Year 2 MBChB

Clinical Skills Session

Cardiovascular Examination

Authors

The Clinical Skills Lecturer Team

Reviewed & ratified by:

Dr Ewan McKay - Cardiovascular System Lead (Consultant Cardiologist)

April 2019

Dr Archana Rao - Cardiologist

Dr Diane Barker – Consultant Cardiologist

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Cardiovascular Examination

Learning objectives

To revise anatomy and physiology of the cardiovascular system

To link the anatomy and physiology to the examination

To be able to perform a cardiovascular examination including an understanding of the common abnormalities

Theory and Background

Revision of stethoscope

The end of the stethoscope has two settings; a bell which is best for listening to low pitched sounds and a

diaphragm which is best for listening to high pitched sounds. The ear pieces should

be angled forwards in the ear and there is a spring which should retain the ear

pieces in the ear comfortably. Fig 1

Anatomy

The cardiovascular system is comprised of the heart and its supporting vasculature.

The purpose of the cardiovascular system is to supply the body with oxygenated blood, nutrients and to play a part

in the removal of waste products, whether that be in the form of ventilating gas off via the respiratory system or

assisting in the excretion waste products via the myriad of other ways of removing waste products from the body.

The heart is at the centre of the system and is a hollow four chambered organ that is composed of a left atria, left

ventricle, right atria & right ventricle. Blood leaves the heart from the left sided chambers and returns back to the

right sided chambers of the heart then to the heart to the lungs and back to the left chambers of the heart via the

vasculature.

The vasculature is divided into two circulatory systems.

Systemic circulatory system

The Systemic circulatory system that supplies the body with oxygenated blood via the arterial system and the

subsequent removal of carbon dioxide carried in its various formats from the tissues and organs via the venous

system and back to the right atria.

Pulmonary circulatory system

The pulmonary circulatory system goes from the right ventricle to the lungs where carbon dioxide is exchanges for

oxygen and the oxygenated blood is carried to the left atria, ventricle and then back into the systemic circulatory

system.

The cardiac sequence from an auscultatory perspective with accompanying explanations of the systolic and

diastolic phases are explained on page 9 under “Cardiac cycle”.

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Indications for the examination

This examination is often done in conjunction with a respiratory exam and vice versa.

Some indications for a cardiovascular examination are;

Chest pain

A general cardiac examination

Shortness of breath

History of palpitations

Syncope – fainting

Follow on examination from finding cardiac abnormalities such as hypertension

Procedure

Patient Safety

On first meeting a patient introduce yourself, confirm that you have the correct patient, with the name and date of

birth, if available please check this with the name band and written documentation and the NHS/ hospital number/

first line of address.

Check the patient’s allergy status, being aware of the equipment you will be using in your examination. Ensure the

procedure is explained to the patient in terms that they understand, gain informed consent and ensure that you

are supervised, with a chaperone available as appropriate. Don personal protective equipment as required,

especially if you are likely to come into contact with bodily fluids.

Be aware of hand hygiene and preventing the spread of disease, WHO (2018) http://www.who.int/infection

prevention/tools/hand-hygiene/en/

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Prior to any clinical examination a detailed history should be taken from the patient, this will enable you to tailor

the examination to the patients presenting complaint and additional symptoms the patient may elude to when you

elicit a full history. For guidance on history taking please click MBCHB students – Year 2 – History taking.

General inspection

When you first observe your patient, as they are in a bed or walking into a clinic room, you should look at them and

note any signs of illness such as cyanosis or pallor. Do they look in pain or distress and are they perspiring? If they

are in a bed observe how they are sitting or lying and if they walk in observe the way they walk. Are they showing

any signs of breathlessness, do they have a malar flush (plum red cheeks due to CO2 retention?) Do they look in

pain or sweaty / clammy?

