Cardiovascular examination

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LOCAS

• Cardiovascular examination

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General advice

• Dont Panic
• Dont listen to horror stories from older years
• Start now
• Try and examine at least one patient a day and
  have someone watch you do it.

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How the station will be set up

• 2 mins-waiting outside collecting your thoughts
• 8 mins-examine the patients CV system
• 2 mins-time to present you findings
• 2 mins in which time the doctor examining will
  question you
• All of it is split up by warnings like in the OSCE

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Going into the station

• Examiner will give you a 1 sentence phrase like
  please examine this patients cardiovascular
  system, and report your findings to me

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1st things to do

• Have ready-made phrases
• hello my name is. I am etc
• I have been asked to do a cv examis that ok?
• are you in any pain
• is there anything I might do that would cause
  you any pain
• if you get uncomfortable please let me know..
• is it ok if I talk to the doctor observing
  whilst I am examining you
• Then wash your hands.

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1. Inspection

• Stand at the end of the bed-general inspection
• Emphasise what you are looking for
• -breathless?
• -discomfort?
• -O2/ breathing devices/ sputum pots around the
  bed
• -ankles
• -how many pillows are they lying on
• -scars
• -swellings

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SCARS

• Usually pneumonectomy
• -bronchiectasis
• -TB
• -Carcinoma lung

• Right thoracotomy

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• Diagnosis
• -pleural effusions
• -pneumothorax
• -other lung disease
• Treatment
• -pleurodesis
• -removal of masses (eg cancer)

• Thoracoscopy scars

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• Transplant
• Bypass surgery
• Congenital heart disease

• sternotomy

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• Usually to biopsy lymph nodes/ masses in the
  mediastinum

• mediastinoscopy

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2. inspection-hands.

• Clubbing

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Clubbing-Why?

• CV -cyanotic congenital heart disease
• -infective endocarditis
• -atrial myxoma
• Resp- bronchial carcinoma
• -chronic suppurative resp conditions
  (CF, bronchiectasis, empyema)
• -TB
• -Mesothilioma
• GI -Malabsorption
• -Inflammatory bowel disease
• -Cirrhosis
• Others-thyroid acropachy
• REMEMBER learn causes of signs in a grouped way
  eg by system-this looks a lot better to the
  examiner than listing whichever comes into your
  head first.

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Splinter haemorrhage
Causes Subacute bacterial endocarditis, SLE,
rheumatoid arthritis, antiphospholipid syndrome,
peptic ulcer disease, malignancies, oral
contraceptive use, pregnancy, psoriasis, trauma
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Koilonychia-Fe deficiency anaemia
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• Tendon xanthoma-hypercholesterolaemia

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nicotine staining
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3. pulses

• Take radial pulse-rate, rhythm
• Check for radio-radial delay (dissection)
• Check for radio femoral delay (coarctation of the
  aorta)
• Check for collapsing pulse (aortic regurgitation)
• Check brachial pulse for character of vessel wall
  etc.

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Collapsing pulse (aortic regurgitation)

• have you got any pain in your shoulder is it
  ok if I lift your arm in the air?
• Place right hand round wrist so radial pulse runs
  across palm of your hand.
• Left hand supporting elbow
• Lift arm up in the air feel for the collapsing
  pulse.
• (hard to describe-need to go and feel one on the
  wards)

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Causes of collapsing pulse

• AORTIC REGURGITATION
• PDA
• PAGETS
• PREGNANCY
• RUPTURED ANEURYSM OF AORTIC SINUS
• FEVER
• ANAEMIA

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Causes of Irregular Pulse

• Atrial Fibrillation
• Ventricular ectopics
• Atrial Flutter

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Inspect The Face

• Xanthalesma- hypercholesterolaemia

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Corneal arcus-hypercholesterolameia
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Central cyanosis
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Acromegaly
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• Mitral facies-mitral regurgitation/ mitral disease

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JVP

• 45 degrees
• Head to left
• Give head support to relax
  sternocleidomastoid (pillow).
• Runs from between sternal and clavicular heads of
  SCM to behind the ear.
• Height measured from angle of Louis vertically to
  point of pulsation.
• Max-4cm

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The JVP waveform
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JVP Interpretation

• Elevated JVP
• Right heart failure
• Constrictive pericarditis
• Superior vena cava obstruction
• Pericardial effusion
• Cardiac tamponade
• Tricuspid valve disease

• Kussmauls Sign
• Paradoxical increase in JVP with inspiration (JVP
  should decrease on inspiration as thoracic
  pressure decreases)
• Causes constrictive pericarditis, restrictive
  cardiomyopathy, pericardial effusion.

