Table 6: Cardiovascular Exam
|Physical Sign / Manoeuvre||Subsets||Rationale||Technique(s)||Interpretation||Evidence||Pre-Clerkship||Clerkship|
|Peripheral cyanosis||Multiple etiologies||Hands and feet||increased extraction of O2 from blood at the peripheries Anemic patients would require more deoxyhemoglobin to have the same amount of cyanosis||4||4|
|Central cyanosis||Multiple etiologies||Lips, oral mucosa||Blood that leaves the heart deoxygenated (causes of increased AaDO2)|
If Hb is 120, then central cyanosis indicates pO2= 45 mm HG
Detects deoxyhemoglobin level of 23.8
+LR = 7.4
-LR = 0.2
|Pallor||Anemia||Conjunctival, nail beds, palm, conjunctival rim pallor||Pallor should be examined at the palmar creases and in the conjunctiva, however no sign has –LR less than 0.5 so anemia can never be ruled out||Palmar crease pallor|
Pallor at multiple sites
Facial pallor in light skinned persons
Nail bed pallor +LR 1.8
Conjunctiva rim pallor
|Edema||Systemic versus regional||High systemic venous pressures, hypo-albuminemia, obstruction to venous flow, lymph-edema, vascular permeability||Pressure applied for minimum of 1 to 2 seconds to area involved or dependent area|
McGee, 2007, Chapter 52.
|A positive sign if depression that is seen and felt lasting more than 2 to 3 seconds||Edema that pits easily and rebounds within 2 to 3 seconds is due to low protein.|
The finding of pitting edema by itself without the knowledge of JVP height is an unreliable sign of cardiac disease.
|Clubbing||Cyanotic heart disease, endocarditis||See resp section||Should not be a routine part of a cardiac exam||Consists of less than 10% of all causes of clubbing|
|Blood pressure||Auscultatory gap White coat effect||Indirect sphygmo-manometer||Identify hypertension||Hemmelgan, 2004.||4||4|
|Pulsus Paradoxus||A exaggerated increase in BP difference between inspiration and expiration; Multiple etiologies including cardiac tamponade, right ventricular infarction, asthma PE, and uncommonly constrictive pericarditis||When assessing BP in the usual way, 1st note the BP at the appearance of Korotkoff sounds on expiration only; then note the BP again when Korotkoff sounds appear in inspiration and expiration. The difference should be less than 12 mmHg||Tamponade:|
+LR = 5.9; -LR – 0.03
+ LR = 2.7; - LR = 0.5
|McGee, 2007, Chapter 13.||2||4|
|Pulse character||Regular versus irregular amplitude rate||Intermittent ectopy,|
|Respiration Rate||Cheyne Stokes respiration||CHF versus neurological disorders||Patients with Cheyne stokes respiration have lower cardiac outputs, higher wedge pressures, and short survival|
McGee, 2007, Chapter 17.
|Inspection of Neck Veins and Carotid Pulse||Inferring the CVP||Measurement of the JVP is useful because it infers the CVP, which is equal to the right ventricular end diastolic pressure||Method of Lewis (CVP equals JVP measured from the sternal angle + 5cm)||>3 cm is abnormal; Physicians tend to underestimate the CVP if measurement taken at semi-reclined position.|
|Users are better able to locate the angle of Lewis than the phlebostatic axis;|
but sternal angle to phelbostatic axis varies with patient factors.
|Locating the top of the JVP||Using sternal angle (angle of Lewis)||Multiple uses the error of the JVP/CVP estimate can be up to 50%.||Clinical estimates of CVP usually within 4cm of catheter estimates 85% of the time|
|Normal JVP versus elevated JVP||>3cm above the sternal angle OR|
Should be right atrium
|If physician believes JVP elevated, LR = 9.0 JVP really elevated by catheter; conversely if physician believes JVP normal, LR = 0.1 CVP will be less than 12 cm by catheter|
Physicians can make useful judgements about CVP at the bedside despite a wide error margin
|What about JVP waveform?||X' dominant normal||CV wave in afib, TR||Brisk X'/Y in tamponade||See|
(paradoxical elevation of JVP inspiration)
|Constrictive pericarditis, severe heart failure, PE, right ventricular infarction
Validity of the Hepato-jugular Reflux as a Clinical Test for Congestive Heart Failure
|JVP that increases in height in inspiration||Likely has to do with a failure to accommodate increase venous return due to increased venous tone, decreased venous volume, and inability of right heart to compensate|
Operational characteristics not well defined
|Observational evidence in each of the following disorders|
Severe Heart Failure:
Hitzig, 1941; Wood, 1961; Ducas, 1983.
Dell’Italia, 1983; Lorell, 1979.
