Introduction
At the start:
Wash your hands, introduce yourself, obtain consent.
Patient position:
Always make sure the patient is comfortable. Sit the patient up at 45o. Obtain adequate exposure - the patient should be exposed upto the waist. For female patients, bras should ideally be removed, or else it can be very difficult to palpate or auscultate at the apex.
Pulse
General tips:
- Note the following: rate / rhythm / character / symmetry (between left & right side).
- Always palpate: Radial and carotid pulses.- Consider palpating: Other relevant pulses (brachial, abdominal aorta, femoral, popliteal, posterior tibial and dorsalis pedis). The brachial pulse should certainly be used if asked to measure the Blood Pressure. It may also be worth routinely palpating for radio-femoral delay (a sign of coarctation of the aorta).
What to do:
1. Palpate the radial pulses of both arms at the same time. Initially count the rate (ideally you should do this for 30seconds). Also befeeling for radio-radial differences/delay (a feature of aortic dissection).
2. Note the following features of the pulse:
Rate: Tachycardia (>100bpm) can be caused by anxiety, pain, congestive cardiac failure, pulmonary emboli,hyperthyroidism, anaemia, fever/sepsis, medications (eg. beta-agonists such as Salbutamol), etc. Bradycardia (<60bpm) can be caused by medications (beta-blockers, hypothyroidism, hypothermia, sick sinus syndrome, etc.).
Rhythm: Is the pulse regular or irregular? If irregular, is it 'regularly' irregular (fixed extra or skippedbeats), or is it 'irregularly' irregular (indicating Atrial Fibrillation).
Character: A collapsing pulse (also known as a 'water-hammer' pulse) is jerky, with a full expansion phase followed by a sudden collapse upon raising the arm to above heart level (seen mainly with Aortic Regurgitation, however other causescan include a Patent Ductus Arteriosus, thyrotoxicosis, A-V fistulae, pregnancy, Paget?s disease and anaemia). An anacrotic (slow rising) pulse is seen in Aortic Stenosis. Pulses alternans (regular rate, alternating amplitude that varies from beat-to-beat) is seen in Left Ventricular Failure. Pulses bisferiens (2 strong systolic peaks separated by a midsystolic 'dip') is seen in aortic valve disease and hypertrophic cardiomyopathy. A diacrotic pulse (two systolic and diastolic peaks) is seen in septic, hypovolaemic and cardiogenic shock. Pulsus paradoxus is seen in severeasthma, cardiac tamponade and massive Pulmonary Emboli. The pulse pressure normal falls with inspiration, however when this is exaggerated(>10mmHg difference) then this is deemed pulsus paradoxus.
3. Mention to the examiner at this point, that you would ideally like to measure the Blood Pressure. If they want to you to do this, thenthey will hand you a sphygmomanometer. If they wish you to carry on with your examination, they will usually tell you what the blood pressureis. Don't ignore what they say - it could give you a clue as to the diagnosis! A narrow pulse pressure (pulse pressure=systolic-diastolic)is a feature of aortic stenosis. A widened pulse pressure is a feature of aortic regurgitation.
4. If you wish to feel for radio-femoral delay (seen in coarctation of the aorta), then do so at this stage. Remember to explain to the patient what you are doing before you just reach for their groin!
5. Palpate the carotid pulse before you examine the face, or else you may forget later. Never palpate both sides at once - inducing a spotof syncope in your older patients is not something you ideally want to do in an exam. Note the same features of this pulse. Some of the signsmay be easier to determine in this pulse, as compared to the radial pulse.
Face
General features:
- Anxious / apprehensive looking facies: pain, anxiety, respiratory distress (could be a sign of a Myocardial Infarction or angina-relatedchest pain, Pulmonary Embolus, Pulmonary oedema / heart failure, and various cardiac arrhythmias, including AF, supraventricular tachycardias and ventricular tachycardia.
- Colour: Many conditions can lead to a change in the normal colour of the skin, particularly noticeable at the face. These include: Malar flush: Red areas on the upper cheeks - seen in Mitral Stenosis and similar to the butterfly rash of Systemic Lupus Erythematosus. Polycythemia: causes a dark reddish appearance to the skin. It is important, as it can be a cause of thrombotic events, infarcts andhypertension. Haemochromatosis: also known as 'bronze diabetes' due to the deposition of iron (can lead to cardiomyopathy). Addison's disease:dark buccal pigmentation (can be a cause of hypotension). Carcinoid syndrome: Release of 5-HT leads to flushing and hypotension.
