CVS

Question 1

1. Introduction

Answer 1

1. Wash hands
2. Introduce self to patient- full name, PA student, role
3. Confirm patient full details
4. Confirm confidentiality
5. Explain exam- conducting a cardiovascular examination. I will be examining your heart, this will involve me standing & inspecting you from the end of the bed and moving in closer and having a look at your chest, feeling your chest and inspecting your chest.
6. Is that ok?
7. Are you in any pain today?
8. Can you remove your socks, shoes and undress form the waist upwards and lie back in the bed
9. Thank you

Question 2

2. General observation (patient sitting or lying down) notes for:

Answer 2

1. Is patient comfortable / distressed at rest?
2. Patient’s build
3. Obvious scars / mechanical sounds
4. Scars: median sternotomy, lateral thoractomy, left upper chest (pacemaker/bypass below)
5. Medical equipment- look around bed-oxygen, cardiac monitor, medications
6. Head nodding- de Musset sign - aortic insufficiency
7. Chest deformities - pectus excavatum sunken, pectus carinatum pigeon
8. Lift arm up one by one for visible heaves and audible prosthetic valves

Question 3

3. Hands

Answer 3

1. Ask about pain before touching patient
2. Look at hands
3. Lift arms straight at front palms down
4. Look at both hands together
5. Pallor- pale colour of skin - due to anaemia, reduced oxyhaemoglobin
6. Peripheral cyanosis- bluish- low oxygen levels in RBC or peripheral vasoconstriction
7. Temperature
8. Tar staining- Rothman’s sign
9. Clubbing - congenital cyanotic heart disease, SBE, loss of Schamroth’s window
10. Splinter haemorrhages- SBE, IE, trauma
11. Rheumatic nodules- limbs under skin close to joints
12. PALMS UP
13. Janeway lesions- palm- SBE
14. Osler’s nodes- SBE - fingers
15. Tendon xanthomas- nodules in tendons of skin- familial hypercholesterolemia fatty yellow deposits
16. Polydactyly - extra fingers
17. Capillary refill (<2 secs normal) turn over hand
18. Cubitus valgus (increased angle )
19. Marfan’s syndrome - extra long fingers

Question 4

4. Arms

Answer 4

1. Assess radial pulse
2. Rate, rhythm, synchrony
3. Do both simultaneous for radial radial delay- aortic coarctation (bilateral)
4. Ask for pain in shoulder
5. Collapsing pulse using radial artery lift over head quickly
6. State would do blood pressure

Question 5

5. Face and eyes

Answer 5

1. Look closely at eyes: Arcus Senilis - grey/white ring around cornea - due to hyperlipidemia if under 60 y/I
2. Pull down eyelid - Anaemia- pale conjunctiva
3. State would do fundoscopic exam
4. Xanthelasma - hyperlipidaemia - yellow deposits of fat underneath skin around eyelids
5. Mahar flush- red butterfly rash - discolouration - due to mitral stenosis due to resulting C02 retention and vasodilatory effects

Question 6

6. Mouth

Answer 6

1. Dentition- source of endocarditis - infection of heart valves / inner lining by bacteria
2. Central cyanosis - stuck tongue to roof of mouth, hypoxia, bluish
3. Angular stomatis- iron deficiency anaemia- inflammatory condition sides of mouth

Question 7

7. Neck

Answer 7

1. Ensure mech relaxed and turned to LHS
2. Patient 45 degrees
3. Look for JVP (sternocleidomastoid border) use internal jugular vein. Shouldn’t be seen.
4. Carotid pulse - auscultation bell then palpate - character and volume. Number of beats 10 secs x 6. Is HR per min.
5. Do you have any pain in your tummy?
6. Do you mind if I press on your tummy?
7. Hepatojugular reflex - pressure on liver observe for rise in JVP (positive result= sustained rise >4 cm not good!)

Question 8

8. Chest - palpate

Answer 8

1. Apex beat: (5 ICS/ MCL) (character and position)
2. Lay hand flat on chest
3. Heaves- ventricular hypertrophy
4. Thrills- vibrating sensation - palpable murmurs both LHS/RHS

Question 9

9. Chest- auscultation

Answer 9

1. I am now going to listen to your heart and feel the pulse in your neck at same time
2. Apex bell (mitral stenosis)
3. Apex bell with person turned to left lateral position- repalpate apex first
4. Tricuspid bell
5. Aortic bell 2nd intercostal space right sternal edge edge
6. Pulmonary at 2nd intercostal space left sternal edge
7. Carotids bell for Brutus or aortic stenosis

Question 10

9. Chest auscultation part 2

Answer 10

1. Diaphragm
2. Apex - mitral regurgitation in expiration
3. Tricuspid- tricuspid stenosis / regurg. In inspiration
4. Pulmonary area- pulmonic stenosis
   Aortic area- aortic stenosis
5. Patient seated forward aortic regurgitation in tricuspid area
6. Lung bases sit UP RIGHT diaphragm for pulmonary oedema with left ventricular failure or fluid overload
7. Sacrum oedema push down- indent?
8. Ankle oedema - indent? ( right ventricular failure)

Question 11

10. Conclusion

Answer 11

1. If indicated I would do blood pressure, peripheral vascular exam, urine dip, bedside capillary blood glucose, record 12 lead ECG (arrhythmias).
2. Wash hands
3. Dress
4. Summarise- no stigmata of CVS disease. Patient is a healthy X X.