Cardiovascular Examination Flashcards
Cardiovascular Exam
What are the key steps in the introduction phase of the Cardiovascular Examination, and why is it important to wash your hands and clean the stethoscope?
Introduce yourself, confirm patient identity, explain the procedure, obtain informed consent, offer a chaperone, expose/position the patient, and wash hands/clean stethoscope to ensure hygiene.
What aspects are observed during the general inspection from the end of the bed in the Cardiovascular Examination?
Observe the patient’s alertness, comfort, color, signs of breathlessness, and check for mechanical ticking. Assess the environment for oxygen, medications (especially GTN), and relevant observations on the drug chart or Yellow book.
Cardiovascular Examination
What are the components of the peripheral examination, and what signs are assessed in the hands and arms?
Components include assessing pulse, tar staining, bruising, capillary refill, peripheral cyanosis, and clubbing. Evaluate blood pressure, scars, and bruising in the arms.
Cardiovascular Examination
What steps are involved in inspecting the praecordium during the Cardiovascular Examination?
Inspect for scars (e.g., sternotomy/pacemaker), observe the apex, and palpate for heaves and thrills.
Cardiovascular Examination
What are the key descriptors to consider when assessing murmurs during the Cardiovascular Examination?
Consider position in the cardiac cycle, character, duration, shape, pitch, quality, location, radiation, relationship to breathing, position, and intensity. Use a grading scale for systolic murmurs.
Cardiovascular Examination
How do you conclude the Cardiovascular Examination, and why is it important to explain the next steps to the patient or summarize findings to the supervisor?
Thank the patient, ensure comfort, wash hands, and explain the next steps or summarize findings for effective communication and patient understanding.
Cardiovascular Examination
When differentiating between Aortic Stenosis and Mitral Regurgitation murmurs, what descriptors would you focus on?
Focus on position in the cardiac cycle, character, location, radiation, and intensity to distinguish between Aortic Stenosis and Mitral Regurgitation murmurs.
Cardiovascular Exam
What are Normal Heart Sounds
S1 and S2.
S1 is caused by the closing of atrioventricular valves at the beginning of systole;
S2 is caused by the closing of aortic and pulmonary valves closing at the beginning of diastole
Cardiovascular Examination
Identify the sound
Aortic Stenosis
Cardiovascular Examination
Identify the sound
Aortic Regurgitation
Cardiovascular Examination
Identify the sound
Mitral Regurgitation
Cardiovascular Examination
Heaves
- Place the heel of your hand parallel to the left sternal edge (fingers vertical) to palpate for heaves.
- If heaves are present you should feel the heel of your hand being lifted with each systole.
- Parasternal heaves are typically associated with right ventricular hypertrophy.
Cardiovascular Examination
Thrills
- palpable vibration caused by turbulent blood flow through a heart valve (a thrill is a palpable murmur).
- You should assess for a thrill across each of the heart valves in turn (see valve locations below).
- To do this place your hand horizontally across the chest wall, with the flats of your fingers and palm over the valve to be assessed.
Cardiovascular Examination
How do you Auscultate the four valves?
- Palpate the carotid pulse to determine the first heart sound.
Auscultate through the valve areas using the diaphragm of the stethoscope whilst continuing to palpate the carotid pulse:
Mitral valve: 5th intercostal space in the midclavicular line.
Tricuspid valve: 4th or 5th intercostal space at the lower left sternal edge.
Pulmonary valve: 2nd intercostal space at the left sternal edge.
Aortic valve: 2nd intercostal space at the right sternal edge.
Repeat auscultation across the four valves with the bell of the stethoscope.
(I’ve done this backwards start aortic)
Cardiovascular Examination
What is an Accentuation manoeuvre?
To amplify sounds such as ejection systolic murmur and early diastolic murmur
Cardiovascular manoeuvres
How to find an ejection systolic murmur caused by aortic stenosis.
Auscultate the carotid arteries using the diaphragm of the stethoscope whilst the patient holds their breath to listen for radiation of an ejection systolic murmur caused by aortic stenosis.
Cardiovascular examinaiton
How to find early diastolic murmur caused by aortic regurgitation?
Sit the patient forwards and auscultate over the aortic area with the diaphragm of the stethoscope during expiration to listen for an early diastolic murmur caused by aortic regurgitation.
Cardiovascular examination
How to find a pansystolic murmur caused by mitral regurgitation?
