THE PHYSICAL EXAMINATION
There are several advantages to obtaining the history of the patient before the physical examination. First, the information gained in the history directs the clinician to pay special attention to aspects of the physical examination. For instance, a history consistent with CHD necessitates careful inspection for signs of vascular disease; a history suggestive of CHF should make the clinician pay particular attention to the presence of a third heart sound. Second, the history allows the clinician to establish a rapport with patients and to assure patients that the clinician is interested in their well-being; clinicians are then allowed to perform a complete physical examination, which is imperative in a complete evaluation. In this light, the therapeutic value of the physical examination to the patient should not be underestimated. Despite the emphasis on technology today, even the most sophisticated patients expect to be examined, to have their hearts listened to, and to be told whether worrisome findings exist or whether the examination results were normal.
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| FIG 2.3 Physical examination: general inspection. |
General Inspection and Vital Signs
Much useful information can be gained by an initial “head-to-toe”
inspection and assessment of vital signs. For instance, truncal obesity may
signal the presence of type 2 diabetes or metabolic syndrome. Cyanosis of the
lips and nail beds may indicate underlying cyanotic heart disease. Hairless,
dry-skinned lower extremities or distal ulceration may indicate peripheral
vascular disease. Other findings are more specific (Fig. 2.3). Abnormalities of
the digits are found in atrial septal defect; typical findings of Down syndrome
indicate an increased incidence of ventricular septal defect or more complex
congenital heart disease; hyperextensible skin and lax joints are suggestive of
Ehlers-Danlos syndrome; and tall individuals with arachnodactyly, lax joints,
pectus excavatum, and an increased arm length-to-height ratio may have Marfan
syndrome. These represent some of the more common morphological phenotypes in
individuals with heart disease. Vital signs can also be helpful. Although
normal vital signs do not rule out CHD, marked hypertension may signal cardiac
risk, whereas tachycardia, tachypnea, and/or hypotension at rest suggest CHF.
Important Components of the Cardiovascular Examination
The clinician should focus efforts on those sites that offer a window
into the heart and vasculature. Palpation and careful inspection of the skin
for secondary changes because of vascular disease or diabetes is important.
Lips, nail beds, and fingertips should be examined for cyanosis (including
clubbing of the fingernails) and, when indicated, for signs of embolism.
Examination of the retina using an ophthalmoscope can reveal evidence of
long-standing hypertension, diabetes, or atheroembolism, denoting underlying
vascular disease. Careful examination of the chest, including auscultation, can
help to differentiate causes of dyspnea. The presence of dependent rales is
consistent with left-sided heart failure. Pleural effusions can result from
long-standing LV dysfunction or noncardiac causes and can be present with
predominantly right-sided heart failure, representing transudation of ascites
into the pleural space. Hyperexpansion with or without wheezing suggests a
primary pulmonary cause of dyspnea, such as chronic obstructive pulmonary
disease or reactive airways disease. The presence of wheezing rather than rales
does not rule out left-sided heart failure. It is not uncommon to hear wheezing
with left-sided CHF. Wheezing from left-sided CHF is most commonly primarily
expiratory. Inspiratory and expiratory wheezing, particularly with a prolonged
inspiratory-to-expiratory ratio, is more likely to be caused by intrinsic lung
disease.
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| FIG 2.4 Important components of cardiac examination. |
The vascular examination is an important component of a complete
evaluation. The quality of the pulses, in particular, the carotid and the
femoral pulses, can identify underlying disease (Fig. 2.4). Diminished or
absent distal pulses indicate peripheral vascular disease. The examiner should
also auscultate for bruits over both carotids, over the femoral arteries, and
in the abdomen. Abdominal auscultation should be performed, carefully listening
for aortic or renal bruits, in the mid-abdominal area before abdominal palpation,
which can stimulate increased bowel sounds. Distinguishing bruits from
transmitted murmurs in the carotid and abdominal areas can be challenging. When
this is a concern, care- fully marching out from the heart using the
stethoscope can be helpful. If the intensity of the murmur or bruit continually
diminishes farther from the heart, it becomes more likely that this sound
originates from the heart, rather than from a stenosis in the peripheral
vasculature. Much information is available about the peripheral vascular
examination, but by following the simple steps outlined herein, the examiner
can gather most of the accessible clinical information.
