7/3/23, 11:57 PM Physical Examination - Textbook of Cardiology Physical Examination The examination of the patient s history is a critical in the evaluation of (suspected) heart disease. It includes information about the present complaints, development of symptoms over time, medical history and the patient's family. By combining this information, a chronology should be constructed in order to get a profound insight of the patient s disease process. Determining what information is pivotal requires a detailed knowledge of the pathophysiology of cardiac disease. The time invested in carefully examining the patients history is well invested because this information is often very valuable in the diagnostic process. Contents History The Present Illness Antecedent Conditions Atherosclerotic Risk Factors Family History Common Symptoms Chest Pain Dyspnoea Syncope and Pre-syncope Transient Central Nervous System Deficits Fluid Retention Palpitation Cough Physical Findings Physical Examination - General inspection General appearance in severe disease Body position Consciousness Nutrient status Body composition Vital signs Height and weight Blood Pressure Pulse Jugular Venous Pulse Lungs Assessment of the praecordium Inspection Palpitation Presence of the apex beat https://www.textbookofcardiology.org/wiki/Physical_Examination 1/24 7/3/23, 11:57 PM Physical Examination - Textbook of Cardiology Location of the apex beat Abnormal types (Size, amplitude, duration) of apex beat: Cardiac Auscultation S1 S2 Extra heart sounds S3 S4 Murmurs Murmurs categorized by time in cardiac cycle History The Present Illness The history taking starts with a careful exploration of the patient s symptoms currently and in the past. The exploration will consist of a thorough questioning of the frequency, intensity, severity, and duration of all patient reported symptoms. Also aggravating and relieving causes should be asked for. In addition to the patient reported symptoms, a strategic questioning of suspected symptoms can be added. Furthermore, current medications, including dosages, the frequency and administration, should be listed. Antecedent Conditions There are several systemic disease which may have cardiac involvement. Disease related to cardiac disease include, but are not limited to, are diabetes mellitus, cancer, thyroid disorders, inflammatory disease, and rheumatic fever. Prior treatments should be asked for because they could reveal the nature of the current problems and/or pre-existing disease. Atherosclerotic Risk Factors Atherosclerotic cardiovascular disease is the most prevalent type of heart disease in industrialized nations. The most important risk factors for atherosclerotic cardiovascular disease should be asked for are: family history of atherosclerotic disease (including age); diabetes mellitus; lipid disorders; hypertension; and smoking history. Family History A family history could provide important information not only in atherosclerotic cardiovascular disease but also for many other cardiac diseases. For example, congenital heart diseases are more common in the offspring of parents, family members or siblings. Genetic diseases, such as neuromuscular disorders, https://www.textbookofcardiology.org/wiki/Physical_Examination 2/24 7/3/23, 11:57 PM Physical Examination - Textbook of Cardiology connective tissue disorders (eg, Marfan syndrome), lipid metabolism disorders can affect the cardiovascular system as well [1] (https://www.textbookofcardiology.org/wiki/Chronic_Coronary_Disea se). Common Symptoms Chest Pain Chest pain has a broad range of causes ranging from non-serious to serious to life threatening (Table 1). Chest pain is one of the important symptoms of ischemic heart disease. Furthermore, it is also associated with several other forms of heart disease. The most commonly used classification of stable angina is the CSS score (Table 2), and the Braunwald classification of unstable angina (Table 3) https://www.textbookofcardiology.org/wiki/Physical_Examination 3/24 7/3/23, 11:57 PM Physical Examination - Textbook of Cardiology Table 1. Cause of Chest Pain Cardiovascular Acute coronary syndrome Stable angina pectoris Aortic dissection (Acute) Pericarditis Cardiac tamponade Arrhythmia Pulmonary Pulmonary embolism Pneumonia (Spontaneous) pneumothorax and tension pneumothorax Tuberculosis Pleurisy Gastrointestinal Disorders of the esophagus (Acid reflu disease, esophagitis, esophageal spasm) Hiatus hernia Achalasia, nutcracker esophagus and other neuromuscular disorders of the esophagus Functional dyspepsia Musculoskeletal Costochondritis Radiculopathy Bornholm disease Psychological Panic attack Anxiety Clinical depression Somatization disorder Hypochondria Others Hyperventilation syndrome Carbon monoxide poisoning Sarcoidosis Lead poisoning Precordial catch syndrome High abdominal pain Breast conditions Herpes zoster commonly known as shingles