Right Ventricular MI:
|Bifid AS/AR or IHSS|
|Carotid Bruit||Detection of atherosclerotic disease in the carotid artery||Listen high in the neck to differentiate between heart murmurs and bruits; also listen at the bifurcation of the carotid artery near the thyroid cartilage; the bell of the stethoscope should be used|
Orient, 2005, p397.
|High grade stenosis in symptomatic patients:+LR = 1.5 to 3.2; LR = 0.6 to 0.3|
Although only 50% of asymptomatic patients with a bruit actually have carotid stenosis; the presence of a bruit alone may be associated with a 3 to 6x incidence of stroke
Orient, 2005, p399.
|Percussion not performed||Cardiac size||Poor diagnostic utility and uncertain clinical significance||+LR = 2.4 to 2.5; |
-LR = 0.05 to 0.1
McGee, 2007, Chapter 33.
|Palpation of the Precordium||Four cardinal positions||Thrills, palpable heart sounds and extra heart sounds such as s3 and s4.||Aortic, pulmonary, tricuspid, and mitral areas||Useful to rule out pulmonary hypertension in MS||Palpable P2 argues for pulmonary hypertension in MS +LR = 3.6, -LR = 0.05|
|Palpable S2||Pulmonary hypertension||See auscultation of loud s2||Detects pulmonary pressures of >50mmHg in patients with MS +LR=3.6, -LR = 0.5|
|Size of apex||Left lateral decubitus position at 45 degrees, diameter of 4cm of more||The location of the apex is a better marker of left end diastolic volume.|
May be done in left lateral decubitus position
|Increased left end diastolic volume. +LR = 4.7 |
|Location of apex|
12 cm from MSL/2.5-3 cm diameter
|Point of maximal impulse does not relate to anatomical apex of heart||Supine; Measured from the mid-clavicular line|
|PMI located outside midclavicular line implicates enlarged, failing heart or volume overload with normal EF|
A displaced apex is useful for detecting enlarged hearts
Palpable in only 25% to 50% of adults regardless of position
McGee, 2007, Chapter 34.
|Enlarged heart on CXR +LR = 3.4|
Ejection fraction is depressed +LR = 5.7
LV end diastolic volume is increased +LR = 8.0
|Amplitude of apex||Increase implies volume overload=AR, MR, VSD||Subjective process||In patient with known mitral stenosis, an increased apex argues for associated aortic stenosis OR mitral regurgitation|
General utility is not high.
|+LR = 11.2|
|Sustained Apex||Detects left sided pressure or volume overload; aortic aneurysm; cardiomyopathy; pulmonary hypertension||Supine position; the distention of the precordium extends to S2 or beyond||A useful sign in very specific circumstances such as in aortic murmurs.|
Up to half of normal pts have sustained apex in left lateral decubitus position
|In the presence of aortic murmur, sustained apex argues for aortic stenosis +LR = 4.1 |
In the presence of aortic regurgitation, a lack of sustained apex argues against moderate to severe AR –LR =0.1
|Palpable S4 / Apex not sustained|
-EF > 50%
Palpable S4 / Apex sustained
S4 not palpable / Apex sustained
-EF < 40%
|Double Apical Impulse||Anterior or apical ventricular aneurysms||Multiple studies|
McGee, 2007, Chapter 34.
|Retracting Apex||Constricture pericarditis and tricuspid regurgitation||Inward motion begins at s1 and does not return until after s2||90% of constrictive pericarditis|
El Sherif, 1971.
|Heaves; lifts, thrusts||refers to sustained or hyperkinetic movements not at the apex; left parasternal heave refers to movement at the left 2nd - 4th interspace||Useful in specific situations such as suspected pulmonary hypertension. Different terms are confusing and should be avoided|
McGee, 2007, Chapter 34.
|Left parasternal heave can discriminate those with RV pressures of >50mmHg +LR = 3.6, -LR = 0.4 |
Right parasternal heave can indicate TR or MR
McGee, 2007, Chapter 34.
|Auscultation||Proper use of the stethoscope||Proper stethoscope use enhances hearing of heart sounds||Most important source of poor acoustic performance is air leak around ear piece. |
Diaphragm attenuates all sounds, therefore dropping low frequency sounds to below range of human hearing; Bell transmits all sounds well, allowing low frequency sounds through.
|Examination in 3 different positions||Sitting|
Left lateral decubitus
|At least 3 positions are necessary to hear all relevant heart sounds||Sitting for splitting of s2, rubs and AR|
Left decubitus for detecting s3 and s4 and MS murmur
McGee, 2007, Chapter 35.
|Order of Examination||Right upper sternal area; Entire left sternal border; Apex|
Using Bell and then diaphragm
Louder than S2 in aortic area
|Mitral valve prolapse, mitral stenosis, left atrial myxoma||Tei, 1982.|
|Faint S1||MI, LBBB, long PR interval, acute AR||LV dysfuntion||McGee, 2007, Chapter 36.||1||4|
|Variable S1||AV dissociation||In patients with pacer, variable S1 indicates AV dissociation +LR = 24.4|
|Wide split S1||RBBB, LV ectopic beats||1||1|
|Loud P2||Defined as either S2 heart better at left base than right base OR as S2 splitting with second sound louder||Studies do not support loud P2 as a sign of pulmonary hypertension||1||1|
|Faint S2||AS||+LR = 3.1||Etchells, 1997.||1||1|
|Wide split S2||RBBB, pulmonic stenosis, MR,||1||1|
|Paradoxical splitting S2|
Fixed split S2
|LBBB, aortic stenosis, WPW with left accessory pathway LV dysfunction|
ASD, RV failure
|Absence of fixed splitting argues against ASD in patients with wide split LR = 2.6|
|S3||Rapid diastolic filling or LV dilatation, dysfunction and volume overload||Best heard over apex with bell if originating from left; best heard over left sternal border if coming from right ventricle|
McGee, 2007, Chapter 37.