Roll the patient onto their left side and listen over the mitral area with the diaphragm of the stethoscope during expiration to listen for a pansystolic murmur caused by mitral regurgitation. Continue to auscultate into the axilla to identify radiation of this murmur.
Cardiovascular examination
How to find a mid-diastolic murmur caused by mitral stenosis.
With the patient still on their left side, listen again over the mitral area using the bell of the stethoscope during expiration for a mid-diastolic murmur caused by mitral stenosis.
Cardiovascular Examination
Why are we using Bell vs Diaphragm?
The bell of the stethoscope is more effective at detecting low-frequency sounds, including the mid-diastolic murmur of mitral stenosis.
The diaphragm of the stethoscope is more effective at detecting high-frequency sounds, including the ejection systolic murmur of aortic stenosis, the early diastolic murmur of aortic regurgitation and the pansystolic murmur of mitral regurgitation
Cardiovascular Examination
Posterior Chest Wall
- Inspect
- Auscultate Lung fields for crackles (PE and Left Ventricular failure) and for abstend air entry and dullness for pleural effusion (left ventricular failure)
- Sacral pitting oedema
- Legs and ankles for pitting pedal oedema (right ventricular failure)
- Inspect the patient’s legs for evidence of saphenous vein harvesting (performed as part of a coronary artery bypass graft).
Cardiovascular Examination
To complete the examination
Explain to the patient that the examination is now finished.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your findings.
Cardiovascular Examination
Example Summary
Example summary
“Today I examined Mrs Smith, a 64-year-old female. On general inspection, the patient appeared comfortable at rest and there were no objects or medical equipment around the bed of relevance.”
“The hands had no peripheral stigmata of cardiovascular disease and were symmetrically warm, with a normal capillary refill time.”
“The pulse was regular and there was no radio-radial delay. On auscultation of the carotid arteries, there was no evidence of carotid bruits and on palpation, the carotid pulse had normal volume and character.”
“On inspection of the face, there were no stigmata of cardiovascular disease noted in the eyes or mouth and dentition was normal.”
“Assessment of the JVP did not reveal any abnormalities and the hepatojugular reflux test was negative.”
“Closer inspection of the chest did not reveal any scars or chest wall abnormalities. The apex beat was palpable in the 5th intercostal space, in the mid-clavicular line. No heaves or thrills were noted.”
“Auscultation of the praecordium revealed normal heart sounds, with no added sounds.”
“There was no evidence of peripheral oedema and lung fields were clear on auscultation.”
“In summary, these findings are consistent with a normal cardiovascular examination.”
“For completeness, I would like to perform the following further assessments and investigations.”
Cardiovascular Examination
Further investigations to offer:
- Measure blood pressure: to identify hypotension, hypertension or significant discrepancies between the two arms suggestive of aortic dissection.
- Peripheral vascular examination: to identify peripheral vascular disease, which is common in patients with central cardiovascular pathology.
- Record a 12-lead ECG: to look for evidence of arrhythmias or myocardial ischaemia.
- Dipstick urine: to identify proteinuria or haematuria which can be associated with hypertension.
- Bedside capillary blood glucose: to look for evidence of underlying diabetes mellitus, a significant risk factor for cardiovascular disease.
- Perform fundoscopy: if there were concerns about malignant hypertension, fundoscopy would be performed to look for papilloedema.
Cardiovascular Exam
Colour is a sign of….
Inspection
pallor suggests poor peripheral perfusion (e.g. congestive heart failure) and cyanosis may indicate underlying hypoxaemia.
Cardiovascular Exam
Tar staining is a sign of….
Inspection
: caused by smoking, a significant risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension).
Cardiovascular Exam
Xanthomata is ….
Inspection
raised yellow cholesterol-rich deposits that are often noted on the palm, tendons of the wrist and elbow. Xanthomata are associated with hyperlipidaemia (typically familial hypercholesterolaemia), another important risk factor for cardiovascular disease (e.g. coronary artery disease, hypertension).
Cardiovascular Exam
Arachnodactyly is
Inspection
fingers and toes are abnormally long and slender, in comparison to the palm of the hand and arch of the foot. Arachnodactyly is a feature of Marfan’s syndrome, which is associated with mitral/aortic valve prolapse and aortic dissection.
Cardiovascular Exam
Finger clubbing is ….
Inspection
Ask the patient to place the nails of their index fingers back to back.
