Clinical Examinations of the CVS system

Roos test – Elevated arm test

Purpose:  To test for the integrity of the thoracic outlet. Test procedure: • The patient is seated. • The examiner observes by standing in front. • The patient is asked to abduct their arms to 900 and flex their elbows upwards also at 900 (the surrender position). The patient is asked to abduct their arms to 90 degrees and flex their elbows upwards also at 900 (the surrender position). The patient is then asked to repeatedly open and close their fists at modest speed for approximately 3 minutes. Expanding the thorax by taking in a large breath may aggravate the symptoms.
Observe for signs of fatigue or a downward drift.
Positive if the patient shows early fatigue, numbness, tingling, heaviness or a sudden drop of the arms.
Signifies compromised thoracic outlet affecting the function of the brachial plexus and subclavian artery.

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Hautant’s Test

 

Purpose: To assess the integrity of the vertebral arteries Test procedure: • The patient is seated • The examiner stands close to the patient • The patient flexes both arms to 90 with forearms supinated. The patient is instructed to close their eyes and tip the head backward. At this point, the patient may report the presence...

Vertebral Artery Test

 

CAUTIONS! Purpose:  Test for the integrity of the vertebral arteries Test procedure: • The patient is in the supine position • The examiner stands at the head end of the patient • The patient is assisted to extend the cervical spine to end of range. Following this, the upper cervical joints are taken into side bending...

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Evaluation of Jugular Venous Pressure

Definition:

Evaluating the pressure in the venous system as the blood is returned to the right side of the heart before it is sent into the pulmonary circulation.

Test procedure:

 

The patient lies supine and at 45 degrees. The internal jugular vein is visualised as it ascends the side of the neck between the two heads of the sternocleidomastoid muscle. If the jugular vein appears to be distended attempt to measure the height of the distension as a vertical column of blood in relation to the sternal angle.

 

Test findings:

A normal jugular venous pressure should not exceed 3-4 cm above the sternal angle.  Higher readings may signify right-sided heart failure, constrictive pericarditis, pleural effusion, obstructed vena cava and other pathologies of the heart and lungs.

Considerations:

To help you visualise the jugular vein observe the patient’s neck when lying complete flat on the couch. Alternatively placing pressure over the liver (hepatojugular reflux) increases venous return and causes temporary jugular vein distension. Do not mistake the external jugular for the internal. The external jugular vein  may appear engorged even in physiological states.

Auscultation of the precordium - heart valves

Definition:

 

The use of a stethoscope to auscultate the heart valves and their sounds at varying anatomical locations.

In healthy adults, auscultation will usually reveal two sounds described as “lub” (S1) and “dub”(S2), with the former occurring upon closure of the atrio-ventricular valves and the later occurring upon closure of the semilunar valves. In addition to the aforementioned sounds, other sounds may be present and are often pathological, these include: heart murmurs, gallop rhythms, adventitious sounds and S3 and S4.

 

Test procedure:

 

With the patient lying inclined at around approximately forty-five degrees, locate the following anatomical landmarks and place your stethoscope over these to listen to the heart valves:

 

  • The fifth intercostal space at approximately one cm medial to the mid-clavicular line. This corresponds to the mitral valve.

  • The fourth intercostal space, at the lower left border of the sternum. This corresponds to the tricuspid valve.

  • The second right intercostal space. This corresponds to the aortic valve.

  • The second left intercostal space. This corresponds to the pulmonary valve.

 

The heart is auscultated in the order described above: mitral, tricuspid, aortic and pulmonary valves.

 

Test findings: Positive & negative

 

Heart sounds and their interpretation:

 

  • Sound one (S1): The intensity of the sound is directly related to the contractility of the left ventricle. Therefore an increased sound may be indicative of: mitral valve stenosis, short PR interval (electrocardiography), increased heart rate and contractility.

A reduced S1 may be indicative of mitral valve regurgitation, a long PR interval, reduced heart rate and contractility.

Varying intensity of S1 may be indicative of intermittent heart block.

 

  • Sound two (S2): An abnormally loud S2 is indicative of high blood pressure as the valves are shut forcefully. Physiologically the sound is spilt in inspiration because of the delay in pulmonic valve closure due to increased venous return.

Abnormally increased splitting may be indicative of Right Bundle Branch Block (RBBB) and pulmonic stenosis. A fixed splitting may be a sign of atrial septal defect.

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  • Sound three (S3): A low pitched mid diastolic (heart relaxation) sound. Caused by the abrupt change in wall motion during ventricular filling in diastole. This is normal in children, adolescents, and adults under the age of forty. Otherwise present may be indicative of dilated congestive heart failure.

 

  • Sound four (S4): Appreciated as a late diastolic sound caused by atrial contraction against a stiff ventricle and is usually pathological at any age. Commonly indicative of diastolic dysfunction and hypertrophic cardiomyopathy.

