Chapter 6Cardiac and Hematological Examinations

(Also seen in Chapter 5 – Respiratory Exam)

• Location: Where is the pain located? Can you point to it? (Angina pain is retro- or sub-sternal)
• Onset: When did the pain start? What were you doing when it started? (e.g. on exertion)
• Palliating/Provoking: Does anything make the pain better or worse?
  • Worse with exertion or emotional stress? Relieved promptly by rest or nitroglycerin? (Consider Angina)
  • Better or worse in certain positions? (e.g. better leaning forward – consider Pericarditis)
  • Worse on inspiration? (With stabbing pain: pleuritic – suggestive of pulmonary embolism, pericarditis, pneumonia, pneumothorax, rib fracture)
  • Worse with palpation? (Consider mechanical cause e.g. rib fracture, costochondritis)
• Quality: How would you describe the pain? Sharp? Pressure?
  • Does it feel like an elephant is sitting on your chest? (make a fist with your hand and press to sternum – common description for angina)
  • Tearing or ripping pain? (consider aortic dissection)
  • Is it a tightness, a pressure or a pain? Is it sharp/stabbing? (consider pericarditis)
• Radiation: Does the pain radiate to the arm, jaw, or neck? (Cardiac)
  • Note: Classical teaching is that myocardial infarction pain radiates down the left arm; however, pain radiating down right arm or both arms increases likelihood of suspected MI further (LR+ve for pain in L arm = 2.2; R arm = 7.3; Both arms = 9.7)
• Severity: How severe is the pain on a scale from 1-10?
• Timing: Does the pain come and go? How frequently? How long has it been ongoing?
  • Chest Pain >30 minutes: Consider myocardial infraction, where target time from door to cath lab is <90 minutes – “time is myocardium”
• Associated Symptoms: Any Shortness of Breath? Nausea or Vomiting? Presyncope? – These can be anginal (chest pain) equivalents (e.g. a patient may present with Nausea as their main symptom for a Myocardial Infarction – be particularly mindful in patients who are elderly, have diabetes, and/or female for more atypical presentations of chest pain)
• Can’t Miss Diagnoses of Acute Chest Pain (PETMAC Mnemonic):
  • Pulmonary Embolism: Pleuritic chest pain, tachycardia, SOB, DVT, Immobilization
  • Esophageal Rupture: Vomiting, Chest/Epigastric Pain, Anxiety, Recent Instrumentation
  • Tension Pneumothorax: Tracheal Deviation, Sudden SOB, Pleuritic Chest Pain, Recent Instrumentation
  • Myocardial Infarction: Retrosternal Chest Pain worse with exertion relieved by rest or nitroglycerin, radiating to arm/jaw; Diaphoresis; Hypotension; Anginal Equivalents (Nausea, Dyspnea, Presyncope)
  • Aortic Dissection/Rupture: Tearing sensation; upper back pain; Hypertension; BP ∆ > 20mmHg for R vs. L arm
  • Cardiac Tamponade: SOB; Beck’s Triad (Hypotension, Jugular Venous Distension, Muffled Heart Sounds)
• Note: Pain and distress can manifest atypically in patients with limited communication and can be difficult to recognize. Nonspecific changes in vital signs, appearance and behavior, including less responsive, more withdrawn or new Behaviors that Challenge (BTC) can indicate pain and distress. Consider tools e.g. Chronic Pain Scale for Nonverbal Adults with Intellectual Disabilities¹, or Non-Communicating Adult Pain Checklist²

(the sensation of shortness of breath)

(Also seen in Chapter 5 – Respiratory Exam)

• Onset: When did the shortness of breath start? Was it sudden or gradual onset?
• Palliating/Provoking: Does anything make the shortness of breath better or worse? Any triggers (e.g. smoking, environmental triggers)? Any treatments help (e.g. puffers – such as salbutamol or ipratropium; or oxygen)?
  • Focus on Exertion i.e. SOB on Exertion (SOBOE):
    • Do you find you become short of breath when walking up a flight of stairs?
    • How many flights of stairs? How many blocks can you walk before you need to rest?
    • Do you find you are short of breath at rest? – Red Flag Symptom
    • Note: Refer to New York Heart Association (NYHA) CHF classifications or MMRC Breathlessness Scale for more info.
  • Focus on Position re. Orthopnea (Breathlessness sensation worse when laying down, better sitting up – occurs immediately when lying flat due to increased preload to heart): Is SOB worse when lying down, better when siting up? Are you able to lay flat? How many pillows do you sleep on?
  • Focus on Paroxysmal Nocturnal Dyspnea (PND – SOB awakening patient after 1-2 hours of sleep – occurs due to ↑ volume from lymphatic resorption of edema, takes longer than orthopnea): Do you wake up in the middle of the night gasping for air or feeling like you can’t breathe? Does it get better after sitting up?
• Severity: On a scale of 0-10, how severe is the shortness of breath?
• Associated Symptoms:
  • Chest Pain (e.g. Myocardial Infarction, Pulmonary Embolism, Infection)
  • Constitutional Symptoms (Fever, Chills, Night Sweats, Weight Loss e.g. Infection, cancer)
  • Orthopnea, Paroxysmal Nocturnal Dyspnea (e.g. Congestive Heart Failure, CHF)
  • Stridor (e.g. Large Airway obstruction)
  • Cough (e.g. COPD, Asthma, Interstitial Lung Disease, etc.)
  • Calf Pain (e.g. Deep Venous Thrombosis/Pulmonary Embolism)
• Edema: Swelling of tissues – commonly dependent e.g. in lower extremities (e.g. CHF)

