Cardiovascular Examination

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In this step-by-step tutorial you will find detailed instructions on how to perform the CVS examination (the cardiovascular assessment).

This course presents the theoretical steps needed to perform a complete and detailed cardiovascular assessment. The examination starts by a careful and detailed clinical assessment of cardiovascular history, immediately after which continue following the steps below:

1-   Evaluation of facial skin color, take a look at the color of the face, to evaluate whether the face is pale, and check for the signs of cyanosis on the lips or ears.[13]

2-   Evaluation of  the neck, look for a pulsatile neck mass (PNM), or seek pulsatile neck arteries, evaluate the carotid arteries and look for visual pulsating neck arteries.[14][15][16]

3-   Checking for pulse on the carotid artery, the carotid pulse may be palpated by compressing against the neck. loud neck pulsations may suggest aortic regurgitation.

4-   Check the neck and evaluate the carotid pulse rhythm, a normal pulse is regular in rhythm and force. (identify s1 and s2).

5-   Visual evaluation of the chest for any scars, to evaluate linear scars, perform a tactile examination of the breast to evaluate the quality of the skin, its color, and look for any scars

6-   Inspection and evaluation of feet for edema, look for swelling in the feet and lower legs; However, a professional evaluation to determine the cause of leg swelling is mandated; Thereafter, begin by inspecting the edematous area for swelling or erythema, palpate the area, find and evaluate the femoral pulses as well, and check for tenderness to palpation over the edematous area, finally rule out edema by pressing this tissue with a fingertip for 5 seconds, then release your finger, a pitting edema leaves a dent in the skin after releasing your finger, the dent will slowly fill back in.

• Non-pitting edema does not leave this type of dent when doing this manual fingertip inspection.

7-   Find the femoral pulse, check for either the dorsalis pedis pulse, which can be found on the top of the foot, or the posterior tibial pulse that is located behind the ankle bone (medial malleolus).

• To find the posterior tibial pulse: place your index and middle fingers of your right hand behind the ankle bone as seen in the pic below (1), after finding the posterior tibial pulse, count the number of beats for 30 seconds then multiply it by two to get the posterior tibial pulse per minute.
  
• To find the dorsalis pedis pulse: first visualize the skin on the top of the foot and check for pulsatile skin above the artery, then place your index and middle fingers of your right hand on the top of the foot as seen in the pic below (2), after finding the dorsalis pedis pulse, count the number of beats for 30 seconds then multiply it by two to get your dorsalis pedis pulse per minute.

 

8-   Hand and Wrist Examination, begin by making a general inspection of the hands and look for warmth, humidity or any external evidence of cyanosis on the nails and fingers.

9-   Find the wrist pulse and take the pulse rate to check overall heart health and fitness level, then check to see if the rhythm is correct (norm rate ~70/min)

10-   Check and compare the wrist pulse with the femoral pulse
11-   Check the eyes for conjunctival pallor and anemia, as paleness seen in the eyes is a reliable sign of anemia.

12-   Evaluation and analysis of cheek skin color, to evaluate skin color and skin tone, look for any skin pigmentation such as the lupus butterfly (a butterfly-shaped mask).

 

13- Examining the tongue, pull out the tongue, and check for central cyanosis, which is seen on the tongue and lips in patients with lung disease.

14-   Check central venous pressure (CVP), which is taken on the 4th intercostal space in the midaxillary line while the patient is lying on his back. Check for double wave pulsation as well.[12]

15-   Look for visible chest pulsations, while exposing the anterior chest and observing its general appearance, note any shape deformity and/or unusual pulsations, looking for thoracic kyphosis or marfan syndrome chest deformity, which is characterized by pectus carinatum (pigeon breast), and pectus excavatum (funnel chest).[9][10][11]

16-   Locate the position of the apex (the apex of heart), which is located at the tip of the left nipple,  in men the nipple is located in the 4th intercostal space, look out for changes in the nipples, look and feel of the nipple and check its temperature, evaluate whether it feels cold or warm.

17-   Auscultation – auscultation of the apex beat, which can be done by placing one hand on the carotid while placing the phonendoscope on the apex, feeling the carotid pulse while auscultating aids in identifying when the murmur is heard during the cardiac cycle (e.g. systole or diastole). If the murmur is heard between beats 1 and 2, then it is systolic, and if it is between beats 2 and 1 then it is a diastolic murmur.[1][6][7]

Where to start from

• Ask the patient to turn his head to the left while listening.
• Auscultate the apex while breathing (inhalation)
• Auscultate the apex while asking the patient to hold his breath, let him take a big breath in, then ask him to exhale and to hold his breath briefly.

• M, Auscultate the apex at the mitral area, to rule out mitral regurgitation, because the murmur can be heard most prominently in this region, as it often radiates around into the axilla.[1][4][8]
• T, Auscultate the tricuspid area between the two nipples
• A-P, Auscultate the aortic area on both sides, located at the upper border of the sternum, auscultate the left side then the right side.
• T, Check for diastolic aortic regurgitation at the middle left of the sternum, while the patient is sitting, ask the patient to take a big breath in, then ask him to exhale and to hold his breath briefly.

18-   Pulmonary auscultation of the chest and back, auscultate the root area of the lungs on both sides, ask the patient to say and repeat “chashka chae” or “tridsat three” while examining.[5]

 

References

Verified by: Dr.Diab (July 27, 2017)

Citation: Dr.Diab. (July 27, 2017). cardiovascular examination simplified for physicians. Medcoi Journal of Medicine, 30(2). urn:medcoi:article3253.