https://www.textbookofcardiology.org/wiki/Physical_Examination 4/24 7/3/23, 11:57 PM Physical Examination - Textbook of Cardiology Table 2. Canadian Cardiovascular Society Functional Classification of Angina Pectoris Class Definition Specific Activity Scale Ability to ski, play basketball, jog at 5 mph, or shovel snow without angina. Ordinary physical activity (e.g., walking and climbing stairs) does not cause angina; angina occurs with strenuous, rapid, or prolonged exertion at work or recreation. I Slight limitation of ordinary activity. Angina occurs on walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, in cold, in wind, or under emotional stress, or only during the few hours after awakening, when walking more than two blocks on level ground, or when climbing more than one flight of stairs at a normal pace and in normal conditions. Ability to garden, rake, roller skate, walk at 4 mph on level ground, have sexual intercourse without stopping. II Marked limitation of ordinary physical activity. Angina occurs on walking one to two blocks on level ground or climbing one flight of stairs at a normal pace in normal conditions. Ability to shower or dress without stopping, walk 2.5 mph, bowl, make a bed, play golf. III Inability to perform any physical activity without discomfort. Anginal symptoms may be present at rest. Inability to perform activities requiring 2 or fewer metabolic equivalents without angina. IV Table 3. Braunwald Classification of Unstable Angina (UA) Clinical Circumstances A B C Develops in presence of extracardiac condition that intensifies myocardial ischemia (secondary UA) Develops within 2 weeks after acute myocardial infarction (postinfarction UA) Severity Develops in the absence of extracardiac condition (primary UA) New onset of severe angina or accelerated angina; no rest pain I IA IB IC Angina at rest within past month but not within preceding 48 hr (angina at rest, subacute) II IIA IIB IIC IIIB Troponin negative Angina at rest within 48 hr (angina at rest, acute) III IIIA IIIC IIIB Troponin positive hr, hours; IAM, myocardial infarction; UA, unstable angina. The five most common characteristics of ischemic chest pain are: https://www.textbookofcardiology.org/wiki/Physical_Examination 5/24 7/3/23, 11:57 PM Physical Examination - Textbook of Cardiology The pain is classically deep, visceral, and intense. Patient often describe this pain as pressing , tearing , constricting , burning . Another common presentation is described as chest heaviness such as a band across the chest , or weight in the centre of the chest . The anginal pain is usually substernal located, but may extend to the left or right chest. Furthermore radiation of the pain is common, typically to the left shoulder and arm. Other locations are possible such as the neck, jaw, epigastrium, and, occasionally, the upper back. The duration of the pain is minutes, not seconds. The pain tends to be precipitated by exercise. The pain can also be provoked by heavy meals or emotional stress. The pain ablates promptly by resting (within minutes) or taking sublingual nitroglycerin. Table 4. Typical feature in various types of chest pain Response to food/fluid Referred pain Response to posture/movement Response to nitroglycerin Cause of pain Type of pain Tenderness Cardiovascular Ischemic cardiac pain Visceral Yes No No No Yes Aortic dissection Visceral Yes No No No No Pericarditis Visceral Yes Yes No No No Arrhythmia Visceral No No No No No Pulmonary disease Visceral/cutaneous Usually no No No No No Pneumothorax Visceral/cutaneous No Yes No Usually no No Musculoskeletal Cutaneous No Yes No Yes No Gastrointestinal Visceral Sometimes No Yes No Sometimes Psychiatric Visceral/cutaneous No No No No No Dyspnoea Dyspnoea is a frequent complaint of patients with a variety of cardiac diseases. Generally four types of dyspnoea can be distinguished: Exertional dyspnoea. Dyspnoea provoked by exercise, usually caused by a mild underlying condition because an increased demand of exertion is needed to precipitate symptoms. Dyspnoea at rest. Dyspnoea is suggestive for severe cardiac disease. Paroxysmal nocturnal dyspnoea. Dyspnoea characterized by the patient awakening after being asleep or recumbent for an hour or more. This type of dyspnoea is commonly caused by the redistribution of body fluids from the lower extremities into the vascular space and back to the heart, resulting in volume overload. Because of this pathophysiological background it suggests a more severe condition. Orthopnoea. Dyspnoea that occurs immediately on assuming the recumbent position. The mild increase in venous return (caused by lying down), before any fluid is mobilized from interstitial spaces in the lower extremities, is responsible for the symptom. https://www.textbookofcardiology.org/wiki/Physical_Examination 6/24 7/3/23, 11:57 PM Physical Examination - Textbook of Cardiology The cause