Cardiovascular Examination

Question 1

Cardiovascular Exam

What are the key steps in the introduction phase of the Cardiovascular Examination, and why is it important to wash your hands and clean the stethoscope?

Answer 1

Introduce yourself, confirm patient identity, explain the procedure, obtain informed consent, offer a chaperone, expose/position the patient, and wash hands/clean stethoscope to ensure hygiene.

Question 2

What aspects are observed during the general inspection from the end of the bed in the Cardiovascular Examination?

Answer 2

Observe the patient’s alertness, comfort, color, signs of breathlessness, and check for mechanical ticking. Assess the environment for oxygen, medications (especially GTN), and relevant observations on the drug chart or Yellow book.

Question 3

Cardiovascular Examination

What are the components of the peripheral examination, and what signs are assessed in the hands and arms?

Answer 3

Components include assessing pulse, tar staining, bruising, capillary refill, peripheral cyanosis, and clubbing. Evaluate blood pressure, scars, and bruising in the arms.

Question 4

Cardiovascular Examination

What steps are involved in inspecting the praecordium during the Cardiovascular Examination?

Answer 4

Inspect for scars (e.g., sternotomy/pacemaker), observe the apex, and palpate for heaves and thrills.

Question 5

Cardiovascular Examination

What are the key descriptors to consider when assessing murmurs during the Cardiovascular Examination?

Answer 5

Consider position in the cardiac cycle, character, duration, shape, pitch, quality, location, radiation, relationship to breathing, position, and intensity. Use a grading scale for systolic murmurs.

Question 6

Cardiovascular Examination

How do you conclude the Cardiovascular Examination, and why is it important to explain the next steps to the patient or summarize findings to the supervisor?

Answer 6

Thank the patient, ensure comfort, wash hands, and explain the next steps or summarize findings for effective communication and patient understanding.

Question 7

Cardiovascular Examination

When differentiating between Aortic Stenosis and Mitral Regurgitation murmurs, what descriptors would you focus on?

Answer 7

Focus on position in the cardiac cycle, character, location, radiation, and intensity to distinguish between Aortic Stenosis and Mitral Regurgitation murmurs.

Question 8

Cardiovascular Exam

What are Normal Heart Sounds

Answer 8

S1 and S2.

S1 is caused by the closing of atrioventricular valves at the beginning of systole;

S2 is caused by the closing of aortic and pulmonary valves closing at the beginning of diastole

Question 9

Cardiovascular Examination

Identify the sound

Answer 9

Aortic Stenosis

Question 10

Cardiovascular Examination

Identify the sound

Answer 10

Aortic Regurgitation

Question 11

Cardiovascular Examination

Identify the sound

Answer 11

Mitral Regurgitation

Question 12

Cardiovascular Examination

Heaves

Answer 12

• Place the heel of your hand parallel to the left sternal edge (fingers vertical) to palpate for heaves.
• If heaves are present you should feel the heel of your hand being lifted with each systole.
• Parasternal heaves are typically associated with right ventricular hypertrophy.

Question 13

Cardiovascular Examination

Thrills

Answer 13

• palpable vibration caused by turbulent blood flow through a heart valve (a thrill is a palpable murmur).
• You should assess for a thrill across each of the heart valves in turn (see valve locations below).
• 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 14

Cardiovascular Examination

How do you Auscultate the four valves?

Answer 14

• Palpate the carotid pulse to determine the first heart sound.

Auscultate through the valve areas using the diaphragm of the stethoscope whilst continuing to palpate the carotid pulse:

Mitral valve: 5th intercostal space in the midclavicular line.

Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge.

Pulmonary valve: 2nd intercostal space at the left sternal edge.

Aortic valve: 2nd intercostal space at the right sternal edge.

Repeat auscultation across the four valves with the bell of the stethoscope.

(I’ve done this backwards start aortic)

Question 15

Cardiovascular Examination

What is an Accentuation manoeuvre?

Answer 15

To amplify sounds such as ejection systolic murmur and early diastolic murmur

Question 16

Cardiovascular manoeuvres

How to find an ejection systolic murmur caused by aortic stenosis.

Answer 16

Auscultate the carotid arteries using the diaphragm of the stethoscope whilst the patient holds their breath to listen for radiation of an ejection systolic murmur caused by aortic stenosis.

Question 17

Cardiovascular examinaiton

How to find early diastolic murmur caused by aortic regurgitation?

Answer 17

Sit the patient forwards and auscultate over the aortic area with the diaphragm of the stethoscope during expiration to listen for an early diastolic murmur caused by aortic regurgitation.

