WIPER Q (wash hands, introduce yourself, seek permission to examine, expose the patient adequately to waist, reposition the patient to 45 degrees, ask if the patient is comfortable/has any pain)
Eyeball the patient from the end of the bed:
- Patient: young – consider congenital heart disease/old, well/unwell, in pain/ comfortable at rest, distressed/breathless, colour (pale/cyanosed/flushed/photosensitive rash), visible pulsations in the neck/earlobe movement, can you hear a prosthetic valve?, is there a scar on the chest+/- leg (CABG)? Are the ankles swollen, is there dysmorphic features (marfans, turners, noonans, Williams, downs, digeorge)? Is there chest deformity? De musset’s sign (head bobbing in AR)
- Midline sternotomy scar but no leg scar: valve replacement (mechanical versus biological), congenital heart surgery, LIMA CABG, AA/AD repair, heart transplant
- Midline sternotomy scar and leg scar: CABG, valve replacement (mechanical versus biological) and CABG
- Surroundings: ECG, Oxygen therapy, fluid restriction signs, GTN spray
Examine the hands
- Temperature and colour and sweating. Cyanosis = dusky blue discolouration of the skin/mucous membranes when sats are low. Causes of peripheral cyanosis: heart failure, cold room, low cardiac output, raynauds, B blockers, peripheral vascular disease. Cutaneous vasoconstriction and stasis of blood.
- Feel for bogginess as well as looking.
- Splinter haemorrhages: fine longitudinal haemorrhagic streaks under nails. Check not due to trauma! Can occur in vasculitis/ infective endocarditis
- Osler nodes (tender erythematous nodules in finger pulps)
- Janeway lesions (painless erythematous macules on palms)
- Capillary refill (press for 5 secs, should be <2secs. If prolonged: hypovolemia, septic)
- Tar staining
- Tendon xanthomata (dyslipidaemia, localised deposits of fat under the skin occurring over joints, tendons, hands and feet)
- Nail fold infarcts (vasculitis)
- Nailbed capillary pulsation (Quinkes sign in AR)
- Arachnodactyly (Marfans)
- Polydactyly (ASD)
- Triphalangeal thumb/radial hypoplasia (Holt oram syndrome)
- Bruising of hands +/- arms (warfarin)
- Needletrack marks (IVDU, IE), picc lines etc
Cardiac causes of clubbing:
- Cyanotic Congenital Heart Disease
- IE (subacute)
- Atrial myxoma
Four stages of clubbing:
- Fluctuant nailbed (tilting from side to side)- press it to feel this
- Loss of angle between nail and nailbed- Schamroths window test: check for normal diamond gap between opposed nails
- Increased longitudinal curvature of the nail
- Increased ST swelling of terminal phalanx- drumstick appearance
Radial pulse: rate and rhythm (too far from heart to appreciate waveform), radial-radial delay (eg. aortic arch aneurysm, Blalock Taussig procedure)
- Take for 15 secs then x4. Fast >100. Slow <60. N= 60-100.
- Pulse >120bpm: fever, bleeding, hypoxia, thyrotoxicosis, anaemia, heart failure, PE, drugs eg. amphetamines, B-agonists, severe electrolyte disturbances
- Pulse <60bpm: athletic heart, drugs eg. b-blockers, digoxin, sinoatrial disease, bigemini, MI, hypothyroid, hypothermia, severe electrolyte disturbance
- Irregularly irregular = AF or atrial flutter with variable block. If AF: check for pulse deficit, auscultate rate at apex
- Regularly irregular = 2nd degree heart block and ventricular bigeminus
- Reduced/Absent radial pulse: unusual anatomical course, congenital absence, atherosclerosis, embolism (AF), external compression of proximal artery by cervical rib/LN/mass, subclavian stenosis, local trauma from ABG/arterial line, radial artery harvest, AV fistula, takayasu’s arteritis, coarctation of the aorta+subclavian patch repair, blalock taussig procedure for tetralogy of fallot. Compare cap refill times on each side. Check for BM testing pricks, request BP in both arms. Look for scars overlying radial artery, arm, shoulder. At the end, palpate and auscultate all pulses.