of dyspnoea is certainly not limited to cardiac disease. Exertional dyspnoea, for example, can be due to pulmonary disease or anaemia. Orthopnoea is also a frequent complaint in patients with chronic obstructive pulmonary disease and postnasal drip. Resting dyspnoea is also a common sign of pulmonary disease such as pneumonia or bronchial infection. However, paroxysmal nocturnal dyspnoea is the most specific symptom for an underlying cardiac cause because alternative diagnoses are limited. Syncope and Pre-syncope Light-headedness, dizziness, pre-syncope, and syncope are important symptoms, often caused by a reduction in cerebral blood flow. The mentioned symptoms are nonspecific and can be due to a broad caused by a broad range of underlying pathophysiology such as metabolic conditions, dehydration, primary central nervous system disease, or inner-ear problems. Because bradyarrhythmias and tachyarrhythmias are important cardiac causes of these symptoms, they are of importance in the cardiovascular examination. A careful history taking, including preceding symptoms such as palpitations or chest pain, are of great importance. Further information on this topic can be found in [2] (https://ww w.textbookofcardiology.org/wiki/Syncope). Transient Central Nervous System Deficits Transient central nerves system deficits such as transient ischemic attacks (TIAs) suggest the existence of (micro) emboli originating form greater vessels, the carotid arteries or the heart. Rarely a TIA can also be caused by emboli from the venous circulation through an intracardiac shunt. As a result, a TIA should prompt the search for underlying cardiovascular disease. Any sudden loss of blood flow to (parts of) the limbs are also suggestive for an underlying cardioembolic event. Fluid Retention Fluid retention is not a very specific symptom for heart disease but may be caused due to reduced cardiac function. Symptoms associated with fluid retention are peripheral oedema, weight gain, bloating, and/or abdominal pain from an enlarged liver or spleen. Decreased appetite, jaundice, nausea and vomiting can also occur from gut and hepatic dysfunction due to a build up of fluids. Palpitation Cardiac activity usually cannot be experienced by individuals in normal resting condition. If a patient is aware of its heart activity it is usually referred to as palpitation. Among cultures and patients there is no standard definition for the type of sensation represented by palpitation. It is often very illustrative to ask the patients to tap with their hand the perceived heartbeat. Most commonly palpitations are caused by an unusually forceful heart beat at a normal rate (60 100 bpm). When a patient senses more forceful contractions as usual without a significant increased heart rate, the palpitations are most commonly the result of endogenous catecholamine excretion. A customary cause of this phenomenon is anxiety. Another common experienced feeling is that of the heart stopping transiently and/or the occurrence of isolated forceful beats. The nature of this sensation is usually premature ventricular contractions. The rapid regular or irregular heart rates most linked to the term palpitations are the least common https://www.textbookofcardiology.org/wiki/Physical_Examination 7/24 7/3/23, 11:57 PM Physical Examination - Textbook of Cardiology sensation reported by individual patients and is usually supraventricular of origin. More information on palpitations caused by arrhythmias can be found in the subsequent chapter [3] (https://www.textbookof cardiology.org/wiki/Cardiac_Arrhythmias). Cough Although cough is usually associated with disease of pulmonary origin, there are also several cardiac conditions that lead to pulmonary abnormalities which causes subsequent pulmonary disease and subsequent cough. A cough from cardiac origin is usually dry and non-productive. Pleural fluid retention from conditions such as heart failure or pulmonary hypertension from any cause may present as cough. Finally, it should be mentioned that angiotensin-converting enzyme inhibitors, which are frequently used in cardiac conditions, can cause a typical dry cough. Physical Findings Physical Examination - General inspection The inspection of the patient is an observational task starting from the first contact all the way during the examination. All signs have to be carefully noticed because they can be of importance in the further diagnostic process. General appearance in severe disease Signs of acute life threatening disease which need acute intervention to avert death. First important symptom is the colour of the face and skin which could be pallor or cyanotic as a sign of diminished circulation and/or respiration. Furthermore, the respiratory pattern and rate should be assessed for severe signs such as slow and irregular pattern, an audible rasp breathing with foam around the mouth, or in some cases