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.
|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.
|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.
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.
|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.
|FIG 2.6 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).