- Shape: Classical 'moon-face' of Cushing's disease (a cause of hypertension).
- Skin texture: Coarse & dry 'toad face' of hypothyroidism (can cause bradycardia).
- Central cyanosis: A blue-ish tongue suggests either a right to left intra-cardiac shunts or lung disease.
- Head shape: Paget's disease: features a large head (can lead to high-output failure). Marfan's syndrome (long narrow face - associated with aortic regurgitation). Williams syndrome (small elf-like forehead, turned up nose, low set ears - associated with Aortic Stenosis). Noonan's syndrome (widely set eyes, web neck - associated with Pulmonary Stenosis.
Eyes:
- Roth spots: Retinal haemorrhages (white/pale centres), usually seen on fundoscopy. Caused by microemboli (bacterial endocarditis). Roth's spots may be observed in leukaemia, subacute bacterial endocarditis, ischemic events associated with elevated venous pressure and systemic vascular conditions with capillary fragility.
- Xanthelasma: Yellowish macules on the eyelids (similar to tendon xanthomata) seen in hypercholesterolaemia.
- Eyelid (periorbital) oedema: Seen in hypothyroidism, nephrotic syndrome, etc.
- Exophthalmos: Along with other signs such as eyelid retraction, is a feature of (hyper)thyroid eye disease (which causes AF and can lead to a high-output heart failure).
- Corneal arcus senilis: A grey-ish ring around the outer cornea. Whilst relatively common in the elderly, in young people it can indicates hypercholesterolaemia.
- Blue sclera: Seen in Marfan's and Ehlers-Danlos syndromes (is associated with Aortic Regurgitation, as well as Mitral Valve Prolapse, and Atrial Septal Defects.) Lens subluxation is another feature of Marfan's.
- Argyll Robertson Pupil: The 'prostitute's pupil' - accommodates, but does not react (to light). Seen in neurosyphilis (which can causeAortic Regurgitation).
Jugular Venous Pressure/Pulse ('JVP')
How to perform:
- Get the patient to turn their head away from you and hold it still. You should then look 'along' the skin (ie. with your line of sight almostin line with the neck surface). Look for the internal jugular (the less obvious waveform) rather than the external (easily seen, superficial).The JVP can be differentiated from the carotid pulse by a number of features (see below). A quick test is to confirm if it can be occluded by pressure - the carotid pulse cannot be, whilst the JVP is occluded by this manoeuvre.
- Remember that the JVP will be affected by the patient's position. It is usually described as the equivalent of a column of fluid - ie. how far the 'column' of the JVP rises above the manubriosternal angle.
- To 'accentuate' the JVP, you can gently press down on the abdomen (hepato-jugular reflux - raises intra-abdominal pressure and enhances venous return). Make sure the patient has no abdominal pain before you do this.
Waveform:
- A-wave: Atrial contraction (systole).
- C: Tricuspid valve closure. Start of ventricular systole. Coincides with palpable carotid pulse and first heart sound.
- X-descent: Ventricular systole.
- V: End of ventricular systole and start of atrial filling (with closed tricuspid valve).
- Y-descent: Tricuspid valve opens.
JVP vs Carotid waveform:
Palpation
Feel for:
- Apex beat: This is defined as the most inferior and lateral site at which the pulse can be palpated. It is located at the 5th left intercostal space, in the mid-clavicular line, and is the 'most forceful' palpable pulsationof the heart. Lateral deviation suggests left ventricular enlargement. If you cannot feel it then try again (dextrocardia is a classic exam trick and it can be very embarrassing to say you felt the apex when it was actually way over the other side...). An impalpable apex can be caused by 'DOPES': Death, Obesity, Pericarditis, Emphysema/COPD, Situs inversus. Normal apex beats are brief outward impulse. There are many confusing wordsused to describe abnormal apex beats - do not try and understand or remember these. Just remember: 'tapping' in Mitral Stenosis and 'hyperdynamic' in Aortic Stenosis.