• Quick Question Screen: Does you ever feel like you’re aware of your heartbeat, or have a rapid pounding sensation in your neck?
  • Note: Palpitations are a common, often alarming, awareness of heartbeats. Differential diagnosis includes cardiac arrhythmias, sinus tachycardia, and increased perception of normal heartbeats – See Appendix 3 for example of Differential Diagnosis.
• Specific Questions to Ask:
  • Known PMHx of cardiac disease? (↑ likelihood of arrhythmias)
  • Known PMHx of panic disorder? (↓ likelihood of arrhythmia)
  • Affected by sleeping? (e.g. vagal tone-mediated Atrial Fibrillation or long-QT syndrome)
  • Duration < 5 mins? (↓ likelihood of arrhythmia)
  • Regular rapid-pounding sensation in neck? (consider cardiac arrhythmia, AVNRT)
• Associated Symptoms: Do you become light-headed during these episodes? (re. pre-syncope)
• Med Review: Any drugs patient is taking that prolong QT interval (e.g. anti-arrhythmic, antihistamines, anti-depressants)?
• Rhythm: Ask patient to tap out rhythm – is it Regular or Irregular? Fast or slow?

• Onset: When did you start feeling this way? Was it sudden or progressive?
• Palliating/Provoking: Does resting help? How is it affected by physical or mental activity?
  • Note: Physiological fatigue relieved by rest vs. Non-physiological fatigue not relieved by rest
• Quality: How would you describe it – Tiredness? Reduced exercise tolerance? Emotional?
  • Note: Clarify baseline level of physical activity - ↓ tolerance may suggest cardiac/heme causes
• Severity: How severe is the fatigue on a scale from 1-10? Is it getting in the way of daily activity?
• Timing: How often do you feel fatigued? Has this ever happened before?
• Associated Symptoms:
  • Muscle weakness (e.g. in neuromuscular etiologies)?
  • Acute infectious symptoms (e.g. in influenza, EBV mononucleosis)?
  • Mood changes (e.g. in psychiatric causes such as depression)?
  • Unintentional weight loss (e.g. in cancer)?
• Medications: Any recent medication changes?
• Hematological - Specific Questions:
  • Adequate Oxygenation: Energy, dyspnea/SOB, exertional capacity, skin/colour changes
  • Blood Loss: Hematemesis, hemoptysis, hematochezia, melena, hematuria, dysfunctional uterine bleeding/menorrhagia, trauma, easily bruised (ecchymosis)
• Hematological-Oncology: Constitutional symptoms (weight loss, fever, chills, night sweats)

• Past cardiac history, Rheumatic Fever, Endocarditis
• Respiratory history; other medical conditions (e.g. GERD, Stroke, Transient Ischemic Attack = TIA); Psychiatric History
• Cardiac Risk Factors: Dyslipidemia (lipid disorder associated with increased risk of vascular disease), Hypertension, Diabetes Mellitus (disorder of carbohydrate metabolism characterized by hyperglycemia – explored in Ch 14 – Diabetes Exam – MF3), Smoking (see Social History); Others: Obesity, Obstructive Sleep Apnea

Relevant Clinical Scores:

• Framingham Risk Score – 10-year MI risk, used for statin initiation, antihypertensive treatment targets, etc.
• ASVCD Risk Calculator – 10-year heart disease or stroke risk, used for statin initiation, etc.
• HEART Score – 6-week risk of cardiac event for patients ≥21 yrs with Acute Coronary Syndrome symptoms
• TIMI Risk Index – In-hospital 30-day mortality risk in Acute Coronary Syndrome (ACS)
• TIMI Score for STEMI + TIMI Score; and TIMI Score for Unstable Angina/NSTEMI – 30-day mortality after STEMI and after UA/NSTEMI, respectively.
• CHA₂DS₂-VASc Score – stroke risk in atrial fibrillation; used for initiation of anticoagulation, builds on CHA₂DS₂ Score
• HAS-BLED Score for Major Bleeding Risk – bleeding risk for patients on anti-coagulation
• Light’s Criteria (Determining exudative vs. transudative pleural effusion)
• STOP BANG Score – screening for obstructive sleep apnea
• Duke Criteria for Infective Endocarditis – diagnoses endocarditis using major and minor clinical criteria

