Cardiovascular System Examination, Evaluation, and Clinical Decision-Making
Cardiovascular evaluation
Start with a focused history: chest discomfort, dyspnea, palpitations, syncope, edema, claudication, and functional change. Quantify with NYHA or Canadian Cardiovascular Society class. Identify risk factors and red flags-pain at rest, diaphoresis, syncope with exertion, unexplained weight gain, orthopnea, or a new murmur-that change urgency.
Physical examination is a sequence, not a single maneuver. Inspect for distress, jugular venous distension, and edema. Palpate pulses and the precordium. Auscultate for S1, S2, S3, S4, murmurs, and rubs; note timing, location, radiation, and dynamic maneuvers. Measure blood pressure correctly: seated, rested, proper cuff size, both arms initially. A pulse deficit suggests atrial fibrillation. Edema has many causes, including venous insufficiency and medications, so do not anchor on heart failure.
Clinical decision-making
Combine findings into syndromes rather than isolated signs. Exertional dyspnea plus elevated JVP, an S3, and bibasilar crackles supports decompensated heart failure. Unilateral crackles, fever, and pleuritic pain suggest pneumonia. A systolic murmur radiating to the carotids suggests aortic stenosis; exertional syncope in that setting is a warning sign. Atypical presentations are common in older adults, women, and people with diabetes.
Worked example. A 68-year-old with hypertension reports two weeks of exertional dyspnea and orthopnea. JVP is elevated, an S3 is audible, and crackles are bilateral. This constellation supports heart failure; a single finding would not. Rule of thumb: one sign is a data point; a constellation plus risk factors is a syndrome. Reassess after treatment and document the response.