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Question 1

Outline the general headings for a CVS examination

Answer 1

IntroGeneral inspectionHandsNeckFaceChestPeripheryConclusions

Question 2

Outline the introduction

Answer 2

Wash handsIntroduce selfCheck patient detailsExplain Consent

Question 3

Describe patient positioning

Answer 3

Lying at 45 degreesStrip to waist for general inspection(For females, remember to cover up again until auscultation)

Question 4

What do you look for in general inspection?

Answer 4

Obvious discomfort or painScarsDeformitiesColourBreathlessnessItems of note around the bed (Nitrate spray, ECG, IV fluids, Oxygen mask)Congenital abnormalities e.g. Down syndrome, Marfan’s

Question 5

Outline hand inspection

Answer 5

1. Inspection2. Radial Pulse3. Brachial pulse

Question 6

What do you look for in hand inspection?

Answer 6

Tar stainingClubbingOsler’s nodesJaneway lesionsCapillary refillSplinter haemmorhages

Question 7

What do you do for the radial pulse?

Answer 7

Check rate fro 15s then multiply by 4Regular/Irregular?CharacterRespiratory rateCollapsing pulse

Question 8

What do you do for brachial pulse?

Answer 8

VolumeCharacterBlood pressure

Question 9

Outline face inspection

Answer 9

EyesMouthColour

Question 10

What do you look out for with the patient’s colour?

Answer 10

PaleCyanosedMalar flushMitral facies

Question 11

What do you look out for with the mouth?

Answer 11

Dental hygieneCyanosisAnaemia

Question 12

What do you look for with the eyes?

Answer 12

Pale conjunctivaCorneal arcusXanthelasma

Question 13

What do you look for at the patients neck?

Answer 13

Jugular venous pressureCarotid pulse

Question 14

What type of things can you feel with the carotid pulse?

Answer 14

1. Collapsing (rapid up and downstroke - aortic regurg)2. Bisiferiens (both collapse and plateau)3. Pulsus alternans (high/low - severe L heart failure)4. Slow rising - aortic stenosis5. Pulsus paradoxicus - vol decreases on inspiration - tamponade, constrictive pericarditis, asthma

Question 15

What type of things can you see with the JVP?

Answer 15

Raised JVP (above 4cm)- R heart failure due to fluid overload

Question 16

Outline what you would examine for at the chest

Answer 16

InspectionPalpationAuscultation

Question 17

Describe what you are looking for when you inspect the chest

Answer 17

ScarsDeformitiesVisible apical pulsationAudible prosthetic heart valveColour

Question 18

Describe what you do when you palpate the chest

Answer 18

Apex beat- roll to left if strugglingHeaves- just L of sternumThrills - in valvular areas

Question 19

Describe what you are auscultating for

Answer 19

1. Apex/ mitral2. Tricuspid3. Pulmonary4. Aortic5. Carotid Bruits6. Aortic regurgitation7. Lung bases

Question 20

What specifically are you listening for with heart sounds?

Answer 20

Normal sounds Any additional sounds - normal sounds will be in time with the carotid pulsations

Question 21

Where do you listen for the mitral valve?

Answer 21

5th intercostal space, left mid-clavicular line

Question 22

Where do you listen for the tricuspid valve?

Answer 22

4th intercostal space, left sternal edge

Question 23

Where do you listen for the pulmonary valve?

Answer 23

2nd intercostal space, left sternal edge

Question 24

Where do you listen for the aortic valve?

Answer 24

2nd intercostal space, right sternal edge

Question 25

Where can you best hear the first heart sound?

Answer 25

Over the mitral valve

Question 26

Where can you best hear the second heart sound?

Answer 26

Over the pulmonary and aortic valve

Question 27

What accentuates left-sided murmurs?

Answer 27

Holding the breath in expiration

Question 28

What accentuates right-sided murmurs?

Answer 28

Holding the breath in inspiration

Question 29

How can you accentuate mitral regurgitation?

Answer 29

Roll patient to the left and listen with the bell over the axilla

Question 30

Where can you hear aortic stenosis?

Answer 30

Whilst listening over the carotid arteries

Question 31

How can you accentuate aortic regurgitation?

Answer 31

Sit the patient forward, ask them to breathe out and hold it whilst you listen over the 5th intercostal space, left sternal edge

Question 32

How do you listen for the lung bases?

Answer 32

Sit the patient forward, listen for any evidence of peripheral oedema/ infection. At the level of T10

Question 33

Describe how you examine the periphery for a CVS examination

Answer 33

Whilst Pt is sitting forward for lung bases, inspect the patient for signs of sacral oedema. Also, palpate for peripheral oedema at the feet by pressing firmly over the tibia for 5 secs behind the medial malleolus and feel if an indentation remains. Check how high up the leg the pitting extends.

Question 34

Where would you find peripheral oedema in a standing and in a bed-bound patient?

Answer 34

Standing – feetBed-bound – sacrum

Question 35

How would you complete the CVS examination?

Answer 35

Cover patient upThank patientAbdominal examBedside testsFundoscopyFull peripheral vascular examination

Question 36

Why would you follow a CVS exam with an abdominal exam?

Answer 36

Check for hepatosplenomegaly and ascites which are signs of heart faliure

Question 37

What bedside tests would you perform after a CVS exam?

Answer 37

TemperatureUrine dipstick Blood pressure

Question 38

Why would you perform a fundoscopy?

Answer 38

In case of:- diabetes- endocarditis- hypertension

Question 39

What does a full peripheral vascular examination involve?

Answer 39

Checking for:- radial- ulnar- brachial- carotid- abdominal aorta- femoral - popliteal- posterior tibialis- dorsalis pedis