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A doctor first asks about symptoms. Chest pain, shortness of breath, palpitations, and swelling in the legs, ankles, and feet or abdomen suggest a heart disorder. Other, more general symptoms, such as fever, weakness, fatigue, lack of appetite, and a general feeling of illness or discomfort (malaise), may suggest a heart disorder. Pain, numbness, or muscle cramps in a leg may suggest peripheral arterial disease, which affects the arteries of the arms, legs, and trunk (except those supplying the heart).
Next, the doctor asks about past infections; previous exposure to chemicals; use of drugs, alcohol, and tobacco; home and work environments; and recreational activity. The doctor also asks whether family members have had a heart disorder or any other disorders that may affect the heart or blood vessels.
During the physical examination, the doctor notes the person's weight and overall appearance and looks for paleness (pallor), sweating, or drowsiness, which may be subtle indicators of heart disorders. The person's general mood and feeling of well-being, which also may be affected by heart disorders, are noted.
Assessing skin color is important because pallor or a bluish or purplish coloration (cyanosis) may indicate anemia or inadequate blood flow. These findings may indicate that the skin is not receiving enough oxygen from the blood because of a lung disorder, heart failure, or various circulatory problems.
The doctor feels the pulse in arteries in the neck, beneath the arms, at the elbows and wrists, in the abdomen, in the groin, at the knees, and in the ankles and feet to assess whether blood flow is adequate and equal on both sides of the body. The blood pressure and body temperature are also checked. An abnormality may suggest a heart or blood vessel disorder.
The doctor inspects the veins in the neck while the person is lying down with the upper part of the body elevated at a 45° angle. These veins are inspected because they are directly connected to the right atrium (the upper chamber of the heart that receives oxygen-depleted blood from the body) and thus give an indication of the volume and pressure of blood entering the right side of the heart.
The doctor presses the skin over the ankles and legs and sometimes over the lower back to check for fluid accumulation (edema) in the tissues beneath the skin.
An ophthalmoscope (see What Is an Ophthalmoscope? ) is used to view the blood vessels of the retina (the light-sensitive membrane on the inner surface of the back of the eye). The retina is the only place a doctor can directly view veins and arteries. Visible abnormalities in the retina are common among people with high blood pressure, diabetes, arteriosclerosis, and bacterial infections of the heart valves.
The doctor observes the chest to determine whether the breathing rate and movements are normal. By tapping (percussing) the chest with the fingers, the doctor can determine if the lungs are filled with air, which is normal, or if they contain fluid, which is abnormal. Percussion also helps determine whether the sac that envelops the heart (pericardium) or the layers of membranes covering the lungs (pleura) contain fluid. Using a stethoscope, the doctor also listens to the breathing sounds to determine whether airflow is normal or obstructed and whether the lungs contain fluid as a result of heart failure.
By placing a hand on the person's chest, the doctor can feel (palpate) where the heartbeat is strongest and thus determine heart size. The quality and force of contractions during each heartbeat can also be determined. Sometimes abnormal, turbulent blood flow within vessels or between heart chambers causes a vibration (called a thrill) that can be felt with the fingertips or palm.
By listening to (auscultating) the heart with a stethoscope, the doctor can hear the distinctive sounds caused by the opening and closing of the heart valves. Abnormalities of the valves and heart structures create turbulent blood flow that causes characteristic sounds called murmurs. Turbulent blood flow typically occurs as blood moves through narrowed or leaking valves. However, not all heart disorders cause murmurs, and not all murmurs indicate a heart disorder. For example, pregnant women usually have heart murmurs because of a normal increase in blood flow. Harmless heart murmurs also are common among infants and children because of the rapid flow of blood through their heart's smaller structure. As blood vessel walls, valves, and other tissues gradually stiffen in older people, blood may flow turbulently, even when no serious heart disorder is present. Also, the doctor may hear clicks and opening snaps when an abnormal valve opens. A gallop rhythm (a sound resembling that of a galloping horse), due to one or two extra heart sounds, is often heard in people who have heart failure.
By placing the stethoscope over arteries and veins elsewhere in the body, the doctor can listen for sounds of turbulent blood flow (bruits). Bruits may be caused by narrowing of blood vessels, increased blood flow, or an abnormal connection between an artery and a vein (arteriovenous fistula).
The doctor feels the abdomen to determine if the liver is enlarged. Enlargement may indicate that blood is pooled in the major veins leading to the heart. Swelling of the abdomen due to fluid accumulation may indicate heart failure. By pressing gently on the abdomen, the doctor checks the pulse and determines the width of the abdominal aorta.
Last full review/revision April 2006 by Paul H. Tanser, MD
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