Overview
Concise notes on a systematic cardiovascular system examination using Look, Listen, Feel. Follows WIPPE prep, inspection, auscultation, palpation/percussion, and closure.
Preparation: WIPPE
- Wash hands; wipe down equipment; ensure cleanliness and safety.
- Introduce self; confirm patient identity with two identifiers.
- Permission: explain exam purpose and steps; obtain consent.
- Position: patient supine at 45°; expose to waist; legs also exposed if useful.
- Exposure: adequate chest and lower limb exposure for inspection and palpation.
Inspection: General
- Observe age, oxygen or devices, distress (e.g., dyspnea), overall wellbeing.
- Color changes: cyanosis, jaundice, marked pallor suggest systemic issues.
- Scars: midline sternotomy (CABG, valve replacement, transplant); leg scars from saphenous vein harvest.
- Dysmorphic features: suggestive of Down, Marfan, Turner syndromes with cardiac associations.
Inspection: Face, Eyes, Mouth, Neck
- Eyes: conjunctival pallor (anemia/poor perfusion); corneal arcus; xanthelasma (hyperlipidemia).
- Cheeks: malar flush linked to mitral stenosis.
- Mouth: central cyanosis under tongue; high palate in Marfan syndrome.
- Muller's sign: systolic uvular pulsation → aortic regurgitation.
- De Musset’s sign: rhythmic head bobbing → aortic regurgitation.
- JVP: observe internal jugular pulsation over sternomastoid; >4 cm above sternal angle is elevated.
- JVP interpretation depends on patient position; inspiration lowers JVP.
- Differentiate carotid vs JVP: JVP not palpable, occludable, varies with respiration, double waveform per arterial pulse.
Inspection: Chest, Abdomen, Limbs
- Devices: pacemaker/ICD usually under left clavicle.
- Chest wall: pectus excavatum/carinatum; excavatum may compress heart and displace apex.
- SVC obstruction: prominent chest wall veins.
- Abdomen: pulsatile mass may indicate abdominal aortic aneurysm.
- Hands: peripheral cyanosis; clubbing (loss of Schamroth window).
- Nails: splinter hemorrhages (infective endocarditis); Quincke pulsation (aortic regurgitation).
- Lesions: Osler’s nodes (painful, purple pulp nodules); Janeway lesions (painless palmar macules).
- Edema: visible ankle/leg swelling; confirm by palpation.
- Leg scars: prior saphenous vein harvest for bypass.
Auscultation: Heart Areas and Additional Listening
- Normal heart sounds: S1 (AV valves close) to S2 (semilunar valves close); systole between S1 and S2.
- Additional sounds may be pathological or benign; correlate clinically.
- Primary areas while palpating radial pulse:
- Aortic: 2nd right intercostal space, right sternal edge.
- Pulmonary: 2nd left intercostal space, left sternal edge.
- Erb’s point: 3rd left intercostal space, sternal edge (S1 and S2).
- Tricuspid: 4th left intercostal space, sternal edge.
- Mitral/apex: 5th intercostal space, midclavicular line.
- Children: include interscapular region for machinery murmur of coarctation.
- Carotids: listen for bruit (stenosis) or radiating systolic murmur (aortic stenosis).
- Periumbilical: bruit may indicate renal artery stenosis (secondary hypertension).
- Lungs: bilateral fine basal crackles (pulmonary edema); wheeze in severe cases.
Palpation and Special Maneuvers
- Apex beat: normally 5th intercostal space, midclavicular line; note displacement or visibility.
- Heaves and thrills: palpable ventricular impulse or murmur vibration.
- Hepatojugular (abdominojugular) test: RUQ pressure increases venous return; sustained JVP rise → right ventricular failure.
- Pulses:
- Radial: rate, rhythm, compare sides; radio-radial delay (dissection).
- Radio-femoral delay: suggests aortic coarctation.
- Brachial and carotid: assess volume; bounding (aortic regurgitation), small volume (aortic stenosis).
- Capillary refill: press fingertip 5 seconds; normal ~2 seconds.
- Peripheral edema: press 10 seconds over anterior tibia; look for pitting; also check hips and sacrum (bedbound).
JVP: Features, Causes, and Differentiation
| Feature | JVP | Carotid Pulse |
|---|
| Palpability | Not palpable | Palpable |
| Effect of pressure | Occludable with gentle pressure | Not occludable |
| Respiratory variation | Falls on inspiration | Minimal change |
| Waveform | Double per arterial pulse | Single upstroke |
| Mnemonic | Cause of Elevated JVP |
|---|
| P | Pulmonary hypertension, pulmonary embolism |
| Q | Quantity of fluid (fluid overload) |
| R | Right ventricular failure |
| S | Superior vena cava obstruction |
| T | Tricuspid regurgitation/stenosis; tamponade (cardiac), pericardial effusion, constrictive pericarditis |
Common Signs and Their Cardiac Associations
| Sign | Description | Likely Association |
|---|
| Malar flush | Reddish cheek discoloration | Mitral stenosis |
| Corneal arcus | Peripheral corneal white/gray ring | Hyperlipidemia |
| Xanthelasma | Periorbital yellow plaques | Hyperlipidemia |
| Muller's sign | Systolic uvular pulsation | Aortic regurgitation |
| De Musset’s sign | Rhythmic head bobbing | Aortic regurgitation |
| Clubbing | Distal phalanx swelling, loss of window | Cyanotic CHD, endocarditis, atrial myxoma |
| Splinter hemorrhages | Longitudinal nail-bed streaks | Infective endocarditis |
| Quincke pulsation | Capillary pulsation in nail bed | Aortic regurgitation |
| Osler’s nodes | Painful purple finger pulp nodules | Infective endocarditis |
| Janeway lesions | Painless palmar macules | Infective endocarditis |
| Fine basal crackles | Late inspiratory, bilateral | Pulmonary edema |
| Bounding carotid | Large-volume upstroke | Aortic regurgitation |
| Small-volume pulse | Low-amplitude pulse | Aortic stenosis |
Closure and Next Steps
- Thank patient; allow to dress; wash hands; summarize findings.
- Next tests: blood pressure measurement; 12‑lead ECG; fundoscopy (papilledema, Roth spots); urine dip (hematuria, proteinuria).
Key Terms & Definitions
- JVP: Jugular venous pressure; reflects right atrial pressure.
- Heave: Sustained precordial impulse from ventricular hypertrophy.
- Thrill: Palpable murmur vibration.
- Hepatojugular reflux: RUQ pressure test assessing right heart function.
- Pitting edema: Indentation after pressure from interstitial fluid excess.
- Erb’s point: 3rd left intercostal space; S1 and S2 best appreciated.
Action Items / Next Steps
- Practice systematic Look-Listen-Feel sequence with WIPPE setup.
- Memorize auscultation sites and JVP features vs carotid pulse.
- Use PQRST mnemonic for elevated JVP causes.
- Incorporate peripheral signs (hands, eyes, mouth) into routine exam.
- Perform adjuncts: BP, ECG, lung exam, fundoscopy, urine dip when indicated.