Question 18

Cardiovascular examination

How to find a pansystolic murmur caused by mitral regurgitation?

Answer 18

Roll the patient onto their left side and listen over the mitral area with the diaphragm of the stethoscope during expiration to listen for a pansystolic murmur caused by mitral regurgitation. Continue to auscultate into the axilla to identify radiation of this murmur.

Question 19

Cardiovascular examination

How to find a mid-diastolic murmur caused by mitral stenosis.

Answer 19

With the patient still on their left side, listen again over the mitral area using the bell of the stethoscope during expiration for a mid-diastolic murmur caused by mitral stenosis.

Question 20

Cardiovascular Examination

Why are we using Bell vs Diaphragm?

Answer 20

The bell of the stethoscope is more effective at detecting low-frequency sounds, including the mid-diastolic murmur of mitral stenosis.

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 and the pansystolic murmur of mitral regurgitation

Question 21

Cardiovascular Examination

Posterior Chest Wall

Answer 21

• Inspect
• Auscultate Lung fields for crackles (PE and Left Ventricular failure) and for abstend air entry and dullness for pleural effusion (left ventricular failure)
• Sacral pitting oedema
• Legs and ankles for pitting pedal oedema (right ventricular failure)
• Inspect the patient’s legs for evidence of saphenous vein harvesting (performed as part of a coronary artery bypass graft).

Question 22

Cardiovascular Examination

To complete the examination

Answer 22

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 23

Cardiovascular Examination

Example Summary

Answer 23

Example summary

“Today I examined Mrs Smith, a 64-year-old female. On general inspection, the patient appeared comfortable at rest and there were no objects or medical equipment around the bed of relevance.”

“The hands had no peripheral stigmata of cardiovascular disease and were symmetrically warm, with a normal capillary refill time.”

“The pulse was regular and there was no radio-radial delay. On auscultation of the carotid arteries, there was no evidence of carotid bruits and on palpation, the carotid pulse had normal volume and character.”

“On inspection of the face, there were no stigmata of cardiovascular disease noted in the eyes or mouth and dentition was normal.”

“Assessment of the JVP did not reveal any abnormalities and the hepatojugular reflux test was negative.”

“Closer inspection of the chest did not reveal any scars or chest wall abnormalities. The apex beat was palpable in the 5th intercostal space, in the mid-clavicular line. No heaves or thrills were noted.”

“Auscultation of the praecordium revealed normal heart sounds, with no added sounds.”

“There was no evidence of peripheral oedema and lung fields were clear on auscultation.”

“In summary, these findings are consistent with a normal cardiovascular examination.”

“For completeness, I would like to perform the following further assessments and investigations.”

Question 24

Cardiovascular Examination

Further investigations to offer:

Answer 24

• 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.

Question 25

# Cardiovascular Exam Colour is a sign of.... | Inspection

Answer 25

pallor suggests poor peripheral perfusion (e.g. congestive heart failure) and cyanosis may indicate underlying hypoxaemia.

Question 26

# Cardiovascular Exam Tar staining is a sign of.... | Inspection

Answer 26

: caused by smoking, a significant risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension).

Question 27

# Cardiovascular Exam Xanthomata is .... | Inspection

Answer 27

raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow. Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension).

Question 28

# Cardiovascular Exam Arachnodactyly is | Inspection

Answer 28

fingers and toes are abnormally long and slender, in comparison to the palm of the hand and arch of the foot. Arachnodactyly is a feature of Marfan’s syndrome, which is associated with mitral/aortic valve prolapse and aortic dissection.

Question 29

# Cardiovascular Exam Finger clubbing is .... | Inspection

Answer 29

Ask the patient to place the nails of their index fingers back to back. In a healthy individual, you should be able to observe a small diamond-shaped window (known as Schamroth’s window) When finger clubbing develops, this window is lost. most likely to appear in a cardiovascular OSCE station include congenital cyanotic heart disease, infective endocarditis and atrial myxoma (very rare).

