Cardiovascular examination

Question 1

Initial observation

Answer 1

• DON PPE
• patient: conscious, cyanosis, SOB, pallor (anaemia), malar flush, cough.
• Equipment: medications, inhalers, nebulisers, oxygen, sputum pot (LOOK INSIDE), NEWS CHART, ECG leads, multiple pillows (heart failure - orthopnoea), physical walking aids, IV access, GTN spray, catheters.

Question 2

Introduction

Answer 2

• introduce yourself
• ask patient name and DOB - THEN check wrist band
• explain examination
• gain consent - MUST BE VERBAL
• ask if they are in any pain
• 45degree bed
• ask patient to remove necessary clothing and COVER with bed linen

Question 3

Hands

Answer 3

examination:
- colour (blue - cyanosis, white - poor perfusion)
- tar staining (sign of smoking)
- xanthomata - high cholesterol (yellow, cholesterol rich deposits on palms)

palpation:

• capillary refill (hold for 5, should refit in 2)
• warmth of hands - compare BOTH (cool - poor peripheral perfusion, sweaty/clammy - acute coronary syndrome)
• finger clubbing - congenital heart disease, infective endocarditis (increased fluctuation of nail bed, loss of ail bed angle, increase in longitudinal nail curvature, increased bulk of soft tissue over the terminal phalanges)
• splinter haemorrhages (endocarditis)
• koilonychia - iron deficiency anaemia (spooning)

tremor:
- fine tremor
- flapping tremor (15 secs) - CO2 retention

Radial pulse and respiratory rate:
- rate (60-100), rhythm (regular, irregularly irregular (AF) regularly irregular, volume (normal, bounding, thready, low volume), character (normal, slow rising, collapsing)

• test for collapsing pulse (pull hand up above the level of the heart whilst feeling the pulse)

Arms: track marks, bruises, scars

Question 4

Head

Answer 4

face:
malar flush - mitral stenosis (CO2 retention)

eyes:

• conjunctivae (white = anaemia)
• xanthelasmata on eyelids (high cholesterol)
• corneal Marcus

Tongue/lips:

• central cyanosis - discolouration of lips and under tongue
• angular stomatitis (iron deficiency anaemia)
• TONSILS (not right now with covid)

Question 5

Chest

Answer 5

Lung bases - crackles (left sided heart failure)

bed bound patients - sacral oedema (press over sacral area)

Question 6

JVP

Answer 6

Jugular vein connects to the right atrium without any connecting valves - so it gives an indirect measure of central venous pressure.

• patient lying at 45 degrees
• patients head turned to LEFT
• IJV sits in medial aspect of sternocleidomastoid - in between the sternal and clavicular heads
• movement will usually be seen more clearly LATERAL to the SCM
• IJV should be behind the sternocleidomastoid more laterally.
• it looks like its flickering rather than pulsing.
• IJV will NOT have a pulse, carotid artery WILL.

JVP normally = <4cm above sternal angle.

Distention of IJV - increase in right atrial pressure (right sided heart failure) or constrictive pericarditis.

Question 7

Precordium

Answer 7

Examination:
Pectus excavatum
Pectus carinatum, 
scars (infraclavicular - pacemaker, median sternotomy - CABG)
kyphoscoliosis, 
pacemaker. 

Palpation:

• pacemaker (infraclavicular area) -CHECK LEFT AND RIGHT SIDES
• tracheal position
• apex beat
• heaves - parasternal heave (right ventricular hypertrophy) - press flat of hand firmly to L of sternum, will feel hand easily lifted on systole
• Thrills - palpable vibration caused by turbulent blood flow (check all 4 valve areas)

Auscultation:

• CHECK CAROTID PULSE AT SAME TIME
• check all 4 valve areas - with diaphragm then bell
• listen for S1 and S2
• carotid pulse should be heart at the same time as S1
• s1 = systole (mitral and tricuspid valves closing)
• s2= diastole (aortic and pulmonary valves closing)
• listen for snaps or clicks - valve replacement mechanical or pigs
• listen for murmurs between S1 and S2 (systolic) and s2 and s1 (diastolic)

Systolic murmurs:

• aortic stenosis - listen to aortic valve area again then listen to both carotid arteries (using diaphragm) for high pitched systolic murmur
• mitral regurgitation - listen to apex beat with diaphragm for pan systolic murmur

Diastolic murmurs: breath should be held in expiration because these are harder to hear

• mitral stenosis - ask patient to roll onto left side and listen at apex will BELL for low pitched rumbling of murmur
• Aortic regurgitation - patient sits up leaning forwards, listen to lower left sternal edge with diaphragm for high pitched early diastolic murmur.

Question 8

legs

Answer 8

Pitting oedema - apply pressure to ankle (If oedema is present then you need to work your way up the shin until it stops.

• ischaemia - cold, hairless, leg ulcers, gangrene
• varicose veins with PATIENT STANDING

Question 9

Pulses

Answer 9

• radial (feel BOTH at same time)
  -brachial
  -carotid
  -femoral
• radio-femoral delay
  -popliteal
  =posterior tibial
• dorsalis pedis
• auscultate - femoral and carotid artery (for bruits)