• Coronary Artery Bypass Graft (CABG) –bypass blocked coronary artery using different, healthy blood vessel from patient
• Percutaneous Coronary Intervention (PCI) – catheterization + angiography for stenting or ballooning of coronary vessels
• Prosthetic Valve (replace dysfunctional original valve with functional prosthetic valve (mechanical or bioprosthetic) either percutaneously (e.g. TAVI/TAVR – Transcatheter Aortic Valve Implantation/Replacement) or open (e.g. SAVR – Surgical Aortic Valve Replacement)
• Permanent Pacemaker (PPM) - Regulates brady-arrhythmias to provide appropriate heart rate and rhythm response
• Implantable Cardioverter-Defibrillator (ICD) - implanted device to prevent sudden cardiac death from arrhythmia

• Cardiovascular Disease (MI Male < 55, Female < 65 1st degree relative); Cancer; Sudden/unexplained deaths; Lung disease

• Pack years = packs/day x years smoking: Use of cigarettes? E-cigarettes? Vapes?
  • Have you thought about quitting within the next 6 months? How long ago did you quit smoking?
  • The benefits of smoking cessation begin with the last cigarette; quit before Age 35, life expectancy same as non-smokers; quit age 35-65, add 5 years to life expectancy; quit age 65-74, add 1 year.
  • 5As approach taking a smoking Hx (Explored in Chapter 38 – Motivational Interviewing – IF)
• Pro-Comp Connection: Regarding patient’s position, do not jump to thinking in terms of “compliance” with recommendations for smoking cessation.

• How often do you drink alcohol (Drinks/Week)? What is the size of 1 drink? What kinds of drinks?

• Any other substance use? (e.g. Cocaine – risk for Cocaine-induced myocardial infarction; IV Drug use – risk factor for Infective Endocarditis)

• Do you work in a sedentary or more physical/active job? Have you been very stressed recently?

• Diet high in sodium? → consider looking into DASH Diet (Dietary Approaches to Stopping Hypertension)

• Angiotensin Converting Enzyme inhibitors (ACEi): End in “-pril” e.g. Perindopril, Ramipril
• Angiotensin Receptor Blockers (ARBs): End in “-sartan” e.g. Candesartan, Irbesartan
• Angiotensin Receptor-Neprilysin Inhibitor (ARNI): Sacubitril/Valsartan (Entresto)
• Beta-blockers (BB): End in “-lol” e.g. Metoprolol, Carvedilol, Bisoprolol, Atenolol
• Calcium Channel Blockers (CCB):
  • Dihydropyridines: End in “-pine” – e.g. Amlodipine, Nifedipine
  • Non-Dihydropyridines: Diltiazem, Verapamil
• Diuretics:
  • Loop Diuretics: Furosemide, Bumetanide
  • Thiazide-Like Diuretic: Hydrochlorothiazide, Chlorthalidone, Metolazone, Indapamide
  • Mineralocorticoid Receptor Antagonists (MRA): Spironolactone, Eplerenone

(Note: Explored further in MF2)

• Anti-platelets (primary hemostasis) – e.g. Acetylsalicylic Acid (ASA), Clopidogrel, Ticagrelor
• Anti-coagulants (secondary hemostasis) –
  • Heparins: e.g. Unfractionated Heparin, Low Molecular Weight Heparin (LMWH)
  • Vitamin K Antagonist: Warfarin
  • Direct Oral Anticoagulants (DOACs): e.g. Dabigatran, Apixaban, Rivaroxaban, Edoxaban

• Class 1 = Sodium channel blockers (e.g. Quinidine, Phenytoin, Flecainide, Lidocaine)
• Class 2 = Beta Blockers (e.g. Propranolol, Atenolol)
• Class 3 = Potassium channel blockers (e.g. Amiodarone)
• Class 4 = Calcium Channel Blockers (e.g. Verapamil, Diltiazem)
• Class 5 = Other (e.g. Digoxin, Adenosine, Magnesium Sulfate)

• Statins: e.g. Atorvastatin, Rosuvastatin, Simvastatin
• Fibrates: e.g. Fenofibrate
• Cholesterol Absorption Inhibitors: e.g. Ezetimibe
• Bile acid-binding resins: e.g. Cholestyramine
• PCSK9 Inhibitors: e.g. Evolocumab, Alirocumab

• Ask about these as well, including any naturopathic medications

• Check Orthostatic vitals (re. dizziness, orthostatic hypotension, severe blood loss)
• Check BP in both arms (e.g. difference ≥ 20 mmHg can be seen in Aortic Dissection)
• Heart rate and rhythm – is it regular, irregularly regular, or irregularly irregular?