Inspect the environment for drugs, walking aids, smoking

paraphernalia or odour from smoking. Does the patient have any

infusions, monitors or oxygen present? Look at the patient’s

previous vital signs (if any patient charts are available) and listen

for any audible bruits, wheezes or any abnormal breath sounds

from the end of the bed.

For the physical examination you will need the patient to remove

their upper garments and provide a gown, sheet or blanket if

required. The patient should ideally be positioned on an

examination couch / bed at an angle of 45 degrees with a pillow to

support the neck. Fig 2

Specific inspection

Start the specific inspection with the patient’s hands and nails. Note the temperature of the hands for perfusion;

what colour are the hands and nails? Check the nails for any clubbing, koilonychia, splinter haemorrhages or signs

of peripheral cyanosis. Observe the fingers for tar staining from smoking and the hands for Osler nodes, Janeway

lesions, Quinke’s sign and the capillary refill time. See ref 1 & 3. Also, refer to “Examination of hands” study guide

for further information.

The capillary refill time is the time taken for the colour to return to a peripheral capillary bed after pressure is

applied to cause blanching (ref 3). It is measured by holding the hand at heart level (as this prevents venous reflux)

and pressing on the fingernail or soft tissues until it blanches (5 seconds), release the pressure and note the time it

takes for the colour to return. A normal capillary refill time is less than 2 seconds, if it is longer than 2 seconds, it

may be due to a condition such as Raynaud’s (see image below), but if it is new to the patient you will need to

inform your senior. If hand is cold, blue or blanched. Do a capillary refill on a central point. i.e bridge of nose.

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.

Palpation

All peripheral pulses should be checked as you progress though the examination, comparing right to left.

The radial pulse (lateral aspect of wrist) is felt and the rhythm is assessed. Check to see if the rhythm is regular or

irregular? An irregular pulse may be an indication of an arrhythmia and will dictate whether the rate is assessed for

30 or 60 seconds. The rate is measured in beats per minute (bpm), if the rhythm is regular assess for 30 seconds

and double the count. If the rhythm is irregular assess for a full 60 seconds (normal rate is 60-100 bpm).

Next you need to check the radio-radial delay, this is done by palpating both radial pulses at the same time. The

pulse wave should reach both radial arteries simultaneously. If there is a delay in will occur at the left radial pulse.

The difference it could be due to a congenital condition known as coarctation of the aorta at a point before the

subclavian artery (also note the volume of the pulse as this may also be affected. To assess for radio-femoral delay

palpate the left radial artery and the left femoral artery, the pulse should occur simultaneously in both arteries. If

there is a delay this may indicate a stenosis (narrowing) of the aorta as it descends away from the heart, this may

be caused by a number of conditions including coarctation of the aorta or aortic dissection.

Sinus Arrhythmia

An irregularity originating in the sino atrial node in young people and can present either as a bradycardia or a

tachycardia. It is often related to the individual’s respiratory rate and pattern and consequently referred to a

Respiratory Sinus Arrhythmia. Typically, the individual breathes in and the heart rate increases and on breathing

out the heart rate decreases. It is benign in nature and decreases with age.

A collapsing pulse (Watson’s water hammer pulse) can indicate if the patient has aortic valve regurgitation. Check

the patient does not have any shoulder problems and then use your left hand to raise the patient’s right arm, while

holding their wrist with your index fingers (do not keep your fingers specifically on the pulse). If you feel the pulse

vibrating back down your fingers this is a collapsing pulse. The character of the pulse may change if there is an

aortic valve incompetence, a “water hammer pulse” may be felt as a tapping impulse at the level of the your little

or ring finger. This occurs due to a fast, high volume flow due to the large amount of blood being ejected from the

left ventricle during systole and a fast ebb as blood quickly empties back (collapses) into the left ventricle during

diastole. 4

The brachial pulse is palpated at the medial aspect of the ante cubital fossa. To assess the character of the pulse

you should note how the pulse flows and ebbs. Feel the vessel wall and note how the artery feels, soft and bouncy

(healthy) or hardened which may indicate arteriosclerosis. Evaluate the pulse volume to see if it is normal, weak

and thready or full and bounding volume. If it is thready it can indicate cardiogenic shock, hypovolemia,

arrhythmias etc. A bounding pulse can be due to fluid overload, exercise, high CO2 levels, sepsis etc.