a very fast and superficial breathing pattern. Additionally, the absence or a very weak pulsation could also be a sign of an acute life threatening disease. (For more detailed assessment of the pulse please notice the paragraph on this topic [4] (https://www.textbookofcardiolo gy.org/wiki/Physical_Examination#Pulse)) Be aware that these symptoms can be apparent, but there absence does not rule out an acute life threatening disease. Signs of severe diseases which are life threatening demands a similar approach with special attention to face colour, respiration and pulse. The face colour can be pallor, cyanotic or red. Respiration can be fast and superficial, often a sign of severe disease. The pulse is also important in case of severe disease, for more information see [5] (https://www.textbookofcardiology.org/wiki/Physi cal_Examination#Pulse). Furthermore it is important to assess signs of lowered degree of consciousness, emaciation, high body temperature and agitation. Body position https://www.textbookofcardiology.org/wiki/Physical_Examination 8/24 7/3/23, 11:57 PM Physical Examination - Textbook of Cardiology Observe the patients position and if there is any preferred position in order to reduce or eliminate pain. For example, the pain of acute pericarditis is often minimized by sitting up, leaning forward, and breathing shallowly. When patients need to sit up right because of increasing dyspnoea when declining, so called orthopnoea, could be a sign of sever heart failure. Consciousness The consciousness state of the patient needs to be assessed to be assured of adequate brain functions or any disturbance. Subtle changes in consciousness are not easy to recognize and need special attention. Orientation in time, place and person need to be questioned. Gradual changes in consciousness can be very subtle, such changing conditions due to a delirium, or more apparent, such as somnolence or coma due to severe disease. In respect to heart disease we should be aware of these signs because they can relate to metabolic disease, such as hypoglycaemia in diabetes, and intoxication by medication or carbon monoxide. Nutrient status A lowered nutrient status can be a sign of several diseases. Generally there can be less intake, due to starvation, a lack of uptake, due to bowel disease, or a high combustion, due to chronic disease in for example metabolic disease or malign tumor growth. Emaciation, (extreme) low body weight, could be a sign of chronic heart failure or another systemic disorder (e.g., malignancy, infection). Body composition The body composition is a combination of skeletal build and soft tissue such as muscles and fat tissue. An abnormal body composition could be one of the signs of syndromes or non-cardiovascular conditions associated with cardiovascular abnormalities, such as for example Marfan syndrome, Down syndrome, Turner syndrome and ankylosing spondylitis [link congenital heart disease]. Vital signs The vital signs, including height, weight, temperature, heart rate, blood pressure, respiratory pattern and rate, and peripheral oxygen saturation, can guide diagnosis and management in heart disease. Height and weight The height and weight permit the calculation of body mass index (BMI) and body surface area (BSA). Regular weight assessment is an important tool in the follow up of heart failure patients with significant fluid retention. Additionally, weight can be used for the adjustment of medication levels. Central obesity, as assed by the waist circumference (measured at the iliac crest) and waist-to-hip ratio (using the widest circumference around the buttocks), is a important determinant in the metabolic syndrome and one of the predictors of long-term cardiovascular risk. Blood Pressure https://www.textbookofcardiology.org/wiki/Physical_Examination 9/24 7/3/23, 11:57 PM Physical Examination - Textbook of Cardiology One of the keystones of the cardiovascular physical examination is the proper measurement of the systemic arterial pressure by cuff sphygmomanometry at both arms. Blood pressure in the arterial system varies during the cardiac cycle, with a peak in the systole and the lowest level in diastole. The difference between the systolic and diastolic pressure is known as the pulse pressure. The arterial pressure is influenced by four important factors: Stroke volume of the left ventricle Compliance of the aorta and large arteries Resistance of the peripheral vasculature, particularly at the arteriolar level Blood volume and viscosity in the arterial system A change in one or more of these factors alters systolic and/or diastolic pressure. The blood pressure fluctuates constantly and is influenced by a variety of factors such as pain, emotional state, physical activity, tobacco, coffee, drug use and consciousness. In order to measure a reproducible blood pressure several aspects have to been taken into account, most