CV exam

Question 1

Hand inspection

Answer 1

Splinter haemorrhages: Infective endocarditis
Clubbing: Congenital cyanotic heart disease, late infective endocarditis
Capillary return: Within 2 seconds, dehydration or peripheral vascular disease
Peripheral cyanosis: Not reliable, central more important
Nicotine staining
Asterixis: CO2 retention

Question 2

Radial pulse assessment

Answer 2

Bradycardia: B blockers, hypothyroidism, heart block, being fit!
Tachycardia: Anxiety, exercise, pyrexia, hyperthyroidism, B2-agonist, arrhythmia, hypovolaemic shock
Rhythm: Heart speeds up in inspiration and slows in expiration (sinus arrhythmia, noticeable -40)
Irregularly irregular: AF, ventricular ectopic beats (disappear on exercise)
Regularly irregular: 2nd degree heart block
Pulse deficit: Measured in AF, difference between the HR and the pulse rate
Palpate both pulses: Aortic dissection, proximal artery disease of axillary artery (can occur after angiography)
Radio-femoral delay: Co-arctation of aorta, say you’d check if there was hypertension and murmur over left sternal edge/ scapula
Collapsing pulse: Aortic regurgitation

Question 3

Face inspection

Answer 3

Malar flush: Mitral stenosis (dilation of cheek capillaries secondary to pulmonary hypertension)
Xanthelasma and corneal arcus: hyperlipidaemia (under 50 in corneal arcus)
Anaemia
Central cyanosis: pulmonary oedema (ischemia, MI, heart failure, valve defects)
Dental hygiene: Common route for bacterial endocarditis

Question 4

Carotid pulse examination

Answer 4

Pulse character: power, how quickly the power is achieved
Slow rising then plateau: Aortic stenosis
Waterhammer, fast collapsing: Aortic regurgitation
Bissfiriens pulse (double impulse): Mixed aortic valve disease

Question 5

JVP examination

Answer 5

Tell difference between carotid and JVP: Occlude, palpate, double waveform, hepatojugular reflex
Right heart failure: ischaemic disease, mitral valve defects
Fluid overload
Tricupsid regurgitation: JVP reflects right venous pressure not right atrial pressure so causes massive V wave on the waveform
Complete heart block
Superior vena caval obstruction: elevated without pulsation, hepatojugular reflex is negative, usually mediastinal lymphadenopathy due to lung cancer
Atrial fibrillation: JVP wave has no wave
Raised JVP can cause a waggling ear lobe

Question 6

Chest inspection

Answer 6

Midline scar: sternotomy scar, previous valve replacement or by-pass surgery
Scar down leg: By pass surgery
Left axilla diagonally down the back: Thoracotomy scar
Chest deformities: Pectus excavatum, pectus carinatum, kyphosis, scoliosis, can cause a non clinically relevant displaced apex beat

Question 7

Apex beat and thrills

Answer 7

Check character and placement
Mitral stenosis: Apex beat is “tapping”
Aortic stenosis: Beat is sustained and heavy, displaced downwards and outwards
Mitral+aortic regurgitation: Displaced down and out due to LV hypertrophy
LV dilation: Heart failure, displaced down and out, pulsation will be very diffuse
Can’t palpate: emphysema, pericadial effusion, dextrocardia, obesity
Thrills: Rare, most common is aortic stenosis

Question 8

Peripheral oedema

Answer 8

Commonly caused by heart failure
Postural oedema due to incompetent venous valves
Check pitting to rule out lymphoedema

Question 9

Peripheral pulses

Answer 9

Check for peripheral vascular disease

Acute (thrombus) or chronic (atherosclerosis)