Cardiovascular examination

Cardiovascular examination
Cardiovascular examination
Purpose	evaluation of the cardiovascular system.

Last updated July 25, 2022

The cardiovascular examination is a portion of the physical examination that involves evaluation of the cardiovascular system. The exact contents of the examination will vary depending on the presenting complaint but a complete examination will involve the heart (cardiac examination), lungs (pulmonary examination), belly (abdominal examination) and the blood vessels (peripheral vascular examination).

The cardiac examination is based on the different methods of evaluation, comprising the following sections: measurement of vital signs; inspection and palpation, percussion and auscultation, pulmonary examination, abdominal examination and peripheral vascular examination.^[1] The evaluation of a real patient will require switching between the different methods and even different organs to save time and keep the patient comfortable: for example, listening to the heart and the lungs of a young child before they get bored. The only materials needed are a sphygmomanometer (blood pressure cuff), a stethoscope and the use of sight, touch, smell and sound.

Measurement of Vital Signs

A good cardiac examination starts as soon you can lay eyes on the patient. Doctors will observe the color of skin, rate of breathing, and emotional state of their patients at a distance before the examination begins.^[1] An accurate blood pressure and heart rate should be measured, as these are direct measurements of how well the heart is working. An automatic blood pressure cuff can be used, but a healthcare professional can also use a manual blood pressure cuff and stethoscope.^[2] The bell of the stethoscope should be placed over the brachial artery when taking a blood pressure manually: the pressure meter when the first two heart beats are heard will show the systolic blood pressure; when the sounds disappear, the meter will show the diastolic blood pressure.^[3] A normal systolic blood pressure will be less than 120 mm Hg, and a normal diastolic blood pressure will be less than 80 mm Hg.^[3] A blood pressure that is more than 15 mm Hg different between the right and left arm may indicate a problem with the patient's blood vessels.^[1]
A normal heart rate is between 60 and 100 beats per minute. This can be measured wherever a pulse can be felt, but is usually measured from the radial artery. Vital signs should be measured at least twice during each patient encounter, with as much time as possible between measurements (e.g. once at the beginning and once at the end of the appointment). A heart rate and rhythm that is normal may be written down as "RRR".

Cardiac examination

The cardiac examination (also known as the precordial exam), involves examination of a person for signs of diseases of the heart. The chest is the main area that will be examined, but other areas that will be examined include the hands, head and ankles.^[4]

Inspection and Palpation

The cardiac examination may continue with the patient resting comfortably, just as before. Before moving any drapes, the patient should be asked if it is okay to move them. If they say yes, then the patient's shirt, pants or gown should be removed and the drape should be lowered to the bottom of the lowest rib so that the doctor can see the whole chest. Inspecting (looking at) the patient closely can show movements of the ventricles or the point of maximal impulse (PMI). Certain conditions can be identified upon inspection. ^[5]
Touching the patient (also known as palpation) can help identify heaves and lifts (a feeling of the chest wall pushing outward), thrills (a feeling of the chest wall vibrating, usually with loud murmurs), impulses (a feeling the heart makes when it presses against the chest wall) and the first (S1) and second (S2) heart sound (the sounds of rushing blood that correlate with different phases of the heart beat).^[3]

The doctor can then ask the patient to relax while the back of the examination table is raised to a 30-45˚ angle. From this position, the jugular venous pressure (JVP) can be estimated. Because the right internal jugular vein flows directly into the superior vena cava and then the right atrium, it is a good estimate of central venous pressure. JVP can be assessed by measuring how far the highest point of pulsation (of the right internal jugular vein) is above the sternal angle (the joint between the manubrium and the sternum). Any height greater than 3 cm is considered elevated.^[1] When the patient is reclining, it is also easier to palpate the PMI. By asking the patient to lean to their left (left lateral decubitis position), the PMI can become even more noticeable. Be aware that in certain diseases (such as right ventricular hypertrophy) the PMI may not always correlate with the apical impulse, in which case it is called a displaced PMI.^[3] Depending on the presentation of the patient, heaves, lifts, thrills, impulses and heart sounds may be detected better when they are reclining, sitting or even leaning forward.

