by Dr James Joseph, MD, CSMU (UKRAINE) 2010]
1. Introduce yourself and ask for permission to examine the heart. This is good bedside manner and will help to establish rapport with px.
2. Make sure the patient is positioned at 450 and adequately exposed.
3. Observe carefully for tachypnea, orthopnea, cyanosis, and “spot diagnoses” that are associated with heart diseases:
•Eg: Presence of titilbation (head-nodding) and Corrigan’s sign in the neck will greatly help in the diagnosis of aortic incompetence.
Malar flush = mitral stenosis
Turner’s syndrome= coarctation and bicuspid aortic valve
Down’s syndrome = ASD, VSD and Fallot’s tetralogy
Noonan’s syndrome = pulmonary valve dysplasia and hypertrophied cardiomyopathy
Marfan’s syndrome= aortic or mitral incompetence
Myx0edema facies = pericardial effusion
4. Upper limbs:
– moisture -> dry @ moist
– temperature -> warm @ cold – colour -> pink @ pale
– cyanosis -> peripheral cyanosis
– capillary filling
– stigmata of IE: Osler nodes, Janeway lesion, Splinter hemorrhage
Splinter haemorrhage may also be seen in trauma, connective tissue diseases, and trichinella infection
Osler’s node is uncommon but important sign of infective endocarditis
Raised tender nodules on the pulp of the fingers, toes, thenar or hypothenar eminences
Janeway lesions (non-tender erythematous maculo-papular lesions containing bacteria)
– tendon xanthomas
– nicotine stain
Begin by feeling the patient’s right radial pulse carefully with the index and middle fingers of the left hand (The radial pulse will be easier to feel if the wrist is slightly flexed)
•Rate (count 60 seconds rather than 15 seconds X 4: you may miss ectopics coming later)
•Rhythm -> regular @ irregular
•Character (particularly looking for collapsing pulse)
•Radio –radial delay
•Radio – femoral delay (in coartation of aorta)
ØThe rest of the pulses are examined to determine if they are present and equal on both sides
Undergraduates are expected to detect atrial fibrillation (irregularly irregular pulse) and a collapsing pulse.
The collapsing pulse is best elicited by grabbing the patient’s left wrist with your left hand (bottom, left). After you have detected the pulsation of his radial pulse in your palm, gradually relax the grip of your hand until the radial pulse just disappear. Then with the help of your right hand, lift the patient’s arm in the air (bottom, right) while maintaining the same grip pressure. If the pulse returns, it has become more forceful and thus deemed collapsing.
Causes of collapsing pulse:
•hyperdynamic circulation: severe anaemia, thyrotoxicosis, Paget’s disease
•peripheral arteriovenous fistula
•Arterosclerotic aorta (in elderlies)
d ) and don’t forget to measure the patients’ BLOOD PRESSURE
a) Carotid pulse
b) Jugular venous pressure
•Examine the internal jugular vein (JVP) in the neck carefully to determine the height (usually this will be sufficient for undergraduates)
•Turn the patient’s face slightly away and look for a pulsation in the neck . If present, determine if it is arterial or venous.
•If it is a venous, measure its height at the sternal angle with the help of 2 rulers always keeping your eyes at the level of the horizontal ruler . When the height is more than 3 cm above the sternal angle, the JVP is raised.
Causes of elevated JVP
•Right ventricular failure
•Tricuspid stenosis or regurgitation
high-arched palate (Marfan’s syndrome)
– stigmata of hyperlipidemia (xanthelasma) & thyroid disease
7. Lower Limbs
a) pitting edema
b) peripheral pulses
c) cyanosis, cold limbs, trophic changes, ulceration (peripheral vascular disease)
d) clubbing of toes
Specific examination of praecordium
Every auscultation, listen for…
•1st & 2nd heart sound & their intensity
•Extra heart sound (S3 & S4)
•Additional sound ( opening snap, systolic ejection click)
•Fixed splitting 2nd heart sound (only in pulmonary area, ASD
**Auscultatory features of heart murmurs
1) When does it occur?
– Time the murmur using heart sounds, carotid pulse and the apex beat, is it systolic or diastolic?
– Does the murmur extend throughout systole or diastole or is it confined to a shorter part of the cardiac cycle?
2) How loud is it? (intensity)
– Grade 1: Very soft (only audible in ideal conditions)
– Grade 2: Soft
– Grade 3: Heard all over the precordium
– Grade 4: Loud, with palpable thrill (ie, a tremor or vibration felt on palpation)
– Grade 5: Very loud, with thrill. May be heard when stethoscope is partly off the chest
– Grade 6: Very loud, with thrill. May be heard with stethoscope entirely off the chest
3) Where is it heard best? (location)
– Listen over the apex and base of the heart, including the aortic & pulmonary areas
4) Where does it radiate?
– Evaluate radiation to the neck, axilla or back
5) What does it sound like? (pitch & quality)-> harsh/blowing/rough
– Pitch is determined by flow ( high pitch indicates high-velocity flow)
– Is the intensity constant or variable?
If there is a murmur, 5 things to comment:
1) timing -> systolic/diastolic
2) area of greatest intensity
3) Radiation -> axilla? neck?
4) Grading -> 1-6
5) changes with alteration of position
( left lateral position@ sitting forward)
6) effect of dynamic maneuvers( mainly respiratory)
à ask pt to inspire, expire fully n hold
Eg: There is a pansystolic murmur best heard over the mitral area with radiation to axilla, graded 3/6 and accentuated during inspiration and left lateral position
Site of murmur radiation
1. mitral regurgitation à left axilla
2. aortic stenosis à right side of neck
3. aortic regurgitationà left sternal bord
– hypertensive retinopathy
– Roth spots (IE)
– palpate liver & spleen(enlarge?)
– percuss -> ascites (shifting dullness)
e) Check for temperature chart , urine output , CXR (if present)
f) Take BP if forget b4 this
*** DDx of chest pain
2) Cardiac: angina, MI, myocarditis, pericarditis, mitral valve prolapse
3) Aortic: aortic dissection, aneurysm
4) Esophageal: esophagitis, esophageal spasm, Mallory-Weiss syndrome
5) Lungs/pleura: bronchospasm, pulmonary infarct, pneumonia, tracheitis, pneumothorax, pulmonary embolism
6) Musculoskeletal: osteoarthritis, rib fracture/injury, intercostal ms injury
7) Neurological: prolapsed intervertebral disk, herpes zoster