients will understand and explain that
you need to examine their hands, face and neck as well as their heart. They will
need to expose their chest but this can be kept covered until the chest is
examined.
 Gain consent.
 Clean your hands
 Position the patient on the bed inclined at 45 degrees.
 Ask the patient if they have any pain, and if so where?
Examination
General inspection
 Do they look well? Are they sweating or in pain? Is their colour normal? Are
they breathless?
 Look around the bed. Any equipment eg ECG monitor, medications eg oxygen,
GTN spray etc?
Hands and nails - remember that the hands may show signs of disease in any body
system.
 Is there a tremor?
 Is the colour normal or abnormal:
 unusually pale
 unusually red (vasodilatation from carbon dioxide retention)
 blue ( cyanosis).
 Are there tar stains on the fingers?
 Are there any Osler’s nodes or Janeway lesions (infective endocarditis)
 Look at the nails – any clubbing or splinter haemorrhages?
 Capillary return rate - squeeze the finger nail firmly for a few seconds and then
release it, how quickly does it go pink again? Colour normally returns within 2-3
sec.
Radial pulses and respiratory rate
 Take hold of both wrists and feel both pulses. Are they the same?
 If so keep hold of the right wrist and count the pulse (15 sec if it is regular or 30
sec if it is irregular). You need to determine the rate, rhythm and volume of the
pulse.
 Count the respiratory rate for 30 sec and determine the rate.
6
Examination of the Cardiovascular system

Feel for a collapsing pulse – ask the patient if they have any shoulder pain – if not
then support and lift the arm above the level of the heart whilst feeling across the
radial pulse with your fingers.
Blood pressure. Tutors –there is no need to do this today but emphasise that this is
when you would normally do it.
Face
 Is there malar flush?
 Look for small fatty deposits around the eyes (xanthalasma) or a white ring
around the iris of the eye (corneal arcus) which may be seen with lipid disorders.
 Look in the lower fornix of the eye – the easiest place to see anaemia (warn the
patient that you are going to do this).
 Look in the mouth for central cyanosis. The best place to look is underneath the
tongue. Ask your patient to touch the roof of their mouth with their tongue to that
you can see this.
 Check dental hygiene using a pen torch.
Neck
 JVP
 When examining from the RHS, ask the person to turn their head to the left.
 It helps to get down so that you are “gazing” across the SCM rather than
looking down at the neck. Shining a light across the SCM may also help.
 Do not confuse the internal jugular vein with the external jugular vein. The
latter is relatively superficial and tends to lie more laterally.
 In order to measure the approximate pressure within the jugular vein draw an
imaginary horizontal line across the top of the pulsation.
 Measure the vertical distance from the manubriuo-sternal angle to this line.
 The JVP is recorded as this height. In a normal person it is usually 2-3cm.
o

If a person has a low JVP you may need to lie them flatter in order to see
the top of the “column” because at 45 degrees the top of the column may be
hidden behind the sternum.
o Conversely, if a patient has a markedly raised JVP, you may need to
increase the angle in order to see the actual height because at 45 degrees
the top of the “column” may be difficult to see behind the ear.
 Describe the wave- form – see self directed learning.
Carotid pulses. Palpate one at a time. Determine the volume and character.
Precordium
 Close inspection
7
Examination of the Cardiovascular system



 Is the chest a normal shape?
 Are there scars eg sterniotomy, pacemaker?
 Is there a visible pacemaker under the skin?
 Can you see the apex beat? Is it normal?
 Listen for audible mechanical sounds (artificial valve)
Palpation
 Apex beat. Feel initially with the flat of the hand and then localise to the point
furthest down and laterally at which the beat can be felt with one finger.
Describe the character and position and of the apex beat in relation to the
intercostal spaces and the clavicle. It is important to be able to locate this
position accurately because it will tell you whether the apex is displaced, for
example due to cardiac enlargement in heart failure. (In a normal person the
apex beat is normally felt in the left 5th ICS, mid-clavicular line).
 Heaves and thrills. Feel to the left and then the right of the sternum with the
flat of the hand. Abnormally forceful heart action will be felt as a “heave” and
loud murmurs will be felt as a “thrill” – a vibration (like a cat purring). You
would not expect to feel anything in a normal subject.
Percussion
 In theory you can percuss the heart to determine its size but this is not useful
or reliable and is no longer done.
Auscultation
 Listen to the four main valve areas keeping one finger on the carotid pulse for
orientation. Use the bell for the mitral area and diaphragm for the other areas.
Mitral area
– apex
Tricuspid area
– lower left sternal edge
Pulmonary area
– 2nd left intercostal space
Aortic area
– 2nd right intercostal space
At each point listen specifically to the first heart sound, then to the second.
Are there any added sounds or murmurs?
Determine the timing of any murmur in relation to the cardiac cycle.
 Then roll the patient onto their left to accentuate mitral valve sounds and
murmurs. Listen again (bell) at the apex and round towards the axilla
 Then sit the patient up leaning forwards and ask them to breathe out and hold
their breath to accentuate aortic valve sounds and murmurs. Listen again
(diaphragm) at the second right intercostal space and to the third or fourth
intercostal space at the left sternal edge. (Don’t let the patient hold their
breath for too long!)
 Then listen over the anterior part of the SCM above the medial end of the
clavicle for aortic bruits / radiation of murmurs. Listen on both sides.
Back of chest and legs (the patient should now be sitting up following
auscultation)
 Inspect for scars
 Auscultate for fluid in the base of the lungs. Mild pulmonary oedema will give rise
to fine crackles/crepitations.
 Palpate for Oedema. Press firmly with a finger or thumb for a few seconds over
the sacrum and ankle. There should be no residual indentation when you remove
your finger.
Full peripheral vascular exam
This is an essential part of any cardiovascular examination. Tutors –there is no need
to do this today but emphasise that this is when you would normally do it.
Closure
8