Cardiovascular Examination

Question 1

Introduction

Answer 1

Wash hands, PPE
Introductions
Explanation of the exam and gain consent
Adjust bed to 45
Ask patient to expose themselves from waist up
-offer blanket
Ask about any pain

Question 2

Step 1 General observations (around the bed)

-what could you find

Answer 2

Medical equipment

• O2
• ECGs
• medication, prescriptions
• catheters (contents and location, IV access)

Mobility aids
-mobility status

Pillows
-orthopnea in CCF => cannot lie flat

Charts
- vital signs
- drugs
- fluid balance

Question 3

Step 1 General observations
(patient)
-what may you see
-what could this mean

Answer 3

Complexion
- pallor => anemia (haemorrhage, chronic disease)/poor perfusion(CCF)
- cyanosed => poor circulation(VC)/inadequate oxygenation(R=>L cardiac shunting)

General state

• SOB => CCF, pericarditis or respiratory disease (PE, pneumonia)
• edema => CCF
• malar flush => MITRAL STENOSIS

Question 4

Step 2 Hands

• what might you look for
• what could this mean

Answer 4

Colour
- pallor => poor peripheral perfusion (CCF)
- cyanosis => hypoxemia

Fingers
- tar staining => smoking, CV risk factor
- arachnodactyly (long, slender fingers, toes => Marfans (mitral/aortic prolapse, dissection)

Endocarditis signs
- splinter haemorrhages
- Janeway lesions (non tender haemorrhagic lesions on palms
- Osler’s nodes => red painful lumps on fingers

Question 5

Step 2 Hands
Clubbing
-what could this mean

Answer 5

Infective endocarditis
Atrial myxoma
Congenital cyanotic heart diseases

Question 6

Step 2 Hands
Temperature
CRT
-what could this mean

Answer 6

NORMALLY SYMMETRICALLY WARM
- cool => poor peripheral perfusion (CCF, ACS)
- clammy => ACS

CRT
-greater than 2s => poor peripheral perfusion (hypovolemia, CCF)

Question 7

Step 2 Hands
Pulses
-what could this mean

Answer 7

Radial rate, rhythm, character

• bradycardia => AV block, medications, sick sinus
• tachycardia => anxiety, SVTachy, hypovolemia, hyperthyroidism
• irregular => AF

RRdelay => aortic dissection/coarctation/subclavian artery stenosis

Collapsing pulse => aortic regurgitation, PDA

Question 8

Step 2 Arms
BP
-what could abnormal readings mean

Answer 8

Narrow pulse pressure (less than 25) => aortic stenosis, CCF, tamponade

Wide pulse pressure (more than 100) => aortic regurgitation, dissection

Question 9

Step 2 Neck
Pulses
-what would be abnormal
-what does this mean

Answer 9

Auscultate carotid
NORMALLY SHOULD NOT HEAR ANYTHING
-bruit => carotid stenosis, aortic stenosis

Palpate carotid pulse
-rate, rhythm, character

Question 10

Step 2 Neck
JVP and hepatojugulareflex
-what would be abnormal
-what does this mean

Answer 10

Raised JVP (venous HTN)

• RHF (LHF)
• tricupsid regurgitation (infective endocarditis)
• constrictive pericarditis
• restrictive cardiomyopathy

Question 11

Step 3 Face
Eyes
-what are you looking for
-what does this mean

Answer 11

Conjunctival pallor => anemia
Corneal arcus => hypercholesteremia
Xanthelasma => hypercholesteremia
Kayser Fleischer rings => cardiomyopathy

Question 12

Step 3 Face
Mouth
-what are you looking for
-what does this mean

Answer 12

Central cyanosis => hypoxemia, shunt

Angular stomatitis => Fe deficiency

High arches palate => Marfans (mitral/aortic prolapse, dissection)

Poor dental hygeine => endocarditis

Question 13

Step 4 Chest
Inspection
-what are you looking for
-what does this mean

Answer 13

Scars
-previous thoracic surgery

Pectus excavatum, carinatum => Marfans (aortic/mitral prolapse, dissection)

Visible pulsations => forceful apex beat (ventricular hypertrophy)

Question 14

Step 4 Chest
Palpation
-what are you looking for
-what does this mean

Answer 14

Heaves (heel of hand lifted during systole
-RVhypetrophy

Thrills (palpable vibration from turbulent blood flow over each valve)

Apex beat
-displaced => ventricular hypertrophy

Question 15

Step 4 Chest
Auscultation
-how would you do this
-what does this mean

Answer 15

Auscultate valves with diaphragm and bell

Roll patient onto left
Expiration, hold, axillary - MR accentuation
Expiration, hold, mitral region - MS
Normal breathing, sit patient up
Inspiration, hold - pulmonary, tricupsid accentuation
Expiration, hold - AR
Carotid expiration hold - aortic accentuation => AS

Question 16

Step 5 Posterior
Inspection, auscultations
-what would you look for
-what does this mean

Answer 16

Deformities/scars
Bottom lung field auscultation
-coarse crackles => oulmonary edema (LVF)
-no air entry, stony dull percussion => pleural effusion (LVF)

Question 17

Step 6 Sacrum, legs

• what would you look for
• what does this mean

Answer 17

Sacral pitting edema, Peripheral pitting edema => RVF

Legs (saphenous vein harvest => CABG

Question 18

Completion of examination

Answer 18

Explain to the patient that the examination is now finished
Thank patient for their time
Dispose of PPE, wash hands
Summarise findings

Possible further investigations

• BP
• Peripheral vascular examination
• 12ECG
• dipstick urine (proteinuria, haematuria => HTN)
• Fundoscopy => HTN
• Capillary glucose => DM, CV risk factor

Question 19

Opening script

Answer 19

Hello, I’m An Nakamura, a 3rd year medical student.
Can I confirm your name and and date of birth?
I would like to perform an examination of your heart. This will involve an examination of your hands, arms, face, neck, chest and legs. It will also require you to remove your top.
Is this ok with you?
Do you have any questions for me?