Examination of the Heart

The following document is one way of examining the heart. There are obviously many ways and techniques to do this which aren't mentioned here. I suspect you will only use this as a guide to your own examining technique which you should evolve to suit your own approach and style. I have also assumed that you have some knowledge of medicine throughout this examination. If you are uncertain to the reasons why i have mentioned things in my examination or need clarification there are some excellent books you can refer to.

I have written this with the idea that this will be used in an exam setting - so you will be presenting your findings as opposed to a clinic setting. i would try and talk constantly whilst examining the patient. It keeps the examiner interested and shows off what you know.

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Introduction

– introduce yourself and explain what you would like to do, then ask for permission.

General

– make a show of standing back from the patient and look at the environment around the patient – check for any equipment, temperature chart, monitors. Make sure that the patient is adequately exposed.

"The patient is lying comfortably at rest at 45 degrees, and appears not to be grossly cyanosised, anaemic nor seems in pain or breathless."

Hands

Assess temperature using the back of your own hand. Pallor in the palm creases.
Clubbing – for cyanotic congenital heart disease and Infective Endocarditis (IE)
Koilonychia – soft, thin, brittle, spoon shaped – evidence of severe iron deficiency.
Nicotine staining around the fingers – indicates only that the patient smokes cigarettes down to the base – it reveals no information about how much the patient actually smokes.
Quincke's sign Capillary pulsation in the nail bed – indicative of aortic regurgitation.
Splinter haemorrhages are tiny lines that run vertically under the nail - having more than 5 raises the possibility of having IE - see image
Osler nodes are finger tip lumps that are white at the apex with a red inflammed surrounds. They are very painful and they are seen in IE - see image
Janeway lesions are dark (painless) patches seen on the palms and feet - they are seen in IE - see image
Xanthelasma over the extensor tendons for hypercholesteremia - see image

You could mention each of these positive or negative findings as you continue your examination or just summarise. For example:

‘There were no signs of systemic disease in the hands’

Or

‘There are signs of infective endocarditis in the hands – namely etc. etc.’

Pulse

Radial pulse - palpate both radial pulses at the same time, then concentrate on just one. (absent pulse = embolus or shunt; radio-radial delay = coarctation)

Assess rate – for 1 minute – in an exam say that you would and the examiner will normally allow you to move on to the next section so that you don’t spend too much time over this.

Assess rhythm – irregular irregular = Atrial fibrillation

Lift arm above level of heart for waterhammer sign = aortic regurgitation.

Try also to assess respiration rate (RR).

Again you can summarise or mention what you find as you go along.

Blood pressure

With the patient relaxed and arm raised to heart height, the cuff is inflated until the radial pulse is no longer palpable. The brachial pulse is auscultated as the pressure in the cuff is reduced, thereby eliciting all five Korotkoff's sounds.

• Pulsus paradoxes – marked (>10mmHg) lowering of the amplitude of the arterial pulse (exaggerated of normal mal decrease) found in asthma and tamponade.

• Hill sign: Systolic pressure in lower extremity greater than systolic pressure in upper extremity by 20 mmHg

Carotid and Brachial Pulses

– I would choose which one to use – most people use the carotid rather than using both.

Assess Volume

• Large amplitude – includes mainly aortic regurgitation (also collapsing)
• Increased blood flow – thyrotoxicosis and other high output states.
• Small Amplitude - aortic stenosis or poor LV function. (aortic stenosis is also known as plateau pulse)

Assess Character

• Slow rising plateau (anacrotic) pulse found in aortic stenosis
• Collapsing waterhammer pulse
• Corrigan pulse (quickly collapsing pulses seen in the neck without needing palpation), found in aortic regurgitation.
• De Musset sign (bobbing of the head), found in aortic regurgitation.
• Bisferiens pulse (two peaked pulse) – mixed aortic regurgitation and stenosis.
• Pulsus Alternans – evidence of LV failure.

Jugular Venous Pressure

Inspect at 45 degrees - ensure the patient relaxes whilst looking straight ahead - use natural light coming in at an angle.

You may be asked how you can differentiate between JVP and the carotid

• JVP has its most rapid movement inward unlike the carotid
• JVP has two peaks and may displace the earlobes until the carotid
• JVP should increase with pressure on the liver (remember to ask whether there is any pain in the abdomen and if you have permission)

You may be asked about the various wave forms and what they mean

• a-wave = atrial contraction – (large = tricuspid/pulmonary stenosis, pulmonary hypertension, 3rd degree heart No& ventricular ectopics - atria contract on closed valve.)
• x-descent = atrial relaxation – c-wave = tricuspid valve bulging into the RA
• v wave = passive rise in pressure of the RA - (large v wave in tricuspid regurgitation)
• y-descent = opening of the tricuspid valve. – (deep wave descent in constrictive pericarditis)

Face

Inspect for:
• Malar flush (mitral stenosis)
• Xanthelasma around the eyes indicate hypercholesteremia - see image
• Arcus senilis round the eyes (hyperlipidaemia).
• Inspect the conjunctiva for pallor – you only need to see one eye for this and ask the patient to lower their own conjunctiva rather than you doing it. most patients are perfectly able to show you this without you jabbing your fingers near their eyes in an exam which could make them flinch and give a bad impression to the examiner.