Examination of the jugular venous pulsations is a commonly forgot- ten
step. Jugular venous pressure, which correlates with right atrial pressure and RV diastolic pressure, should
be estimated initially with the patient lying with the upper trunk elevated 30
to 45 degrees. In this position, at normal jugular venous pressure, no
pulsations are visible. This correlates roughly to a jugular venous pressure of
<6 to 10 cm. The absence of jugular vein pulsations with the patient in this
position can be confirmed by occluding venous return by placing a fingertip
parallel to the clavicle in the area of the sternocleidomastoid muscle. The
internal and external jugular veins should partially fill. Although normal
jugular venous pressure examination of the waveforms is less important, the
head of the examination table can be lowered until the jugular venous
pulsations are evident. When the jugular venous pulsations are visible at 30
degrees, the examiner should note the waveforms.
It is possible to observe and time the a and v waves by
simultaneously timing the cardiac apical impulse or the carotid impulse on the
contralateral side. An exaggerated a wave is consistent with increased
atrial filling pressures because of tricuspid valve stenosis or increased RV
diastolic pressure. A large v wave generally indicates tricuspid valve
regurgitation, a finding easily confirmed by auscultation.
Finally, it is important to palpate the precordium before cardiac
auscultation. This is the easiest way to identify dextrocardia. Characteristics
of the cardiac impulse can also yield important clues about underlying disease.
Palpation of the precordium is best performed from the patient’s right side
with the patient lying flat. The cardiac apical impulse is normally located in
the fifth intercostal space along the mid- clavicular line. Most examiners use
the fingertips to palpate the apical impulse. It is often possible to palpate
motion corresponding to a third or fourth heart sound. Use of the fingertips
offers fine detail on the size and
character of the apical impulse. A diffuse and sustained apical impulse is
consistent with LV systolic dysfunction. In contrast, patients with
hypertrophic cardiomyopathy often have a hyperdynamic apical impulse. Thrills,
palpable vibrations from loud murmurs or bruits, can also be palpated.
The RV impulse, if identifiable, is located along the left sternal
border. Many clinicians prefer to palpate the RV impulse with the base of the
hand, lifting the fingertips off the chest wall. In RV hypertrophy, a sustained
impulse can be palpated, and the fingertips then can be placed at the LV
impulse to confirm that the two are distinct. In patients with a sustained RV
impulse, the examiner should again look for prominent a and v waves
in the jugular venous pulsations.
Cardiac Auscultation
Hearing and accurately describing heart sounds is arguably the most
difficult part of the physical examination. For this reason and because of the
commonplace use of echocardiography, many clinicians perform a cursory
examination. The strongest arguments for performing cardiac auscultation
carefully are to determine whether further diagnostic testing is necessary and
to correlate findings of echocardiography with the clinical examination so that
in longitudinal follow-up, the clinician can determine the progression of
disease without repeating echocardiography at each visit. In addition, as clinicians
make more of these correlations, their skills in auscultation will become
better, and their patients will be better served. With normal general cardiac
physical examination results, the absence of abnormal heart sounds, and a
normal electrocardiogram, the use of echocardiography for evaluation of
valvular or congenital heart disease
is not indicated. Furthermore, if there are no symptoms of CHF or evidence of
hemodynamic compromise, echocardiography is not indicated for assessment of LV
function. Practice guidelines from cardiologists and generalists agree on this
point, as do third-party insurers. It is neither appropriate nor feasible to
replace a careful cardiovascular examination using auscultation with more
expensive testing.
The major impact of echocardiography has been in the quantitative
assessment of cardiovascular hemodynamics, that is, the severity of valvular
and congenital heart disease. It is no longer necessary for the clinician to
make an absolute judgment on whether an invasive assessment (cardiac
catheterization) is needed to further define hemodynamic status or whether the
condition is too advanced to allow surgical intervention based on history and
physical examination. Instead of diminishing the role of cardiac auscultation,
the advent of echocardiography has redefined it. Auscultation remains important
as a screening technique for significant hemodynamic abnormalities, as an
independent technique to focus and verify the echocardiographic study, and as
an important means by which the physician can longitudinally follow patients
with known disease.
There are several keys to excellence in auscultation. Foremost is the
ability to perform a complete general cardiac physical examination, as
described. The findings help the examiner focus on certain auscultatory
features. Second, it is important to use a high-quality stethoscope. Largely
dictated by individual preference, clinicians should select a stethoscope that
has both bell and diaphragm capacity (for optimal appreciation of low-frequency
and high-frequency sounds, respectively), fits the ears comfortably, and is well insulated so that external sounds are
minimized. Third, it is important to perform auscultation in a quiet
environment. When skills in auscultation are developing, trying to hone these
in the hall of a busy emergency department or on rounds while others are
speaking is time poorly spent. In addition, taking the time to return to see a
patient with interesting findings detected during auscultation, and repetition,
are keys to becoming competent in auscultation.
