Helen Ward: I'm checking around underneath the eyes looking for signs of xanthelasma that may indicate cholesterol deposits. I'm having a look at the lower, pulling down the lower lids and having a look at the conjunctiva to check for signs of anemia. I'm having a look around the pupil of the eye to look for corneal arcus to check for signs of possible hyperlipidemia. Here I'm looking for a raised pulsation from the internal jugular vein. If that was raised that would come up from behind the clavicle, up through the sternomastoid muscle, up behind the ear.
And next I'm going to have a look at the hair distribution on the lower limbs. Lack of hair distribution on the lower limbs may indicate vascular disease. I'm also having a look at the condition of the lower limbs to have a look for things like cellulitis or varicose veins or leg ulcers.
Helen Ward: Hello, my name is Helen Ward and I'm Principal Lecturer at London South Bank University on the Advanced Nurse Practitioner programs and Non-Medical Prescribing programs. Today I'm going to talk you through physical examination of the cardiovascular system. This will include general inspection of the patient, it will include physical examination of the peripheral vascular system, and then physical examination of the cardiac system.
(Written: With Helen Ward, Principal Lecturer, the Faculty of Health and Social Care, London South Bank University, England.)
Helen Ward: My patient has just arrived and I've asked him to get onto the bed for me so I can perform the physical examination. It's very important when you're doing a physical examination of the cardiovascular system to ensure that you've got a private environment and that the room is quite quiet for the patient. It's also important that the patient is lying on the couch in the supine position at an angle of 30–45 degrees.
Hello, Daniel. I'm going to do a physical examination of your cardiovascular system today and I wonder if that's okay with you.
Daniel: That's fine, thank you.
Helen Ward: Okay. Would you mind just removing your top for me, please, and I'm going to wash my hands.
Daniel: Okay.
Helen Ward: Put that on the chair for you.
Daniel: Thanks.
Helen Ward: Okay. All right. Now the first thing I'm going to do is have a look at Daniel's face. I'm going to have a look for any obvious signs of distress. I'm checking around underneath the eyes looking for signs of xanthelasma that may indicate cholesterol deposits. I'm having a look at the lower, pulling down the lower lids and having a look at the conjunctiva to check for signs of anemia. I'm having a look around the pupil of the eye to look for corneal arcus to check for signs of possible hyperlipidemia.
Now I'm going to move onto the mouth. I'm having a look around the lips. I'm checking to see if there's any signs of central cyanosis. I'm looking at the corner of the mouth to check for any cracking that may indicate iron deficiency anemia or vitamin B deficiency.
If you could just open your mouth for me please, Daniel. I'm just going to have a look inside Daniel's mouth looking for the general condition of the oral hygiene to check for signs of, that would indicate bacterial endocarditis. And then I'm going to just ask you to stick your tongue out for me, please, and I'm just checking the tongue for signs of dehydration.
Now I'm going to move on to the hands. If you'd just like to hold your hands out for me, Daniel, please. First of all I'm going to check for temperature. They're nice and warm. I'm going to check for capillary refill. That's nice and brisk. If you could put your fingers together for me, Daniel, like that. I'm looking to check for finger clubbing. Should see a nice diamond shape at the base of the fingernails there. Clubbing will occur in chronic respiratory or cardiac disease. I'd just like to turn your hands over for me, please Daniel. I'm having a look now in the creases of the palms to check for any paleness, again, that may indicate anemia.
Now I'm going to move on to the assessment of the peripheral vascular system. But first of all I'm going to measure the JVP. Daniel, if you'd just to turn your head over to the left for me, please. Here I'm looking for a raised pulsation from the internal jugular vein. If that was raised that would come up from behind the clavicle, up through the sternomastoid muscle, up behind the ear. You need to have a look in a triangle around about this place here and then you need to have a look for an obvious pulsation within the sternomastoid muscle here. You can see that quite clearly. That will be the carotid pulse.
Now I want to have a look—in some people you can see quite clearly distention of the external jugular vein. If the internal jugular vein was raise or the JVP was raised it would come up here. Some people measure it but it's not usually measured any more. Anything above 2 centimeters is regarded as raised JVP and a raised JVP would be visible in patients with right-sided heart failure or portal hypertension.