Collapsing pulse (any pain in arm/shoulder?, raise arm above head, feel with 3 fingers) : ‘waterhammer’ pulsation in forearm in AR, PDA, hyperdynamic states such as pregnancy. Also look at neck at the same time for Corrigan’s sign (forceful rise and quick fall of carotid pulsations)
Brachial pulse: volume and waveform character (medial to biceps tendon insertion)
BP (Ask for the BP. Is it the same in both arms?) Systolic- pressure at which the pulse is first heard on cuff deflation. Diastolic- when the heart sounds disappear. Calculate the pulse pressure (narrow AS, wide in AR).
Carotid pulse: volume and character (between larynx and sternocleidomastoid)
- Small volume pulses = AS, poor cardiac contractility due to ischaemic heart disease/cardiomyopathy/pericarditis/tamponade, hypovolemia/shock
- Large volume = AR, high output states eg. thyrotoxicosis
- Bounding = CO2 retention, liver failure, sepsis
- Collapsing pulse (rapidly rising carotid pulse which collapses in early diastole owing to back flow through aortic valve) = AR, AVM, PDA
- Anacrotic (slow-rising) pulse = AS, B-blocker, LV dysfunction
- Bisferiens = AS and AR combined
- Pulsus alternans = alternating strong and weak beats = LVF, cardiomyopathy, AS
- Jerky pulse = HOCM
- Pulsus paradoxus (systolic pr declines in insp by >10) = severe asthma, pericardial constriction, cardiac tamponade
JVP: ask patient to turn head slightly to left, bed at 45 degrees (lower bed if cannot see it or can fill and empty external jugular). Look at height and waveform of the pulse. It is deep to SCM so want SCM relaxed and look for SCM movement. Seen between heads of or behind SCM. Look from the front to your left. (hepato- and abdominojugular reflux sign positive if the rise in JVP is persistent throughout a 15s compression = RV failure, heart can eject increased VR). Does patient have pain in abdo?). Pr in RA can be estimated from JVP because internal jugular vein is in continuity with RA (no valves). RA pr = CVP. Vertical height of the pulse (<4 cm) above sternal angle (measured from angle of Louis to the upper part of the JVP pulsation) with the patient lying at 45 degrees. Pressing on the upper abdomen may increase VR to the heart which elevates the RA pr and therefore the JVP. If it is 8cm, then RA pr is 13cm of blood. Normal RA pressure should be less than 9 cmH2O, which corresponds to less than 4cm distance above sternal angle
- Raised JVP with pulsation/normal waveform:
- Congestive heart failure and RHS HF
- Fluid overload
- Constrictive pericarditis, tamponade, pericardial effusion
- Cor pulmonale due to high RA pressure (pulmonary HT)
- Complete heart block
- Raised JVP with absent pulsation: SVCO. See engorged neck veins. Malignancy eg.bronchial Ca in upper mediastinum.
- Large a wave = pul HT/ pulmonary stenosis, tricuspid stenosis, MVD, cor pulmonale.
- Cannon a wave = when the RA contracts against a closed tricuspid valve, complete heart block, single chamber ventricular pacing, ventricular arrhythmias/ectopics eg. VT (marks coincident atrial and vent systole). A wave occurs before the pulse
- Absent a wave = AF
- Large systolic v waves = severe TR look for earlobe movement (ivdu IE, heart failure). V waves occur with/after the pulse.