Blood Pressure is measured at the brachial artery. Ensure that the sphygmomanometer remains at the level of the

patient’s heart irrespective of their position. You should measure blood pressure in both arms; a difference in

Fig 3

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readings of greater than 10 mmHg may indicate coarctation of the aorta or an aortic aneurysm. Additionally

measure the blood pressure of the patient in both a lying and standing position as a fall of more than 20mmHg

(systolic) may indicate postural hypotension.

Moving up to the face inspect for central cyanosis, this may be seen on the lips or under the tongue. It is not an

environmental effect and is more worrying than peripheral cyanosis

(O2 should be provided for a patient with central cyanosis and your

senior should be informed). There may be a malar flush present

(plum red cheeks / butterfly rash) which may be associated with

mitral valve stenosis. Observe the patient for signs of pain, possibly

due to angina, pericarditis, myocardial infarction or other

conditions. Check around the eyes for xanthelasma which is seen as

yellowish macules on the eyelids due to hypercholesterolemia. Fig 4

Inspect the eyes and see if the conjunctiva are pale or a healthy pink colour. A pale conjunctiva may be a sign of

acute or chronic anaemia. Arcus senilis may be present, a white ring within the cornea, which may indicate

hypercholesterolemia (significant in the younger age groups).

Image supplied by EyeRounds.org

The mouth may show signs of cyanosis, as mentioned before, so check under the patient’s tongue. You can also

observe for signs of hydration on the tongue and in the mouth. Check the state of the patient’s teeth as well, dental

caries (rotten teeth) may allow bacteria a direct entry portal into the blood stream which increases the risk of

bacterial endocarditis.

Check the carotid pulses one at a time, so s to avoid any over stimulus of the baroreceptors. You are checking for

the same 5 features that you were checking for when palpating the brachial pulse points.

Jugular venous pressure

Inspect the right side of the neck and measure the jugular venous pressure (JVP), it may be raised due to a hyper

dynamic circulation, heart failure or pulmonary emboli. The JVP is a visualisation of the pulsation of the right

internal jugular vein which allows a bedside measurement of the pressures within the right atrium (venous

circulation). The right internal jugular links directly with the right atrium as there are no competent venous or

cardiac valves to interfere with the internal jugular vein and is therefore able to act as a manometer of right atrial

pressure. The JVP is recorded as the height, in centimetres, of the observed venous wave form in the internal

jugular vein. With the patient at 45o. The position of the right atrium is approximately 5 cm below the Angle of

Louis. Measurement from the angle of Louis approximates to the in the right atria.

Fig 5 Arcus senilis

Fig 4 Xanthelasma

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Ask the patient to turn their head to the left side and

observe across the surface of the right side of their neck,

looking along the line of the internal jugular vein (from the

angle of the jaw, deep to the sternocleidomastoid muscle to

the sternal end of clavicle). Observe for a double-complex

waveform (waves a & v) and estimate its vertical height

above the angle of Louis. This looks like a double waveform

due to changes in atrial pressure throughout the cardiac

cycle. The normal JVP should measure less than 4 cm above

the Angle of Louis. To measure the JVP, locate the double waveform and estimate the top of the waves to the

vertical height above the Angle of Louis (in cm) to give the JVP. Both the internal and external jugular veins may be

seen in the neck. Fig 6

The external jugular vein passes over the sternocleidomastoid muscle towards the mid-clavicle. It is easier to see

than the internal jugular vein but it is easily kinked as it passes through the fascia of the neck and may give a false

