🩺 Cardiovascular Examination

The cardiovascular examination is a focused assessment designed to evaluate the structure and function of the heart and the integrity of the vascular system. It involves an integration of peripheral signs (hands, face) and central findings (JVP, precordium). By systematically evaluating the heart sounds and pulses, clinicians can diagnose valvular stenosis or regurgitation, heart failure, and arrhythmias. It is a critical component of the 'ABCDE' assessment in acute care and long-term chronic disease management.

This examination is indicated for patients presenting with chest pain, palpitations, syncope, breathlessness, or peripheral oedema. It is a requirement for monitoring patients with known valvular heart disease, heart failure, or hypertension. It is also central to the preoperative assessment of surgical patients and the routine screening for cardiovascular risk factors in primary care. Any suspicion of systemic infection (fever) may also warrant an exam to rule out endocarditis.

There are no contraindications to a cardiovascular examination, though it should be streamlined in patients with acute coronary syndrome or haemodynamic instability. For patients with suspected carotid artery stenosis or recent stroke, avoid vigorous palpation of the carotid pulses and never palpate both carotids simultaneously. Ensure the patient is comfortable and stop if they experience significant chest pain or dyspnoea during the procedure.

The essential equipment is a stethoscope with both a diaphragm (for high-pitched sounds like MR/AR) and a bell (for low-pitched sounds like Mitral Stenosis). A pen-torch is useful for visualizing the JVP. A sphygmomanometer is required for blood pressure measurement. The patient should be on a clinical couch capable of being adjusted to a 45-degree angle to properly assess the jugular venous pressure.

Inspect the patient from the end of the bed (dyspnoea, scars). Examine the hands (perfusion, clubbing, endocarditis markers) and pulse (rate, rhythm, character). Observe the JVP at 45 degrees. Inspect the chest for scars or visible pulsations. Palpate the apex beat and check for heaves or thrills. Auscultate the four valve areas with both the bell and diaphragm. Check the lung bases for crackles (heart failure) and the ankles for pitting oedema. Assist the patient into specific positions for dynamic auscultation if murmurs are heard.

A displaced, forceful apex beat suggests left ventricular hypertrophy or dilatation. An elevated JVP suggests right-sided heart failure or fluid overload. Heart murmurs must be timed: a pansystolic murmur at the apex radiating to the axilla is typical of Mitral Regurgitation, while an ejection systolic murmur at the right upper sternal border radiating to the carotids suggests Aortic Stenosis. Displaced apex beats and S3 gallops are hallmarks of congestive heart failure. Peripheral signs like clubbing and splinter haemorrhages strongly suggest Infective Endocarditis.

Neglecting to check for a carotid or radial pulse deficit or failing to palpate the liver (for pulsatile hepatomegaly in tricuspid regurgitation) are common omissions. Many students forget to look for splinter haemorrhages or Janeway lesions/Osler nodes, which are crucial for diagnosing Infective Endocarditis. Incorrectly positioning the patient at 45 degrees for JVP assessment or failing to use tangential lighting can lead to missing venous pulsations. In auscultation, failing to time murmurs against the carotid pulse can lead to confusion between systolic and diastolic bruits.

Adopt a systematic 'periphery to centre' approach. Always palpate the carotid pulse while auscultating the heart to identify S1 and time murmurs. When assessing the JVP, ensure the patient’s head is turned slightly to the left and look for the double flicker. Specifically ask the patient to roll onto their left side to listen to the apex (mitral sounds) and lean forward in expiration to listen for aortic regurgitation. Mention you would finish by checking the blood pressure in both arms and performing fundoscopy in hypertensive patients.

Relates to MLA 'Heart failure', 'Valvular heart disease', and 'Infective endocarditis'. Students must understand the significance of 'red flag' symptoms like exertional syncope in Aortic Stenosis. Recognition of atrial fibrillation via pulse palpation is a key competency. Knowledge of the Duke Criteria for endocarditis and the NYHA classification for heart failure is expected in the context of clinical findings.