Percussion and Auscultation

For the best cardiac examination, it is important to have the patient both sit up and lay down at a 30-45˚ angle. Tapping with the fingertips (also known as percussion) can be used to estimate the size of the heart, though palpation is more accurate.^[3] From the left side of the chest, the doctor can tap the spaces between the ribs with the tips of their middle finger to listen for the dullness that will be present over the heart.^[1] Listening with a stethoscope (also known as auscultation) to all four areas of the heart: aortic, pulmonic, tricuspid and mitral. Any murmurs, rubs or gallops should be noted. Gallops are also known as a third (S3) or fourth (S4) heart sound. The absence of abnormalities (normal) may be recorded as "no m/r/g". The ACC and the AHA have called cardiac auscultation "the most widely used method of screening for valvular heart disease."^[3] Because of its importance to the cardiac examination, cardiac auscultation has been covered in-depth elsewhere.

Pulmonary Examination

A customized pulmonary examination can also help diagnose a cardiac disease, such as in the auscultation of certain lung sounds or pleural effusions (e.g., in the case of heart failure). An unusual sound that comes from the pulmonary examination can point to a disease of the heart. Inspection, palpation, percussion and auscultation of the lungs are all important for the cardiac examination. The specifics of pulmonary examination can be covered elsewhere.

Abdominal Examination

The cardiovascular system includes many big vessels that carry blood into and beyond the belly (abdominal cavity). The largest blood vessel in the body, the aorta, should be palpated and auscultated over the belly for any thrills or bruits. Draping will be important here, so that the belly is exposed but the chest and hips are covered. The renal arteries, which branch off at the same level of the 1st or 2nd lumbar vertebra, should be examined for thrills or bruits as well. Edema can be caused by many different conditions, and can be found in the abdominal cavity by testing for a fluid wave and/or shifting dullness. These maneuvers have been covered in the abdominal examination section.

Peripheral Examination

From head to toe, there are several places in the body where arterial pulses can be felt for their strength and quality. Many arteries that are on both sides of the body (bilateral) may be palpated at the same time for the sake of comparison, except for the carotid arteries; deep palpation of both carotid arteries can cut off blood flow to the brain.^[3] The carotid arteries, should be auscultated to listen for bruits, as this can indicate the buildup of plaque inside of the vessel (also known as atherosclerosis). The brachial arteries may be palpated underneath the biceps tendon.^[3] The radial pulses can be found on the forearm, above the wrists.^[3] Femoral pulses can be palpated below the inguinal ligament, about halfway between the pubic symphysis and the anterior superior iliac spine.^[3] The popliteal arteries are harder to palpate, but can be found by pressing deeply with the knee slightly bent. If the femoral pulse is strong, but the popliteal pulse is weak, this can indicate atherosclerosis of the vessels in the thigh.^[2] Finally, the posterior tibial and dorsalis pedis arteries provide a good indicator of circulation to the extremities. These can be palpated just behind the ankle and on the top of the foot, respectively.^[3]

The extremities of the patient should be observed for the presence of edema (swelling, usually due to fluid collection). Pitting edema, where pressing the skin may leave indentation, suggests that intravascular fluid has leaked into the interstitial tissues. Nonpitting edema is more likely to be caused by a blockage in the lymphatic or circulatory systems.^[1]
The ankle-brachial pressure index compares the systolic blood pressure of the ankle to the systolic blood pressure of the arm. A ratio that is outside of the range of 1-1.3 may indicate a disease of the vessels, such as peripheral arterial disease (the ankle-brachial index would be low).^[1]

Related Research Articles

The heart is a muscular organ in most animals. This organ pumps blood through the blood vessels of the circulatory system. The pumped blood carries oxygen and nutrients to the body, while carrying metabolic waste such as carbon dioxide to the lungs. In humans, the heart is approximately the size of a closed fist and is located between the lungs, in the middle compartment of the chest.

In medicine, a pulse represents the tactile arterial palpation of the cardiac cycle (heartbeat) by trained fingertips. The pulse may be palpated in any place that allows an artery to be compressed near the surface of the body, such as at the neck, wrist, at the groin, behind the knee, near the ankle joint, and on foot. Pulse is equivalent to measuring the heart rate. The heart rate can also be measured by listening to the heart beat by auscultation, traditionally using a stethoscope and counting it for a minute. The radial pulse is commonly measured using three fingers. This has a reason: the finger closest to the heart is used to occlude the pulse pressure, the middle finger is used get a crude estimate of the blood pressure, and the finger most distal to the heart is used to nullify the effect of the ulnar pulse as the two arteries are connected via the palmar arches. The study of the pulse is known as sphygmology.

