Cardiac examination Flashcards
Preparation.
a) Patient position
a) Sit patient up at 45 degrees
General inspection (end-of-the-bed-o-gram).
a) General features
b) Cardiac features
a) - Do they look well?
- Are they comfortable/ in pain/ SOB?
- Are they alert and oriented? (good cerebral perfusion)
- Obs stable?
b) - Do they look cyanosed? (hypoxia - ?T1RF)
- Do they look pale? (?anaemia, ACS)
- Do they look clammy/sweaty (ACS)
Inspection of hands.
a) General CV signs
b) Infective endocarditis
c) Pulse
d) Then as you go up arm, say…?
a) - Cool peripheries (?hypotension, shock, PAD)
- Clammy hands (?ACS, ?hyperthyroid)
- Finger clubbing (?congenital HD, lung disease)
- CRT
- Tremor (?hyperthyroid, adrenergic state)
b) - Osler nodes (fingers)
- Janeway lesions (palms)
- Splinter haemorrhages (nails)
c) - Rate
- Rhythm
- Character (thready, bounding, collapsing, slow-rising)
- Radio-radial delay, or weaker on one side (?CoA, subclavian stenosis, aortic dissection, Takayasu)
d) I would take BP (in both arms)
Inspection of head and neck.
a) Eyes
b) Mouth
c) Face
d) Neck
a) - Xanthelasma
- Subconjunctival pallor
- Corneal arcus
- Exophthalmos (?hyperthyroid)
b) - Dry mucous membranes
- ?anaemia
- Dental caries (?endocarditis)
c) - Malar flush (?mitral stenosis)
d) - JVP
- Carotid pulses
- ?thyroid swelling
- ?tracheal position
Inspection of chest.
a) Things to look for
b) If patient has median sternotomy scar, you should also look where?
a) - Scars (eg. median sternotomy
- Pectus carinatum/ excavatum
-
b) Calf - venous graft for CABG
Palpation of chest.
- Heaves or thrills
- Apex beat
(Palpation for hepatomegaly / ascites comes later)
Auscultation of chest.
a) Valve areas
b) Manoeuvres
c) Then auscultate the…? (and press on…?)
c) 2 most common murmurs to hear
a) - Valve areas (A, P, T, M)
b) - MR: left lateral position, held expiration, auscultate apex and axilla
- AR: sit forward, help expiration, auscultate LLSB
c) - Lung bases (if crackles - will likely require CXR and ECHO)
- Press the sacrum to assess for sacral oedema - more likely in bedbound patients
d) AS and MR
Systolic murmurs.
a) Main 2 and characteristics (vs.)
b) Other 2 valvular murmurs
c) Non-valvular systolic murmurs
d) Differentiating right/left heart systolic murmurs
e) Mid-systolic click - occurs in…?
a) - Aortic stenosis (AS) - ESM, loudest at RUSB, radiates to the carotids, soft S2 (or absent in severe stenosis)
- Mitral regurgitation (MR) - pansystolic murmur, loudest at apex, radiates to the axilla
b) - Pulmonic stenosis - ESM loudest at LUSB
- Tricuspid regurgitation (TR) - pansystolic murmur, loudest at apex, radiates to the axilla
d) - Left-sided murmurs are generally louder (higher pressure system)
- If at apex, very likely to be mitral
- Right louder on inspiration, left on expiration (RILE)
- TR classically causes signs of right heart failure, including pulsatile hepatomegaly and raised JVP
e) Mitral valve prolapse (MVP): associated with conditions like Marfan’s, Ehler’s-Danlos and ADPKD
Differentiating systolic vs diastolic murmurs
- Systolic murmurs will be louder as systole is a higher pressure period than diastole
- Systolic murmurs may be innocent flow murmurs, whereas diastolic are always pathological
Diastolic murmurs.
a) Left-sided (ARMS)
b) Right-sided
a) - Aortic regurgitation (AR) - early diastolic, heard loudest at LLSB in held expiration
- Mitral stenosis (MS) - opening snap, rumbling diastolic murmur
b) - Pulmonary regurgitation (PR) - early diastolic (as for AR)
- Tricuspid stenosis (TS) -
Other abnormal added heart sounds (non-murmurs)
- S3 (gallop rhythm) - may be normal < 30 years, otherwise associated with heart failure
- S4 - usually indicates ventricular hypertrophy
- Split S1 or S2
- Pericardial rub (like walking through snow)
- Prosthetic heart valves - loud click (S1 or S2)
- Venous hum (common in children)
Murmur grading:
3 = ?
4 = ?
(the others can be derived from this)
3 = Loud murmur WITHOUT a palpable thrill
4 = Loud murmur WITH a palpable thrill
After auscultation - examination of…?
a) Abdominal
b) Other
a) - Liver (+ ascites if distension)
- ?Spleen (?endocarditis)
- ?Abdominal aorta
b) - Ankles (press above medial malleolus to assess for pitting oedema)
- ?femoral pulses
To complete examination.
a) In all cases (4 things)
b) If murmur auscultated
c) If crackles at lung bases
d) If signs of acute chest pain
e) If very tachycardic
a) - Lying and standing BP in both arms
- Femoral pulses - and assess for radio-femoral delay
- Fundoscopy
- 12 lead ECG
b) - ECHO
c) - CXR, and ECHO
d) - Troponins
- Routine bloods: FBC, CRP, lipids, glucose, TFTs
- Angiography
e) - FBC, U+Es, TFTs, etc.
- D-dimer (or CTPA), troponins, lactate, etc.
Summarising findings.
- Examination performed and patient details
- General inspection
- Peripheral signs (including pulse volume, rate and rhythm)
- Face, eyes and mouth
- JVP - raised or not?
- Chest inspection
- Apex beat
- Heart sounds (I + II + added sounds)
- If murmur - characterise (loud/faint/grade, systolic/diastolic, ESM/PSM, radiation)
- Lung bases and ankle oedema
- In summary… (main findings + differential diagnoses)
Example: 80 year old woman with classical AS murmur and congestive cardiac failure
- “I performed a cardiac examination on an 80 year old woman (?with known PMHx),
- …who appeared (comfortable) at rest
- The hands were (warm and well-perfused), pulse was (low volume, 72 bpm and regular) and there was (a cannula in situ, bruising, clubbing, etc.)
- In the face, eyes and mouth, (there were no signs of cardiac disease)
- JVP was (raised)
- On inspection of the chest, (there were no chest wall deformities or scars from previous cardiothoracic surgery)
- Apex beat was (palpable in the 5th ICS, mid-clavicular)
- There were (no) palpable heaves or thrills
- On auscultation, (S1 was clear but S2 was soft, and a grade III ESM was heard, which radiated to the carotids)
- There were bibasal crackles and pitting oedema bilaterally up to the ankles
In summary…
- There was a loud ESM heard, radiating to the carotids, consistent with AS
- And evidence of fluid overload in the lung bases and ankles, consistent with CCF (possibly secondary to AS)
- There was no evidence of endocarditis or AF