Question 30

# Cardiovascular Exam Splinter haemorrhages are.. | Inspection

Answer 30

longitudinal, red-brown haemorrhage under a nail that looks like a wood splinter. Causes include local trauma, infective endocarditis, sepsis, vasculitis and psoriatic nail disease. ENDOCARDITIS

Question 31

# Cardiovascular Exam Janeway lesions are.... | Inspection

Answer 31

non-tender, haemorrhagic lesions that occur on the thenar and hypothenar eminences of the palms (and soles). Janeway lesions are typically associated with infective endocarditis. ENDOCARDITIS

Question 32

# Cardiovascular Exam Osler’s nodes are.... | Inspection

Answer 32

red-purple, slightly raised, tender lumps, often with a pale centre, typically found on the fingers or toes. They are typically associated with infective endocarditis. Palpation ENDOCARDITIS

Question 33

# Cardiovascular Examination Temperature suggests... | Palpation

Answer 33

In healthy individuals, the hands should be symmetrically warm, suggesting adequate perfusion. Cool hands may suggest poor peripheral perfusion (e.g. congestive cardiac failure, acute coronary syndrome). Cool and sweaty/clammy hands are typically associated with acute coronary syndrome.

Question 34

# Cardiovascular Examination Capillary Refill time

Answer 34

Apply five seconds of pressure to the distal phalanx of one of a patient’s fingers and then release. In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two seconds. A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g. hypovolaemia, congestive heart failure) and the need to assess central capillary refill time.

Question 35

# Cardiovascular Examination Assessing Heart Rate

Answer 35

You can calculate the heart rate in a number of ways, including measuring for 60 seconds, measuring for 30 seconds and multiplying by 2 or measuring for 15 seconds and multiplying by 4. The shorter the interval used, the higher the risk of obtaining an inaccurate result, so wherever possible, you should palpate for a full 60 seconds. For irregular rhythms, you should measure the pulse for a full 60 seconds to improve accuracy.

Question 36

# Cardiovascular Examination Normal and Abnormal Heart Rates

Answer 36

* In healthy adults, the pulse should be between 60-100 bpm. * A pulse <60 bpm is known as bradycardia and has a wide range of aetiologies (e.g. healthy athletic individuals, atrioventricular block, medications, sick sinus syndrome). * A pulse of >100 bpm is known as tachycardia and has a wide range of aetiologies (e.g. anxiety, supraventricular tachycardia, hypovolaemia, hyperthyroidism). * An irregular rhythm is most commonly caused by atrial fibrillation, but other causes include ectopic beats in healthy individuals and atrioventricular blocks.

Question 37

# Cardiovascular Examination Radio Radial Delay

Answer 37

**loss of synchronicity between the radial pulse on each arm, resulting in the pulses occurring at different times. ** Palpate both radial pulses simultaneously. In healthy individuals, the pulses should occur at the same time. If the radial pulses are out of sync, this would be described as radio-radial delay. Causes of radio-radial delay include: Subclavian artery stenosis (e.g. compression by a cervical rib) Aortic dissection Aortic coarctation

Question 38

# Cardiovascular Examination What is a collapsing pulse?

Answer 38

* **is a forceful pulse that rapidly increases and subsequently collapses. It is also sometimes referred to as a ‘water hammer pulse’.** * * Ask the patient if they have any pain in their right shoulder, as you will need to move it briskly as part of the assessment for a collapsing pulse (if they do, this assessment should be avoided). * Palpate the radial pulse with your right hand wrapped around the patient’s wrist. * Palpate the brachial pulse (medial to the biceps brachii tendon) with your left hand, whilst also supporting the patient’s elbow. * Raise the patient’s arm above their head briskly. * Palpate for a collapsing pulse: As blood rapidly empties from the arm in diastole, you should be able to feel a tapping impulse through the muscle bulk of the arm. This is caused by the sudden retraction of the column of blood within the arm during diastole.

Question 39

# Cardiovascular Examination What are the causes of a collapsing pulse?

Answer 39

Normal physiological states (e.g. fever, pregnancy) Cardiac lesions (e.g. aortic regurgitation, patent ductus arteriosus) High output states (e.g. anaemia, arteriovenous fistula, thyrotoxicosis)

Question 40

# Cardiovascular Examination Auscultate the carotid artery

Answer 40

Prior to palpating the carotid artery, you need to auscultate the vessel to rule out the presence of a bruit. The presence of a bruit suggests underlying carotid stenosis, making palpation of the vessel potentially dangerous due to the risk of dislodging a carotid plaque and causing an ischaemic stroke. Place the diaphragm of your stethoscope between the larynx and the anterior border of the sternocleidomastoid muscle over the carotid pulse and ask the patient to take a deep breath and then hold it whilst you listen. Be aware that at this point in the examination, the presence of a ‘carotid bruit’ may, in fact, be a radiating cardiac murmur (e.g. aortic stenosis).

Question 41

# Cardiovascular Examination Palpate the carotid pulse

Answer 41

If no bruits were identified, proceed to carotid pulse palpation: 1. Ensure the patient is positioned safely on the bed, as there is a risk of inducing reflex bradycardia when palpating the carotid artery (potentially causing a syncopal episode). 2. Gently place your fingers between the larynx and the anterior border of the sternocleidomastoid muscle to locate the carotid pulse. 3. Assess the character (e.g. slow-rising, thready) and volume of the pulse.

