CV Examination

Question 1

General structure of CV exam

Answer 1

General inspection

Obs/vitals

Hands: clubbing, anaemia, signs of SBE

Conjunctivae, tongue

JVP

Carotid pulse and auscultation

Apex beat, heaves, thrills,

Cardiac auscultation: positions, manoeuvres

Chest

Abdomen: hepatosplenomegaly

Oedema (sacral or peripheral)

Peripheral vascular examination

Question 2

How common are peripheral signs of SBE? What are they?

Answer 2

IE is rare and peripheral signs are rare even in cases of IE; absence of peripheral signs does not rule out IE

Suspect IE if there is fever + murmur

Peripheral signs include spinter haemorrhages, Osler’s nodes, Janeway lesions, Roth’s spots, nail-fold infarcts

Question 3

What is the best way to determine severity of valve lesions?

Answer 3

Echo (not physical signs)

Question 4

Is apex beat a reliable measure of heart size?

Answer 4

No

Question 5

What aspects are important to examine for on general inspection?

Answer 5

Colour, breathing, pain, posture

Attachments: ECG monitoring, lines (IV, central venous, arterial), urinary catheter, fluid/drug infusions, incisions, scars, dressings

Question 6

When can the radial artery not be palpated?

Answer 6

Used for coronary grafting (in this case, use ular artery at wrist or brachial artery)

Question 7

What does an irregularly irregular pulse suggest?

Answer 7

AF

Question 8

What does a regularly irregular pulse suggest?

Answer 8

Premature beats (usually)

Question 9

What does jugular venous pressure provide an indication of?

Answer 9

Measurement of R atrial pressure (R-sided filling pressure, which usually correlates with L-sided filling pressure)

“Moderately accurate” (more important whether elevated or not elevated, rather than actual level)

Question 10

6 ways the jugular venous pressure can be distinguished from the carotid pulse

Answer 10

2 to see:

1) Double impulse (if in sinus rhythm)
2) Falls with inspiration, rises with expiration

2 to feel:

3) Not palpable
4) Can be occluded by gentle finger pressure

2 to do:

5) Varies with sitting up or lying down
6) Increases with hepato-jugular reflux

Question 11

What does a raised JVP indicate?

Answer 11

High RA pressure (e.g. in cardiac failure, fluid overload)

Question 12

What does a single wave JVP suggest?

Answer 12

AF

Question 13

What is a JVP which rises with inspiration called and what does it suggest?

Answer 13

Kussmaul’s sign in constrictive pericarditis

Question 14

What does a large “a wave” in the JVP suggest?

Answer 14

Stiff RV

Question 15

What does a large “v wave” in the JVP suggest?

Answer 15

TR

Question 16

What is the carotid pulse a good indicator of?

Answer 16

Most accurate representation of aortic pulse (in time with aortic pulse - the radial is delayed)

Question 17

What does a small volume, late rise carotid pulse indicate?

Answer 17

AS (specific but not sensitive)

Question 18

What does a high volume, rapid fall (collapsing) carotid pulse indicate?

Answer 18

AR

Question 19

What do carotid bruits indicate?

Answer 19

Carotid narrowing; but not sensitive or specific, and poor predictor of TIA and stroke

Question 20

What should be looked for on inspection of the chest wall?

Answer 20

Scars

Visible pulsation

Question 21

In what % of adults is the apex beat palpable?

Answer 21

50%

Question 22

What are the possible different characters of apex beat and what does each suggest?

Answer 22

Heaving (sustained): ventricular hypertrophy

Tapping: loud 1st heart sound (e.g. MS)

Dyskinetic: ventricular dysfunction (e.g. aneurysm)

Question 23

What does listening with the bell help with?

Answer 23

HS (low pitched)

Question 24

What does listening with the diaphragm help with?

Answer 24

Murmurs (high pitched)

Question 25

What added HS may be heard?

Answer 25

S3 before S2

S4 before S1

Question 26

What does S3 indicate?

Answer 26

Turbulence during early filling of ventricle

May be normal or may be due to dilated L ventricle (e.g. in dilated cardiomyopathy, volume overload - MR, AR)

Question 27

What does S4 indicate?

Answer 27

Turbulence during atrial contraction

In stiff ventricle (e.g. HTN, AS, hypertrophic cardiomyopathy)

Question 28

Describe the murmur of AS

Answer 28

Crescendo-decrescendo (“ejection systolic”); increases in volume as pressure increases during systolic ejection

Question 29

Describe the murmur of MR

Answer 29

Pansystolic (there is a very high pressure gradient throughout systole so the murmur has the same intensity)