What is involved in a cardio physical examination and what are the potential findings?

Cardiovascular Physical Examination: Components and Findings

A comprehensive cardiovascular physical examination should systematically assess vital signs, cardiovascular system, peripheral vessels, and signs of hemodynamic compromise to identify precipitating causes of myocardial ischemia, comorbid conditions, and life-threatening alternative diagnoses. 1

Essential Vital Signs Measurement

Measure blood pressure in both arms (if aortic dissection is suspected), heart rate, respiratory rate, temperature, and oxygen saturation at the start of every cardiovascular examination. 1 Unequal blood pressures between arms or unequal pulses suggest aortic dissection, which presents with pain radiating to the back and carries significant mortality risk. 1

Cardiovascular System Examination

Heart Sounds and Murmurs

• Listen for an S3 gallop, which indicates left ventricular dysfunction and identifies patients at high risk of severe underlying coronary artery disease and poor outcomes. 1
• Detect a fourth heart sound (S4), which may appear during anginal episodes and disappear when symptoms resolve—this requires careful auscultation technique. 2
• Identify murmurs of acute mitral regurgitation, as these patients have higher likelihood of severe coronary disease and elevated mortality risk. 1
• Auscultate for a murmur of aortic regurgitation, which suggests aortic dissection when combined with back pain and pulse deficits. 1
• Listen for a pericardial friction rub, which is diagnostic of acute pericarditis—a biphasic sound indicating pleural inflammation. 1, 3

Precordial Examination

• Palpate for abnormal precordial pulsations that may develop during ischemic episodes and subsequently disappear. 2
• Assess for chest wall tenderness, though 7% of patients with reproducible chest wall pain still have acute coronary syndrome, so this finding does not exclude cardiac pathology. 3

Pulse Assessment

• Check for pulsus alternans (alternating strong and weak pulses), which may accompany angina pectoris. 2
• Detect pulsus bigeminus (coupled beats), another hemodynamic abnormality that can occur during anginal attacks. 2
• Measure pulsus paradoxus (>10 mmHg drop in systolic pressure during inspiration), which indicates cardiac tamponade. 1

Peripheral Vascular Examination

Examine peripheral vessels for bruits or pulse deficits, as these findings suggest extracardiac vascular disease and identify patients with higher likelihood of significant coronary artery disease. 1 The presence of peripheral arterial disease has 97% specificity for acute coronary syndrome (likelihood ratio 2.7). 4

Pulmonary Examination

Lung Auscultation

• Listen for rales (crackles), which indicate left ventricular dysfunction and pulmonary edema—these patients are at high risk of poor outcomes. 1
• Assess for unilateral decreased or absent breath sounds with hyperresonant percussion, which suggests pneumothorax (the classic triad includes dyspnea, pleuritic pain, and these findings). 1, 3
• Detect differential breath sounds, which when combined with acute dyspnea and pleuritic chest pain indicate pneumothorax. 1
• Listen for regional dullness to percussion and egophony, which suggest pneumonia when combined with fever and productive cough. 3

Identifying Precipitating Causes

Screen for conditions that increase myocardial oxygen demand or decrease oxygen delivery:

• Uncontrolled hypertension—measure blood pressure to identify this reversible precipitant. 1
• Thyrotoxicosis—assess for tachycardia, tremor, and thyroid enlargement. 1
• Anemia from gastrointestinal bleeding—look for pallor and obtain hemoglobin/hematocrit. 1
• Fever—measure temperature to identify infectious causes like pneumonia or pericarditis. 1

Critical Life-Threatening Diagnoses

Aortic Dissection

Look for the triad: back pain, unequal pulses between extremities, and murmur of aortic regurgitation. 1 This diagnosis carries significant mortality if missed and requires immediate recognition.

Cardiogenic Shock

Identify hypotension with evidence of organ hypoperfusion, which occurs in up to 5% of non-ST-elevation myocardial infarction patients with mortality rates exceeding 60%—this constitutes a medical emergency. 1

Cardiac Tamponade

Detect pulsus paradoxus combined with elevated jugular venous pressure and muffled heart sounds (Beck's triad). 1

Pneumothorax

Recognize acute dyspnea, pleuritic chest pain, unilateral absent breath sounds, and hyperresonance to percussion. 1

Assessment of Hemodynamic Impact

Evaluate for signs of hemodynamic instability:

• Tachycardia and tachypnea (present in >90% of pulmonary embolism cases) 3
• Hypotension suggesting cardiogenic shock or massive pulmonary embolism 1
• Signs of poor perfusion (cool extremities, delayed capillary refill, altered mental status) 1

Comorbidity Assessment

Identify comorbid conditions that impact therapeutic decision-making:

• Pulmonary disease—assess respiratory pattern, use of accessory muscles, wheezing 1
• Malignancies—note cachexia, lymphadenopathy 1
• Valvular heart disease—auscultate for systolic murmurs suggesting valve insufficiency 1
• Hypertrophic cardiomyopathy—listen for systolic murmur that increases with Valsalva 1

Common Pitfalls to Avoid

• Do not assume chest wall tenderness excludes cardiac disease—7% of patients with reproducible tenderness have acute coronary syndrome. 3
• Do not rely on a single normal examination—hemodynamic abnormalities during angina (elevated blood pressure, S4 gallop, abnormal precordial pulsations) may disappear when symptoms resolve. 2
• Do not dismiss atypical presentations—physical examination is often completely normal in acute coronary syndrome, particularly in younger patients, elderly patients, women, and diabetics. 1
• Do not overlook the jugular venous pulse—this provides valuable assessment of central venous pressure and right heart function. 5