Cardiovascular: Examination
  1. Environment, general appearance
  2. Nails, hands, arms
  3. Face, eyes, mouth
  4. Neck, JVP
  5. Chest: insp, palp, ausc
  6. Back
  7. Abdomen
  8. Legs, feet
Environment
  • ECG leads, machine.
  • Support hosiery.
General appearance
  • Colors:
    Cyanotic.
    Pallid (anemia).
    Jaundiced (anemia, EPO insufficiencies).
    Hyperpigmented (hemochromatosis cardiomyopathy, Addisonian hypotension).
    See Skin Colors Reference.
  • Weight loss.
  • Glaring breathing problems.
  • Syndromes: Down's, Marfan's, Turner's.
  • Leg hanging over edge of bed: peripheral vascular dz.
Nails
  • Ask pt. to sit at 45.
  • Clubbing, stage 1-5 (cyanotic heart dz, IE).
  • Splinter hemorrhages (IE).
  • See Nails Reference.
Hands
  • Peripheral cyanosis.
  • Arachnodactyly (Marfan's).
  • Pallor of palmar creases (anemia 2 to blood loss, malabsorption).
  • Osler nodes [0.5-1 cm red-brown painful subcutaneous papules on fingertips, palmar eminences] (IE).
  • Janeway lesions [rare, painless flat erythematous macules on thenar and hypothenar eminences] (IE).
  • Wrist: tendon xanthoma [yellow deposit over extensors] (type II hyperlipidemia).
  • Heat (thyrotoxicosis).
  • Tremor (thyrotoxicosis).
  • Pulse: rate, rhythm, character, radiofemoral delay, radioradial inequality. See Pulse Reference. Say "character, volume better assessed at the carotid".
  • If suspect AR, assess 'water hammer pulse':
    Dr's 4 fingers horizontal over pt's palmar wrist, as flex and extend pt's elbow.
Arms
  • Take blood pressure.
  • IV drug injection scars (IE).
  • Optionally raise arm to see if less circulation.
Face
  • Facies:
    Apprehension, pain (angina, MI, PE, etc).
    Cushing's (HTN).
    Acromegaly (CHF, HTN).
    Paget's (high output failure).
  • Malar flush [thin face, purple cheeks] (mitral stenosis).
  • Earlobes (cyanosis).
Eyes
  • Xanthelasma [yellow plaque periobital deposits] (hypercholestolemia, DM).
  • Lid edema (myxedema, SVC syndrome, nephrotic syndrome, etc).
  • Exophthalmos, lid retraction (thyrotoxicosis).
  • Corneal arcus (severe hypercholesterolemia).
  • Blue sclera (Marfan's Ehlers-Danlos's [AR, ASD, MVP]).
  • Subluxated lenses (superior: Marfan's, inferior: homocystenuria).
  • Argyll-Robertson pupil (syphilis).
  • Ophthalmoscope fundi: 
    Roth's spots [small red hemorrhage with pale center, due to vasculitis] (endocarditis).
    Hypertensive changes.
    See Fundus Examination.
Mouth
  • Lips: central cyanosis.
  • Tongue underside: central cyanosis.
  • Tongue enlargement (amyloidosis).
  • Torch: high arch palate (Marfan's).
  • Breathing: dyspnea + wheezing (asthma, COPD, asthma, LV failure).
  • Breathing: Chyne-Stokes breathing (stroke, CHF, sedation, uremia).
Neck
  • Tell pt. to remove shirt now or during chest exam. Cover woman's breasts with loose material.
  • Using accessory muscles of respiration (pulmonary edema, asthma, fulminant pneumonia, COPD).
  • Carotid: inspect for carotid pulsations.
  • Carotid: compress one carotid at a time [fingers behind neck, thumb at or below cricoid cartilage level. Optionally use just L thumb to assess R carotid--some teachers disapprove but carotid pulse outweighs thumb]. Assess:
    Amplitude.
    Contour of pulse.
    Variations in amplitude.
  • Carotid: auscultate bruit:
    Use bell of stethoscope.
    Tell pt. to hold their breath while Dr listens.
JVP
  • JVP [use R one]: inspect height, character.
  • JVP: Kussmaul's sign [change on inspiration].
  • See JVP Reference for more details.
Chest: inspection
  • Scars, including mitral valvotomy laterally on L breast.
  • Deformities, dressings, stitches, etc.
  • Visible pulsations.
  • Apex beat.
Chest: palpation
  • Ask pt. if any part is tender, examine that last.
  • Pacemaker boxes.
  • Palpate apex beat for presence, deviation, character. See Apex Beat Reference.
  • Parasternal impulse:
    Heel of Dr's hand to L of sternum.
    If RV, LA dilated, heel will lift on systole.
  • Thrills and heaves:
    Dr's hand horizontal under R pectoral, then vertical up medial side R pectoral, then horizontal across center of ribcage, below sternal notch.
    Diastolic thrill: doesn't coincide with apex beat.
    Systolic thrill: coincides with apex beat.
  • Pulmonary component of S2.
Chest: auscultation
  • Heart sounds, 1st, 2nd split.
  • Murmurs.
  • Time according to carotid pulse (atrial fibrillation: not all apex beats become pulses).
  • Dynamic auscultation.
  • If systolic murmur, do Valsava maneuver (hypertrophic cardiomyopathy).
  • If mitral stenosis, hear thrill by rolling pt onto pt's  L side [brings apex closer to chest wall].
  • See Heart Sound Reference.
Back
  • Pt. leans forward.
  • Inspect for deformities (ankylosing spondylitis, with AR).
  • Percuss back (exclude an RVF pleural effusion).
  • Palpate sacral edema.
Abdomen
  • Liver: find, examine edge.
    See Liver Palpation.
  • Liver: pulsatile liver (tricuspid regurgitation).
  • Splenomegaly (endocarditis).
  • AAA.
Legs
  • Inspect: edema.
  • Inspect: peripheral vascular dz.
    May also see marks of pt squeezing thigh to increase perfusion.
  • Femoral pulse.
  • Varicose veins. See Varicose Veins Examination.
  • Ulcers. See Ulcers Examination.
Feet
  • Rest of peripheral pulses.
  • Achilles tendon xanthomata.
  • Same signs as Hands and Fingernails.