Cardiology - Examination & presenting problems

Question 1

How should the patient be positioned for the cardiovascular exam?

Answer 1

Position the patient at 45 degrees to the horizontal and expose the chest (maintain dignity for women). There are cardiac “patterns” that can lead to a diagnosis in the examination.

Question 2

What is the character of the pulse in aortic stenosis?

Answer 2

The pulse is slow rising and is often accompanied by low blood pressure and a narrow pulse pressure.

Question 3

What the quality of the apex beat in aortic stenosis?

Answer 3

The apex beat is sustained but not usually displaced, as the ventricle is hypertrophied not dilated.

Question 4

What murmur is heard in aortic stenosis? Does it radiate?

Answer 4

An ejection systolic murmur is heard in aortic stenosis, which is loudest over the aortic area. It radiates to the carotids.

Question 5

What is the character of the pulse in aortic regurgitation?

Answer 5

The pulse is a collapsing or “water hammer pulse”. Peripheral signs include nail bed pulsatations (Quinke’s sign) and carotid pulsation (“dancing” carotids, or Corrigan’s sign). Pistol shot femorals (Durosier’s sign) are another.

Question 6

Is the apex beat affected by aortic regurgitation?

Answer 6

Yes. The apex beat is characteristically displaced and sustained to the left.

Question 7

What murmur is heard in aortic regurgitation?

Answer 7

An early diastolic murmur is present (S2 may be diminished) which is loudest over the left sternal edge and may radiate along the left sternal border.

Question 8

How should one listen for aortic regurgitation?

Answer 8

Diastolic murmurs are low frequency murmurs and require accentuation to hear them. The patient should be sat up and leant forward. The breath should be held in expiration with the examiner listening at the left sternal edge.

Question 9

What is the character of the apex beat in mitral stenosis?

Answer 9

The apex beat is tapping but not displaced, and felt at the left sternal edge. There can often be a parasternal heave (late on) due to right ventricular hypertrophy secondary to pulmonary hypertension.

Question 10

What is the character of the murmur in mitral stenosis?

Answer 10

Classically, mitral stenosis has a low frequency mid diastolic murmur which is heard best at the apex. The patient should be placed in the left lateral position, and because it is a diastolic murmur it does not radiate.

There is an opening mid-diastolic “click”, and a loud S1.

Question 11

Is the pulse altered in mitral stenosis?

Answer 11

Patients are often in AF and have an irregularly irregular pulse. Malar flush (mitral faces) and signs of CCF may also be present.

Question 12

How is the apex beat affected by mitral regurgitation?

Answer 12

The apex beat is heaving and displaced due to ventricular dilatation. Dilatation is the ONLY reason an apex beat will be displaced.

Question 13

Describe the murmur in mitral regurgitation

Answer 13

Mitral regurgitation has a pansystolic murmur that is loudest at apex. As with mitral stenosis, the patient should be on the left lateral position. The murmur radiates to the axilla.

Mitral regurgitation and aortic stenosis (“MR AS”) constitute the systolic murmurs. Mitral stenosis and aortic regurgitation (“ARMS”) are the diastolic murmurs.

Question 14

What features should be sought on general inspection of the patient?

Answer 14

In a quick visual survey, observe whether the patient is:

• breathless
• cyanosed
• pale, or
• whether he has a malar flush (mitral stenosis)

Look briefly at the earlobes for creases (Frank’s sign) and then at the neck for pulsatations:

• forceful carotid pulsations (Corrigan’s sign in aortic incompetence; vigorous pulsatation in coarctation of the aorta)
• tall, sinuous venous pulsatations (congestive cardiac failure, tricuspid incompetence, pulmonary hypertension etc)

Run your eyes down onto the chest looking for:
- left thoracotomy scar (mitral stenosis) or a midline sternal scar (valve replacement) and then down to the feet looking for:
ankle oedema. As you take the arm to feel the pulse, complete your visual survey by looking at the hands (a quick look, don’t be ponderous) for
- clubbing of the fingers (congenital cyanotic heart disease, subacute bacterial endocarditis, atrial myxoma) and splinter haemorrhages (infective endocarditis)

Question 15

What features of the hands should be sought on cardiovascular examination?

Answer 15

Check for signs of infective endocarditis:

• Splinter haemorrhages
• Oslers nodes (painful)
• Janeway lesions (non painful)

Peripheral cyanosis
Clubbing

Question 16

What should you assess after the hands?

Answer 16

Move onto the pulse, feeling for rate and rhythm.
Ascertain whether the pulse is collapsing (particularly if it is a large volume pulse meaning aortic regurgitation) or not. Ask the patient about any pain in there shoulder then palpate the brachial pulse and lift the arm up.

Next check for radio-femoral delay (coarctation of the aorta). Feel the brachial pulse followed by the carotid pulses to see if the pulse is slow rising, especially if the volume (the upstroke) is small.

Question 17

What is Corrigans sign?

Answer 17

You should note any interesting features you see in the neck on your initial visual survey. Now confirm these impressions. Corrigan’s sign (forceful rise and quick fall of the carotid pulsation) may already have been reinforced by the discovering of a collapsing radial pulse and suggests aortic aortic regurgitation.

Question 18

What does a “v” and an “a” wave suggest?

Answer 18

Timing of the individual waves of a large venous pulse are timed by palpating the opposite carotid pulsation. A large v wave, which sometimes oscillates the earlobe, suggests tricuspid incompetence and you should later demonstrate peripheral oedema and the pulsatile liver using the bimanual technique. If the venous wave comes BEFORE the carotid pulsation, it is an a wave, suggestive of pulmonary hypertension (mitral valve disease, cor pulmonale) or pulmonary stenosis.

After, assess the height of the venous pressure in centimetres, vertically above the sternal angle.

Question 19

What is the normal position of the apex beat?

Answer 19

5th intercostal space, mid clavicular line.
Localise the apex beat first by inspecting for visible pulsation and secondly by palpation. The impulse can be graded as just palpable (normal), lifting (diastolic overload, i.e. mitral or aortic incompetence), thrusting (stronger than lifting) or heaving (outflow obstruction). Remember that only a dilatation displaces the apex beat.

Question 20

What is a thrill?

Answer 20

Thrills are palpable murmurs. Palpation with your hand placed from the lower left sternal edge to the apex will detect a tapping impulse (left atrial “knock” in mitral stenosis) or thrills over the mitral area (mitral valve disease), if present.