important summarized in Table 5. Table 5. Important aspects of blood pressure measurements Patient seated comfortably, back supported, bared upper arm, legs uncrossed Arm should be at heart level Cuff length/width should be 80%/40% of arm circumference Cuff should be deflated at <3 mm Hg/sec Column or dial should be read to nearest 2 mm Hg First audible Korotkoff sound is systolic pressure; last sound, diastolic pressure No talking between subject and observer The best way to measure the blood pressure starts with the palpation of the brachial artery, over which the diaphragm of the stethoscope has to be placed over it in the antecubital fossa. The onset and disappearance of the Korotkoff sounds define the systolic and diastolic pressures, respectively. There are some exceptions where the described assessment of the Korotkoff sounds is obsolete. For example, if the diastolic pressure drops near to zero, the point of muffling of the sounds is usually wrongly recorded as the diastolic pressure. The definition of hypertension dictates repeated measures under the same conditions, therefore the operator should record the arm (left/right) and the body position (lying/suspine/upright) of the patient to allow reproducible measurements to be made on serial visits. Normal and abnormal blood pressure levels in adult are represented in table 6. Please note that the normal levels in children are lower. The risk of cardiovascular disease increases progressively above 115/75 mmHg. Regarding hypotension, in daily practice blood pressure is considered too low only if noticeable symptoms are present. Clinical trials have demonstrated that humans who maintain arterial pressures at the low end of these pressure ranges have much better long term cardiovascular health. Elevations in all age categories, although more commonly seen in elderly, are generally associated with increased morbidity and mortality. https://www.textbookofcardiology.org/wiki/Physical_Examination 10/24 7/3/23, 11:57 PM Physical Examination - Textbook of Cardiology Table 6. Classification of blood pressure for adults Category systolic, mmHg diastolic, mmHg Hypotension <90 <60 Desirable 90 120 60 79 Prehypertension 121 139 or 80 89 Stage 1 Hypertension 140 159 or 90 99 Stage 2 Hypertension 160 179 or 100 119 Hypertensive Crisis 180 or 120 Measuring the blood pressure in a different position can be of clinical importance, for example to determine any orthostatic changes in blood pressure. In order to measure orthostatic hypotension the patient has to move from a supine to a standing position with a significant blood pressure drop within 3 minutes. Orthostatic hypotension is defined as a fall in blood pressure of more than 20 mm Hg systolic and/or more than 10 mm Hg diastolic. Orthostatic changes are of special interest in patients complaining of transient central nervous system symptoms, weakness, or unstable gait. Especially elderly have an increased tendency toward orthostatic hypotension due to a decreased compliance of the arteries and/or a decreased compensation mechanism increasing the stroke volume, resulting in a sudden drop of blood pressure which can cause dizziness or syncope. A difference in pressure between the right and left arm of 10 mmHg or more suggests an arterial obstruction in the arterial system of the arm were the lowest pressure is measured. Causes of significant differences between the blood pressure at the right an left arm are subclavian artery disease, aortic coarctation, supravalvular aortic stenosis or dissection. Additionally, in future assessment of the blood pressure the arm with the highest pressure should be measured. Furthermore, note that the pulse pressure is a crude measure of left ventricular stroke volume. A widened pulse pressure suggests that the stroke volume is large; a narrowed pressure, that the stroke volume is small. A widened pulse pressure also can be an indication of atherosclerotic disease, characterised by lengthened, more tortuous, and harder and less resistant arteries. Pulse The peripheral pulsations should be assed by both palpitation of the pulse and auscultation for bruits. Pulse abnormalities and bruits increase the likelihood of peripheral arterial disease. Pulsations should be assessed and documented in several arteries in the body in order to get an idea of the state of peripheral vasculature. Easily and fast palpable pulses in healthy individuals include the brachial, radial, and ulnar arteries of the upper extremities and the femoral, popliteal, dorsalis pedis, and posterior tibial arteries of the lower extremities. Minor or absent pulsations suggest a severe stenotic lesion proximal of the palpation site. To asses the cardiac (dys)function through the pulse generally an artery close to the heart should be selected, such as the carotid. Bounding high-amplitude carotid pulses suggest an increase in stroke volume and should be