Examination

Question 1

General inspection

Answer 1

• Cyanosis
• SOB
• Pallor
• Malar Flush
• Oedema
• Check for number of pillows
  -Fluid balance

Question 2

Hand inspection

Answer 2

• Colour
• Tar staining
• Xanthomata
• Arachnodactyly -
• Clubbing
• Splinter haemorrhages -
• Janeway lesions
• Osler nodes

Question 3

Palpation

Answer 3

• Temperature
• CRT
• Radial pulse - radio radial delay -
• Assess for collapsing pulse brachailly - Slow-rising (associated with aortic stenosis). Bounding (associated with aortic regurgitation as well as COretention). Thready (associated with intravascular hypovolaemia in conditions such as sepsis)
• BP- high low wide narrow difference
• Carotid pulse
• JVP and HPR

Question 4

Face

Answer 4

• Eyes - pallor, corneal arcus, Xanthelasma, Kayser-fleischer rings
• Mouth - Cyanosis, stomatitis, high arched palate, dental hygiene

Question 5

Chest

Answer 5

• Scars
• Pectus excavatum
• Pectus Carinatum
• Visible pulsations
• Palpate apex beat, heaves, thrills,
• Auscultate with both diaphragm and bell all 4 valves
• Auscultate left axilla for mitral incompitance
• Auscultate carotid pulse for aortic stenosis

Question 6

Accenuation manoeuvres aortic regurgitation

Answer 6

Sit the patient forwards and auscultate over theaorticareawith the diaphragm of the stethoscope duringexpirationto listen for anearly diastolic murmurcaused byaortic regurgitation.

Question 7

Accenuation manoeuvres mitral regurgitation

Answer 7

Roll the patient onto theirleft sideand listen over themitral areawith thediaphragm of the stethoscopeduring expirationto listen for apansystolic murmurcaused bymitral regurgitation. Continue to auscultate into theaxillato identifyradiationof this murmur.

Question 8

Mitral stenosis accentuation

Answer 8

With the patientstill on their left side,listen again over themitral areausing thebell of the stethoscopeduring expirationfor amid-diastolic murmurcaused bymitral stenosis.

Question 9

Aortic stenosis accentuation

Answer 9

Auscultate thecarotidarteriesusing the diaphragm of the stethoscope whilst the patient holds their breath to listen for radiation of anejection systolic murmurcaused byaorticstenosis.

Question 10

Final steps

Answer 10

• Posterior chest wall for scars or deformities
• Sacral oedema
• Legs
• BP in both arms standing and sitting
• Ophthalmoscopy for hypertensive retinopathy.

Question 11

Further investigatiojns

Answer 11

BP
Peipheral vascular examination
Dipstick urine - proteinuria with HTN
BG
Fundoscopy
ECG

Question 12

Thoracic scars

Answer 12

• Median sternotomy scar:located in the midline of the thorax. This surgical approach is used for cardiac valve replacement and coronary artery bypass grafts (CABG).
• Anterolateral thoracotomy scar:located between the lateral border of the sternum and the mid-axillary line at the 4or 5intercostal space. This surgical approach is used for minimally invasive cardiac valve surgery.
• Infraclavicular scar:located in the infraclavicular region (on either side). This surgical approach is used for**pacemaker insertion.
• Left mid-axillary scar:this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-defibrillator (ICD).

Question 13

Causes of clubbing

Answer 13

• congenital cyanotic heart disease,infective endocarditisandatrial myxoma(very rare).

Question 14

Causes of splinter haemorrhages

Answer 14

Causes include local trauma, infective endocarditis, sepsis, vasculitis and psoriatic nail disease.

Question 15

Causes of arachnodactyly

Answer 15

a feature of Marfan’s syndrome, which is associated with mitral/aortic valve prolapse and aortic dissection.

Question 16

Cause of radio and radial delay

Answer 16

Subclavian artery stenosis (e.g. compression by a cervical rib). Aortic dissection. Aortic coarctation

Question 17

Types of pulse abnormalities

Answer 17

• Slow-rising (associated with aortic stenosis). Bounding (associated with aortic regurgitation as well as COretention). Thready (associated with intravascular hypovolaemia in conditions such as sepsis)