Clinical Examination of the Cardiovascular System

Observation
- breathlessness, distress
- body mass (obesity, cachexia), Marfans and other syndromes
- tissue perfusion skin temperature, sweating, urine output

Hands - clubbing, cyanosis, splinter haemorrhages and other stigmata of infective endocarditis

Radial pulse rate, rhythm

Blood pressure

Carotid pulses stroke volume and arterial compliance determine character, and is best assessed
by palpating the carotid or brachial arteries. Aortic regurgitation, anaemia, sepsis, and other causes
of large stroke volume typically produce a bounding pulse with a high amplitude and wide pulse
pressure. Normal sinus rhythm produces a pulse that is regular in time and force. Arrhythmias may
cause irregularity. Atrial fibrillation produces a pulse that is irregular in time and volume.

Jugular venous pressure the internal jugular vein, superior vena cava and right atrium are in
continuity, so the height of the jugular venous pulsation reflects right atrial pressure and therefore is
elevated in right heart failure and reduced in hypovolaemia. When patient is place at 45 degrees
with head supported and turned to the left, the JVP is visible along the line of the
sternocleidomastoid muscle. If JVP is not seen, then it may be highlighted by placing pressure on the
abdomen. In sinus rhythm, the two venous peaks, the a and v waves, approximate to atrial and
ventricular systole respectively. The x descent reflects atrial relaxation and apical displacement of
the tricuspid valve ring. The y descent reflects atrial emptying early in diastole. Tricuspid
regurgitation produces giant v waves that coincide with ventricular systole.

Distinguishing venous/arterial pulsation in the neck venous pulse has two peaks in each cardiac
cycle, the arterial pulse has one. The height of the venous pulse varies with respiration falls on
inspiration) and position. Abdominal compression causes the venous pulse to rise. Venous pulse is
not palpable and can be occluded by light pressure.

Face, mouth, and eyes pallor, central cyanosis, malar flush, dental caries, fundi (retinopathy),
xanthelasma and corneal arcus, stigmata of hyperlipidaemia and thyroid disease.

Precordium
- Technique place fingertips over apex to assess for position and character. Place heel of hand over
left sternal edge for a parasternal heave. Assess for the presence of thrills in all areas including the
aortic and pulmonary areas.
- Common abnormalities of the apex beat volume overload, such as mitral or aortic regurgitation:
displaced, forceful. Pressure overload, such as aortic stenosis, hypertension: discrete, thrusting.
Dyskinetic, such as left ventricular aneurysm: displaced, incoordinate.
- Other abnormalities palpable S1 (tapping apex beat: mitral stenosis), palpable P2 (severe
pulmonary hypertension), left parasternal heave felt by heel of hand (right ventricular
hypertrophy), palpable thrill (aortic stenosis)

Auscultation use the diaphragm to examine at the apex, lower left sternal edge (tricuspid) and
upper left (pulmonary) and right (aortic) sternal edges. Use the bell to examine low pitched noises,
particularly at the apex for mid-diastolic murmurs. Time the sounds and murmurs by feeling the
carotid pulse; systolic murmurs are synchronous with the pulse. Listen for radiation of systolic
murmurs, over the vase of the neck (aortic stenosis) and in the axilla (mitral incompetence). Listen
over the left sternal border with the patient sitting forward (aortic incompetence), then at the apex
with the patient rolled on to the left side (mitral stenosis)

Back lung crepitations, sacral oedema

Abdomen hepatomegaly, ascites, aortic aneurysm, bruits

Tendon xanthomas - hyperlipidaemia

Femoral pulses radio femoral delay, bruits

Legs peripheral pulses, oedema, vasculitis in a patient with infective endocarditis