Numerous things should happen during any physical exam, but the cardiovascular exam should include: visual examination, palpation, and auscultation; with most of the focus on the neck and chest.
So what to do...
Take a few blood pressures. Check each arm and one leg, normally the leg will have the higher blood pressure. If not, add coarctation of the aorta to the differential.
Feel for pulses. While weak distal pulses does not have to mean pathology, left ventricular hypertrophy is one possible cause. Keep in mind that LVH occurs due to conditions such as AS, IHSS, AR, MR, and event HTN.
Look at the eyes. Using the ophthalmoscope check for neovascularization, which suggests the blockage of arteries having resulted in the formation of new ones. Two important disease entities to consider if you see this: diabetes, and coronary artery disease.
Examine the neck. This means giving more than a shear glance and looking at the internal jugular vein, which includes checking for differences during inspiration and expiration; and listening for bruits in the carotid arteries.
- Bruit: the turbulent flow of blood past an obstruction, otherwise understood as the abnormal sound blood makes as it passes an obstruction. Because of the pumping of blood the bruit will make two sounds--the upstroke and the decline. The importance lies in the speed of the upstroke and the speed of the decline, which together can aid in a diagnosis.
- Rapid upstroke, Rapid decline: aortic regurgitation
- Rapid upstroke, Delayed decline: IHSS
- Delayed upstroke, Delayed decline: aortic stenosis
- Slow upstroke, Normal decline: atherosclerosis, only occurs in the carotid with the plaque
- Internal Jugular Vein: correlates with pressure in the right atrium. The pulse should normally be seen around 5 centimeters above the Angle of Louis of the sternum. To look for this the patient should lay on the table at an incline of 30 to 45 degrees. For comparison: 10cm from the Angle is the mandible; at 12cm is the ear lobe. Two important entities need consideration when checking the internal jugular:
- Hepatojugular Reflux: a sign of right atrial overload, will stay elevated on inspiration and expiration.
- Kussmual's Signs: distention of the internal jugular with inspiration; suggestive of pericardial effusion and impending respiratory failure.
Next, move on to the chest.
Palpate the chest. Particularly check three areas:
- Apex: should be at the left 5th intercostal space at the midclavicular line, but can vary slightly depending on the heart's deviation. However, barely feeling it during S4 suggests a small heart, where as a large heart will generally create a sensation across all palpating fingers during S3.
- Sternum: roughly located above the right ventricle. Normally one will not feel it; only right ventricular hypertrophy is felt. If felt you should add tricuspid regurgitation to your list, auscultating a systolic murmur in the tricuspid area would only further support this diagnosis.
- Sternal border: correlates well with the left atrium, and just like the right ventricle it will only be felt if enlarged. With left atrial enlargement consider disease states such as mitral stenosis, mitral regurgitation, and dilated cardiomyopathy.
Listen to the heart. Listen for heart sounds and check for murmurs. Focus on the four main areas:
- Aortic: the right 2nd intercostal space
- Pulmonic: the left 2nd intercostal space
- Tricuspid: the left sternal border
- Mitral: the left 5th intercostal space at the midclavicular line
And of course: always take a good history!
More on heart sounds and cardiac history taking later...
Unfortunately the physical exam has lost its importance to many practitioners.
In lieu of looking, listening, and palpating CT, MRI, US, and XR have come in as replacements. While radiographic and ultrasonographic imaging have benefits, they have downsides as well. After all, a physical exam doesn't expose the patient to radiation, require a contrast medium, or cost any more money than the salary to employ the practitioner. But in a society clamoring for big money lawsuits clinicians need to protect themselves, and imaging modalities can provide conclusive answers without the subjectivity of the clinician's skills.
Some medical schools require their students to do rotations in rural areas, which often lack the bells and whistles of large cities. It is unfortunate that the bodies which govern medical education across the board don't mandate such training. Only when one must go without reliance on imaging will he or she learn to appreciate a good physical exam.
Jauhar, S. (2006). The Demise of the Physical Exam New England Journal of Medicine, 354 (6), 548-551 DOI: 10.1056/NEJMp068013