accompanied by a wide pulse pressure on the blood pressure measurement. A weak carotid pulse suggests a reduced stroke volume. [Figure 1] When examining the peripheral arterial pulsations by palpitation three important aspects should be noticed: The amplitude of the pulse, which correlates with the pulse pressure The contour of the pulse wave, depicted by the speed of up- and downstroke and the duration of its summit. In a physiological situation the upstroke is rapid, smooth and almost directly after the first https://www.textbookofcardiology.org/wiki/Physical_Examination 11/24 7/3/23, 11:57 PM Physical Examination - Textbook of Cardiology heart sound. The summit is roughly midsystolic and has a smooth and rounded nature. The downstroke is generally less abrupt than the upstroke in a normal situation. Variations in the amplitude, either with respiration or from beat to beat. The contour of the pulses depends on the stroke volume, ejection velocity, vascular capacity and compliance, and systemic resistance. The palpable pulsations reflect both the antegrade pulsatile flow of blood and reflection of the propagated pulse the peripheral artery returning system. The arterial pulse upstroke increases with distance from the heart. In a physiological state, the percussion wave begins with systolic ejection (just after the is the mainly first heart sound) and the monophasic pulse appreciated at (an notch bedside. exaggerated, diastolic wave) demonstrates the aortic valve closure. A bounding pulse may occur in hyperkinetic states such as fever, anaemia, and thyrotoxicosis, or in pathologic states such as severe bradycardia, aortic regurgitation, fistula. Two distinct or arteriovenous pressure peaks in systole relate to a bifid pulse. This phenomenon is consistent with increased vascular compliance and may occur with fever or after exercise in a normal individual. With chronic severe aortic regurgitation, a large stroke volume ejected rapidly into a noncompliant arterial tree produces a reflected wave of sufficient amplitude to be palpated during systole. Hypertrophic obstructive cardiomyopathy can rarely produce a bifid systolic pulse with percussion and tidal (or reflected) waves. Usually the strength of the pulse is graded on a scale of 1 to 4, where 2 is a normal pulse amplitude, 3 or 4 is a hyperdynamic pulse, and 1 is a weak pulse. A low- amplitude, slow-rising pulse, which may be associated with a palpable vibration (thrill), suggests aortic stenosis. In patients over 70 years of age it is particularly important to palpate the abdominal aorta because abdominal aortic aneurysms are more prevalent. from The dicrotic early, Figure 1. Body locations for examining the pulse. A more than 10 mm Hg fall in systolic pressure with inspiration (pulsus paradoxus) is considered pathologic and a sign of pericardial or pulmonary disease, and can also occur in obesity and pregnancy without clinical disease. Pulsus paradoxus is measured by noting the difference between the systolic pressure at which the Korotkoff sounds are first heard (during expiration) and the systolic pressure at which the Korotkoff sounds are heard with each beat, independent of respiratory phase. Between these two pressures, the sounds are heard only intermittently (during expiration). In order to appreciate this subtle finding, the cuff pressure must be decreased slowly. Tachycardia, AF, and tachypnea make its https://www.textbookofcardiology.org/wiki/Physical_Examination 12/24 7/3/23, 11:57 PM Physical Examination - Textbook of Cardiology assessment difficult. Pulsus paradoxus may also be palpable when the pressure difference exceeds 15 to 20 mm Hg. Pulsus paradoxus is not specific for pericardial tamponade and can also accompany massive pulmonary embolus, hemorrhagic shock, severe obstructive lung disease, or tension pneumothorax. Pulsus alternans is defined by a beat-to-beat variability of the pulse amplitude. When only every other phase 1 Korotkoff sound is audible as the cuff pressure is slowly lowered, in a patient with a regular heart rhythm, independent of the respiratory cycle. Pulsus alternans is generally seen in severe heart failure. Important provoking factors of this phenomenon are severe aortic regurgitation, hypertension, and hypovolemic states. This phenomenon is attributed to cyclic changes in intracellular calcium levels and action potential duration. If it is the pulsus alternans is associated with electrocardiographic T wave the combination appears to increase arrhythmic risk. Bruits often indicate accelerated blood flow velocity and/or flow disturbance at sites of arterial stenosis. By auscultation the supraclavicular and infraclavicular fossae should be assessed for evidence of subclavian artery stenosis. Additionally, the abdomen, flank, and pelvis should be examined with a stethoscope for evidence of stenosis in the aorta and its branch vessels; and each groin