Say: I will measure the blood pressure using a manual Blood Pressure cuff.

Do: Similar to manual blood pressure measurement detailed in Chapter 4, with an additional recorded value.

1. Listen for first Korotkoff sound that appears then disappears with inspiration (recorded as SBP, as usual).
2. Listen for when the sound no longer disappears with inspiration (a pressure in between SBP and DBP).
3. Calculate the difference between these values; a difference of < 10 mmHg is normal – above this, is positive for pulsus paradoxus.
4. Then listen for last sounds in series (DBP, as usual), deflate cuff more quickly as normal.

Report: The recorded drop in systemic blood pressure is <10mmHg, which is negative for pulsus paradoxus.

What is Normal: A drop of <10mmHg is physiologic due to increased venous return on inspiration → pressure transmitted to RV wall, accommodated → more blood in pulmonary circulation.

Why Check:

• Can’t Miss Diagnosis – Cardiac Tamponade: The presence of pulsus paradoxus increases likelihood of suspected cardiac tamponade, and the lack of pulsus paradoxus reduces the likelihood (At >12mmHg, LR+ve 5.9 and LR-ve 0.03; at >10mmHg, LR+ve 3.3 and LR-ve 0.03. Also look for Beck’s Triad for acute cardiac tamponade i.e. distended neck veins, low arterial blood pressure, and muffled heart sounds.
  • Mechanism: In Cardiac tamponade, the intrapericardial volume reaches above the elastic limit and becomes fixed. This means as the right heart fills, the left heart compresses, and vice versa. Inspiration increases preload → pressure transmits to ventricular septum → septal deviation towards LV → decreased stroke volume → decreased systolic blood pressure.
  • Cardiac Tamponade vs. Pericarditis/Pericardial Effusions:
• Distinguishing Cardiac Tamponade from Pericarditis and Pericardial Effusions: On EKG, both Severe Pericardial Effusions and Cardiac Tamponade may show Electrical Alternans (i.e. alternating QRS complex amplitudes). Cardiac Tamponade may be secondary to Pericarditis (inflammation of pericardium). The classic symptoms of pericarditis are pleuritic chest pain worse on inspiration and in supine position.
• Differential Diagnosis for Pulsus Paradoxus: Severe constrictive pericarditis & severe asthma/COPD exacerbations. False Negatives may occur with Aortic Regurgitation and Atrial Septal Defect (ASD)

Say: I will begin with general inspection of the head and torso.

Do: Look for signs of respiratory distress (see Chapter 5 – Resp Exam), and diaphoresis (heavy perspiration/ sweating). Is patient endomorphic (overweight), ectomorphic (underweight), or mesomorphic (normal weight)? Observe their level of consciousness: are they alert and oriented to person, place and time?

Report: I note no signs of respiratory distress such as accessory muscle use (in an OSCE station, state full list of signs of increased work of breathing). Patient not diaphoretic with a mesomorphic body habitus, alert and oriented to person, place and time.

Why Check: Creates an initial picture; important especially when formulating impression of presentation.

Say: Can you open one eye and pull the lower eyelid down? Now the other side?

Do: Look for conjunctival pallor, scleral icterus (jaundice) or arcus senilis (grey arc around cornea)

Conjunctival Pallor⁴ · Scleral Icterus⁵ · Arcus Senillis⁶

Report: I note no conjunctival pallor, scleral icterus (jaundice) or arcus senilis (grey arc around cornea).

Why Check: Conjunctival pallor is a sign of anemia; Scleral Icterus (jaundice) can be a sign of Pre-hepatic (e.g. hemolytic anemia), Hepatic (e.g. Acute hepatitis) or Post-Hepatic (obstructive – cholecystitis, choledocholithiasis, etc.) hyperbilirubinemia. Arcus senilis can be a sign of dyslipidemia (lipid deposits)

Say: I will inspect under the tongue and the hands.

Do: Look for the following abnormalities in the hands and mouth

1. Splinter Hemorrhages: tiny blood clots running vertically under nails.
2. Janeway Lesions: small nodular lesions on palms
3. Osler Nodes: painful red, raised lesions on hands and feet.
4. Respiratory findings: clubbing, tar staining, peripheral cyanosis (Ch 5 – Respiratory Exam).
5. Capillary Refill Time: <2 seconds for children and adult men; <3 seconds for women; <4 seconds for elderly patients (see Ch 8- Peripheral Vascular Exam).
6. Tremor: an involuntary, oscillating movement of a fixed frequency/rhythmic quality.
7. Pallor: Assess hands at palmar creases & nailbeds.
8. Central Cyanosis: in the mouth, assess under tongue for central cyanosis (see Ch 5 – Respiratory Exam)

Splinter Hemorrhages⁷ · Janeway Lesions⁸

Osler Nodes⁹ · Palmar Pallor⁴

Report: I note no signs of central cyanosis or findings in the hands (in an OSCE station, verbalize all findings).