Question 42

# Cardiovascular examination JVP

Answer 42

provides an indirect measure of central venous pressure. the internal jugular vein (IJV) connects to the right atrium without any intervening valves, resulting in a continuous column of blood. Position the patient in a semi-recumbent position (at 45°). 2. Ask the patient to turn their head slightly to the left. 3. Inspect for evidence of the IJV, running between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid (it may be visible between just above the clavicle between the sternal and clavicular heads of the sternocleidomastoid. The IJV has a double waveform pulsation, which helps to differentiate it from the pulsation of the external carotid artery. 4. Measure the JVP by assessing the vertical distance between the sternal angle and the top of the pulsation point of the IJV (in healthy individuals, this should be no greater than 3 cm).

Question 43

# Cardiovascular Examination What causes a raised JVP

Answer 43

Right-sided heart failure: commonly caused by left-sided heart failure. Pulmonary hypertension is another cause of right-sided heart failure, often occurring due to chronic obstructive pulmonary disease or interstitial lung disease. Tricuspid regurgitation: causes include infective endocarditis and rheumatic heart disease. Constrictive pericarditis: often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying causes.

Question 44

# Cardiovascular Examination Conjunctival pallor | Inspection

Answer 44

suggestive of underlying anaemia. Ask the patient to gently pull down their lower eyelid to allow you to inspect the conjunctiva.

Question 45

# Cardiovascular Examination Corneal arcus | Inspection

Answer 45

a hazy white, grey or blue opaque ring located in the peripheral cornea, typically occurring in patients over the age of 60. In older patients, the condition is considered benign, however, its presence in patients under the age of 50 suggests underlying hypercholesterolaemia.

Question 46

# Cardiovascular Examination Xanthelasma | Inspection

Answer 46

yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia.

Question 47

# Cardiovascular Examination Kayser-Fleischer Rings

Answer 47

dark rings that encircle the iris associated with Wilson’s disease. The disease involves abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues (including the heart where it can cause cardiomyopathy).

Question 48

# Cardiovascular Examination Central cyanosis | Inspection

Answer 48

bluish discolouration of the lips and/or the tongue associated with hypoxaemia (e.g. a right to left cardiac shunt)

Question 49

# Cardiovascular Examination Angular stomatitis | Inspection

Answer 49

a common inflammatory condition affecting the corners of the mouth. It has a wide range of causes including iron deficiency.

Question 50

# Cardiovascular Examination High arched palate:

Answer 50

a feature of Marfan syndrome which is associated with mitral/aortic valve prolapse and aortic dissection.

Question 51

# Cardiovascular Examination Dentition | Inspection

Answer 51

Poor dental hygiene risk for infective endocarditis

Question 52

# Cardiovascular examination Pectus excavatum | Inspection

Answer 52

: a caved-in or sunken appearance of the chest.

Question 53

# Cardiovascular Examination Pectus carinatum | Inspection

Answer 53

protrusion of the sternum and ribs

Question 54

# Cardiovascular examination Visible pulsations | Inspection

Answer 54

a forceful apex beat may be visible secondary to underlying ventricular hypertrophy.

Question 55

# Cardiovascular examination Thoracic Scars | Inspection

Answer 55

* Median sternotomy scar: located in the midline of the thorax. This surgical approach is used for cardiac valve replacement and coronary artery bypass grafts (CABG). * Anterolateral thoracotomy scar: located between the lateral border of the sternum and the mid-axillary line at the 4th or 5th intercostal space. This surgical approach is used for minimally invasive cardiac valve surgery. * Infraclavicular scar: located in the infraclavicular region (on either side). This surgical approach is used for pacemaker insertion. * Left mid-axillary scar: this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-defibrillator (ICD).