|S3 is worthwhile heart sound to look for||Detects EF < 50% +LR= 3.8|
Detects EF < 30% +LR 4.1
Detects elevated left heart filling pressures +LR 5.7
Predicts post-op pulmonary edema +LR =14.6
Predicts post-op MI or cardiac death +LR = 8.0
|S4||Stiff ventricle||Best heard just medial to the apex with bell if originating from left; best heard over lower left sternal border if coming from right ventricle and is more obvious with inspiration|
McGee, 2007, Chapter 37.
|More study is needed for s4's significance||Predicts 5 year mortality after MI +LR = 3.2|
Does not reliably predict AS alone
|Murmurs||Presence or absence of murmurs||Cardiologists seem to be able to rule in abnormal systolic murmurs with fair degree of accuracy.|
However Sapira suggests that this doesn’t mean it can’t be done.
|Intensity||Relates to whether a murmur is innocent or pathologic||Grade 1 to 6 as described by:|
Orient, 2005, p359.
|Innocent murmurs are almost never grade 3 or more but pathologic murmurs can certainly be less than grade 3|
Orient, 2005, p359.
|Location of maximal intensity||Relates to the origin of the murmur||1||2|
|Radiation||Relates to the origin of the murmur||1||2|
|Shape||Relates to the diagnosis of the murmur||1||2|
|Timing||Systolic versus diastolic murmur||Early, mid, late systolic||Early or prolonged diastolic||See www.Blaufuss.org||1||3|
|Examination of peripheral pulses||Inspection and palpation||Radial, brachial, carotid, femoral, popliteal, dorsalis pedis, posterior tibial pulses all can be palpated||the dorsalis pedis pulse is not palpable in 3 to 14% of people; posterior tibial pulse not palpable in up to 10% of the time HOWEVER only 0 to 2% have BOTH pulses absent pedal pulses||- absent posterior tibial and dorsalis pedis pulses 14.9;|
- LR = 0.3- absent femoral pulse + LR=6.1
McGee, 2007, Chapter 50.
|Auscultation||Carotid, subclavian, femoral, pulses could be auscultated for bruits||Bruits represent turbulent flow through a stenotic vessel||- limb bruit present +LR = 7.3; - LR = 0.3|
|Signs of arterial Insufficiency||Observation and palpitation of pallor, loss of hair, coolness, impaired nail growth, atrophic shinny skin appearance, arterial ulcers||- The most important signs are absence of both pedal pulses; the presence of any limb bruit; presence of sores, absence of femoral pulse, and asymmetrical coolness||- presence of sore on foot +LR = 7.0|
- foot color abnormally blue, red or pale +LR-2.8; -LR=0.7
-atrophic skin +LR=2.7
-absent lower limb hair +LR =1.7
-foot asymmetrically cool +LR=6.1; - LR=0.9
McGee, 2007, Chapter 50.
|Capillary refill||This is a test of peripheral vascular disease and not a test of anemia||Multiple areas have been described from toe to index finger to thumb; duration of pressure is from 2 to 5 seconds; degree of pressure is not define; exact time of normal cap refill is from 2 to 5 seconds but may depend on age||Capillary refill time is a poor predictor of hemodynamic status in children|
Lighting conditions may have a bearing on interpretation of cap refill
|See excellent review by Ewan Kinnear at http://www.northampton.ac.uk/downloads/podiatry/ekdiss.pdf|
Cap refill time > 5 seconds +LR = 1.9
Lewis and Pickering both showed this is an unreliable sign
McGee, 2007, Chapter 50.
|Ankle brachial index||Diminished blood flow to the lower limbs causes relative decrease in BP in the pedal pulses.||Highest systolic pressure at the Dosalis pedis and posterior tibial arteries with a handheld Doppler, divided by BP at the brachial artery (values > 0.92 are abnormal)||Check with thick cuff around calf and palpable at ankle.||Hiat, 1995.||1||2|
|Buerger’s test||Elevate leg 90 degrees for 2 minutes, then dangle perpendicular to table edge for 2 minutes||A positive test is abnormal pallor with elevation and the appearance of dusky red flush spreading proximally from the toes in the dependent position||1||2|
|Signs of venous Insuffiency||Observation and palpation of rubor, purpura, warmness, edema, venous stasis ulcers||1||2|
|Vein emptying time (venous filling)||Pick one vein on the leg while patient supine, elevate leg at 45 degrees for 1 minutes; the patient sits and dangles leg over exam table; record time it takes for vein to reappear||Times greater than 20 seconds are abnormal||+LR = 3.9 |
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