Why Check:

• Splinter hemorrhages, Janeway lesions and Osler nodes are signs of infective endocarditis due to immune complex deposition and/or septic micro-emboli, and can be used as minor criteria in the Duke Criteria for Infective Endocarditis.
• Tremor can be seen in thyrotoxicosis (see Thyroid Exam – Ch 15 – MF3).
• Pallor in palmar creases & nailbeds are signs of anemia.
• Peripheral cyanosis indicates circulatory insufficiency; central cyanosis indicates poor oxygenation in the lungs (specifically PaO2 <50mmHg given an Hb of 140-160g/L; PaO2 45mmHg if Hb 120 g/L).

Also seen in Ch 9 – Volume Status Exam – MF2

• JVP - [4, 4]
• JVP Waveform- [2, 3]

Say: Please lay back on the exam table and tilt the head all the way to the left.

How do you differentiate the JVP from the Carotid Pulse?

Do:

1. Prop up head of exam table to 30-45°. Stand at right side. Look for JVP between 2 heads of sternocleidomastoid (i.e. sternal head medially, clavicular head laterally), or look lateral to sternal head of sternocleidomastoid.
2. Once you have located the JVP, measure by placing ruler on sternal angle facing vertically
3. Make a right-angle triangle going from the apex of the JVP to the ruler.
4. The height on the ruler is the measured JVP.

Note: on OSCE, estimate using your fingers, < 3 finger breadths is normal – not expected to use ruler.

What is Normal: 3-4 cm Above Sternal Angle (ASA)

Report: JVP was located and is < 5 cm above the sternal angle

Why Check: The Jugular Venous Pressure (JVP) is used to check the intravascular volume status of patients (termed “wet” if the patient is volume overloaded and the JVP is elevated, or “dry” if the patient is volume depleted and the JVP is flat). The JVP is an indirect measure of right atrial pressure via visualization of the internal jugular vein. The Central Venous Pressure (cm H2O) can be estimated from the JVP by adding 5cm to the measured value, since right atrium is approximately 5cm below the sternal angle. In the appropriate clinical context (e.g. dyspneic patients in Emergency Department), an elevated JVP increases the likelihood of suspected Congestive Heart Failure (LR+ 5.1; LR- 0.66) If the JVP increases with inspiration, this is called Kussmaul’s Sign and may be a sign of severe pericarditis or right-sided heart failure. Beck’s Triad (for Acute Cardiac Tamponade) includes distended neck veins, low Arterial Blood Pressure, and Muffled Heart Sounds.

Say: I will briefly inspect the abdomen for abnormalities.

Do: Look for signs of ascites, any pulsations or surgical scars in abdominal area

Report: I note no ascites, pulsations or surgical scars in the abdomen.

Why Check: Looking for signs of portal hypertension – note that patients may have ascites without physical findings (Ultrasound more sensitive). May also look for other signs of venous congestion (e.g. Edema, Jugular Venous Distension – see JVP assessment above), and for other signs of liver disease (e.g. jaundice, coagulopathy, telangiectasias, etc. – see Abdominal Exam – Ch 13 – MF3)

Say: I will briefly inspect the legs for abnormalities.

Do: Look for signs of edema, erythema, surgical scars and peripheral vascular disease.

Report: I note no edema, erythema, surgical scars or concerns for peripheral vascular disease.

Why Check: Assessing extent of vasculopathy (see Peripheral Vascular Exam – Ch 8 – MF1 for more details), potential extent of Congestive Heart Failure, etc.

Say: I will inspect for any visible yellow depositions.

Do: Assess for Xanthomata (yellowish cholesterol-rich fat depositions). Common sites include eyes, joints, hands, and tendons (e.g. Achilles tendon)

Report: No xanthomata visible on inspection

Xanthoma¹⁰

Why Check: Xanthomata are complications of hyperlipidemia – significant risk factor of cardiovascular disease

Say: I am going to inspect for any signs of coagulopathy

Do: Assess for Hematomas: Based on size, either Petechiae (1-2 mm diameter red spot), Purpura (3-10 mm), and/or Ecchymosis (>10 mm); as well as Telangiectasias (spider veins)

Report: No Petechiae, purpura or ecchymosis noted on inspection.

Petechiae¹¹ · Telangiectasias¹²

Why Check: Signs of both platelet disorders, and vascular disorders.