- Parasternal heave: Use the lateral edge of your palm. Palpate either side of the sternal border. Palpable upwards movements are suggestive of Right Ventricular Hypertrophy, although they can also be felt in patients with thin chest walls.
- Thrills: Palpable murmurs. Again, using the lateral edge/palm of your hands, feel at the upper chest (just below the clavicles).
Auscultation
Listen for:
- Listen at the 4 main areas: Aortic (2nd right intercostal space), Tricuspid (lower left sternal edge), Pulmonary (2nd left intercostal space) and Mitral (apex beat). Always start at the apex. A good way to remember the order, is the mnemonic 'At The Post Mortem' (Aortic, Tricuspid, Pulmonary, Mitral), going diagnonally up-and-down the chest. Always palpate a 'central' pulse (the carotid, or alternatively the subclavian - can be easier to palpate and is found just above the medial border of the clavicle), at the same time. This will help you to time any murmurs.
- Heart sounds: 1st sound = mitral and tricuspid closure, 2nd sound = aortic and pulmonary closure. Listen at the apex for extra heartsounds: 3rd sound = immediately after the 2nd sound - like 'ken-tucky' (normal in young patients, suggests over-rapid ventricular filling with a failure of the ventricle to relax, eg. in heart failure, thyrotoxicosis), 4th sound = immediately before the 1st sound - like 'tenne-ssee' (always abnormal, cause by a stiff ventricle, found in left ventricular hypertrophy, hypertrophic cardiomyopathy, acute infarction, etc.)
- Murmurs: At the apex, use the bell and then the diaphragm. The bell will be useful for low frequency diastolic murmurs. Get the patient to lean on their left side (left lateral position) whilst auscultating at the apex. This will accentuate the mid-diastolic murmurof mitral stenosis. Remember to listen in the axilla for radiation of mitral murmurs.
- Listen at the carotids, for both, bruits and radiation of aortic area murmurs. Tell the patient to hold their breath so breath sounds do not impede what you can hear. Ejection systolic murmurs heard at the aortic area but thatdo not radiate to the carotids may be cause by aortic (calcific) sclerosis rather than stenosis.
- Get the patient to lean forwards, whilst holding your stethoscope at the lower left sternal edge. Get the patient to take a deep breath in, breath all the way out, then hold it there. Listen during held expiration for the early diastolic murmur of aortic regurgitation.
- See the 'murmurs' notes for more information on cardiac murmurs.
- Finally, listen at the lung bases (posteriorly) for signs of pulmonary oedema (left sided heart failure).
To complete your examination
Also examine:
- Feel the pre-tibial area for pedal pitting oedema (sign of right heart failure).
- Palpate the peripheral pulses for abnormalities (eg. aneurysms). Start from the abdominal aorta, then palpate bilaterally at the femorals, popliteal, posterior tibial and dorsalis pedis). You can usually skip this step in examinations unless specifically asked - saying to the examiner that'to complete my examination, I would like to palpate the peripheral pulses' is usually enough.
- Also mention that you would like to palpate the abdomen for signs of right heart failure ('smooth' hepatomegaly and hepatic pulsatility).
Finally:
- Ask for the following investigations to complete your examination: Temperature (raised in endocarditis), Urine Dipstick (blood in hypertension or endocarditis, glucose in diabetes), Blood Pressure (if not already done so), Chest X-ray (approximate heart size, rib notching in coarctation of the aorta), and a cardiac echo scan (especially if a murmur was heard or there was any evidence of heart failure).
Presenting your findings
Example presentation:
On examination, Mrs Jones appeared mildly short of breath at rest. She was on 5L of Oxygen through nasal prongs. She had tar staining on her hands, and there was a packet of cigarettes by the side of the bed, suggesting that Mrs Jones is a smoker. Her pulse was slow rising, and her bloodpressure was 96/70, demonstrating a narrow pulse pressure. There were no other peripheral stigmata of cardiovascular disease. On palpation, her apex beat was presentand hyperdynamic in character. On auscultation, both heart sounds were present, however the second heart sound was quiet. There was an ejectionsystolic murmur that was loudest at the 2nd right intercostal space, and that radiated to the carotids. There were no signsof heart failure. In summary, these findings are consistent with a diagnosis of aortic stenosis.