for evidence of femoral artery stenosis. When patients suffer from aortoiliac disease, muscle atrophy in the legs may be seen. Other signs of chronic low-grade ischemia include thickened and brittle toenails, smooth and shiny skin, and subcutaneous fat atrophy of the digital pads. Patients with limb ischemia with dysfunction of the small arteries have a prolonged capillary refill of 3 seconds or more. Jugular Venous Pulse Assessment of the jugular venous pulse (JVP) is a method to assess central venous pressure and right atrium pressure. The examination can provide information about the patient s volume status and cardiac function. Note that the JVP is not useful to asses in children younger than 12 years, because it is hard to asses in this age group. Ideally the patient is positioned into the semi-upright posture, with an elevation of the head of the bed to 30 , that permits visualization of the top of the right internal jugular venous blood column. A venous arch may be used to measure the JVP more accurately. The JVP is the elevation at which the highest oscillation point of the jugular venous pulsations is usually seen in euvolemic patients. The height of the column of blood seen in the internal jugular vein, vertically from the sternal angle, is added to 5 cm of blood (the presumed distance to the centre of the right atrium from the sternal angle) to obtain an estimate of central venous pressure in centimetres of blood. In patients who are hypovolemic, you may anticipate that the jugular venous pressure will be low. Likewise, in hypervolemic patients, you may anticipate that the JVP will be high. As a result, in hypovolemic patients the head should be in a lowered position (up to 0 ), while in a hypervolemic state the head should be subsequently raised of the bed. Additionally, the characteristics of the right internal jugular pulse should be assessed, because they can be reveal clinical signs of right-heart function and rhythm disturbances. The distinctive waves of the jugular vein are summarized in Table 7 and visualized in Figure 2. https://www.textbookofcardiology.org/wiki/Physical_Examination 13/24 7/3/23, 11:57 PM Physical Examination - Textbook of Cardiology Figure 2. Jugular venous pulse waveform. Table 7. The jugular venous pulsation has a biphasic waveform. The a wave corresponds to right Atrial contraction and ends synchronously with the carotid artery pulse. The peak of the 'a' wave demarcates the end of atrial systole. The c wave corresponds to right ventricular Contraction causing the triCuspid valve to bulge towards the right atrium. The x descent follows the 'a' wave and corresponds to atrial relaXation and rapid atrial filling due to low pressure. The x'(x prime) descent follows the 'c' wave and occurs as a result of the right ventricle pulling the tricuspid valve downward during ventricular systole. The x' (x prime) descent can be used as a measure of right ventricle contractility. The v wave corresponds to Venous filling when the tricuspid valve is closed and venous pressure increases from venous return - this occurs during and following the carotid pulse. The " y " descent corresponds to the rapid emptYing of the atrium into the ventricle following the opening of the tricuspid valve. An elevated JVP is the classic sign of venous hypertension, typically in right sided heart failure. JVP elevation can be visualized as jugular venous distension, whereby the JVP is visualized at a level of the neck that is higher than normal. The paradoxical increase of the JVP with inspiration (instead of the expected decrease) is referred to as the Kussmaul sign, and indicates impaired filling of the right ventricle. The differential diagnosis of Kussmaul's sign includes constrictive pericarditis, restrictive cardiomyopathy, pericardial effusion, and severe right-sided heart failure. https://www.textbookofcardiology.org/wiki/Physical_Examination 14/24 7/3/23, 11:57 PM Physical Examination - Textbook of Cardiology There are many JVP abnormalities which can be appreciated after careful assessment. These abnormalities can be linked a broad spectrum of disease as highlighted below: Raised JVP, normal waveform Bradycardia Fluid overload Heart Failure Raised JVP, absent pulsation Superior vena cava syndrome Large a wave (increased atrial contraction pressure) Tricuspid stenosis Right heart failure Pulmonary hypertension Cannon 'a' wave (atria contracting against closed tricuspid valve) Atrial flutter Premature atrial rhythm (or tachycardia) Third degree heart block Ventricular ectopics Ventricular tachycardia Absent a wave (no univocal atrial depolarisation) Atrial fibrillation Large v wave (c-v wave) Tricuspid regurgitation Slow y descent Tricuspid stenosis Parodoxical JVP (Kussmaul's sign: JVP rises with inspiration, drops with expiration) Pericardial effusion Constrictive pericarditis Pericardial tamponade Lungs Evaluation of the lungs