Cardiovascular Examination

Question 1

Components of a physical exam?

Answer 1

Introduction
Inspection
Palpation
Percussion
Auscultation

Question 2

Order of examination?

Answer 2

‘general’ > hands > pulse > neck > face > chest > abdomen > legs

Question 3

Introduction?

Answer 3

1. Ensure adequate hygiene of hands and stethoscope
2. Introduce self and confirm patient’s name
3. Ask if patient is in any discomfort
4. Briefly explain what the examination will involve using patient-friendly language.
5. Seek permission to examine the cardiovascular system (gain Consent)
6. Position patient appropriately with chest adequately exposed (45 degrees, shirt off)

Question 4

Order of inspection?

Answer 4

> Begin with general inspection of the patient
inspect the hands, pulse, BP
work up to the head and neck
finally moving to the chest

Question 5

General inspection?

Answer 5

1. Signs of discomfort / respiratory distress
2. Oxygen

Question 6

Inspection of hands?

Answer 6

1. Warmth / capillary refill
2. peripheral cyanosis
3. Tar/tobacco staining
4. nail clubbing
5. splinter haemorrhages / Janeway lesions / Osler’s nodes
6. Koilonychia/xanthoma (palmar or tendon)

Question 7

What are the signs of endocarditis?

Answer 7

1. splinter haemorrhage
2. Oslers nodes
3. Janeway lesions

Question 8

Palpation (pulses)?

Answer 8

1. Radial
   - Rate
   - Rhythm (Regular / irregular / irregularly irregular)
   - Blood pressure
2. Carotid:
   - volume Character

Question 9

What is jugular venous pressure exam?

Answer 9

aspect of assessing a patients volume status especially in patients with heart failure, liver failure and kidney failure

Question 10

How to measure the jugular venous

Answer 10

by assessing the vertical distance between the sternal angle and the top of the pulsation point of IJV
- in healthy individuals this should be no greater than 3 cm
Note:
- with patient at 45 degrees
- located between 2 heads of SCM
- raised right heart failure

Question 11

Inspection of the face?

Answer 11

1. malar flush
2. Pallor
3. xanthelasmata
4. corneal arcus
5. central cyanosis

Question 12

Malar flush?

Answer 12

a plum red discolouration of the high cheeks
- associated with mitral valve stenosis due to the resulting CO2 retention and its vasodilatory effects

Question 13

Pallor/anemia?

Answer 13

pale palmar creases
- sign of anemia

Question 14

Xanthelasma?

Answer 14

yellow bump on or near your eyelid skin
- a type of xanthoma or cholesterol deposit
NB: sign of hyperlipidemia

Question 15

Corneal arcus?

Answer 15

blue or white crescent shape (arc) made of lipid (fatty deposits) that curves around the outer edges of the cornea of the eye

Question 15

Corneal arcus?

Answer 15

blue or white crescent shape (arc) made of lipid (fatty deposits) that curves around the outer edges of the cornea of the eye

Question 16

Inspection of the preacordium?

Answer 16

1. Scars
2. Shape (bulge on left side of chest due to cardiac enlargement
3. Visible apex
4. Other pulsations

Question 17

What are scars indicative of?

Answer 17

suggestive of previous thoracic surgery

Question 18

What is the shape indicative of?

Answer 18

1. Pectus excavatum:a caved-in or sunken appearance of the chest.
2. Pectus carinatum:protrusion of the sternum and ribs

Question 19

What is a visible apex indicative of?

Answer 19

Visible pulsations:a forceful apex beat may be visible secondary to underlying ventricular hypertrophy

Question 20

Name and describe thoracic scars?

Answer 20

1. Median sternotomy scar
   - located in the midline of the thorax
   - cardiac valve replacement and coronary artery bypass grafts (CABG).
2. Anterolateral thoracotomy scar
   -located between the lateral border of the sternum and the mid-axillary line at the 4thor 5thintercostal space
   - minimally invasive cardiac valve surgery.
3. Infraclavicular scar
   -located in the infraclavicular region (on either side)
   -pacemaker insertion.
4. Left mid-axillary scar
   - insertion of a subcutaneous implantable cardioverter-defibrillator (ICD).

Question 21

What to look out for on palpation?

Answer 21

the location of theapex beatand to identifyheavesorthrills.

Question 22

Apex beat?

