Physical Examination of the Cardiovascular System

A thorough physical examination can provide clues to the presence and severity of cardiovascular disease, and alert one to the presence of life-threatening conditions even before the results of any diagnostic workup are available.

General Appearance

Dyspnea, tachypnea, use of accessory respiratory muscles, discomfort from pain, diaphoresis, and cyanosis may all indicate underlying cardiac disease.

Pulse

The pulse should be examined for rate, regularity, volume, and character. Some abnormalities in the character of the pulse may be diagnostic for certain cardiovascular conditions:

• Irregularly irregular: Atrial fibrillation, multifocal atrial tachycardia.
• Collapsing: Aortic insufficiency
• Bisferiens (double impulse): Combined aortic stenosis (AS) and insufficiency
• Pulsus parvus (weak) et tardus (delayed): Severe aortic stenosis
• Pulsus altenans (alternating strong and weak pulse): Severe LV dysfunction
• Pulsus paradoxus (marked inspiratory decrease in strength of pulse): Cardiac tamponade, pericardial constriction, severe obstructive airway disease.

Jugular Venous Pressure (JVP)

The jugular venous pulsation is best visualized with the patient lying with the head tilted up 30-45°. The central venous pressure can be estimated by adding 5 cm (the vertical distance between the center of the right atrium (RA) and the sternal angle) to the maximum vertical height of the pulsations above the sternal angle. The JVP is elevated in heart failure and not identifiable in volume depletion. When heart failure is present, firm pressure over the abdominal right upper quadrant will cause persistent elevation of the JVP (hepatojugular reflux). Characteristic abnormalities of the jugular venous waveforms occur in a variety of cardiac disorders (Figure 4-1).

Inspectioon and palpation of the chest

The point of maximal impulse (PMI) of the LV apex should be located and palpated. It is usually in the 5 ^th intercostal space at the mid-clavicular line; it is displaced laterally with right ventricle (RV) dilation and inferolaterally with LV dilation. It is diffuse with dilated cardiomyopathy or LV aneurysm, and may demonstrate a double impulse with hypertrophic cardiomyopathy, AS, or hypertension. A left parasternal heave may be evident with RVH.

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Auscultation of the chest