 

Other sounds: heart murmurs are sounds created by turbulent blood flow, which may occur inside or outside the heart. Murmurs can be benign or pathological, with the later often the result of stenosis of a heart valve, valvular insufficiency and/or regurgitation. These are graded from 1 (very faint) to 6 (very loud with thrill).

S4 when audible in an adult is called a presystolic gallop or atrial gallop. This gallop is produced by the sound of blood being forced into a stiff/hypertrophic ventricle.

 

Special considerations:

 

Cardiologists are experts in their fields with years of experience. The detection of subtle sounds by an untrained ear can be extremely difficult. It is advisable to refer when in doubt and/or if any warning signs are detected.

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Special considerations:

 

Another test is to assess the patient’s blood pressure on both arms. A difference of more than 10 mmHg between the two hands is abnormal and may be indicative of an abdominal aortic aneurysm (AAA).

 

Contra-indication: if an AAA is suspected, palpating the aorta should be avoided, as added pressure may further damage or rupture the aorta. Referral to emergencies is required.

Palpation of the abdominal aorta

 

Definition:

 

The use of palpation to determine the approximate width and location of the abdominal aorta.

 

Test procedure:

 

Lay your patient slightly inclined with their knees bent and propped up so as to relax their abdomen. Starting at one side, gently palpate the area between the umbilicus and xiphoid, starting laterally, roughly at the linea semi-lunaris (lateral portion of the rectus abdominus) and moving medially towards the linea alba. Whilst doing so, the practitioner is attentively palpating for the pulsations of the abdominal aorta. Once the pulsations are felt, the practitioner keeps a finger-tip at that point ant repeats the procedure on the other side. The distance between the practitioner’s two finger-tips is than measured.

 

Test findings: Positive & negative

 

The majority of aneurysms are asymptomatic. However, as abdominal aortic aneurysms expand, pain may ensue in the flanks, back and abdomen along with pulsating sensations in the abdomen and/or pain in the chest, lower back and/or scrotum.

As with other pulses, the rate, rhythm and quality of the pulsations of the abdominal aorta are appreciated.

An aneurysm is usually defined as an outer aortic diameter over three cm, with a normal diameter being of approximately two cm. If the outer diameter exceeds five and half cm, the aneurysm is considered to be large.

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Venous flow test

Definition:

 

The venous flow test is a clinical examination performed to evaluate the integrity of the veins, their filling and emptying.

 

Test procedure:

 

Locate a visible vein on your patient’s body and with you indexes indent the middle portion of this vein between two valves than draw your fingers apart from each other in the direction of the valves. Following this, release one index and appreciate the results and repeat the procedure releasing the other index. Various sites can be used over the body, depending on which location you wish to assess.

 

Test findings: Positive & negative:

 

A normal response is for the vein to refill rapidly after releasing index pressure. An abnormal response is for the filling time to be abnormally prolonged or incomplete.

 

Special considerations:

 

This test may reveal valve disorders and/or other vascular pathologies.

Evaluation of pulse

Definition:

 

The clinical use of palpation to obtain a qualitative and quantitative reading of an individual’s pulse.

 

Test procedure:

 

The exact procedure will vary according to the site at which an individual’s pulse is being taken. There are however, certain principles common to all evaluation sites:

  

  • the use of palpation to locate the artery to be assessed.

  • the recording of the number of pulsations per minute.

  • the patient being at rest and free of any stimulants when examined.

  • the screening of the pulse for any pathological signs.

  

Test findings: Positive & negative:

 

Pulse patterns:

 

  • Pulsus bisferiens: uncommon finding typically associated with patients suffering from aortic valve diseases. The practitioner will note two pulses per heart beat as opposed to the normal one beat.

  • Pulsus alternans: indicative of progressive systolic heart failure. The practitioner will note a strong pulse followed by a weak pulse.

  • Pulsus paradoxus: associated with exaggerated decrease in blood pressure during the inhalation phase of respiration, diagnostic of respiratory and cardiac conditions. The practitioner notes that some heartbeats cannot be detected at the radial artery during inspiration.

  • Pulsus bigeminus: the detection of hoof beats and potential gallop rhythm during auscultation. Gallop rhythms may be heard benignly in young athletes but may also be indicative of heart failure and pulmonary oedema especially in adults.

  • Pulsus tardus et parvus: indicative of a loss in compliance in the aortic valve. The practitioner notes a slower than normal rise in the tactile pulse.

  • Tachycardia is the term used to describe an abnormally elevated resting pulse rate.

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An individual’s pulse is also classified according to its strength:

 

  • 0: absent

  • 1: hardly palpable

  • 2: easily palpable

  • 3: full

  • 4: aneurysmal or bounding pulse.

 

Special considerations:

 

The quality and quantity of pulses will only give the practitioner so much information pertaining to an individual’s health and often only offers a rough guide. Further investigations such as ElectroCardioGrams (ECG) are often necessary.