Journal Of Paramedic Practice - Cardiovascular examination

Abstract

The clinical examination is an important part of any patient consultation. After the primary survey and taking the patient history, a more in-depth examination is sometimes required to aid making a working diagnosis and help negate other differential diagnoses. The extent of this depends on the stability of the patient and may not be possible in time-critical circumstances. However, clinical examination is an increasing part of paramedic practice owing to the continued expansion of the scope of the paramedic role in both urgent and emergency care. Education on clinical examination concerning each of the main body systems is now an integral part of undergraduate paramedic curricula.

This clinical examination series provides a step-by-step overview for each of the main body systems. Continuing professional development (CPD) is an essential requirement for all clinicians to maintain and demonstrate that they are staying up to date and advancing in their roles.

This series gives an overview of each type of examination to support students, newly qualified paramedics and paramedics wishing to use these articles as a CPD development activity and an aide-memoire for clinical practice. This article, which explores the cardiovascular system, gives an overview of initial examination considerations, including first impressions.

How to use these guides

The articles in this series, which can be torn out for use in practice, are intended to support clinician development and to assist in the overall assessment of patient presentations. The information should be used to aid consideration of differential diagnoses in situations where life-threatening conditions have been ruled out.

The extent and explanation of each examination will not be to the depth of those provided in core literature texts, so further reading and consolidation are advised to support understanding supplemental to these articles. Key questions are included for reader consideration and to direct further study.

Most examinations are taught in a rigid format. However, in clinical practice, practitioners need to be flexible and adapt their approach depending on the presenting condition and circumstances. While there is no single set way to carry out each of these examinations, a good structure will reduce omissions and errors, and support the gathering of information to inform patient care.

Contemporary texts provide the underpinning reference sources throughout this series, as many of the examination processes and techniques are universally applied; however, differences will be highlighted. Readers will be signposted to these key texts for each clinical examination.

The series will cover the following systems:

Cardiovascular system

Peripheral vascular system

Neurological system (upper and lower limbs)

Cranial nerves

Gastrointestinal system

Respiratory system

Musculoskeletal system

Cardiovascular examination

This article sets out a structured approach to the assessment of the cardiovascular system, enabling clinicians to identify abnormalities of the heart and circulatory system (Harris and Nicholls, 2016).

Clinical examination is intended to obtain information about your patient, and begins as soon as you meet them. Remember that you, as the practitioner, are obtaining both subjective and objective information, bringing both together to understand the patient's presenting complaint. The subjective element is obtained from the patient in terms of their symptoms and initial history (Bickley et al, 2017), while the objective data are gathered through signs noted throughout your clinical examination (Bickley et al, 2017).

Depending on the patient's clinical presentation, you may choose a flexible, focused or problem-orientated assessment (Bickley et al, 2017), linking them with aspects of other system examinations such as the respiratory or gastrointestinal.

As the series overview stated, it is important to introduce yourself to the patient, explain what you intend to do for each part of the assessment, and gain consent from the patient before carrying the assessment out (Kirk, 2020). Ensure to adhere to infection control principles before starting and throughout the examination.

Equipment required

Stethoscope

Patient positioning

The patient should be seated, leaning back to 45°, supported by pillows with their chest, arms, and ankles (if appropriate) exposed (Thomas and Monaghan, 2014).

General observations

Look at the patient and their surroundings and note:

Obvious discomfort/pain

Colour of the patient

Oedema

Items around the bed that may indicate cardiovascular disease (Thomas and Monaghan, 2014).

REFLECTION

Consider what bedside items could indicate evidence of underlying cardiovascular disease

Hands

Inspect both hands starting with the nails, then dorsum of the hand and then the palms (Swartz, 2014).

You should be able to recognise and know the significance of the following:

Clubbing (Schamroth window test)

Splinter haemorrhages (small streak-like bleeds in the nail bed)

Anaemia

Peripheral cyanosis

Tar staining

Temperature (may be cold in congestive cardiac failure)

Osler nodes (small, red/purple, raised, tender lesions often on finger pulps)

Janeway lesions (irregular, flat, red, non-tender macules on the palmar aspect of the hand).

REFLECTION

Consider the underlying causes of hands being: warm and sweaty; or cold and clammy

Radial pulse

Assess the rate, rhythm, volume and character (Innes et al, 2018). Note: it is good practice not to use your thumb to feel pulses as you may mistake your own pulse (which can be felt weakly in the thumb) for the patient's (Thomas and Monaghan, 2014); however, in stronger pulses, such as the brachial or carotid, the thumb may be used as confusion is less likely (Gregory and Mursell, 2010)

Count the pulse over 15 seconds and multiply by 4 to obtain the beats per minute (bpm) (Innes et al, 2018)

Is the pulse irregular?