Heart sounds are the noises generated by the beating heart and the resultant flow of blood through it. Specifically, the sounds reflect the turbulence created when the heart valves snap shut. In cardiac auscultation, an examiner may use a stethoscope to listen for these unique and distinct sounds that provide important auditory data regarding the condition of the heart.

Heart murmurs are unique heart sounds produced when blood flows across a heart valve or blood vessel. This occurs when turbulent blood flow creates a sound loud enough to hear with a stethoscope. Turbulent blood flow is not smooth. The sound differs from normal heart sounds by their characteristics. For example, heart murmurs may have a distinct pitch, duration and timing. The major way health care providers examine the heart on physical exam is heart auscultation; another clinical technique is palpation, which can detect by touch when such turbulence causes the vibrations called cardiac thrill. A murmur is a sign found during the cardiovascular exam. Murmurs are of various types and are important in the detection of cardiac and valvular pathologies.

A sphygmomanometer, a.k.a. a blood pressure monitor, or blood pressure gauge, is a device used to measure blood pressure, composed of an inflatable cuff to collapse and then release the artery under the cuff in a controlled manner, and a mercury or aneroid manometer to measure the pressure. Manual sphygmomanometers are used with a stethoscope when using the auscultatory technique.

Pulse pressure is the difference between systolic and diastolic blood pressure. It is measured in millimeters of mercury (mmHg). It represents the force that the heart generates each time it contracts. Resting blood pressure is normally approximately 120/80 mmHg, which yields a pulse pressure of approximately 40 mmHg.

Chest pain is pain or discomfort in the chest, typically the front of the chest. It may be described as sharp, dull, pressure, heaviness or squeezing. Associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with nausea, sweating, or shortness of breath. It can be divided into heart-related and non-heart-related pain. Pain due to insufficient blood flow to the heart is also called angina pectoris. Those with diabetes or the elderly may have less clear symptoms.

The jugular venous pressure is the indirectly observed pressure over the venous system via visualization of the internal jugular vein. It can be useful in the differentiation of different forms of heart and lung disease. Classically three upward deflections and two downward deflections have been described.

An abdominal examination is a portion of the physical examination which a physician or nurse uses to clinically observe the abdomen of a patient for signs of disease. The physical examination typically occurs after a thorough medical history is taken, that is, after the physician asks the patient the course of their symptoms. The abdominal examination is conventionally split into four different stages: first, inspection of the patient and the visible characteristics of their abdomen. Auscultation (listening) of the abdomen with a stethoscope. Palpation of the patient's abdomen. Finally, percussion (tapping) of the patient's abdomen and abdominal organs. Depending on the need to test for specific diseases such as ascites, special tests may be performed as a part of the physical examination. An abdominal examination may be performed because the physician suspects a disease of the organs inside the abdominal cavity, or simply as a part of a complete physical examination for other conditions. In a complete physical examination, the abdominal exam classically follows the respiratory examination and cardiovascular examination.

An arteriovenous fistula is an abnormal connection or passageway between an artery and a vein. It may be congenital, surgically created for hemodialysis treatments, or acquired due to pathologic process, such as trauma or erosion of an arterial aneurysm.

The ankle-brachial pressure index (ABPI) or ankle-brachial index (ABI) is the ratio of the blood pressure at the ankle to the blood pressure in the upper arm (brachium). Compared to the arm, lower blood pressure in the leg suggests blocked arteries due to peripheral artery disease (PAD). The ABPI is calculated by dividing the systolic blood pressure at the ankle by the systolic blood pressure in the arm.

Valvular heart disease is any cardiovascular disease process involving one or more of the four valves of the heart. These conditions occur largely as a consequence of aging, but may also be the result of congenital (inborn) abnormalities or specific disease or physiologic processes including rheumatic heart disease and pregnancy.

In medicine, the cardiac examination, also precordial exam, is performed as part of a physical examination, or when a patient presents with chest pain suggestive of a cardiovascular pathology. It would typically be modified depending on the indication and integrated with other examinations especially the respiratory examination.