and respiration is an important part of the physical examination: Both diseases of the lung can affect the heart, as well as diseases of the heart can affect the lungs. Auscultation and percussion is also a very important feature of the clinical examination of the lungs and respiratory system. The borders of the lung should be assessed by percussion. Furthermore percussion can reveal dullness, associated with for example abnormal pleural effusion. Several areas of the lungs should examined by auscultation in an upright position, if possible, both at the back and front of the patients, both base and apical fields covering all lung lobes. https://www.textbookofcardiology.org/wiki/Physical_Examination 15/24 7/3/23, 11:57 PM Physical Examination - Textbook of Cardiology During auscultation the patient s respiratory pattern and rate should be assed. Tachypnoea is defined as increased breaths 20 or more breaths per minute. Physiological causes of tachypnoea are, for example, heightened oxygen demand due to exercise or labour during pregnancy. Amongst pathophysiological causes, tachypnoea can be a symptom of carbon monoxide poisoning, haemothorax or pneumothorax. Furthermore, pursing of the lips, a breathy quality to the voice, and an increased anteroposterior chest diameter would favour a pulmonary rather than cardiovascular cause of dyspnoea. Special attention is needed in case of so called Cheyne-Stokes respiration or Kussmaul breathing. Cheyne-Stokes is an abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing called an apnoea. These phenomena can occur during wakefulness or during sleep, where they are called the Central sleep apnoea syndrome. It may be caused by physiological abnormalities in chronic heart failure or damage to respiratory centres. Kussmaul breathing is defined as abnormally slow deep respiration characteristic of air hunger. This typical breathing pattern is caused by respiratory compensation for a metabolic acidosis, most commonly occurring in diabetics in diabetic ketoacidosis. The observation of respiration during sleep may reveal signs of disordered breathing associated with cardiovascular disease (e.g. obstructive sleep apnoea). A clinical significant finding in the cardiovascular examination is rales at the pulmonary bases, indicating alveolar fluid collection. This fluid collection can be an important sign of heart failure in patients, however it is not always possible to distinguish rales caused by heart failure from those caused by pulmonary disease. Also the presence of pleural fluid, although useful in the diagnosis of heart failure, can be due to other causes. An additional combination of symptoms, dullness at the left base combined with bronchial breath sounds suggests an increase in heart size from pericardial effusion (Ewart sign) or cardiac enlargement due to another cause. Pathophysiological it is thought to be due to compression by the heart of a left lower lobe bronchus. If severe right-heart failure develops or when venous return is restricted from entering the heart, venous pressure will increase in the abdomen, leading to hepatosplenomegaly and eventually ascites. These physical findings are not specific for heart disease, nonetheless they do help establish the diagnosis. Heart failure also leads to generalized fluid retention, usually manifested as lower extremity oedema. Oedema in de lower extremities is a sign of fluid retention, the skin can be compressed and will stay in this shape for a limited time. Oedema in lower extremities can also be caused by decreased venous return due to thrombosis or dysfunction of the venous system. Assessment of the praecordium Inspection The praecordium is the front of the chest overlying the heart. First a global inspection should include the assessment shape and symmetry of the chest. A barrel chest could be a sign of chronic breathing problems. Also abnormalities of the shape of spine such as a kyphosis or scoliosis should be noticed, not only because of pathophysiological implications, but also demanding special care with regarding cardiac auscultation. Scars could be found at different locations as signs of prior thoracic surgery. Most common locations include: Midline sternal scar: prior major thoracic surgery such as coronary artery bypass grafting and/or valve replacement Left sided thoracic scar (diagonal from under left breast to left axilla): Mitral valve surgery. https://www.textbookofcardiology.org/wiki/Physical_Examination 16/24 7/3/23, 11:57 PM Physical Examination - Textbook of Cardiology Inferior of clavicula (left and/or right sided): Pacemaker / internal cardiac defibrillator implantation. Above all, focus should be on visible cardiac pulsations, mostly in the apex region of the heart. In lean people the apex beat may be visible. A visible apex beat could also be a sign of abnormal conditions such as left ventricular aneurysm. Palpitation