Say: Please lay back on the exam table and tilt the head to the left. I’m going to press on the upper abdomen and monitor the veins in the neck.

Do: Press firmly over right upper quadrant or centre of abdomen for 10-15 seconds. Observe the JVP. If JVP does rise significantly (≥4cm), observe if JVP returns to baseline while applying pressure. Sustained elevation of JVP beyond 10 seconds is abnormal. This can be confirmed by suddenly releasing abdominal pressure and seeing a return to baseline (≥4cm fall).

What is Normal: In an otherwise healthy individual, the JVP remains constant or temporarily rises for 1-2 heartbeats before returning to normal.

Report: Abdominojugular Reflux lasted less than 10 seconds, which is normal.

Why Check: An alternative test for measuring JVP, method to assess right ventricular failure. This is also useful if you are having trouble seeing or differentiating the JVP from carotid.

Say: I will now be palpating the chest at the four valve regions of the heart.

Where to Palpate: See image

Do: Use whole hand to palpate heaves, then pads of 2-3 fingers to palpate for thrills at each valve region (Heaves = Hands, Thrills = Tips)

Report: There are no heaves or thrills on palpation.

Why Check: Heaves provide evidence of hypertrophy. Thrills provide evidence of turbulent blood flow, complemented by murmurs heard on auscultation.

• Loc.– [3, 4]
• Amp. – [1, 1]
• Dur. – [1, 2]
• Size – [2, 4]

Say: I will palpate the chest for where the heart beats strongest. Can you lean forward?

Do: Using 2-3 fingers, locate the 5th intercostal space at left mid-clavicular line (MCL) – the expected site of PMI. Assess Location, Amplitude, Duration and Size (LADS).

Report: PMI located at 5th intercostal at left MCL, is brisk and tapping, lasts 2/3rd systole, and size of quarter.

Why Check: Apex beat being palpated can provide evidence of hypertrophy – PMI not always apical impulse

• Location of Apex: Displaced location can be evidence of decreased ejection fraction, left ventricular dilatation, increased left atrial pressure, or enlarged Cardiothoracic Ratio on Chest X-Ray.
• Amplitude of Apex: If patient has known mitral stenosis, increased apex amplitude suggests comorbid aortic stenosis or mitral regurgitation
• Duration of Apex: Sustained apex with an aortic murmur argues for aortic stenosis; Lack of sustained apex with Aortic Regurgitation argues against moderate-severe severity of Aortic regurgitation
• Size of Apex: Increased size evidence of increased LV End-Diastolic Volume

(Also seen in Ch 8 – Peripheral Vascular Exam – MF1)

Say: I will palpate for leg swelling (Sacral edema if patient immobile). Please tell me if you are in discomfort.

Do: Press firmly with pads of your thumbs on the dorsal surface of patient’s leg, just above the ankle at bony prominence. Hold for 10s, then release. Look for pitting edema – skin does not bounce back immediately (i.e. pits). How high does it go on the leg? Is it pitting (transudate) or non-pitting (exudate)? Look at patient for signs of discomfort and stop exam signs of distress.

Pedal Edema¹³

Grading: 0 = none; 1+ = 2mm depression; 2+ = 4mm depression; 3+ = 6mm depression; 4+ = 8mm depression

Report: I note (grade) pitting edema bilaterally, up to the level of (location e.g. ankles).

Why Check: Edema is excess interstitial fluid accumulation causing swelling, particularly in gravity dependent areas (e.g. feet). Normally, this fluid returns through lymphatic drainage. Pitting edema = transudate (non-protein filled) – sign of increased hydrostatic pressure (e.g. congestive heart failure, decreased venous return) or decreased oncotic pressure (e.g. nephrotic syndrome, hypoalbuminemia). Non-pitting edema = exudate (protein) filled, or an issue with lymphatic drainage (e.g. lymphedema).

Say: I will palpate the central pulses in the neck, arms and groin.

Do: Palpate for pulses bilaterally. For peripheral pulses, you can palpate the most distal pulse. If it is non-palpable, move more proximally. Should be symmetrical, regular rate/rhythm and no delay between them. Note that Lower Limb Peripheral Pulses are explored in Ch 8 – Peripheral Vascular Exam.

Where to Palpate – Upper Extremities:

• Radial: Along radius bone just proximal to wrist on palmar side of hand
• Brachial: Medial to biceps tendon and 2-3cm above antecubital fossa

Where to Palpate – Central Pulses:

• Carotid: Medial to sternocleidomastoid muscle, roughly at level of cricoid cartilage
• Abdominal Aorta: Slightly left and superior to umbilicus
• Femoral: Midway between ASIS and Symphysis pubis

Note: Auscultate for carotid bruits before palpation of carotid pulses using bell of stethoscope (see below)

Grading: 0 = Non-palpable; 1 = Barely palpable; 2 = Easily Palpable (Normal); 3 = Bounding; 4 = Aneurysmal.

