Clinical Skills - CV Exam

Question 1

Examination Structure

Answer 1

Introduction
Patient identification
Gain consent
Obtain chaperone (if required)
General inspection
Pulses
Palpitation
Auscultation
Conclude the examination

Question 2

End of bed inspection

Answer 2

From end of bed look for:

Environment:
Cardiac monitors
Oxygen
GTN sprays
IV drips
Look at observation chart/NEWS chart

Patient:
Look well/unwell
In pain/comfortable
SoB
Sweaty/clammy
Scars - central sternotomy scar, pacemaker

Question 3

Inspection of hands

Answer 3

Look for:
Clubbing - congenital heart disease
Tar staining - smoker (risk factor)
Splinter haemorrhages - infective endocarditis
Janeway’s lesions (non tender) - infective endocarditis
Osler’s nodes (tender) - infective endocarditis
Colour
Warmth
Measure capillary refill time - squeeze finger/thumb for 5s, should go back to normal in 2s

Question 4

Pulses

Answer 4

Radial pulse - rate and rhythm (regular, regularly irregular, irregularly irregular)
Radio-radial delay - should be synchronous
Mention radio-femoral delay
Collapsing pulse - sign of aortic regurgitation
Brachial pulse (arm)
Carotid pulses - one at a time
Blood pressure
JVP - patient look away, look at neck for a double pulsation (raised in right sided HF and can be caused by resp. diseases), not palpable, should be no higher than 3 fingers (4cm) above the sternal angle with patient at 45 degrees.

Question 5

Inspection of face

Answer 5

Inspect eyes and surrounding tissue for:

• Corneal arcus - deposit of cholesterol, phospholipids and triglycerides in an ‘arc’ on the top or bottom of the iris in the cornea
• Xanthelasma - yellowish-white lumps of fatty material accumulated under the skin on the inner parts of the upper and lower eyelids

Inspect cheeks for a rosy appearance:
- Malar flush - associated with mitral stenosis

Inspect the mouth for:

• Central cyanosis - when lips/tongue/mouth turn blue
• Poor dentition (teeth inspection) - a route of entry for bacteria, consider in infective endocarditis

Question 6

Inspection of precordium (chest wall)

Answer 6

Observe chest wall for:

• Shape - pectus excavatum (breastbone sunk into chest), carinatum (chest pokes out), scoliosis (sideways curvature of spine)
• Scars - midline or median sternotomy, pacemaker - left upper chest
• Pulsation - visible heaving or flickering

Question 7

Palpation

Answer 7

Palpate:

• Apex beat - 5th intercostal space (ICS), mid-clavicular line (displaced in left ventricular dilation from severe hypertension, aortic stenosis or dilated cardiomyopathy)
• Thrills - vibrations of palpable murmur at each valve location (like a cat purring or phone vibrating)
• Heaves - a forward motion generated by hypertrophy of the underlying cardiac tissue (get patient to hold breath in expiration)

2 manoeuvres:

• Patient roll on left side (apex beat)
• Patient lean forward (heaves)

Question 8

Auscultation

Answer 8

Heart sounds should be timed with carotid pulse - place thumb on carotid pulse, S1 should barely precede pulse, S2 is clearly out of phase

Aortic valve - right sternal edge in 2nd ICS
Pulmonary valve - left sternal edge, 2nd ICS
Tricuspid valve - 4th ICS of left sternal edge
Mitral valve - 5th ICS, mid-clavicular line

Systolic murmurs are aortic stenosis or mitral regurgitation (ASMR).

Also listen to axilla (armpit) for radiation of mitral regurgitation and carotids for radiation of aortic stenosis or a carotid bruit (turbulent flow of stenotic vessel)

Diastolic murmurs are aortic regurgitation or mitral stenosis (ARMS)
AR - patient sitting up
MS - patient lying on left side

Question 9

Concluding examination

Answer 9

Auscultate the chest posteriorly to listen to bases of lungs for fine crackles (associated with pulmonary oedema - sign of left sided HF).
If abnormal, examine sacrum and ankles for oedema (sign of right sided HF)

Check for pitting oedema - press with 2-3 fingers for a few seconds and release, may be uncomfortable, look for impression of fingers

Thank patient, wash hands, any questions?