In a healthy individual, you should be able to observe a small diamond-shaped window (known as Schamroth’s window)
When finger clubbing develops, this window is lost.
most likely to appear in a cardiovascular OSCE station include congenital cyanotic heart disease, infective endocarditis and atrial myxoma (very rare).
Cardiovascular Exam
Splinter haemorrhages are..
Inspection
longitudinal, red-brown haemorrhage under a nail that looks like a wood splinter. Causes include local trauma, infective endocarditis, sepsis, vasculitis and psoriatic nail disease.
ENDOCARDITIS
Cardiovascular Exam
Janeway lesions are….
Inspection
non-tender, haemorrhagic lesions that occur on the thenar and hypothenar eminences of the palms (and soles). Janeway lesions are typically associated with infective endocarditis.
ENDOCARDITIS
Cardiovascular Exam
Osler’s nodes are….
Inspection
red-purple, slightly raised, tender lumps, often with a pale centre, typically found on the fingers or toes. They are typically associated with infective endocarditis.
Palpation
ENDOCARDITIS
Cardiovascular Examination
Temperature suggests…
Palpation
In healthy individuals, the hands should be symmetrically warm, suggesting adequate perfusion.
Cool hands may suggest poor peripheral perfusion (e.g. congestive cardiac failure, acute coronary syndrome).
Cool and sweaty/clammy hands are typically associated with acute coronary syndrome.
Cardiovascular Examination
Capillary Refill time
Apply five seconds of pressure to the distal phalanx of one of a patient’s fingers and then release.
In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two seconds.
A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g. hypovolaemia, congestive heart failure) and the need to assess central capillary refill time.
Cardiovascular Examination
Assessing Heart Rate
You can calculate the heart rate in a number of ways, including measuring for 60 seconds, measuring for 30 seconds and multiplying by 2 or measuring for 15 seconds and multiplying by 4. The shorter the interval used, the higher the risk of obtaining an inaccurate result, so wherever possible, you should palpate for a full 60 seconds.
For irregular rhythms, you should measure the pulse for a full 60 seconds to improve accuracy.
Cardiovascular Examination
Normal and Abnormal Heart Rates
- In healthy adults, the pulse should be between 60-100 bpm.
- A pulse <60 bpm is known as bradycardia and has a wide range of aetiologies (e.g. healthy athletic individuals, atrioventricular block, medications, sick sinus syndrome).
- A pulse of >100 bpm is known as tachycardia and has a wide range of aetiologies (e.g. anxiety, supraventricular tachycardia, hypovolaemia, hyperthyroidism).
- An irregular rhythm is most commonly caused by atrial fibrillation, but other causes include ectopic beats in healthy individuals and atrioventricular blocks.
Cardiovascular Examination
Radio Radial Delay
**loss of synchronicity between the radial pulse on each arm, resulting in the pulses occurring at different times.
**
Palpate both radial pulses simultaneously.
In healthy individuals, the pulses should occur at the same time.
If the radial pulses are out of sync, this would be described as radio-radial delay.
Causes of radio-radial delay include:
Subclavian artery stenosis (e.g. compression by a cervical rib)
Aortic dissection
Aortic coarctation
Cardiovascular Examination
What is a collapsing pulse?
- is a forceful pulse that rapidly increases and subsequently collapses. It is also sometimes referred to as a ‘water hammer pulse’.
- Ask the patient if they have any pain in their right shoulder, as you will need to move it briskly as part of the assessment for a collapsing pulse (if they do, this assessment should be avoided).
- Palpate the radial pulse with your right hand wrapped around the patient’s wrist.
- Palpate the brachial pulse (medial to the biceps brachii tendon) with your left hand, whilst also supporting the patient’s elbow.
- Raise the patient’s arm above their head briskly.
- Palpate for a collapsing pulse: As blood rapidly empties from the arm in diastole, you should be able to feel a tapping impulse through the muscle bulk of the arm. This is caused by the sudden retraction of the column of blood within the arm during diastole.
Cardiovascular Examination
What are the causes of a collapsing pulse?
Normal physiological states (e.g. fever, pregnancy)
Cardiac lesions (e.g. aortic regurgitation, patent ductus arteriosus)
High output states (e.g. anaemia, arteriovenous fistula, thyrotoxicosis)
Cardiovascular Examination
Auscultate the carotid artery
Prior to palpating the carotid artery, you need to auscultate the vessel to rule out the presence of a bruit. The presence of a bruit suggests underlying carotid stenosis, making palpation of the vessel potentially dangerous due to the risk of dislodging a carotid plaque and causing an ischaemic stroke.
