Core Cardiovascular Exam

Introduction

• Comprehensive guide to core cardiovascular exam
• Covers maneuvers, pathologic findings, and documentation
• Includes both screening and diagnostic maneuvers
• Insight into links between observed findings and underlying pathophysiology

Cardiovascular Anatomy and Surface Landmarks

• Sternal Angle: Key landmark
  • Junction of manubrium and body of sternum
  • Palpable and relatively immobile
  • AKA Angle of Louis/Lewis
• Importance:
  • Junction of 2nd rib and sternum
  • Locates critical structures: aortic arch, tracheal bifurcation, pulmonary trunk
• Imaginary Lines: Midsternal, midclavicular, anterior/mid-axillary lines
• Localization Grid: Ribs, intercostal spaces, and imaginary lines for consistent findings

Positions for Cardiovascular Exam

• Typically performed in multiple positions
• Vital Signs: Generally assessed by nurses; discussed in separate video
• Pulse Assessment: Varies by patient age and risk factors
  • Radial pulse: Healthy, younger, asymptomatic patients
  • Additional pulses: Older/middle-aged, or younger with risk factors

Pulse Points and Palpation

• Radial Pulse: Flexor surface of lateral wrist
• Brachial Pulse: Medial and proximal to biceps tendon
• Dorsalis Pedis Pulse: Lateral to extensor tendon of the great toe
• Posterior Tibial Pulse: Behind and below medial malleolus
• Popliteal Pulse: Behind the knee in the popliteal fossa
• Femoral Pulse: Distal to inguinal ligament, mid femur
• Carotid Pulse: Medial to sternocleidomastoid muscle

Assessment of Pulses

• Regularity and Strength
  • Regularity: Determine if pulse is regular, irregularly irregular, or with missed beats
  • Strength: Absent, diminished, normal, or bounding
• Detecting peripheral vascular disease, low cardiac output, aortic stenosis, and other conditions
• Evaluation Principles: Look for symmetry; qualitative over numerical descriptors

Peripheral Edema

• Assessment: Applying pressure to assess pitting
  • Unilateral/Bilateral, symmetric, or non-pitting (suggests lymphatic issues)
• Etiology: Heart failure, cirrhosis, renal failure, malnutrition, DVT, and others
• Avoid using vague numerical scales; qualitative descriptions preferred

Jugular Venous Pressure (JVP)

• JVP Measurement: Surrogate for right atrium CVP
• Noting vertical distance above sternal angle
• Limitations of accuracy (visibility, body habitus, respirations)
• Practical angle for measurement: 30-45 degrees
• Techniques for differentiating jugular and carotid pulsations
• Normal JVP: ≤8 cm H₂O
• JVP abnormalities linked to heart failure, pulmonary hypertension, other causes

Carotid Bruits

• Auscultation: Listen for turbulent blood flows indicating atherosclerosis
• Evidence: Presence increases likelihood of stenosis
• Loud systolic sound vs. venus hum

Cardiac Auscultation

• Positions: 30-45 degrees, upright, supine, left lateral decubitus
• Standard Locations:
  • 2nd right intercostal space (aortic)
  • 2nd left intercostal space (pulmonic)
  • 4th left intercostal space (tricuspid)
  • 5th midclavicular (mitral)
  • Optional 5th location: 3rd intercostal space (Erb's point)
• Auscultation Techniques: Preferably expose chest, patient positioning tips
• Stethoscope Use: Diaphragm for high-pitch, bell for low-pitch

Heart Sounds and Murmurs

• Normal Sounds: S1 and S2, with splitting during inspiration for S2
• Abnormalities: S3, S4, ejection clicks, opening snaps
• Murmurs: Identification, description (timing, shape, location, radiation)
  • Flow murmur: Normal valve, abnormal flow (anemia, sepsis)
  • Ejection murmur: Controversial nomenclature
• Evidence Behind Findings:
  • Abnormal S2 linked to aortic stenosis
  • S3 for reduced ejection fraction
  • Personal experiences and literature evidence

Documentation of Cardiovascular Exam

• Inspection: Generally omitted
• Summarize findings clearly: RRR (regular rate and rhythm), S1/S2 characteristics, no murmurs/rubs/gallops
• Details of Murmurs: Intensity, timing, shape, radiation
• Carotid auscultation and JVP: Standard location vs. neck section
  • JVP documentation: normal/elevated/extremely elevated
  • Use descriptive terms for pulses and edema instead of numeric scales