Answer 22

• Most lateral and inferior place you can detect a cardiac impulse
• A sign of cardiac enlargement
• Measure rib space from sternal angle
• Mention site in relation to clavicular / axillary lines

Question 23

What are Heaves?

Answer 23

An impulse along the left sternal edge lifting the hand

Question 24

How to palpate for heaves?

Answer 24

A parasternal heave is a precordial impulse that can be palpated. 1. Place the heel of your hand parallel to the left sternal edge (fingers vertical) to palpate for heaves. 2. If heaves are present you should feel the heel of your hand being lifted with each systole. Note: Parasternal heaves are typically associated with right ventricular hypertrophy.

Question 25

What are thrills?

Answer 25

palpable murmurs

Question 26

How do you palpate for thrills?

Answer 26

a thrill is a palpable vibration caused by turbulent blood flow through a heart valve (a thrill is a palpable murmur). 1. You should assess for a thrill across each of the heart valves in turn 2. To do this place your hand horizontally across the chest wall, with the flats of your fingers and palm over the valve to be assessed.

Question 27

What to listen for in auscultation of heart sounds?

Answer 27

1st and 2nd sounds Added sounds (3rd and 4th, clicks) Murmurs (turbulent flow) Use diaphragm and bell in all 4 areas

Question 28

How to distinguish between heart sounds in auscultation?

Answer 28

Use carotid pulse to distinguish 1st and 2nd heart sounds and to ‘time’ murmurs: - Palpable pulse implse = systole

Question 29

Sites for auscultation?

Answer 29

1. mitral/apex area - 5th intercostal space, ICS, mid clavicular line 2. tricuspid area - 4th left ICSs, at the left sternal edge, LSE 3. pulmonary area - 2nd left ICS lateral to sternum, LSE 4. aortic area - 2nd right ICS lateral to sternum

Question 30

Describe different kinds of murmurs?

Question 31

Describe manoueuvres to accentuate murmurs?

Answer 31

1. Roll on left side: - Listen for diastolic murmur of Mitral Stenosis with the bell - Listen for axillary radiation of mitral regurgitation 2. Sit forward / breathe out: - Listen for diastolic murmur of aortic regurgitation

Question 32

Bell vs diaphragm in a stethoscope?

Answer 32

1. The bell of the stethoscope is more effective at detecting low-frequency sounds, including the mid-diastolic murmur of mitral stenosis. 2. The diaphragm of the stethoscope is more effective at detecting high-frequency sounds, including: - the ejection systolic murmur of aortic stenosis - the early diastolic murmur of aortic regurgitation - the pansystolic murmur of mitral regurgitation

Question 33

What else to listen to on auscultation besides heart sounds?

Answer 33

1. The neck (carotids) 2. The back (crackles of pulmonary oedema)

Question 34

What to look for on palpation?

Answer 34

1. Sacral oedema - Inspect and palpate the sacrum for evidence of pitting oedema. 2. Hepatomegaly 3. Leg warmth / discoloration of poor perfusion 4. Leg pulses (radio-femoral delay) 5. Leg oedema - Inspect and palpate the patient’s ankles for evidence of pitting pedal oedema (associated with right ventricular failure). 6. BP (if not done already)

Question 35

Examination of the posterior aspect?

Answer 35

1. Inspect the posterior chest wall for any deformities or scars (e.g. posterolateral thoracotomy scar associated with previous lung surgery). 2. Auscultate the lung fields posteriorly - Coarse crackles are suggestive of pulmonary oedema (associated with left ventricular failure) - Absent air entry and stony dullness on percussion are suggestive of an underlying pleural effusion (associated with left ventricular failure).

Question 36

To complete the examination?

Answer 36

Explain to the patient that the examination is now finished. Thank the patient for their time. Dispose of PPE appropriately and wash your hands. Summarise your findings.

Question 37

Further assessments and investigations?

Answer 37

Measure blood pressure: to identify hypotension, hypertension or significant discrepancies between the two arms suggestive of aortic dissection. Peripheral vascular examination: to identify peripheral vascular disease, which is common in patients with central cardiovascular pathology. Record a 12-lead ECG: to look for evidence of arrhythmias or myocardial ischaemia. Dipstick urine: to identify proteinuria or haematuria which can be associated with hypertension. Bedside capillary blood glucose: to look for evidence of underlying diabetes mellitus, a significant risk factor for cardiovascular disease. Perform fundoscopy: if there were concerns about malignant hypertension, fundoscopy would be performed to look for papilloedema.