Cardiovascular Examination

Question 1

What is the procedure of the cardiovascular examination?

Answer 1

Vital signs
Blood pressure
Carotid pulse assessment
Inspection
Palpation
Auscultation
Auscultation of S2 splitting

Question 2

What do we access with vital signs?

Answer 2

Access pulse at : Wrist (radial artery), Neck (Carotid artery)
Breathing (BPM)
Temperature

Question 3

What is the process of blood pressure?

Answer 3

Find estimation of systole? (Osculatory gap)
Place bell over artery to the estimated range
Very slowly release until you can hear heart beat = systole Keep slowly releasing and when the heart rate can’t be heard = diastole

Question 4

What is involved in the carotid pulse assessment?

Answer 4

1. Obtain consent; drape your patient
2. Gently palpate the right & left carotid artery pulses, individually
3. Assess and describe the pulse amplitude and contour
4. Note abnormalities e.g. large bounding, pulses alternate
5. Auscultate both carotid arteries with patient holding breath using the diaphragm of the stethoscope

Question 5

What steps are involved in inspection of the patient?

Answer 5

1. Assess patient as whole:
   Access if they look ill, overweight, feeble, frail, clutching chest, breathing problems, coughing
2. Examine their hands:
   Look for peripheral cyanosis, clubbing, tar in between fingers, perform capillary refill test on nail beds (distal phalanges)
3. Examine their arms:
   Look for track marks indicating IV drug use and possible heart valve infection,
4. Examine their head & face:
   Look for central cyanosis or oral mucosa on lips + gums.
5. Examine the patients chest, note any abnormalities (pigeon or barrelled)
6. Examine their lower limbs:
   Looking for the presence of pitting oedema (May indicate right side heart failure)

Question 6

What is involved in the palpation aspect?

Answer 6

Consent, drape and have the patient laying supine with the head of the table at 30 degrees.

Palpate the following areas
- Aortic valve area (right 2nd intercostal space)
- Pulmonary valve area (left 2nd intercostal space)
- Tricuspid valve area (left 3rd, 4th, 5th intercostal spaces)
Mitral valve area (1cm medial to the left midclavicular line & 5th intercostal space)

Palpate the right ventricular impulse - Method 1: Place your finger pads parasternally in left 3rd, 4th and 5th interspaces
Method 2: Place your fingers in the epigastric area; palpate as patient inhales

Question 7

What are some abnormalities you can find during palpation?

Answer 7

Heaves/lifts (ventricular enlargement)
Thrills (vibrations due to turbulent blood flow)

Question 8

What is involved during the auscultation?

Answer 8

Auscultate the 4 listening areas
- Aortic
- Pulmonary
- Tricuspid
- Mitral

Question 9

What features are noted during auscultation?

Answer 9

Rate
Rhythm
Loudness of S1 and S2
Identify the systolic and diastolic periods

Question 10

What listening areas are the S1 and S2 sounds best heard?

Answer 10

S2 - Pulmonary, Aortic (not as much)
S1 - Tricuspid, Mitral

Question 11

What is involved in the auscultation of S2 splitting?

Answer 11

Listen to S2 in each of the normal valve auscultation areas
Ask your patient to inhale quickly & deeply; they should briefly hold their breath at the end of inspiration to facilitate your auscultation
Note the physiological splitting of S2

Question 12

What is the splitting of S2?

Answer 12

It is the delay of the pulmonary valves closing, causing a splitting sound of S2 (aortic valve closing slightly before pulmonary)

Question 13

Is the S3 heart sound normal?

Answer 13

Yes - In young people (<40) and athletes
No - Older people (usually indicated congestive heart failure)

Question 14

When does the S3 heart sound appear?

Answer 14

It occurs early in diastole

Question 15

Is the S4 heart sound normal?

Answer 15

No - always pathological
Occurs in people with coronary artery disease, hypertension and aortic stenosis

Question 16

When does the S4 heart sound appear?

Answer 16

It appears late in diastole