impression of right atrial pressure. Therefore, the internal jugular is used in preference to the external jugular vein. To confirm that the pulsation originates in the jugular vein rather than the carotid artery remember that unlike an

arterial pulse, venous pulsation is not palpable. A venous pulse is obliterated by light pressure with the vein filling

above the point of compression. Pulsation of the jugular vein will vary with position (i.e. it will disappear the more

upright the patient is or will rise in the neck with a more horizontal position). Additionally, deep inspiration causes

the jugular pressure to rise, but arterial pulsation is unaffected. If you ask the patient to inhale and to hold in a

deep inhaled breath it will cause a rise in the JVP. Fig 7

The arterial waveform is a simple “up and

down” the jugular venous waveform is a

complex (double wave-form per cardiac

cycle). Pressure exerted over the liver also

causes a rise in the jugular pressure this is

called hepato-jugular reflux. (This test will

not be demonstrated for safety reasons.) This

is a test that can indicate the early onset of

heart failure through the heart’s inability to

handle increased volume in the right

ventricle with the JVP distended for more

than 15 seconds. It should only be performed by an experienced clinician who is familiar with the patient’s history

as it may cause significant pain.

After assessing the JVP, palpate the carotid pulses which are lateral to the trachea, do not palpate them

simultaneously as you risk over stimulating the baroreceptors and could potentially cause a stroke, check both

carotid arteries independently. Assess the pulses are palpable and check the state of the vessel wall. Note: if the

arteries feel hardened do not over manipulate it due to the risk of plaque rupture and possible stroke.

Looking at the patient’s chest, you need to inspect for;

Scars e.g. sternotomy or thoracotomy scars, you need to examine in sub mammary breast fold and

posteriorly

Rashes e.g. with shingles the patient may have chest pain prior to the rash appearing.

Fig 7

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Any pulsation which may be caused by an enlarged heart or vessels.

Signs of trauma, there may be bruising over the precordium, left lateral chest wall or to the axilla area.

Palpation of the chest

Apex Beat

The apex beat is defined as the most inferior and lateral point at which a distinguishable pulsation is transmitted

through the chest wall. The apex beat is normally a short, sharp impulse felt

deep to the chest wall which may be quite faint. An impalpable apex beat can

be due to a number of things, including; the most common reason - obesity,

emphysema, where the chest is over-inflated or a pericardial effusion.

To feel for the apex beat the patient would normally be supine at a 45° angle;

however they may be asked to sit forward or to roll to the left slightly if it is

difficult to locate. Place the index, middle and ring finger tips into the left mid-

axillary line approximating to the 4th, 5th and 6th intercostal spaces. Then

gradually bring tips of fingers medially until one feels the beat (may only be a

faint tapping). If it cannot be found then move the fingers slightly upwards or downwards to different intercostal

spaces and start again. Fig 8

The position of the apex beat is described in relation to the intercostal spaces

(ICS) and vertical landmarks of the chest (e.g. mid-clavicular line, anterior

axillary line, mid-axillary line). Palpate down from the sternal notch to the

raised sterno-manubrial Fig 9 joint (Angle of Louis) situated approximately

5cm below sternal notch. With a finger on the angle of Louis feel laterally onto

either the 2nd rib (this is blue on the image) or the 2nd intercostal space (ICS), it

will be one or the other (so if you move

laterally from the Angle of Louis and land in

a dip, it is the 2nd intercostal space, if you

land on a rib, it is the 2nd rib). The dip

below the 2nd rib is the 2nd ICS. Once your finger is in the 2nd ICS, walk your

fingers over each rib counting each dip (intercostal space) as you go. To initially

identify ribs / intercostal spaces it is easier to start at the sternal edge counting

downwards on the anterior chest wall then move laterally to the point you need

to identify. The apex beat is normally

palpated within the 5th intercostal space at

the mid-clavicular line, but it may be displaced due to cardiomegaly, mediastinal

shift (Displacement of the major structures i.e. trachea, oesophagus heart etc.)

or dextrocardia. Fig 10

A heave is a sustained outward pushing on palpation. A right ventricular heave

is felt either at the left sternal edge (LSE) or the right sternal edge (RSE) and a

left ventricular heave is felt at the apex. Fig 11

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A thrill is a palpable vibration that may accompany a cardiac murmur. They can be felt over the same areas where a

murmur will be heard. Murmurs are described further down.