Question 56

# Cardiovascular Exam Identify: | Inspection

Answer 56

Peripheral Cyanosis

Question 57

# Cardiovascular Exam Identify: | Inspection

Answer 57

Tar Staining

Question 58

# Cardiovascular Exam Identify: | Inspection

Answer 58

Oslers Nodes

Question 59

# Cardiovascular Exam Identify: | Inspection

Answer 59

Janeway Lesions

Question 60

# Cardiovascular Exam Identify: | Inspection

Answer 60

Clubbing

Question 61

# Cardiovascular Exam Identify: | Inspection

Answer 61

Splinter Haemorrhage

Question 62

# Cardiovascular Exam Identify: | Inspection

Answer 62

CABG scar

Question 63

# Cardiovascular Exam Identify: | Inspection

Answer 63

Malar Flush

Question 64

# Cardiovascular Exam Identify: | Inspection

Answer 64

Xanthalasma

Question 65

# Cardiovascular Exam Identify: | Inspection

Answer 65

Corneal Arcus

Question 66

# Cardiovascular Exam Identify: | Inspection

Answer 66

Conjunctival Palor

Question 67

# Cardiovascular Exam Identify: | Inspection

Answer 67

Central Cyanosis

Question 68

# Cardiovascular Exam Identify: | Inspection

Answer 68

Midline Sternotomy

Question 69

# Cardiovascular Exam Identify: | Inspection

Answer 69

Pacemaker

Question 70

# Cardiovascular Exam Identify: | Inspection

Answer 70

Sacral Oedema

Question 71

# Cardiovascular Exam Identify: | Inspection

Answer 71

Ankle Oedema

Question 72

# Cardiovascular Exam Identify: | Inspection

Answer 72

CABG scar

Question 73

# Cardio Exam Introduction

Answer 73

Name/role Check patients name Explain examination and exposure Explain that they will be examined again by supervisor Consent Offer Chaperone Document Ask about pain Clean your hands and stethoscope (unless using patients own) Position at 45 degrees Ensure adequate exposure

Question 74

# Cardio exam Inspection

Answer 74

Bedside Equipment (ECG, GTN spray, oxygen) Patient Distress/Pain/Pallor/Cyanosis/Sweating/Breathless

Question 75

# Cardio exam Hands

Answer 75

HANDS Nails Clubbing (congenital heart disease, atrial myxoma, endocarditis) Splinter haemorrhages (infective endocarditis) Capillary refill time (2-3s) Tar stains (smoker) Sweaty/clammy (e.g. MI) Peripheral cyanosis Peripheral stigmata of infective endocarditis (Janeway lesions, Osler’s nodes)

Question 76

# Cardio exam Radial Pulse

Answer 76

RADIAL PULSE Rate (15s X 4 [normal is 60-100]) Rhythm (regular, irregular) Character (slow rising = AS, collapsing = AR) Volume (hypovolaemic/’thready’ - MI/heart failure/AS)) Radial-radial delay (aortic dissection) Radial-femoral delay

Question 77

# Cardio exam Resp

Answer 77

RESPIRATORY RATE 15s X 4 (N = 12-16)

Question 78

# Cardio exam ARMS

Answer 78

ARMS Blood pressure Pulse pressure (wide/>40 = AR, narrow/<40 = AS) Scars CABG graft from radial artery

Question 79

# Cardio exam Face

Answer 79

EYES Xanthalasma (hyperlipidaemia) Corneal arcus (hyperlipidaemia) Conjunctival pallor (anaemia) FACE Malar flush (MS) MOUTH Central cyanosis Dental hygiene Dehydration

Question 80

# Cardio exam Neck

Answer 80

NECK JVP (>3cm = R heart failure, TR) Carotid pulse Volume Slow rising

Question 81

# Cardio exam CHEST INSPECTION

Answer 81

Scars (e.g. midline sternotomy) Pacemaker Apex beat Metallic heart valve (audible without stethoscope)

Question 82

# Cardio exam PALPATION

Answer 82

Apex beat Heaves (L parasternal heave = RVH) Thrills

Question 83

# Cardio exam AUSCULTATION

Answer 83

HS 1+2 (time with carotid pulse ) Murmurs + added sounds Time with carotid pulse Inspiration (to accentuate R sided sounds) and expiration (accentuate L sided sounds) Apex/mitral (5th ICS mid-clavicular line) Bell and diaphragm Tricuspid (4th ICS L sternal edge) Pulmonary (2nd ICS L sternal edge) Aortic (2nd ICS R sternal edge) Special positions Left lateral position with bell over mitral area -MS murmur Sitting up, leaning forward with diaphragm over left sternal edge - AR murmur For radiation Carotid Axilla For bruit Carotid Lung bases (crackles- pulmonary oedema)

Question 84

# Cardio exam BACK/ANKLES/SHINS

Answer 84

Sacral oedema Peripheral oedema Signs of PVD

Question 85

# cardio exam CONSIDER OTHER EXAMINATIONS

Answer 85

Peripheral vascular examination Abdomen - enlarged liver (in heart failure) Fundoscopy (flame shaped haemorrhages in infective endocarditis) Temperature (pyrexia in infective endocarditis)