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| FIG 2.5 Cardiac auscultation: correlation of murmurs and other adventitious sounds with underlying pathophysiology. |
The patient should be examined while they are in several positions: while
recumbent, while in the left lateral decubitus position, and while sitting
forward. Every patient is different, and by using all three positions, the
examiner can optimize the chance that soft heart sounds can be heard. Likewise,
it is important to listen carefully at the standard four positions on the chest
wall (Fig. 2.5), as well as over the apical impulse and RV impulse (if
present). It is also best to isolate different parts of the examination in
time. Regardless of the intensity of various sounds, it is best always to
perform the examination steps in the same chronological order so that the
presence of a specific heart sound (e.g., loud murmur) does not result in
failure to listen to the other heart sounds.
Listen for S1 (the first heart sound) first. As with jugular
venous pulsations, the heart sounds can be timed by simultaneously palpating
the cardiac apical impulse or the carotid upstroke. Even the most experienced
clinician occasionally needs to time the heart sounds. Is a single sound
present, or is the first heart sound split? Is a sound heard before S1,
indicating an S4? Next, listen to the second heart sound. Normally,
the first component (A2, the aortic valve closing sound) is louder
than the second component (P2, the pulmonic valve closing sound). A
louder second component may indicate
increased pulmonary pressure. A more subtle finding is a reversal of A2
and P2 timing that occurs with left bundle branch block and in some
other circumstances. In addition, it is important to assess whether A2
and P2 are normally split or whether they are widely split with no
respiratory variation—a finding that suggests an atrial septal defect. The
examiner should then listen carefully for a third heart sound. An S3
is often best heard over the tricuspid or mitral areas, and is a low-frequency
sound. It is heard best with the bell and is often not heard with the
diaphragm.
After characterizing these heart sounds, it is time to listen carefully
for murmurs. Murmurs are classified according to their intensity, their
duration, their location, and their auscultatory characteristics: crescendo,
decrescendo, and blowing, among others. It is also important to note the site
where the murmur is loudest and whether the murmur radiates to another area of
the precordium or to the carotids. All of these features contribute to
determining the origin of the murmur, the likelihood that it represents an
acute or chronic process, and how it affects the diagnostic and therapeutic
approaches. Most importantly, it is necessary for clinicians to judge whether a
murmur represents cardiac disease or is innocent. Innocent murmurs, also termed “flow murmurs,” are common in children.
More than 60% of children have innocent murmurs. Innocent murmurs become
less common in adults; however, an innocent murmur can still be found into the
fourth decade of life. Alterations in hemodynamics induced by pregnancy,
anemia, fever, hyperthyroidism, or any state of increased cardiac output can
produce an innocent murmur. These murmurs are generally midsystolic, heard over
the tricuspid or pulmonic areas, and do not radiate extensively. They are often
loudest in thin individuals. Innocent murmurs do not cause alterations in the
carotid pulse and do not coexist with abnormal cardiac impulses or with other
abnormalities, such as extra heart sounds (S3 and S4), in
adults. A systolic murmur that shares auditory characteristics with the murmur
of aortic stenosis is a common finding in older adults; however, carotid
upstrokes are normal. This finding, aortic sclerosis, may necessitate
confirmation by echocardiography. It represents sclerosis of the aortic
leaflets but without significant hemodynamic consequence.
The characteristics of the most common and hemodynamically important
murmurs are shown in Fig. 2.5. As noted, the murmur is
defined not only by its auditory characteristics but also by the company it
keeps. Often, the key to excellence in auscultation is being thorough in all aspects of the cardiovascular
examination.
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| FIG 2.6 Maneuvers. |
Maneuvers
No discussion of cardiac auscultation would be complete without the use
of maneuvers to accentuate auscultatory findings. As shown in Fig. 2.6, patient positioning can alter peripheral
vascular resistance or venous return, accentuating murmurs that are modulated
by these changes. Murmurs associated with fixed valvular lesions change little
with changes in position or the maneuvers illustrated in Fig.
2.6. Thus these maneuvers are most useful for diagnosing entities in which
hemodynamic status affects murmurs. The two classic examples are the click and
murmur of mitral valve prolapse, as shown, and the aortic outflow murmur of hypertrophic cardiomyopathy (not
shown).
