Cardiovascular examination

Question 1

How would you begin the examination?

Answer 1

Wash hands and don PPE
Introduce self (name and role)
Identify patient (name and DOB)
Explain examination and gain consent
Ask if patient has any pain
Move head of bed to 45 degrees
Expose chest and ankles (offer blanket)

Question 2

What would you look for on general observation?

Answer 2

Patient: Cyanosis, Pallor, Oedema, SOB, malar flush
Environment: Oxygen, Mobility aids, Medications, Vital signs, ECG leads, pillows, fluid balance

Question 3

What would you look for on inspection of the hands?

Answer 3

Colour
Xanthomata
Tar staining
Clubbing
Arachnodactyly
Splinter haemorrhages
Osler's nodes
Janeway lesions

Question 4

What would you palpate on the hands?

Answer 4

Temperature
Capillary refill
Radial pulse - rate, rhythm, character
Radio-radial delay
Collapsing pulse

Question 5

What are some causes of radio-radial delay?

Answer 5

Subclavian stenosis
Aortic dissection
Aortic coarctation

Question 6

What are the causes of collapsing pulse?

Answer 6

Normal state (fever, pregnancy)
Cardiac lesions (aortic regurgitation, PDA)
High output states (anaemia, arteriovenous fistula, thyrotoxicosis)

Question 7

What would you examine involving the arms?

Answer 7

Brachial pulse - volume, character

Blood pressure - both arms, lying + standing

Question 8

What would you examine on the neck?

Answer 8

Carotid bruits
If no bruits, palpate carotid pulse
JVP
Hepatojugular reflex if JVP at least 3m from angle of mandible. Measure JVP distance from sternal angle

Question 9

How would you assess for carotid bruits? What does the presence of a bruit suggest?

Answer 9

Place diaphragm between anterior angle of sternocleidomastoid and larynx. Ask patient to hold breath and listen for sounds
Bruit suggests carotid stenosis
But could be radiation of aortic stenosis murmur

Question 10

What indicates a raised JVP and what could cause this?

Answer 10

Raised JVP = >3cm between sternal angle and top of double wave JVP pulsation
Causes: tricuspid regurgitation, Right heart failure, constrictive pericarditis

Question 11

How do you elicit a hepatojugular reflex? What indicates a positive reflex?

Answer 11

Do if baseline JVP is at least 3cm from angle of mandible
Exert pressure on liver (uncomfortable for patient so warn them)
Watch JVP rise - normally will return to normal after 1-2 cardiac cycles
Positive reflex: Sustained rise >4cm

Question 12

What causes a positive hepatojugular reflex?

Answer 12

Inability for ventricles to cope with increased venous return

• constrictive pericarditis
• RV failure, LV failure
• Restrictive cardiomyopathy

Question 13

What signs of cardiovascular disesase can you look for in the eyes?

Answer 13

Conjunctival pallor (anaemia)
Corneal arcus (hypercholesterolaemia)
Xanthelasma (hypercholesterolaemia)
Kayser-Fleischer rings (Wilson disease)

Question 14

What signs of cardiovascular disease can you look for in the mouth?

Answer 14

Cyanosis (lips, tongue)
Angular stomatitis
High arched palate (Marfan’s)
Dental hygiene

Question 15

What can you inspect for on the chest?

Answer 15

Scars
Pectus excavatum
Pectus carinatum
Visible pulsations (ventricular hypertrophy)

Question 16

What do you palpate on the chest?

Answer 16

Apex beat (mid-clavicular line, 5th intercostal space)
Parasternal heaves (RV hypertrophy)
Thrills (over valve landmarks)

Question 17

Where are the locations for palpating/auscultating over valves?

Answer 17

Mitral valve = mid-clavicular, 5th intercostal
Tricuspid = left sternal edge, 4th/5th intercostal
Pulmonary = left sternal edge, 2nd intercostal
Aortic = right sternal edge, 2nd intercostal

Question 18

What accentuation manoeuvre can you do for auscultating aortic stenosis?

Answer 18

Auscultate carotid artery with diaphragm of stethoscope and patient holding breath
= ejection systolic murmur

Question 19

What accentuation manoeuvre can you do for aortic regurgitation?

Answer 19

Auscultate with diaphragm over aortic valve (right sternal edge, 2nd intercostal).
Ask patient to sit forward
On expiration will hear early diastolic murmur

Question 20

What accentuation manoeuvre can you do for mitral regurgitation?

Answer 20

Ask patient to lie on left side
Auscultate with diaphragm over mitral valve (mid-clavicular, 5th intercostal)
On expiration will hear pansystolic murmur
Continue auscultating into axilla to find radiation

Question 21

What accentuation manoeuvre can you do for mitral stenosis?

Answer 21

Ask patient to lie on left side
Auscultate with BELL over mitral valve (mid-clavicular, 5th intercostal)
On expiration will hear mid-diastolic murmur

Question 22

When would you use bell vs diaphragm for auscultation?

Answer 22

Bell is for low frequency sounds e.g. mitral stenosis mid-diastolic murmur
Diaphragm is for high frequency sounds e.g. aortic stenosis, regurgitation, mitral regurgitation

Question 23

What would you examine on the back of the patient?

Answer 23

General inspection - scars, deformities
Auscultate lung field posteriorly
Percuss lung fields
Palpate for sacral oedema

Question 24

What would you examine on the legs of the patient?

Answer 24

Ankles for pitting oedema

Check for evidence of saphenous vein harvesting used in CABG

Question 25

How would you complete the examination?

Answer 25

Thank the patient and explain examination is finished
Tell them they can get dressed
Remove PPE and wash hands
Summarise findings
To complete: blood pressure (both arms, lying+standing), hepatojugular reflex (if not already done), fundoscopy, urinalysis (protein/haematuria), blood glucose, ECG, peripheral vascular examination (femoral pulses)

Question 26

What are the signs of infective endocarditis to look for on inspection?

Answer 26

Hands: splinter haemorrhages, osler’s nodes, janeway lesions
Mouth: poor dental hygiene
Peripheral scars, venous insufficiency (IVDU?)

Question 27

What are the peripheral signs to look for in CVD examination that suggest Marfan’s syndrome?
What are the CVD risks with Marfan’s?

Answer 27

Signs: Arachnondactyly, long limbs, pectus excavatum/carinatum, high-arched palate
Risks: Aneurysms, dissections, mitral/aortic prolapse