Medical Education Without Limits!

Cardiovascular examination

Intro (WIIPPPPE)

  • Wash your hands
  • Introduce yourself
  • Identity of patient – confirm
  • Permission (consent and explain examination)
  • Pain?
  • Position at 45°
  • Privacy
  • Expose chest to waist

General Inspection

  • Surroundings
    • Monitoring
      • pulse oximeter
      • ECG monitoring
      • Daily weights/ fluid restriction chart
    • Treatments
      • Oxygen therapy: type (e.g. venturi) and rate (e.g. 25% or 5L) of delivery
      • GTN spray
      • Warfarin INR card
      • Insulin pen
      • IV infusions
    • Paraphernalia
      • Wheelchair, walking aids
      • Cigarettes, nicotine patches, gum
  • Patient
    • General
      • Well or unwell; short of breath; alert and orientated or drowsy and confused; comfortable at rest or in pain?
    • Syndromic features (e.g. Down’s or Marfanoid)
    • Colour
      •  Pale (anaemia); malar flush (mitral stenosis); cyanosis (low sats – consider lung disease and cor pulmonale)

Systemic examination

  • Chest
    • Inspect
      • Scars
        • Lateral thoracotomy (mitral valve)
        • Midline sternotomy (CABG or valve)
        • Left subclavicular (pacemaker, AED)
        • Back (coarctation or ballic-torso shunt)
      • Deformity (e.g. pectus escavatum in Marfan’s syndrome)
      • Pacemaker or AED
    • Ticking of metallic heart valve? (stop to think about this or you may miss it)
  • Face
    • Inspect
      • Malar flush (mitral stenosis)
      • Eyes:
        • Corneal arcus (elderly, hyperlipidaemia in young)
        • Conjunctival pallor (anaemia)
        • Petechial haemorrhages (endocarditis)
        • Xanthelasma (hyperlipidaemia)
      • Mouth
        • Hydration status
        • Dentition (risk of endocarditis)
        • Central cyanosis (under tongue)
        • High-arched palate (Marfan’s syndrome)
  • Neck
    • Inspect and palpate
      • Carotid pulse (character and volume)
        • Collapsing: aortic regurgitation
        • Slow-rising: aortic stenosis
        • Thready: shock
        • Bounding: CO2 retention
      • JVP
        • JVP can be differentiated from carotid by:
          • Hepatojugular reflux; occludable; not pulsatile; double waveform
        • JVP is raised if vertical height is >3cm above sternal notch
      • See questions below for more information on the JVP
    • Auscultate
      • Carotid bruits
  • Arms
    • Inspect
      • Scars from forearm vein harvesting
      • IV access
      • Track marks (IV drug use is an endocarditis risk factor)
      • Bruising
        • Anticoagulation therapy
    • Palpate
      • Offer to measure BP
        • Pulse pressure
          • Narrow (aortic stenosis)
          • Wide (aortic regurgitation)
        • Unequal arm BPs
          • Aortic dissection
          • Subclavian artery stenosis: BP reduced on side of stenosis
  • Hands
    • Inspect
      • Temperature
      • Capillary refill (at level of heart)
      • Colour (peripheral cyanosis)
      • Clubbing – perform Shamroth’s window test and consider cardiac causes
        • Congenital cyanotic heart disease; endocarditis; atrial myxoma
      • Cigarette tar staining (not nicotine!)
      • Blood glucose testing on fingertips
      • Tendon xanthomata (hyperlipidaemia)
      • Janeway lesions (endocarditis)
      • Osler nodes (endocarditis)
      • Splinter haemorrhages
        • trauma, vasculitis, endocarditis
      • Pale palmar creases (anaemia)
      • Palmar erythema
        • Hyperthyroidism; pregnancy, polycythaemia
      • Arachnodactyly (Marfan’s syndrome)
      • Quincke’s sign (aortic regurgitation)
    • Palpate:
      • Radial pulse (rate, rhythm)
        • Weak left pulse post-Fontan procedure
      • Radio-radial delay
        • Aortic dissection
        • Aortic coarctation (delayed on left depending on level of coarctation)
        • Subclavian artery stenosis
      • Radio-femoral delay
        • Aortic coarctation
      • Collapsing pulse (aortic regurgitation)
        • Ask about pain in shoulder first
    • Palpate
      • Apex beat
        • Normal: 5th intercostal space, mid-clavicular line
        • Forceful: LVH, aortic stenosis
        • Heaving/thrusting: aortic regurgitation, mitral regurgitation
        • Tapping: mitral stenosis
        • Double: HOCM
      • LV and RV heave (ventricular hypertrophy)
      • Thrills (palpable murmur)
    • Auscultate
      • Listen to heart sounds in four areas with diaphragm whilst feeling carotid pulse
      • If a systolic murmur is heard:
        • Listen in the axilla for radiation (mitral regurgitation)
        • Listen over the carotids for radiation (aortic stenosis)
      • Always perform the reinforcement manoeuvres to detect diastolic murmurs:
        • Bell on apex, roll on left side, hold breath in expiration (mitral stenosis)
        • Sit forwards, left lower sternal edge with diaphragm, hold breath in expiration (aortic regurgitation)
      • With patient sat forward, auscultate lung bases
        • Reduced air entry, bilateral crepitations (pulmonary oedema)
  • Sacrum
    • Sacral oedema (heart failure, fluid overload)
  • Legs
    • Check for pain in ankles first
    • If present find upper limit of peripheral oedema and feel for pulsatile liver (tricuspid regurgitation)
      • Scars (medial calf for saphenous vein harvesting)
      • Peripheral oedema (heart failure, fluid overload)

Closure

  • Thank patient
  • Patient comfortable?
  • Help getting dressed?
  • Wash hands
  • Turn to examiner, hands behind back, holding stethoscope (try not to fidget!) before saying: “To complete my examination, I would like to…”
    • Further examinations:
      • Perform a peripheral arterial examination
      • Perform fundoscopy (hypertensive retinopathy, Roth spots in endocarditis)
    • Bedside investigations:
      • Obs: resp rate, pulse, BP, O2 sats, temperature
      • Measure lying and standing BP
      • 12-lead ECG
      • Urine dip
      • Blood glucose
    • Further investigations
      • Bloods: consider BNP (heart failure) and troponin (ischaemia or myocarditis)
      • Echo
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