To get a good approximation of the cardiovascular examination, it is convenient to remember the function of the heart. This body, the motor of the body, in the physiological state fulfills the function of supplying the needs of oxygen (variables in time) of the cells of the organism.
When this is altered, they manifest in a series of recognized symptoms and signs that can guide the precise cause.
Within the faults it could happen that the myocardium had a decrease in the blood that expels, due to problems of contractibility, alteration of filling, limitation to the exit, etc.
Any of these will result in a patient showing signs of low flow; Cold extremities, fill in the capillary, alteration of the skin (color, turgor, gynaeum, hydration), collapse of the large examining vessels, alteration of the nails, pallor of mucous membranes, among many others that vary according to the chronicity of the picture.
On the other hand it could happen that the amount of blood that reaches the heart pump is smaller, for example when the blood is accumulated in the interstitium, in the extravasular space of the rest of the organs. In that case signs of systemic congestion will be appreciated; Edema, ascites, hepatomegaly, effusions, hepatoabdominal reflux, jugular engorgement, paradoxical pulse, etc., in the case of compromised right cavities, or pulmonary level, with pleural and pericardial effusion, in the left faulty constipation. These alterations of low flow, or backward congestion can be expressed in any of the chambers. Also, both mechanisms and bilateral alteration (right and left cavities) could coexist. This is common in long-standing cardiovascular disorders.
Taking into account the above, it is easy to agree that the clinical evaluation of the cardiovascular system is much broader than simple auscultation of the thorax. It requires an integral view of the patient as a whole.
Basically, it involves evaluating, with some examples:
- Attitude and position: Orthopnea (Heart Failure), Genupectoral position (pericarditis), dyspnea, respiratory difficulty
- Constitution: Obesity (CV Risk Factor), cachexia (terminal heart failure)
- Skin and mucous membranes: Anemia, gravid edema (heart failure), sweating, cyanosis, palides
- Nails: Fill capillary, splinter hemorrhages
- Fever: In infective endocarditis, including AMI, PE.
- Head: Pupillary beat, Musset’s sign (the “nodding” with head to beat of heart, in Aortic Insufficiency), peripheral cyanosis
- Neck: Estimated central venous pressure measuring jugular, jugular engorgement (cardiac insufficiency, cardiac tamponade), carotid dance (aortic insufficiency), auscultation of murmurs (irradiated from the heart or by local atheromatosis)
- Abdomen: Hepato-jugular reflux (heart failure), hepatosplenomegaly, ascites, abdominal cramps (Aortic stenosis or renal arteries)
Cardiovascular Thoracic Examination
Inspection: Tip collision (left ventricle) in 5th Intercostal Space (EIC), Clavicular midline (CML). Difficult to see, not necessarily pathological.
Palpation: Confirms clash of the tip (in the same place), its outward and downward movement indicates VI hypertrophy. “Sustained” beats, pressure surges (AHT, aortic stenosis), versus “live” beats differ in volume overloads (aortic insufficiency). Pericardial thrusts or rhythms may also be felt.
Percussion: In disuse, before it was looked for projection of the heart (“Cardiac mastness”)
- For a systematic evaluation, it is suggested to follow the foci of auscultation:
Aortic: 2nd right parasternal EIC (focus on aortic valve)
Pulmonary: 2nd left parasternal EIC (focus on pulmonary valve)
Aortic Attachment: 3rd left parasternal EIC
Mesocardial: 3rd and 4th left parasternal EIC (interventricular septal noises)
Mitral: apex area (LMC 5th EIC Iº). (Focus on mitral valve)
Tricuspid: Infrared. (Focus on tricuspid valve)
- The behavior of noises versus inspiration-exhalation and changes of position
First noise, by closure of the Auriculoventricular (AV, mitral and tricuspid) valves. It can be separated, for example. In branch blocks.
Second noise, by closing the sigmoid valves (pulmonary and aortic), being shorter and sharper. It unfolds physiologically in inspiration.
Third noise, for fast (passive) filling of the ventricle. Physiological in young people, tends to disappear with age. It may appear in hyperdynamic states or pathologically if there is diminished compliance.
- Fourth noise, due to active filling of the ventricle (atrial systole), indicating abrupt distension of a rigid ventricle, eg. In heart failure.
Blows, which correspond to turbulent blood flow due to sudden changes in velocity. They are classified according to temporality in:
Systolic, during ventricular systole (between 1st and 2nd noises). They can be pansystolic (all systole), mesosystolic (half) or end-systolic (at the end)
Diastolic, between 2nd and 1st noises, being able to be protodiastolic (at the beginning of diastole), mesodiastolic or presystolic (at the end of diastole)
Maximum intensity site (measuring I-VI), irradiation and character should be evaluated.
In addition, there are innocent murmurs, in young people or hyperdynamic states. They are not very intense, they maintain the 2nd noise, never pansystolic or diastolic.
Rub pericardial, like “sandpaper scraping”, at any point in the cycle. It is heard in inflammations of the pericardium, recent cardiac surgery or renal failure.
- Suárez, L. (2009) “Physical examination of the cardiovascular system” In Argente, H. and Álvarez, M., Medical semiology. (Pp. 341 – 390) Medical Editorial Panamericana, Argentina.
- Chamorro, G. (2009) “Cardiovascular examination” in Goic, A., Chamorro, G. and Reyes, H. Medical semiology (pp. 393-405) Editorial Mediterráneo, Chile.