Place the diaphragm of your stethoscope between the larynx and the anterior border of the sternocleidomastoid muscle over the carotid pulse and ask the patient to take a deep breath and then hold it whilst you listen.
Be aware that at this point in the examination, the presence of a ‘carotid bruit’ may, in fact, be a radiating cardiac murmur (e.g. aortic stenosis).
Cardiovascular Examination
Palpate the carotid pulse
If no bruits were identified, proceed to carotid pulse palpation:
- Ensure the patient is positioned safely on the bed, as there is a risk of inducing reflex bradycardia when palpating the carotid artery (potentially causing a syncopal episode).
- Gently place your fingers between the larynx and the anterior border of the sternocleidomastoid muscle to locate the carotid pulse.
- Assess the character (e.g. slow-rising, thready) and volume of the pulse.
Cardiovascular examination
JVP
provides an indirect measure of central venous pressure. the internal jugular vein (IJV) connects to the right atrium without any intervening valves, resulting in a continuous column of blood.
Position the patient in a semi-recumbent position (at 45°).
- Ask the patient to turn their head slightly to the left.
- Inspect for evidence of the IJV, running between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid (it may be visible between just above the clavicle between the sternal and clavicular heads of the sternocleidomastoid. The IJV has a double waveform pulsation, which helps to differentiate it from the pulsation of the external carotid artery.
- Measure the JVP by assessing the vertical distance between the sternal angle and the top of the pulsation point of the IJV (in healthy individuals, this should be no greater than 3 cm).
Cardiovascular Examination
What causes a raised JVP
Right-sided heart failure: commonly caused by left-sided heart failure. Pulmonary hypertension is another cause of right-sided heart failure, often occurring due to chronic obstructive pulmonary disease or interstitial lung disease.
Tricuspid regurgitation: causes include infective endocarditis and rheumatic heart disease.
Constrictive pericarditis: often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying causes.
Cardiovascular Examination
Conjunctival pallor
Inspection
suggestive of underlying anaemia. Ask the patient to gently pull down their lower eyelid to allow you to inspect the conjunctiva.
Cardiovascular Examination
Corneal arcus
Inspection
a hazy white, grey or blue opaque ring located in the peripheral cornea, typically occurring in patients over the age of 60. In older patients, the condition is considered benign, however, its presence in patients under the age of 50 suggests underlying hypercholesterolaemia.
Cardiovascular Examination
Xanthelasma
Inspection
yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia.
Cardiovascular Examination
Kayser-Fleischer Rings
dark rings that encircle the iris associated with Wilson’s disease. The disease involves abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues (including the heart where it can cause cardiomyopathy).
Cardiovascular Examination
Central cyanosis
Inspection
bluish discolouration of the lips and/or the tongue associated with hypoxaemia (e.g. a right to left cardiac shunt)
Cardiovascular Examination
Angular stomatitis
Inspection
a common inflammatory condition affecting the corners of the mouth. It has a wide range of causes including iron deficiency.
Cardiovascular Examination
High arched palate:
a feature of Marfan syndrome which is associated with mitral/aortic valve prolapse and aortic dissection.
Cardiovascular Examination
Dentition
Inspection
Poor dental hygiene risk for infective endocarditis
Cardiovascular examination
Pectus excavatum
Inspection
: a caved-in or sunken appearance of the chest.
Cardiovascular Examination
Pectus carinatum
Inspection
protrusion of the sternum and ribs
Cardiovascular examination
Visible pulsations
Inspection
a forceful apex beat may be visible secondary to underlying ventricular hypertrophy.
Cardiovascular examination
Thoracic Scars
Inspection
- Median sternotomy scar: located in the midline of the thorax. This surgical approach is used for cardiac valve replacement and coronary artery bypass grafts (CABG).
- Anterolateral thoracotomy scar: located between the lateral border of the sternum and the mid-axillary line at the 4th or 5th intercostal space. This surgical approach is used for minimally invasive cardiac valve surgery.
- Infraclavicular scar: located in the infraclavicular region (on either side). This surgical approach is used for pacemaker insertion.
- Left mid-axillary scar: this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-defibrillator (ICD).