Now we're going to check the pulses. We're going to check the pulses for rate, rhythm, and density. First of all, I'm going to check the carotid pulse, one at a time. Okay. Once I've checked the carotid pulse I'm going to listen at the carotid pulses with the bell of a stethoscope for any carotid bruits. Next I'm going to check the radial pulses and I'm going to check the brachial pulses.
Now I'm going to move on to examine the cardiac system. First of all, I'm having a look at the precordium area of the, of the body and I'm having a look to see if there's any old scarring. I'm also having a look to see, at eye level to see if there is any lifts or heaves in the precordial area. I'm having a look to see if there's any obvious apical impulse or aortic impulse.
After I've had a look I'm going to palpate the precordium area. I'm going to start by having, by palpating in the mitral area for lifts, heaves, and thrills, which may indicate pericarditis, and in the aortic area here.
The next thing I need to do is to find the point of maximum impulse, which is the apex beat of the heart that is found at the 5th intercostal space, midclavicular line. So I need to count down, 1, 2, 3, 4, 5, and across. So I'm having a feel here at the 5th intercostal space to see if I can feel for the apical impulse. If I can't feel it there I'm going to ask my patient to roll over onto the left-hand side, okay, which should bring the apex of the heart closer to the chest wall so that I can feel the apical impulse there, which I can very clearly. That indicates to me that the heart is not enlarged. If you'd like to move back onto your back now.
Once I've located the point of maximum impulse, which is just here, I can move on to auscultate the heart for heart sounds. I'm going to be auscultating with the diaphragm of the stethoscope, first of all, and then I'm going to be auscultating with the bell of the stethoscope. The diaphragm of a stethoscope with pick up the higher pitched heart sounds and the bell of the stethoscope will pick up the lower heart sounds. I'm going to start in the aortic area, listening to several cycles of the cardiac cycle as I go down. Now I'm in the pulmonic area. Now I'm listening down the left sternal border to the mitral area, which is between the 4th and the 5th intercostal space.
To complete this examination there are two special maneuvers that we need to perform. First of all, I'm going to ask Daniel to roll onto the left-hand side and then I'm going to listen with the bell of the stethoscope over the apex of the heart, listening here for any mitral regurgitation or mitral stenosis. Okay, if you'd just like to lay back for me. Okay. Now, if you could sit up for me, Daniel, please. Okay, and I'd like to just lean forward slightly for me, exhale, and hold your breath. Now I'm going to listen with the diaphragm of the stethoscope over the mitral area and now along the left sternal border. Need to breathe out again and breathe again and then hold your breath again. And here I'm listening here for aortic regurgitation or aortic stenosis.
(Written: Recap. Stethoscope Positions. The aortic area. The 2nd intercostal space: right sternal border. NB: patient's right. The pulmonic area. The 2nd intercostal space: left sternal border. NB: patient's left. Tricuspid area. The 4th and 5th intercostal space: left sternal border. NB: patient's left. Mitral area. The 5th intercostal space: left midclavicular line. NB: patient's left.
Listen now to the normal heart beat. In health, each heart beat has two sounds. These are S1 and S2. (Heart beat sounds.) S1 represents closure o the tricuspid and mitral valves. S2 represents closure of the pulmonary and aortic valves. To auscultate heart sounds you need a good understanding of anatomy and physiology and the guidance of a competent mentor in practice.)
Helen Ward: Now we're going to move on to the assessment of the lower limbs. First of all, I'm going to have a look at the ankles to check for any ankle edema that may indicate signs of heart failure. And next I'm going to have a look at the hair distribution on the lower limbs. Lack of hair distribution on the lower limbs may indicate vascular disease. I'm also having a look at the condition of the lower limbs to have a look for things like cellulitis or varicose veins or leg ulcers.
I'm now going to check the lower limb pulses, so I'm going to check for dorsalis pedis. Okay. I'm going to check for the posterior tibial pulse and I'm going to check for the popliteal pulse. If you just bend your leg slightly for me, please, now Daniel, and I'm going to check under here for the popliteal pulse. Okay. That's all fine. Put your leg down.
And that concludes our physical examination of the cardiovascular system. So thank you very much, Daniel.
Daniel: Thanks.
Helen Ward: You can get dressed now.
Daniel: Thank you.
Helen Ward: So, to summarize, we've done a general inspection of our patient, we've done an examination of the peripheral vascular system, and we've done an examination of the cardiac system. We strongly recommend that if you want to practice you need to get yourself a mentor and we've provided some further reading for you. And thank you very much for joining me.