- Kussmauls sign in constrictive pericarditis: high plateau of JVP which rises on inspiration. Also deep x and y descents. Heart cannot accommodate the inspiratory increase in VR
- Absent JVP: reduced circ volume
- 7 differences between JVP and arterial pulse
- JVP not palpable but pulsations visible
- Double waveform/pulse for every arterial pulse
- Changes with respiration
- Changes with movement/posture
- Occludable by finger pr on the vessel
- Fills from above
- Hepatojugular reflex
Neck: jvp as above plus central access scars, plucked chicken skin appearance of pseudoxanthoma elasticum, photosensitive rash
Eyes: conjunctival pallor (ask pt to pull down either eyelid, anaemia), corneal arcus (dyslipidaemia if less than 50yo, crescentic-shaped opacity at the periphery of the cornea) and xanthelasma (dyslipidaemia, lipid deposits on the eyelid), ectopia lentis, blue sclerae, jaundice, exopthalmos (Graves disease)
Face: malar flush (cyanosis and telangiectasia: MS, pulmonary hypertension and low cardiac output), signs of Graves (exophthalmos/goitre), dysmorphic face (Downs, Marfans, Turners, Noonans, Williams), bobbing of the head (de Musset’s sign in AR)
Mouth: central cyanosis (due to significant hypoxia eg.R to L shunting of deoxygenated blood in CHD, pulmonary oedema prevents adequate oxygenation of blood, lung disease eg . R to L pulmonary shunt due to no perfusion of lung tissue from collapse/consolidation. Look at lips and oral mucosa, tongue. Ask patient to stick out tongue and look at underside. At least 5g/dL reduced Hb in blood. PaO2 below 6kPa.) Check the dentition and look for a high-arched palate. Look with a torch. Don’t miss mullers sign (uvula).
- Scars: median sternotomy (CABG + look at leg for long saphenous vein graft, Valve replacement, transplant for CHD), lateral thoracotomy scar (mitral valvotomy), pacemaker scar, central access/tunnelled lines scar eg. source of IE/long term antibiotics, PPM/ICD scar. Lift arms to check for lateral scars too. Lift breast to check for mitral valvotomy scar.
- Pacemakers/ ICD box (on left below clavicle)
- Chest wall deformity: pectus excavatum may compress the heart and displace the apex beat. Pectus carinatum
- Visible apex beat- AS,AR,MR
- Abnormal pulsations eg. due to large ventricular/aortic aneurysms
- Prominent venous collaterals on chest wall = SVCO
- Gynaecomastia (digoxin, spironolactone)
- Listen for audible clicks at bedside
- Apex Beat (5th IC mid-clav line)
- Show examiner you can find apex beat. Inspect first for pulsation then palpate. Is it displaced? Measure position in fingerbreadths from mid-clav line and count down to the apex beat. If displaced check for shifted mediastinum (feel the trachea position). Displaced in CCF (not LVF), AR, MR, cardiomegaly not hypertrophy. If cannot feel it, tilt the patient onto their left side and check on right hand side in case dextrocardia. Assess the rate and rhythm.
- Impalpable: dextrocardia/ COPD (emphysema)/obesity/pericardial effusion /pleural effusion/pneumothorax (fat/fluid/air between apex and palpating hand)
- Heaving (outflow obstruction eg. AS, systemic HT leading to LVH but no displacement, large LV due to MR/AR which results in displacement)
- Thrusting (volume overload eg. MR/AR, ASD)
- Tapping (palpable S1 in MS). Place hand from lower left sternal edge to apex to detect tapping pulse.
- Diffuse (LV failure, dilated DM)
- Double apex beat (HOCM)
- Rate if pulse irregular eg. AF. (is there apical-radial pulse mismatch?)
- Heaves and thrills: place hand to left then right of sternum.
Heave: forceful ventricular contractions. Sustained, thrusting usually felt at left sternal edge = RV enlargement in pul stenosis, cor pulmonale, ASD, pul HT). LVH in AS = heaving apex.
Thrill: palpable murmur (felt as vibration beneath hand). In AS/MR. feel like stroking a purring cat! Should be able to hear a murmur easily if present.
Place flat of palm parasternally over RV area/left sternal edge to apex to feel for a RV/left parasternal heave suggestive of RV hypertrophy (RV pressure overload due to pulmonary hypertension). In this same position feel for the thrill of a small VSD or TR or MR.
Palpate pulmonary area for palpable S2 suggestive of pulmonary hypertension and for a thrill.
Palpate aortic area for the thrill of AS/AR
Auscultate: feel carotid at same time (pulse felt at S1). Bell then diaphragm at apex (mitral area) and all other areas. Diaphragm for high-pitched sounds. Bell for low-pitched sounds. Left sided murmurs loudest in expiration (exp increases blood flow to the left side of the heart). Right sided loudest in insp.