• Cannon A Waves
• Happen when the right atrium contracts against a
  closed tricuspid valve
• Causes complete heart block, (sometimes VT).

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Palpation

• Feel for Apex beat
• Palpate for heaves and thrills

1.
2.
3.
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Auscultation

• Do initial auscultation with patient at normal 45
  degrees
• Same as taught by clinical skills initially
• Listen with diaphragm at aortic, pulmonary,
  tricuspid and mitral areas

Mitral area (5th ICS MCL) Tricuspid area (Lower
left sternal edge) Aortic area (2nd ICS right
sternal edge) Pulmonary area (2nd ICS left
sternal edge)
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Auscultation continued

• When listening to left sided heart sounds (mitral
  aortic) get the patient to FULLY EXHALE.
• When listening to right sided hear sounds
  (pulmonary tricuspid) get the patient to FULLY
  INHALE.

• WHY?
• -in order to exhale, your respiratory muscles
  relax, this increases intrathoracic pressure and
  air leaves along the pressure gradient.
• -at the same time, in response to this increased
  pressure, blood is squeezed out of your thorax.
• -blood coming from your thorax enters the left
  heart.
• -therefore by breathing out you have increased
  the amount of blood passing through the left side
  of the heart.
• -more blood crossing the valves makes a louder
  noise-ie the murmur gets louder.
• (the opposite happens for right side. Breathing
  in lowers intrathoracic pressure, so more blood
  enters the thorax in response, this blood comes
  from the right heart and so more blood flows
  across the valves of the right heart and the
  murmur gets louder.)

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Auscultation step by step

• After initial auscultation turn stethoscope to
  BELL
• Listen in mitral area, and while listening roll
  patient onto LEFT SIDE and ask patient to exhale.
• With patient on left side move bell of scope to
  the armpit and listen to see if murmur radiates
  here (mitral regurgitation radiates to the
  armpit)
• Roll patient back to supine and ask to sit
  forward.
• Turn stethoscope back to diaphragm and leave like
  that for the rest of the examination.
• Listen in TRICUSPID area and ask patient to
  INHALE
• Move to PULMONARY area and ask patient to INHALE
• Move to AORTIC area and ask patient to EXHALE.
• Whilst exhaling listen over CAROTIDS (aortic
  stenosis can radiate to the carotids)
• While patient I sitting forward feel for SACRAL
  OEDEMA
• Finally listen to LUNG BASES on patients back for
  basal crepitations
• Finish off by checking for ankle oedema and pedal
  pulses.

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Heart murmurs
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Heart sounds
normal
Mitral stenosis
Mitral regurgitation
Aortic stenosis
Aortic regurgitation
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Grade of Murmurs
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Finally

• Say thankyou to the patient tell them they can
  get dressed.
• Ask the patient if its ok that you present your
  findings to the doctor
• Say something like I would like to complete the
  exam by taking the blood pressure, doing a full
  respiratory exam, dipsticking the urine etc
• Present your findings..

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Case 1

• ANY Ideas?
• Aortic Regurgitation

• Normal BP
• Pulse 76
• Collapsing pulse
• Patient nodding his head in time to pulse
• Early diastolic murmur heard at 2nd IC space
  right sternal edge.

• Questions Asked
• What other clinical signs might you expect to
  find in aortic regurgitation?
• What are the causes of aortic regurgitation?

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Answers case 1

• Q2

• Q1
• Corrigans sign
• Duroziezs sign
• Traubes sign
• Austin-Flint murmur
• Quinckes sign