The places that you would palpate for a thrill are based on the direction of

blood flow through specific valves; Fig 12

The normal position of the apex beat (5th ICS, MCL) corresponds to

the position of the mitral valve,

The 4th ICS on the right or left sternal edge corresponds to the

tricuspid valve

The 2nd ICS on the left corresponds to the pulmonary valve

The 2nd ICS on the right corresponds to the aortic valve.

The order that you palpate is Mitral, Tricuspid, Pulmonary, Aortic (M-T-P-A).

The final element of palpation is the abdomen. Palpate for the aorta, the liver and the spleen.

To palpate for the aorta you should place your hands flat one on either side above the umbilicus press firmly and

gradually move your hands towards the mid line if you feel a pulsation STOP and measure the distance between

your hands. This should be less than 5cm in health. Palpate for the liver as there may be enlargement due to heart

failure and the spleen as enlargement may be due to endocarditis see GI study guide.

Auscultation

Auscultation can provide the examiner with information about a patient’s heart rate (may highlight

arrhythmias), quality of the heart sounds and additional heart sounds.

Sinus Arrhythmia

An irregularity originating in the sino atrial node in young people and can present either as a bradycardia or a

tachycardia. It is often related to the individual’s respiratory rate and pattern and consequently referred to as a

Respiratory Sinus Arrhythmia. Typically, the individual breathes in and the heart rate increases and on breathing

out, the heart rate decreases. It is benign in nature and decreases with age.

The other type occurs in older individuals and is referred to as Non-Respiratory Sinus Arrhythmia. Like the other

variation, its cause is not understood, but it is associated with heart disease and therefore may be serious.

Cardiac Cycle

The cardiac cycle consists of diastole and systole.

Diastole. The chambers of the heart are relaxed and they are passively filled with blood. Atrial systole occurs

leading to ventricular filling.

Systole. The ventricles are filled with blood and contract to pump blood to the lungs and the rest of the body.

To ensure you are able to relate sounds correctly to the cardiac cycle, palpate the right carotid artery whilst

auscultating.

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Heart sounds in health

Heart sound 1 (S1) is the closure of the mitral and tricuspid valves. It is loudest at the apex and precedes systole. It

generates the sound “lub” which is a low pitched sound that is longer in duration than S2. It is heard in time with

the pulse.

Heart sound 2 (S2) is the closure of aortic and pulmonary valves. It is heard loudest at LSE in 2nd ICS and it creates

the sound “dup” a higher pitched sound that is shorter than S1. Normally you hear the aortic valve loudest. The

aortic valve closes first and then the pulmonary valve.

The sounds of the valves can be separated during deep inspiration. This delayed pulmonary valve closure causes

the 2nd heart sound to split “dup-p”. This is referred to as a physiological split. Physiological split S2. As the patient

deeply inhales it increases the venous return to the right atria and ventricles. This increase in blood volume takes

fractionally longer to expel through the pulmonary valve and consequently the valve’s closure occurs later than it

would otherwise with the result of a separate sound. The splitting of these valve sounds is noticeable, hence the

term split S2.

The 3rd heart sound (S3) occurs in diastole and coincides with the end of the rapid phase of ventricular filling, which

produces a characteristic sound like Kentucky - Ken---tu-ky. It can be present due to physiological reasons in the

young (usually occurring due to increased cardiac output such as in exercise, pregnancy or fever). Whether it is a

normal S3 or pathological S3 the sound is generated by blood striking a very compliant left ventricle.