Report: Central and most distal upper limb peripheral pulses are symmetrical with regular rate and rhythm.

Why Check: Note that palpation of peripheral and central pulses is a core element of the Peripheral Vascular Exam (see Chapter 8 – Peripheral Vascular Exam). Specific findings include Pulses alternans (two strong systolic with mid-systolic dip) suggests LV dysfunction or Cardiac tamponade. An Irregularly irregular rhythm may suggest Atrial fibrillation.

Modification for Patients with Obesity: Use a handheld Doppler Ultrasound to locate pulses if they are difficult to appreciate by palpation. In this population, a doppler may be more sensitive than palpation.

• S3, S4- [1, 3]
• Murmur [1, 3]
• Abnormal S1, S2 [1, 1]
• Position [1, 4]

Say: I will auscultate the chest for heart sounds. Please breathe normally as I listen.

Do: Listen carefully with the diaphragm of the stethoscope at each valve region (Aortic, Pulmonic, Tricuspid, and Mitral). Listen for abnormal heart sounds or murmurs.

Report: I note a normal S1 and S2. There are no extra heart sounds or murmurs present.

What Is Normal? S1 and S2, regular rate and rhythm, with no extra heart sounds and no murmurs

• S1 = loudest at Tricuspid & Mitral valves (re atrioventricular valves closing at start of systole)
• S2 = loudest at Aortic & Pulmonic valves (re semilunar valves closing at end of systole). Physiologic splitting of S2 is normal on inspiration due to ↑ negative intrathoracic pressure – best heard in a sitting position.

Abnormal Findings – Abnormal S1 and S2 and Associated Conditions:

Abnormal Findings – Extra heart sounds: Best heard in left lateral decubitus position.

• S3: Heard just after S2, with rapid and early diastolic filling of ventricles, “Sloshing in” (e.g. volume overload). In the appropriate clinical context (e.g. dyspneic patients in Emergency Department), hearing an S3 increases the likelihood of Congestive Heart Failure (LR+11, LR- 0.88).
• S4: Heard just before S1, with diastolic rapid late filling of ventricles, “A stiff wall” (e.g. pressure overload, Left Ventricular Hypertrophy).
• S3 + S4: Summation gallop

Abnormal Findings – Murmurs (represent Turbulent blood flow). Listen for Location (i.e. identify valve); Radiation (e.g. to carotids, left sternal border, etc.); Timing (e.g. Systolic vs. Diastolic); Configuration (e.g. Crescendo, Decrescendo, Crescendo-decrescendo, Plateau); Quality (e.g. high vs. low pitch; harsh, musical, blowing, rumbling, etc.); Change with maneuvers (e.g. with inspiration, Valsalva, squat); and Volume/Grade

• Systolic Murmur: Grades 1 (very faint); Grade 2 (soft, readily detectable); Grade 3 (easily detectable without thrill); Grade 4 (easily detectable with thrill); Grade 5 (very loud murmur audible with stethoscope placed lightly on chest); Grade 6 (extremely loud, audible with stethoscope off chest)
• Diastolic Grade: Grade 1 (barely audible); Grade 2 (audible, soft); Grade 3 (easily audible); Grade 4 (loud)

Mitral Stenosis (MS)

• Pathophysiology: Mitral valve should be open in diastole – mitral stenosis causes incomplete opening of mitral valve in diastole
• Murmur: Diastolic murmur with Opening Snap best heard at cardiac apex in left lateral decubitus position. Worsened by ↑ venous return (squat/leg raise)

Aortic Regurgitation / Insufficiency (AR/AI)

• Pathophysiology: Aortic valve should be closed in diastole – aortic regurgitation causes incomplete closing of aortic valve in diastole
• Murmur: Diastolic murmur heard best at right base in sitting position. Worsened by ↑ venous return (squat/leg raise)

Aortic Stenosis (AS)

• Pathophysiology: Aortic valve should be open in systole – aortic stenosis causes incomplete opening of aortic valve in systole
• Murmur: Systolic murmur with crescendo-decrescendo pattern heard best at right base. Radiates to R clavicle and/or R carotid. Worsened by ↑ venous return (squat/leg raise)

Hypertrophic Cardiomyopathy (HCM)

• Pathophysiology: LV Outflow Tract Obstruction due to sarcomere gene mutations.
• Murmur: Systolic murmur with crescendo-decrescendo pattern heard best at cardiac apex and left lower sternal border. May radiate to axilla. Improved by ↑ venous return (squat/leg raise)

Mitral Regurgitation (MR)