Pulsus paradoxus, also paradoxic pulse or paradoxical pulse, is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg. When the drop is more than 10 mmHg, it is referred to as pulsus paradoxus. Pulsus paradoxus is not related to pulse rate or heart rate, and it is not a paradoxical rise in systolic pressure. The normal variation of blood pressure during breathing/respiration is a decline in blood pressure during inhalation and an increase during exhalation. Pulsus paradoxus is a sign that is indicative of several conditions, including cardiac tamponade, chronic sleep apnea, croup, and obstructive lung disease.

Cardiac asthma is the medical condition of intermittent wheezing, coughing, and shortness of breath that is associated with underlying congestive heart failure (CHF). Symptoms of cardiac asthma are related to the heart's inability to effectively and efficiently pump blood in a CHF patient. This can lead to accumulation of fluid in and around the lungs, disrupting the lung's ability to oxygenate blood.

A peripheral vascular examination is a medical examination to discover signs of pathology in the peripheral vascular system. It is performed as part of a physical examination, or when a patient presents with leg pain suggestive of a cardiovascular pathology.

Right ventricular (RVH) is a condition defined by an abnormal enlargement of the cardiac muscle surrounding the right ventricle. The right ventricle is one of the four chambers of the heart. It is located towards the lower-end of the heart and it receives blood from the right atrium and pumps blood into the lungs.

The following outline is provided as an overview of and topical guide to cardiology, the branch of medicine dealing with disorders of the human heart. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease and electrophysiology. Physicians who specialize in cardiology are called cardiologists.

Doppler ultrasonography Ultrasound imaging of the movement of tissues and body fluids using the Doppler effect

Doppler ultrasonography is medical ultrasonography that employs the Doppler effect to perform imaging of the movement of tissues and body fluids, and their relative velocity to the probe. By calculating the frequency shift of a particular sample volume, for example, flow in an artery or a jet of blood flow over a heart valve, its speed and direction can be determined and visualized. Color Doppler or color flow Doppler is the presentation of the velocity by color scale. Color Doppler images are generally combined with grayscale (B-mode) images to display duplex ultrasonography images, allowing for simultaneous visualization of the anatomy of the area.

Arterial blood pressure is most commonly measured via a sphygmomanometer, which historically used the height of a column of mercury to reflect the circulating pressure. Blood pressure values are generally reported in millimetres of mercury (mmHg), though aneroid and electronic devices do not contain mercury.

References

1 2 3 4 5 6 7 Porter S., Robert (July 11, 2011). Merck Manual. Merck. p. 3754. ISBN 978-0911910193 . Retrieved December 28, 2018.
1 2 Litin, M.D., Scott (May 5, 2018). Mayo Clinic Family Health Book. Mayo Clinic. ISBN 978-1945564024.
1 2 3 4 5 6 7 8 9 10 11 Bickley, Lynn S. (September 6, 2016). Bates' Guide to Physical Examination and History Taking (Twelfth ed.). LWW. p. 1064. ISBN 9781469893419 . Retrieved December 28, 2018.
↑ Douglas, Graham; Nicol, Fiona; Robertson, Colin (2013). "The cardiovascular system". Macleod's Clinical Examination (13th ed.). Churchill Livingstone. ISBN 9780702042782.
↑ Cardiovascular examination. Remedica. 2004.

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[:0-1] 1 2 3 4 5 6 7 Porter S., Robert (July 11, 2011). Merck Manual. Merck. p. 3754. ISBN 978-0911910193 . Retrieved December 28, 2018.

[:2-2] 1 2 Litin, M.D., Scott (May 5, 2018). Mayo Clinic Family Health Book. Mayo Clinic. ISBN 978-1945564024.

[:1-3] 1 2 3 4 5 6 7 8 9 10 11 Bickley, Lynn S. (September 6, 2016). Bates' Guide to Physical Examination and History Taking (Twelfth ed.). LWW. p. 1064. ISBN 9781469893419 . Retrieved December 28, 2018.

[4] Douglas, Graham; Nicol, Fiona; Robertson, Colin (2013). "The cardiovascular system". Macleod's Clinical Examination (13th ed.). Churchill Livingstone. ISBN 9780702042782.

[5] Cardiovascular examination. Remedica. 2004.

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