OnExam

Vital Signs

Assess vital signs.

Inspection

  • General appearance
    • Weight: underweight, ideal weight, overweight, obese
    • Facies: malar flush, acromegaly, Paget's disease, Cushing's disease
    • Eyes:
      • Anemia: Conjunctival pallor
      • Hypercholesteremia: xanthelasmas,tendinous xanthomas
      • Eyelid Edema: Myxedema, SVC syndrome, Nephrotic syndrome
    • Fundoscopy: ophthalmoscope for Roth's spots, cotton wool spots, retinal hemorrhages and papilledema
    • Skin and mucous menbranes: cyanosis, hyperpigmentation, jaundice, pallor
    • Respiration: tachypnea, bradypnea, dyspnea, Cheyne-stokes breathing, accessory muscle use, pursed lip breathing
      • Dyspnea: Increased work of breathing resulting in accessory muscle use, intercostal indrawing and/or abdominal breathing
      • Cheyne-stokes breathing: Tachypnea and/or dyspnea followed by periods of apnea
    • Hands:
      • Markers of Perfusion:
      • Peripheral cyanosis, delayed capillary refill, temperature, Janeway lesions and Osler notes, palmer crease pallor
    • Endocarditis Phenomena:
      • Janeway lesions: small, non-tender erythematous or hemorrhagic lesions on palms or soles of feet indicative of endocarditis
      • Osler nodes: Tender, raised, red lesions on hands or feet characteristic of endocarditis
      • Palmar crease pallor: Indicative of secondary anemia caused by malabsorption or blood loss
    • Nails: clubbing, splinter hemorrhages, spoon deformity, nicotine stains
  • Thorax
    • Patient should be properly draped with chest visualized fully
    • Examine for color, scars, visible pulsations, or deformities (pectus excavatum; pectus carinatum)
    • Normal chest wall: sagittal representation
    • Pectus carinatum: sagittal representation
    • Pectus excavatum: sagittal representation
  • Jugular venous pressure
    • For detailed instructions see jugular venous pressure
    • This is the most accurate estimate of right atrial pressure, volume status and cardiac function of the patient; sensitivity for this test is 65-77% and specificity is 68-85%
  • Carotid upstroke and bruits
    1. Position the patient at 30 degree angle and examine each carotid pulse separately, never simultaneously
    2. Carotid pulse present just medial to the sternocleidomastoid muscle and inspect for carotid pulsations
    3. Palpate the carotid pulse by pressing posteriorly in the lower third of the neck with index and middle finger for upstroke, amplitude and contour of pulsations
    4. Have the patient hold their breath and listen for rate, rhythm, and bruits with stethoscope
      • Especially useful for aortic stenosis or insufficiency, overlying thrills and/or bruits.

Palpation

  • Identify any point of tenderness before palpating and examine that area last
  • Have patient hold breath periodically through exam to distinguish thrills from chest movements
  • Palpate with pads of fingers along the entire chest wall for tenderness, heaves, lifts and thrills
  • Press firmly over the aortic, pulmonic, right ventricular and left ventricular areas for thrills
    • Aortic - 2nd intercostal space, just right of sternum
    • Pulmonic - 2nd intercostal space, just left of sternum
    • Left ventricular - 5th intercostal space at the midclavicular line
    • Right ventricular - Point where 5th rib meets sternum

  • Palpate PMI, noting size (in normal cases, should be about 2.5 cm), location, amplitude, displacement and length (2/3 of systole)
  • Occasionally will palpate 3rd and 4th heart sounds and can establish timing by auscultating or palpating carotid pulse during palpation. However, these sounds are harder to find and hear in normal individuals.

Auscultation

  • Used to assess S1/S2, extra heart sounds of S3 and S4, and murmurs, splitting, opening snaps and ejection clicks.
    • Precision with regards to measuring any murmurs through auscultation is fair at best; examinations for systolic murmurs and opening snaps is much better
  • Position patient in supine position with the head of the bed at 30 degrees and fully expose the chest
  • Auscultate along the aortic, pulmonic, tricuspid and mitral valve areas, first with diaphragm and then with the bell of stethoscope. For each area, assess the timing and regularity of the heart sounds, checking for the presence or absence of murmurs. See below for a detailed look at murmurs and other heart sounds.
  • Have patient in left lateral decubitus (LLD) position with bell over apex to listen for mitral regurgitation
  • Have patient sit up, lean forward, exhale, and hold their breath. Listen over apex and left sternal border for aortic regurgitation

Murmurs

Murmurs should be described using the following characteristics:
  • Pitch - High, medium, low
  • Quality - Blowing, harsh, rumbling, musical
  • Radiation - Across the precordium, into the right 2nd intercostal space, axillae, into carotids
  • Shape - Crescendo, decrescendo, crescendo-decrescendo, plateau
  • Timing - Systolic, diastolic, continuous
  • Intensity - On a graded scale from 1-6
  • Location - Across the precordium
Common Murmurs:
  • Systolic murmurs
    • Mid-systolic - Innocent and physiologic murmurs
    • Pan/holo-systolic - Aortic stenosis most commonly, also mitral and tricuspid regurgitation, ventricular septal defect
    • Late-systolic - Mitral valve prolpase
  • Diastolic murmurs
    • Early diastolic - Aortic regurgitation
    • Mid-diastolic - Mitral or tricuspid stenosis
Shape of Murmurs:

Crescendo murmur (e.g. mitral stenosis)


Decrescendo murmur (e.g. aortic regurgitation)


Crescendo-descrescendo murmur (e.g. aortic stenosis)


Plateau murmur (e.g. mitral regurgitation)


Gradation of Murmurs:
    1/6 Faint – not immediately heard, no thrill
    2/6 Faint – immediately heard, no thrill
    3/6 Moderately loud - no thrill
    4/6 Moderately loud - thrill palpable
    5/6 Loud - can hear with stethoscope partially off chest wall, thrill palpable
    6/6 Loud - heard without a stethoscope, thrill palpable

Selected Heart Sounds

Ventricular Gallop
  • Low-frequency diastolic sounds best heard with the bell that originate in the ventricle; pathologic S3 sound
  • Can indicate decreased contractility, mitral or tricuspid regurgitation, or volume overload of a ventricle
Atrial Gallop
  • Dull, low-pitched sound heard best with the bell; occurs just before S1 sound
  • Decreased contractility and compliance; associated with coronary artery disease and aortic stenosis
Aortic Ejection Click
  • High-frequency click; early systolic sound best heard with diaphragm
  • Associated with deformed but mobile AV, aortic root dilatation, AV stenosis, bicuspid aortic valve, AR, and aneurysm of ascending aorta
Pulmonic Ejection Click
  • Decreased intensity/disappearance during inspiration
Opening Snaps
  • High-frequency, early diastolic sound
  • Associated with MV or TV opening
Friction Rub
  • Heard during atrial systole, ventricular systole and rapid-filling phase of ventricle; superficial scratching or grating quality best heard with diaphragm, during held inspiration and with firm pressure
  • Friction of two inflamed layers of pericardium during maximal movement of the heart within pericardial sac
Continuous Murmur
  • Continuous, loud murmur heard throughout the precordium
  • Patent ductus arteriosis
  • Splitting of S2
    • Physiologic-split S2 on inspiration only
      • Increased venous return leads to longer right ventricular systole (delayed P2) and decreased left ventricular preload leads to shorter left ventricular systole (early A2)
    • Widened Split - split S2 on expiration and wider split on inspiration
      • Right bundle branch block, pre-excitation of left ventricle, paced left ventricle.
      • Pulmonary stenosis
      • Pulmonary arterial hypertension (Ex. massive pulmonary embolism)
    • Fixed Splitting - splitting on inspiration and expiration but does NOT lengthen with inspiration
      • Anterior septal defect
      • Right heart failure
      • Pulmonary hypertension
    • Paradoxical Splitting - splitting only during expiration, NOT during inspiration
      • Left bundle branch block
      • Pre-excitation right ventricle
      • Right ventricle pacing
      • Aortic stenosis

Special Maneuvers

References

  1. Bickley L, Hoekelman R. Bates’ Guide to Physical Examination and History Taking. Philadephia, Pa: Lippincott; 2009.
  2. Cook DJ and Simel DL. (1996). The Rational Clinical Examination: Abnormal Central Venous Pressure. Journal of the American Medical Association; 275(8).
  3. Chatterjee K. Examination of the Jugular Venous Pulse. September 2010. Uptodate Online 18.3. Accessed January 3rd 2011 from http://www.uptodate.com/online/content/topic.do?topicKey=cardeval/2280&selectedTitle=4~150&source=search_result#H20.
  4. Sinisalo J, Rapola J, Rossinen J and Kupari, M. (2007). Simplifying the Estimation of Jugular Venous Pressure. American Journal of Cardiology; 100(12), 1779-81.
  5. Badgett RG, Lucey CR and Mulrow CD. (1997). The Rational Clinical Examination: Can the Clinical Examination Diagnose Left-Sided Heart Failure in Adults. Journal of the American Medical Association; 277(21).
  6. Chatterjee K. Auscultation of heart sounds. September 2010. Uptodate Online 18.3. Accessed January 3rd 2011 from http://www.uptodate.com/online/content/topic.do?topicKey=cardeval/4680&selectedTitle=1~150&source=search_result.
  7. Etchells, E., Bell, C., Robb, K. (1997). The Rational Clinical Examination: Does this Patient Have an Abnormal Systolic Murmur? Journal of the American Medical Association; 277(7), pp. 564-571.
  8. East Tennessee State University. Kussmaul’s Sign. Retrieved online on January 10, 2011 from http://www.etsu.edu/com/medicalmystery/KussmaulsSign.aspx.
  9. University of Washington, Department of Medicine. Physical Exam: Heart Sounds and Murmurs. Retrieved online on January 10, 2011, from http://depts.washington.edu/physdx/heart/physical.html.