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Cardiovascular: Examination
Environment, general appearance
Nails, hands, arms
Face, eyes, mouth
Neck, JVP
Chest: insp, palp, ausc
Back
Abdomen
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.

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