Pathophysiological causes of split S2 and / or S3 – that may be heard

Pathological split S2 occurs with such conditions as atrial septal defects, aortic stenosis, hypertrophic obstructive

cardiomyopathy and left bundle branch block. Producing a characteristic Lup-dup-p sound.

The 3rd heart sound (S3) occurs typically in patients over the age of 40. It occurs in diastole and coincides with the

end of the rapid phase of ventricular filling. There are also pathological reasons, usually a marker for severe left

ventricular dysfunction. Pathological causes are nearly always associated with a tachycardia shortening the S1 and

S2 and producing a characteristic gallop rhythm as described above.

The 4th heart sound (S4) occurs just before systole, occurring with atrial contraction. This can be heard in patients

with left atrial hypertrophy and produces a sound that is described as “Tennessee”. Ten-ne---see

Additional Sounds

Other sounds that may be heard are; ejection clicks, these occur when valves which have gone through a structural

change ‘snap’ open. Mitral stenosis may produce a click at the beginning of diastole, whereas a mitral valve

prolapse may have a mid-systolic click along with a murmur. An ejection click may be heard immediately after S1 in

aortic and pulmonary stenosis.

Pericardial rub, occurs when there are inflammatory changes due to pericarditis. It is a frictional rub and has three

phases that correspond to the movement of the heart. The visceral and parietal layers of the pericardial sac rub

together causing the sound and it may be associated with centralised chest pain. The sound produced can be

described as squeaky leather with a rasping quality. To distinguish between pericardial rub and pleural rub ask the

patient to hold their breath out, pleural rub will cease whereas pericardial rub will still be evident.

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Heart Sounds

When listening for heart sounds we are listening to the sounds produced when the heart valves snap shut.

In clinical practice you may see clinicians palpating the carotid pulse

whilst listening to heart sounds; this enables them to relate the

auscultatory findings to the cardiac cycle. As described earlier for

palpation of heaves and thrills you auscultate over the areas on the

chest wall that the sounds are projected, NOT over the anatomical

position of the valves. You will also listen for additional sounds

which may indicate cardiovascular conditions.

For example to listen to the Mitral valve. Position the patient by

asking them to lie on their left lateral side. This is referred to as the

decubitus position. This posture helps to amplify the sounds

emanating from the Mitral valve. Place the bell part of the

stethoscope over the point where you located the apex beat. This is

where the Mitral valve will be best heard. You may have to re-position the bell of the stethoscope to the tip of the

left Scapula, as there are times when this valve may be better assessed at this point. Listen with the BELL for a low

pitched mitral *murmur. The majority of the auscultation can then be performed using both the bell and

diaphragm. Fig 13

*A murmur is the sound of agitated blood flow within the heart due to structural changes. The significance may

indicate pathological conditions or may be benign in nature. These sounds are best picked up with a stethoscope.

Routine Auscultation Sites

Position the patient at a 45 degree angle and when listening to the aortic and mitral valves, roll the patient slightly

to the left. This helps to make the sounds more audible. Ensure the patient has no hip conditions that may cause

discomfort. The areas where the sounds are best heard are:

The normal position of the apex beat (5th ICS, MCL) corresponds to the position of the mitral valve,

The 4th ICS on the right or left sternal edge corresponds to the tricuspid valve

The 2nd ICS on the left corresponds to the pulmonary valve

The 2nd ICS on the right corresponds to the aortic valve.

The order that you auscultate is Mitral, Tricuspid, Pulmonary, Aortic (M-T-P-A).