Buccal mucous membranes

• blue discolouration for evidence of cyanosis
• Look for a high arched palate - Marfan's syndrome / down’s syndrome
• Muller sign = Pulsations of the uvula in AR

Examination of the fundi

Again offer to do this in the examination – with any luck the examiner will ask you to forget it and move on to save time. What you would be looking for is signs of:

• Hypertension – know the 5 stages
• Roth's spots for IE
• Dancing retinal arteries in AR

Precordium

Inspection

"there seem to be no scars or deformities on inspection nor is there a visible cardiac beat"

Palpation

Position of the apex beat. Be seen to calculate the mid-clavicular line and 5th or 6th intercostal space then palpate the apex. If you are examining a clearly normal person in an exam make sure you calculate where the apex beat is before you actually look for it. if you do this the other way round and you find the apex beat slightly off where it should be the examiner will say – ‘so you think there is something wrong with this patient then do you?’ probably best to avoid this situation.
• Tapping apex beat = mitral stenosis
• Forceful apex beat = increased cardiac output
• At the same time palpate for left and right ventricular heaves(hold your hand down over the area to feel the chest rise)

Palpate really lightly for evidence of thrills (palpable murmurs) which feel like a cat purring

• Apical thrill - systolic mitral regurgitation and papillary muscle rupture - diastolic mitral stenosis
• Left parasternal thrill - ventricular septal defect
• Basal thrills - systolic aortic/pulmonary stenosis - diastolic aortic/pulmonary regurgitation.

Auscultation

High frequency sounds are best heard with the diaphragm, whereas low frequency sounds are heard by the bell. Always auscultate each valve area with the diaphragm and then the bell. The areas are:
• Apex area – mitral valve
• Lower left sternal area – tricuspid valve
• Upper left sternal area – pulmonary valve
• Upper right sternal area – aortic valve

Whilst auscultating, coordinate yourself with your left hand on the carotid pulse so you know which sound you are listening to. Not all heart sounds are ‘lub dub’ and it can be difficult to know where you are in the cycle. Also the examiner will expect it.

Turn the patient over on his left to auscultate the apex and then move to the axilla to hear the pansystolic murmur of mitral regurgitation.

Using the bell, auscultate each carotid artery for evidence of a stenosis or systolic murmur of aortic stenosis.

Sit the patient up and lean them forward and tell them to hold their breath in expiration whilst auscultating the lower left sternal edge with the bell for the early "blowing" diastolic murmur of aortic regurgitation. Say something like:
‘If you could sit forward for me please – what I would like you to do is take a deep breath in (wait) and now breathe out completely (wait) and hold it there (now listen for AR) – breathe away now – thank you.’

Systolic murmurs of peripheral pulmonary stenosis and coarctation of the aorta are heard maximally over the back.

As a rule of thumb if a murmur is heard, remember to ask the patient to take slow deep breaths in and out. Generally murmurs that are louder on inspiration are left sided (originating from the tricuspid or pulmonary valves) and those that are louder on expiration are right sided (aortic and mitral)

If you are desperate and you don’t know what the murmur is in an exam – if you are in a developed country you will probably get away with the rule that if the murmur is heard loudest below the nipples then it is a pansystolic murmur. Above the nipples is ejection systolic. This is obviously not true in all patients – but use it if you are completely stuck and are being pushed for an answer.

Lungs

Auscultate the lungs for evidence of bilateral basal crackles (LV failure). At the same time you can press the sacrum area with your thumb to look for pitting oedema signifying peripheral oedema (RV failure).

Abdomen

Ask if there is any pain in the abdomen and seek permission to continue your examination.

• Inspect for scars, pulsations and swellings.
• Palpate the aorta for AAA.
• Palpate the liver and the spleen - see abdominal examination.
• Auscultate the abdominal aorta and the renal arteries.

Legs

• Look for scars.
• Palpate the femorals and check for radio-femoral delay (palpate the radial artery at the same time).
• Pistol shot femorals, (loud systolic sound over femoral arteries)
• To and fro Duroziez's Sign (compression of femoral artery with a stethoscope produces a systolic-diastolic murmur) = AR
• Palpate the politeal, posterior tibial, and dorsalis pedis pulses
• Look for varicose veins
• Leg oedema (measure level of pitting oedema).

Conclusion

Try and summarise your findings in a sentence and then offer to do further investigations such as:

• Test the urine for glucose, protein (hypertensive nephropathy) and blood (Infectious endocarditis)
• Ask to see a chest radiograph
• Ask to see an ECG
• Ask to see anything you think might help you and that is relevant to your examination.
• Remember to say thank you to the patient and wash your hands.

There are some excellent resources online

A Practical Guide to Clinical Medicine - The Cardiac Examination
The Cardiac Exam: Auscultation
The Cardiac Examination
You Tube video - The Cardiac Examination

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