Cardiac Examination

Question 1

Describe the first inspection stage of the cardiac exam? Inspection 1 (surroundings, appearance, and hands)

Answer 1

• Inspect the around the bed space for clues e.g. GTN spray
• Inspect the general appearance of the patient (colour, breathing, comfort, position, build)

• Inspect the patient’s hands for cardiac signs:
o Tar staining
o Vasodilatation/constriction, temperature
o Sweating (suggests increased sympathetic drive)
o Pallor of palmar creases
o Peripheral cyanosis
o Clubbing
o Splinter haemorrhages
o Osler’s nodes and Janeway lesions
o Tendon xanthomas

Question 2

Describe the pulse stage of the cardiac exam?

Answer 2

• Check the presence of both radial pulses simultaneously. Assess rate and rhythm in one radial pulse (usually the right).
• Assess the character and volume of the brachial pulse (normal, slow rising, collapsing). Ask the patient if they have pain in their arm before checking for collapsing/waterhammer pulse (aortic regurgitation)
• Assess the character and volume of the carotid pulse (one side at a time)

Question 3

Describe the second inspection stage of the cardiac exam? (Eyes, Face, and Mouth)

Answer 3

• Look for cardiac signs in the eyes:
o Subconjunctival pallor
o Corneal arcus
o Xanthelasmata

• Look for cardiac signs in the face:
o Malar flush (mitral stenosis)

• Look for cardiac signs in the mouth/lips:
o Central cyanosis (under tongue or on mucous membranes inside lips)
o High-arched palate (Marfan’s)
o Dental caries (may predispose to infective endocarditis)

Question 4

Describe the second palpation stage of the cardiac exam? JVP

Answer 4

• Position the patient at 45° and check for raised JVP (normal = 2 - 4cm above sternal angle). Check for low JVP using hepatojugular reflux by compressing the liver and observing the JVP (will rise). Check for high JVP by sitting patient upright and looking near the ear lobes for venous pulsation. Identify the two main waves by palpating the carotid.

Question 5

Describe the precordium inspection stage of the cardiac exam?

Answer 5

Expose the patient’s chest and inspect the precordium
 o sternotomy scar 
o severe pectus excavatum 
o severe kyphoscoliosis 
o visible cardiac pulsation

Question 6

Describe the palpation of the heart?

Answer 6

• Palpate for the apex beat and parasternal heaves (outward displacement of the palpating hand by cardiac contraction e.g. in left ventricular hypertrophy) and thrills (palpable murmurs)

Question 7

Describe the auscultation of the heart?

Answer 7

• Auscultate aortic, pulmonary, tricuspid and mitral valve areas. If extra sounds are heard, palpate the carotid pulse to time them with the first and second heart sounds. The start of the carotid pulsation will be synchronous with the first heart sound.
• Auscultate left axilla for mitral incompetence
• Switch to the bell and auscultate the apex with the patient rolled 45° to the left (for mitral stenosis).
• Switch back to the diaphragm, sit the patient forward and auscultate at the 4th/5th intercostal space to the left of the sternum on held expiration (aortic regurgitation)
• Auscultate lung bases, assess for sacral oedema. If coarctation is suspected, auscultate to the left of the spine in the 3rd/4th intercostal space
• Sit the patient back and auscultate the carotids for bruits or a transmitted systolic murmur

Question 8

Describe the abdominal palpation aspect of the cardiac exam?

Answer 8

• Lay the patient flat, if they can tolerate it, and palpate for hepatomegaly. If the liver is enlarged, feel for pulsation (tricuspid regurgitation).
• If you suspect ascites, test for shifting dullness (percuss from the centre toward the left flank. If a dull note is heard, keep the finger in position and roll the patient onto their right side. Wait a few seconds for the fluid to redistribute. If the note becomes resonant, percuss back towards the umbilicus until the note becomes dull i.e. shifting dullness).
• Check the femoral pulses. Check synchrony with the radial pulse (radiofemoral delay in coarctation). (In the OSCE, you should state that you would do this).
• Check for pitting oedema at the ankles. If this is present, you should always also check for ascites (see test for shifting dullness above).

Question 9

What additional tests could follow a cardiac exam and should you state in your osce?

Answer 9

• Check the blood pressure in both arms and lying and standing in one arm. (In the OSCE, you should state that you would do this)
• Perform ophthalmoscopy for hypertensive retinopathy (In the OSCE, you should state that you would do this).
• Obtain a 12-lead ECG (In the OSCE, you should state that you would do this).