Is it regularly irregular? For example, in Wenckebach's phenomenon, you may feel the time increasing between each pulse until one is ‘missed’ and then the cycle repeats (Thomas and Monaghan, 2014)

Is it irregularly irregular? For example, causes may include atrial fibrillation or multiple ectopic beats (Harris and Nicholls, 2016)

Assess for a radio-radial delay (including volume differences) (Thomas and Monaghan, 2014). Causes may include:

Coarctation of the aorta (Innes et al, 2018)

Aortic dissection.

Assess for a collapsing pulse. This occurs when the peak of the pulse occurs early and is followed by a rapid descent (Thomas and Monaghan, 2014). The rapid fall in pulse pressure imparts the ‘collapsing’ sensation, which is exaggerated by raising the patient's arm above the level of the heart (Innes et al, 2018). Causes may include:

Aortic regurgitation—this feels as though the pulse suddenly hits your fingers and falls away just as quickly. It is sometimes referred to as a ‘water hammer’ pulse (Thomas and Monaghan, 2014).

REFLECTION

What are the underlying causes of pulsus paradoxus, pulsus bisferiens and pulsus alternans?

Arms

Assess the brachial pulse, detecting rate, rhythm, volume and character (Thomas and Monaghan, 2014)

Use your index and middle finger. Feel for the pulse just medial to the bicep tendon (Bickley et al, 2017)

Obtain a blood pressure

Depending on patient presentation, this may need to be measured in both right and left arms; and standing and supine. This is undertaken to rule out pathology of the aorta or upper extremity arterial obstruction (Gregory and Mursell, 2010).

Note: The size of the cuff is important for an accurate blood pressure measurement (Swartz, 2014). Using a cuff that is too large results in the blood pressure being underestimated (Talley and O'Connor, 2014), whereas using a cuff that is too small gives an overestimated blood pressure reading (Gregory and Mursell, 2010). The difference in the systolic and diastolic pressures is the pulse pressure.

A narrow pulse pressure can indicate aortic stenosis (Harris and Nicholls, 2016)

A wide pulse pressure can indicate aortic regurgitation (Harris and Nicholls, 2016).

Face

Inspect the eyes. Findings may include:

Xanthelasma—yellow raised lesions around the eyes—which can indicate hypercholesterolaemia (Swartz, 2014)

Conjunctival pallor (Swartz, 2014)

Corneal arcus—a yellowish/grey ring surrounding the iris. This is significant in patients aged <40 years but not in older people. This can indicate hypercholesterolaemia (Thomas and Monaghan, 2014)

Mitral facies—rosy cheeks—which can indicate mitral stenosis (Thomas and Monaghan, 2014). It is important to remember, however, that there are other causes of redness of the cheeks

Inspect the mouth. Note:

Central cyanosis: this may be caused by heart failure or, rarely, congenital heart disease (Innes et al, 2018)

A high arched palate: this can be suggestive of Marfan syndrome and can also indicate mitral valve prolapse (Swartz, 2014)

Dental hygiene: this is important if considering sources for infective endocarditis (Thomas and Monaghan, 2014)

Inspect the neck

Palpate the carotid pulse:

Assess its character and volume (Thomas and Monaghan, 2014)Note: NEVER palpate both carotid arteries at the same time (Bickley et al, 2017)

Listen for bruits over both carotid arteries using the diaphragm of your stethoscope during held inspiration (Innes et al, 2018). A bruit is caused by turbulent blood flow and can indicate narrowing of a blood vessel (Talley and O'Connor, 2014)

Inspect the patients' jugular venous pressure (JVP). The JVP is an indication of right ventricular function (Innes et al, 2018). Causes of an elevated JVP include:

Heart failure

Acute pulmonary embolism

Cor pulmonale

Tamponade

Tricuspid stenosis (Innes et al, 2018).

JVP examination sequence

Ensure the head of the bed is raised to approximately 45o. Turn the patient's head slightly away from the side you are inspecting, which should be to the left (Bickley et al, 2017)

Measure the vertical distance from the top of the pulsation to the sternal angle (Thomas and Monaghan, 2014)

Identify the timing and waveform of the pulsation and note any abnormalities (Innes et al, 2018). If necessary, readjust the position of the patient until the waveform is visible (Innes et al, 2018).

Chest

Expose the precordium, making sure you maintain patient dignity, covering them up before and after the examination.