Murmurs

Murmurs are caused by turbulent blood flow in the heart due to valve dysfunction or heart defects occurring at

specific points during the cardiac cycle, this could be due to disease, narrowing or flaccidity of the valves etc. There

are some characteristic features to note to aid identification of the cause, these include the site, radiation,

characteristics, timing, effect of respiration and effect of position. During inspiration, the venous blood flow into

the right atrium and ventricle are increased due to negative thoracic pressure. This increases the stroke volume of

the right ventricle during systole. As a result, a right sided murmur (pulmonary or tricuspid) will increase during

inspiration and conversely left sided murmurs (aortic or mitral) will increase on exhalation.

Fig 13

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Murmurs during systole;

o Aortic stenosis

o Pulmonary stenosis

o Mitral regurgitation

o Tricuspid regurgitation

Aortic Murmurs

Aortic stenosis would best be heard at the 2nd ICS RSE

and the carotids. Aortic regurgitation would best be

heard in the 3rd ICS LSE (known as Erb’s point).

If the patient sits forward with their breath held out it

will be easier to hear these sounds. Fig 14

Pulmonary Murmurs

Pulmonary stenosis and regurgitation would best be

heard at the 2nd ICS LSE.

If the patient sits forward with their breath held in it will

be easier to hear these sounds. Fig 15

Tricuspid Murmurs

Tricuspid stenosis is best heard at the 4th ICS LSE.

Tricuspid regurgitation is best heard at the 4th ICS RSE

and LSE

The patient remains at a 45 degree angle with their

breath held in it will be easier to hear these sounds. Fig

16

Murmurs during diastole;

o Aortic regurgitation

o Pulmonary regurgitation

o Mitral stenosis

o Tricuspid stenosis

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Mitral Murmurs

Mitral stenosis is best heard at the apex of the

heart, with the patient rolled to the left (left

decubitus position). Mitral regurgitation is best

heard in the left axilla and maybe even at the

inferior edge of the left scapula. Fig 17

If the patient is lying in a decubitis position (Lying

supine and on their left side.) with their breath held

out it will be easier to hear these sounds.

Describing Murmurs & additional heart sounds

Whilst as a 2nd year student doctor you may not be able to diagnose what you have auscultated, you should

however be able to describe what you have heard. Being able to do that puts you half way to a diagnosis.

Questions to consider:

Which heart valve is the sound most prominent?

Phase of the cardiac cycle? i.e. when

How it sounds? – the character of the murmur

Anything thing else? i.e. pericardial rub. A sound that is not a valvular disorder

Grading of murmurs is assessed using the Levine Scale.

Grading a Murmur – Levine Scale

Grade 1 The murmur is only audible on listening carefully for some time.

Grade 2 The murmur is faint but immediately audible on placing the stethoscope on the

chest.

Grade 3 A loud murmur readily audible but with no palpable thrill

Grade 4 A loud murmur with a palpable thrill.

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Grade 5 A loud murmur with a palpable thrill. The murmur is so loud that it is audible

with only the rim of the stethoscope touching the chest.

Grade 6 A loud murmur with a palpable thrill. The murmur is audible with the

stethoscope not touching the chest but lifted just off it.

Bruits

A bruit is audible (turbulent) blood flow in arteries associated with distortion of the vessel walls, (aneurysms or

stenosis.) The character of the sound produced is dependent on its cause.

The sites to auscultate for bruits are: Fig 18

o The carotids, listen lateral to the trachea, the patient should hold

their breath, to eliminate breath sounds.

o An aortic bruit is heard in the midline of abdomen superior to

umbilicus.

o A renal bruit would be heard 2.5 cm superior and 2.5 cm lateral to

umbilicus (on either side). This is often auscultated posteriorly.

o An iliac bruit would be heard 2.5 cm inferior and 2.5 cm lateral to

umbilicus, again on either side.

o A femoral bruit would be heard at the mid inguinal point (either

side).

Peripheral Vascular Assessment

Check the state of peripheral tissues in the arms and legs (bilaterally) noting the colour to see if it is normal, and

evidence of any venous congestion. Feel for the temperature is it normal, warm or cool. Check the viability of the

limb as in severe cases patients may need a limb amputating. Assess the venous circulation (bilaterally) and check

for varicose veins and ulcers.