• Pathophysiology: Mitral valve should be closed in systole – mitral regurgitation causes incomplete closing of mitral valve in systole.
• Murmur: Systolic murmur with holosystolic pattern heard best at cardiac apex. Radiates to axilla. Worsened by ↑ venous return (squat/leg raise)

Mitral Valve Prolapse (MVP)

• Pathophysiology: Mitral valve should be closed in systole, where thickened mitral valve leaflets in MVP cause imperfect closure of mitral valve in systole.
• Murmur: Systolic murmur similar to Mitral regurgitation, but improved by ↑ venous return (squat/leg raise)

Maneuvers to Accentuate/Differentiate Murmurs:

Note on Pediatric Cardiac Auscultation: Not all pediatric murmurs are pathologic; pathology more likely if murmur is systolic grade 3+; holosystolic; associated systolic click; diastolic; worse on standing; or harsh.

Modification for Patients with Obesity: Ask the patient to lean forward if sitting, or to place their above their head if supine. Leaning forward brings the heart closer to the chest wall & placing arms above the head when supine redistributes the soft tissue of the chest wall, making heart sounds easier to appreciate.

Say: I will auscultate the carotid arteries in the neck (point on yourself to where you will auscultate) for signs of turbulent blood flow.

Do: Listen with Bell of Stethoscope. Listen for duration, intensity, and pitch. If applicable, also listen for any radiation of a systolic murmur to the right carotid (e.g. Aortic Stenosis)

Report: I note no carotid bruits on auscultation bilaterally.

Why Check: Can assess for carotid artery stenosis prior to palpating, where the presence of a carotid bruit has a 53% sensitivity and 83% specificity of a clinically relevant stenosis¹⁴. In addition, radiation of a systolic murmur to the right carotid ↑ likelihood of suspected aortic stenosis (LR+ 8.1, LR- 0.29)

Say: I will continue auscultating the heart while I also palpate over a carotid artery on one side of the neck (point on yourself to where you will palpate).

Setup: Auscultate over the valve that you suspect may be stenotic or regurgitant. Place the pads of your 2-3 fingers over the carotid artery gently (after auscultating for carotid bruits).

Do: As you listen for murmur, there should be no delay between murmur onset (systole) and carotid pulse.

• If carotid pulse is delayed and relatively diminished, this is Pulsus parvis et tardus (sign of aortic stenosis).
• If the carotid pulse is brisk, this may be a sign of aortic regurgitation.
• If the carotid pulse is biphasic (2 pulses per cardiac cycle), this is called pulsus bisferiens and may be a sign of coexisting Aortic Stenosis and Regurgitation.

Report: I note a normal carotid upstroke with no delay between the murmur and carotid pulse.

Why Check: Carotid upstroke is a conditional test that can be used if you suspect an aortic stenosis or aortic regurgitation murmur. Aortic stenosis is expected to cause carotid upstroke to be delayed and diminished due to partially obstructed forward flow, where this finding (pulsus parvis et tardus) increases likelihood of suspected aortic stenosis (LR + 9.2, LR- 0.56). Aortic regurgitation is expected to cause brisk carotid upstroke due to ↑ preload from regurgitation. Biphasic carotid pulse (pulsus bisferiens) due to comorbid Aortic stenosis and Aortic regurgitation is a combination of these morphologies.

• Video 1 – Cardiac Exam OSCE Style (Link: https://videopress.com/v/k7npdLgU)
• Video 2 – Cardiac Exam Special Tests (Link: https://videopress.com/v/FvzO3Mim https://videopress.com/v/PBR0adsa)

Note – 3 Chest Pain Criteria:

• Substernal chest discomfort with characteristic quality and duration
• Provoked by exertion or emotional stress
• Relieved promptly by rest or nitroglycerin

• Associated Findings:
  • Reduced or absent second heart sound (S2)
  • Reduced carotid volume
  • Slow rate of increase of carotid pulse (slow carotid upstroke)
  • Maximal murmur intensity in second right intercostal space
• Note: Moderate or severe aortic stenosis defined as valve area <1.2cm² or peak transvalvular gradient ≥25mmHg

• Note: Severe mitral regurgitation defined as regurgitant fraction of 40% or more detected by echocardiography

Note: Anemia defined as Hct <35%, Hgb <110g/dL, or Hgb <11g/dL for women and <13 g/dL for men

*Note: In Chapter 31 – “Complete” Screening Neuro Exam (MF4), an additional table of evidence is presented from the same JAMA Rational Clinical Exam article regarding distinguishing syncope from seizure (explored in MF4 Clinical Skills). In cases of transient loss of consciousness, syncope or seizure should be considered, where the most common causes are cardiac syncope, reflex syncope (e.g. vasovagal episode) and orthostatic hypotension (explored in MF2 Clinical Skills – Volume Status Exam).