Inspection Pectus excavatum or pectus carinatum can displace the heart (Innes et al, 2018). Pectus excavatum is a depression of the lower portion of the sternum, which can compress the heart and great vessels (Bickley et al, 2017). Pectus carinatum is a localised prominence of the sternum and costal cartilages (Talley and O'Connor, 2014)

Observe for scars: for example, sternotomy (coronary artery bypass grafting surgery or aortic valve replacement) (Innes et al, 2018) or infraclavicular (pacemaker or defibrillator implantation) (Innes et al, 2018). Pacemaker or implantable defibrillators are usually implanted over the left pectoral region (Thomas and Monaghan, 2014)

Are there any visible pulsations (Thomas and Monaghan, 2014)?

Next, palpate the precordium

Locate and palpate the apex beat: the cardiac impulse results from the left ventricle moving forward and striking the chest wall during systole. The apex beat is normally located in the fifth intercostal space at the mid-clavicular line (Innes et al, 2018). Note that in overweight or muscular patients, the apex beat may be impalpable (Innes et al, 2018). This can also be the case with patients who have asthma or chronic obstructive pulmonary disease (COPD) because the chest is hyperinflated (Innes et al, 2018). If you cannot locate the apex beat, ask the patient to roll partly onto their left side and palpate again (Bickley et al, 2017)

Parasternal heave: a sustained, thrusting pulsation, usually felt at the left sternal edge, indicates right ventricular enlargement (Thomas and Monaghan, 2014). To palpate for heaves, use your palm and/or your finger pads against the chest (Bickley et al, 2017)

Thrill: this is a palpable murmur felt as a shudder beneath your hand. It is caused by severe valvular disease:

If systolic: aortic stenosis, ventricular septal defect or mitral regurgitation

If diastolic: mitral stenosis (Thomas and Monaghan, 2014).

This should be assessed by pressing the ball of your hand firmly on the chest in the following areas (Bickley et al, 2017):

Aortic valve: second intercostal space at the right sternal edge (Harris and Nicholls, 2016)

Pulmonary valve: second intercostal space at the left sternal edge (Thomas and Monaghan, 2014)

Mitral valve: fifth intercostal space at the mid-clavicular line (Harris and Nicholls, 2016)

Tricuspid valve: fifth intercostal space at the left sternal edge (Thomas and Monaghan, 2014).

Auscultation: This involves auscultation of the four heart valves. Practice is needed here, and you should listen to many hearts so you become familiar with normal heart sounds (Thomas and Monaghan, 2014). The normal heart has two distinct sounds heard during the single cardiac cycle, which are described as a ‘lub’ and ‘dub’ (Gregory and Mursell, 2010). The first heart sound (S1 [lub]) is caused by the closure of the mitral and tricuspid valves (Innes et al, 2018). The second heart sound (S2 [dub]) is caused by the closure of the pulmonary and aortic valves (Innes et al, 2018).

The aortic valve is best auscultated in the second intercostal space at the right sternal edge (Harris and Nicholls, 2016)

The pulmonary valve is best auscultated in the second intercostal space at the left sternal edge (Thomas and Monaghan, 2014)

The mitral valve is best auscultated in the fifth intercostal space at the mid-clavicular line (Harris and Nicholls, 2016)

The tricuspid valve is best auscultated in the fifth intercostal space at the left sternal edge (Thomas and Monaghan, 2014). For each of the heart valves, the place of auscultation is not the surface location of each of them, just the site where they can be best heard. Examination sequence

Palpate one carotid pulse while listening to the heart: this enables you to ‘feel’ systole. It can be difficult to decide which heart sound is which. Palpation of the carotid pulse will indicate the timing of systole and enable the heart sounds to be easily distinguished (Talley and O'Connor, 2014). The carotid pulsation occurs with S1 (Thomas and Monaghan, 2014).

Auscultate all areas using the diaphragm then the bell of your stethoscope (Thomas and Monaghan, 2014). Note: the diaphragm is better for picking up high-pitched sounds and the bell is more sensitive to low-pitched sounds (Bickley et al, 2017).

Auscultate the carotid arteries, with the patient holding their breath, and listen for bruits (Innes et al, 2018)

Ask the patient to move onto their left side and auscultate the mitral area during expiration to listen for mitral stenosis (Bickley et al, 2017).

Ask the patient to sit up and lean forward. While they are holding their breath (intermittently), auscultate the aortic and tricuspid areas with the diaphragm, listening for aortic regurgitation (Innes et al, 2018).

REFLECTION

Consider the different heart sounds you may hear, including S3 and S4. What are the different types of murmurs and what would they indicate?

On completion of your examination, thank the patient and document your findings. Also consider alternative diagnoses that may require clinical examination of another system. Cardiovascular and respiratory conditions often overlap and mimic each other; an example is pulmonary fibrosis and left ventricular failure (Thomas and Monaghan, 2014).

This concludes the cardiovascular examination. You may consider an examination of the patient's peripheral vascular system, which will be explored in next month's issue.