A venous ulcer tends to be large, superficial and wet, whereas an arterial ulcers tends to be punctate, deep and dry.

Lower limb pulses

o Femoral pulse – located laterally to the femoral vein and medially to the femoral nerve in the groin. (See

page 8 of your year 1 CVS study guide for revision) Assess for coarctation by assessing for the presence of

radio femoral delay.

o Popliteal pulse – located in the popliteal fossa.

o Tibialis posterior is located at the midpoint between the medial malleolus and the calcaneus. (See page 9 of

the year 1 CVS study guide)

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o Dorsalis pedis – On dorsal surface of the foot just lateral to the extensor hallucis longus tendon. (See pages

9 & 10 of year 1 CVS study guide.)

o Check all pulses bilaterally

Peripheral oedema

Peripheral oedema may be present at the ankles in the

ambulant patient or sacrum if the patient is bed-bound.

Peripheral oedema is caused by an increase in hydrostatic

pressure in the peripheries due to heart failure. Fig 19

To assess, press the tissue at the posterior malleolar space

(or dorsum of the foot) and maintain moderate pressure

for a few seconds. This pressure will squeeze oedema fluid

away from the pressure point. If oedema is present the

impression remains imprinted (indentation) in the skin for

a short while after the pressure is removed and as the

oedema redistributes the indentation will disappear.

Repeat this compression test more proximally (over bony prominences) to assess the upper margin of oedema. If

the patient has been lying in bed for a period of time, oedema will be most prominent over the sacrum and lower

back. Compress the mid sacral area and observe for an indentation. Continue up the back until indentation marks

are no longer left.

Oedema can be present in hypoproteinaemia states due to malnutrition and malabsorption, severe cardiac or renal

failure, generalised increase in capillary permeability (due to septic shock and severe allergic reactions or poor

venous return.

Pulmonary Oedema

Heart failure can cause pulmonary oedema which is an accumulation of fluid

within the lung tissue and airways. Although a fine crackling sound may be

heard throughout the lung fields, the sound may be more evident at the

bases of the lungs. To assess for pulmonary oedema you should auscultate

at the 10th intercostal space on the posterior chest wall bilaterally. If crackles

are evident then a more thorough respiratory examination will be required.

Fig 20

16

Further reading / information

Explanation of murmurs https://www.youtube.com/watch?v=6YY3OOPmUDA

Glossary

Cachexia - weakness and wasting of the body due to severe chronic illness.

Cyanosis – a bluish tinge to the skin and mucous membranes, usually caused by low oxygen levels in the red blood

cells.

References

1. Farrior, J.B.; Silverman M.E. (1976). "A consideration of the differences between a Janeway's lesion and an

Osler's node in infectious endocarditis". Chest. 70 (2): 239–243.

2. Osler, W (1908–1909). "Chronic infectious endocarditis". Quarterly Journal of Medicine (Oxford) 2: 219–

230.

3. King, D; Morton, R; Bevan, C (Nov 13, 2013). "How to use capillary refill time.". Archives of disease in

childhood. Education and practice edition.

4. Elizabeth D Agabegi; Agabegi, Steven S. (2008). Step-Up to Medicine (Step-Up Series). Hagerstwon, MD:

Lippincott Williams & Wilkins.

5. Bradley JG, Davis KA (Dec 2003). "Orthostatic hypotension". Am Fam Physician. 68 (12): 2393–8

Further information

http://uk.youtube.com/watch?v=gJmwiu06Z9c&feature=related

https://www.youtube.com/watch?v=IwvbeHa9yHs&index=7&list=PLF1C2FB2C5DFEA8EE

http://www.youtube.com/watch?v=NqXIuov1X9o&feature=BFa&list=PLF1C2FB2C5DFEA8EE