- 1st and 2nd HS normal? 1st HS= mitral + tricuspid closing before carotid pulse felt, loudest at apex or btw apex and lower left sternal border. Then 2nd HS = aortic and pulmonary closing, after carotid pulsation. Best heard at upper left sternal edge using diaphragm. Loud 2nd HS = HT/pul HT.
- Added sounds? (3rd/4th heart sounds). Split sounds? Prosthetic sounds?
- Murmurs? Systolic= with carotid pulse. Diastolic = not with pulse. Is it louder in insp/exp?
- Diastolic murmurs are more difficult to hear and require manoeuvres to bring the relevant part of the heart closer to the stethoscope
- Listen at apex (mitral area) with diaphragm, listen for the pansystolic murmur of MR. Ask the patient to hold breath in exp. Check for radiation in axilla
- Listen at apex (mitral area) with bell (apply gently), listen for the first heart sound- is it normal/loud as in MS/soft as in MR. Listen for diastolic murmur. Put patient in left lateral position breath held in exp. (“Roll onto your left side, now take deep breath in and out and hold it there”). Rumbling mid-diastolic murmur = MS
- Listen at the tricuspid area (lower left sternal edge) with the bell for 3rd and 4th heart sounds. Then listen with the diaphragm for the murmur of TR/VSD. Ask the patient to hold breath in insp if you hear a murmur
- Listen at the pulmonary area (left of manubrium in 2nd IC) for the second heart sound with the diaphragm. Is it loud? Is it split? Is there a systolic murmur? Ask the patient to hold breath in insp if you hear a murmur. Does it radiate to the back?
- Listen in the aortic area (right of manubrium 2nd IC) with the diaphragm for an ESM= AS. Check for radiation to carotids. Is it louder in expiration? What is the character of the second heart sound?
- Sit patient up and lean forward and listen at the aortic area and lower left sternal edge (tricuspid area) with diaphragm with patient breath held in exp (early diastolic murmur: AR)
- Assess the character, timing, loudness, area where loudest, radiation, accentuating manoeuvres
- Systolic murmurs 1-6, diastolic murmurs graded 1-4 NB: can be inaudible yet severe
- 1- very soft, only heard after listening for a while
- 2- soft, but detectable immediately
- 3-clearly audible, but no thrill
- 4- clearly audible with thrill
- 5- audible with stethoscope only partially touching the chest
- 6- can be heard without stethoscope
A Place To Meet.
Aortic area- 2nd IC space right sternal edge
Pulmonary area – 2nd IC space left sternal edge
Tricuspid area – 4th IC space left sternal edge
Mitral area – 5th IC space, mid-clav line
Whilst pt sitting forward palpate for sacral oedema and auscultate the lung bases
Auscultate for carotid bruits “breathe in, out and hold” with the bell. Causes: atherosclerosis (elderly), vasculitis (young). NB: if bilateral likely to be radiation of murmur.Unilat=more likely bruits.
Check for ankle oedema and look at toe nails- splinters/clubbing and legs for vein harvest scar
Lie the patient flat and feel for a pulsatile liver, splenomegaly of IE. And check for radiofemoral delay (coarctation of the aorta- make sure to check for hypertension and systolic murmur).
Thanks very much that completes my examination. Cover patient and wash hands.
Take stethoscope off and put behind back and present findings.
To complete the examination:
- Palpate peripheral pulses- femoral, popliteal, posterior tibial, dorsalis pedis
- Palpate for an AAA
- Auscultate lung bases for bibasal insp crackles and effusions if not already done
- Palpate for sacral and ankle oedema in heart failure if not already done (firm pressure for a few seconds. Tell patient because it hurts). Also legs and torso if oedema++
- Check lower limbs for vein grafts
- Examine abdomen: hepatomegaly and ascites in right sided heart failure, pulsatile hepatomegaly with TR, splenomegaly with IE
- Temperature chart, O2 sats etc
- Dip urine (haematuria in IE, glucose)
- Fundoscopy: roth spots (retinal infarcts) in IE, hypertensive changes, diabetic retinopathy
- Check for radial-femoral delay
- Demonstrate other features of syndromes if suspicious eg. marfans, ankylosing spondylitis etc.
Written by Dr Sarah Kennedy using the resources outlined in the references section of this PACES website.