Cardiovascular Exam
Identify:
Inspection
Peripheral Cyanosis
Cardiovascular Exam
Identify:
Inspection
Tar Staining
Cardiovascular Exam
Identify:
Inspection
Oslers Nodes
Cardiovascular Exam
Identify:
Inspection
Janeway Lesions
Cardiovascular Exam
Identify:
Inspection
Clubbing
Cardiovascular Exam
Identify:
Inspection
Splinter Haemorrhage
Cardiovascular Exam
Identify:
Inspection
CABG scar
Cardiovascular Exam
Identify:
Inspection
Malar Flush
Cardiovascular Exam
Identify:
Inspection
Xanthalasma
Cardiovascular Exam
Identify:
Inspection
Corneal Arcus
Cardiovascular Exam
Identify:
Inspection
Conjunctival Palor
Cardiovascular Exam
Identify:
Inspection
Central Cyanosis
Cardiovascular Exam
Identify:
Inspection
Midline Sternotomy
Cardiovascular Exam
Identify:
Inspection
Pacemaker
Cardiovascular Exam
Identify:
Inspection
Sacral Oedema
Cardiovascular Exam
Identify:
Inspection
Ankle Oedema
Cardiovascular Exam
Identify:
Inspection
CABG scar
Cardio Exam
Introduction
Name/role
Check patients name
Explain examination and exposure
Explain that they will be examined again by supervisor
Consent
Offer Chaperone
Document
Ask about pain
Clean your hands and stethoscope (unless using patients own)
Position at 45 degrees
Ensure adequate exposure
Cardio exam
Inspection
Bedside
Equipment (ECG, GTN spray, oxygen)
Patient
Distress/Pain/Pallor/Cyanosis/Sweating/Breathless
Cardio exam
Hands
HANDS
Nails
Clubbing (congenital heart disease, atrial myxoma, endocarditis)
Splinter haemorrhages (infective endocarditis)
Capillary refill time (2-3s)
Tar stains (smoker)
Sweaty/clammy (e.g. MI)
Peripheral cyanosis
Peripheral stigmata of infective endocarditis (Janeway lesions, Osler’s nodes)
Cardio exam
Radial Pulse
RADIAL PULSE
Rate (15s X 4 [normal is 60-100])
Rhythm (regular, irregular)
Character (slow rising = AS, collapsing = AR)
Volume (hypovolaemic/’thready’ - MI/heart failure/AS))
Radial-radial delay (aortic dissection)
Radial-femoral delay
Cardio exam
Resp
RESPIRATORY RATE
15s X 4 (N = 12-16)
Cardio exam
ARMS
ARMS
Blood pressure
Pulse pressure (wide/>40 = AR, narrow/<40 = AS)
Scars
CABG graft from radial artery
Cardio exam
Face
EYES
Xanthalasma (hyperlipidaemia)
Corneal arcus (hyperlipidaemia)
Conjunctival pallor (anaemia)
FACE
Malar flush (MS)
MOUTH
Central cyanosis
Dental hygiene
Dehydration
Cardio exam
Neck
NECK
JVP (>3cm = R heart failure, TR)
Carotid pulse
Volume
Slow rising
Cardio exam
CHEST
INSPECTION
Scars (e.g. midline sternotomy)
Pacemaker
Apex beat
Metallic heart valve (audible without stethoscope)
Cardio exam
PALPATION
Apex beat
Heaves (L parasternal heave = RVH)
Thrills
Cardio exam
AUSCULTATION
HS 1+2 (time with carotid pulse )
Murmurs + added sounds
Time with carotid pulse
Inspiration (to accentuate R sided sounds) and expiration (accentuate L sided sounds)
Apex/mitral (5th ICS mid-clavicular line)
Bell and diaphragm
Tricuspid (4th ICS L sternal edge)
Pulmonary (2nd ICS L sternal edge)
Aortic (2nd ICS R sternal edge)
Special positions
Left lateral position with bell over mitral area -MS murmur
Sitting up, leaning forward with diaphragm over left sternal edge - AR murmur
For radiation
Carotid
Axilla
For bruit
Carotid
Lung bases (crackles- pulmonary oedema)
Cardio exam
BACK/ANKLES/SHINS
Sacral oedema
Peripheral oedema
Signs of PVD
cardio exam
CONSIDER OTHER EXAMINATIONS
Peripheral vascular examination
Abdomen - enlarged liver (in heart failure)
Fundoscopy (flame shaped haemorrhages in infective endocarditis)
Temperature (pyrexia in infective endocarditis)
