Medicine Bedside: CVS Examination

Question 1

2 parts of Examination

Answer 1

1. General examination
   - Inspection:
   —> Face: Down’s, Marfanoid features, Pallor, Cyanosis (Central + Peripheral), Malar flush (MS associated with pulmonary hypertension), Edema, High arch palate (Marfan)

—> Hands: Finger clubbing (Cyanotic heart disease, Infective endocarditis), Splinter haemorrhage, Osler nodes, Janeway lesion, Tar stain, Arachnodactyly (Marfan)

—> Lower limb: Ankle edema, Toe clubbing, Ulcer, Temperature

2. Cardiovascular examination
   - Arterial system: Pulses (Rate, Rhythm, Volume, Character)
   - Venous system: JVP
   - Heart: Precordium

Question 2

Characteristic of pulse

Answer 2

1. Carotid pulse:
   - **Volume + **Character
   - right thumb on left neck / vice versa
2. Radial pulse:
   - Collapsing pulse / Corrigan’s sign (rapid upstroke, rapid decay: more obvious when raise hand)
   —> **Aortic regurgitation (next stroke volume ↑ —> radial pulse reappear)
   —> **Hyperdynamic circulation (anaemia, AV fistula, thyrotoxicosis)
   —> ***PDA
   —> Atrioventricular malformation

• Radio-radial delay
  —> **Aortic dissection
  —> **Subclavian stenosis
  —> ***Severe peripheral arterial disease
• Radio-femoral delay
  —> ***Aortic coarctation (主動脈窄縮)

3. JVP (reflect Right atrial pressure)
   - IJV: lateral to SCM
   - measure from sternal angle
   - normal: level below clavicle, not observable
   - pathological: level at neck, observable
   - lower bed to make JVP more obvious

• distinguish from carotid pulsation
  —> JVP: visible but not palpable, can be obliterated but pressing against clavicle, change with posture / inspiration / expiration
  —> carotid pulse: palpable
• Hepato-jugular reflux
  —> right costal margin
  —> increase blood return to right heart to increase right atrial pressure
• DDx
  —> ***Right heart failure
  —> Tricuspid regurgitation
  —> Tricuspid stenosis

Question 3

Heart: Precordium

Answer 3

Inspection:
1. Chest wall deformity
- Chest wall depression
- Kyphosis
- Scoliosis

2. Scar
   - Left thoracotomy scar
   - Mid sternotomy scar
3. Obvious pulsation

Palpation:
1. Apex
- deviation: left ventricular dilatation
- characteristics:
—> Normal
—> Heaving / Pressure overload (拳頭舉起手) (sustained lifting force: Aortic stenosis, Severe systemic hypertension)
—> Thrusting / Hyperdynamic / Volume overload (拳頭撞手, Diffuse) (Mitral regurgitation, Aortic regurgitation)
—> Dyskinetic / Double (Hypertrophic obstructive cardiomyopathy)
—> Tapping (手指撞手, Small area as a coin) (***Mitral stenosis)

2. Parasternal heave
   - **Right ventricular hypertrophy
   - **Left atrial enlargement
3. Thrills
   - apex, tricuspid, pulmonary, aortic area

Auscultation (Mitral, Tricuspid, Pulmonary, Aortic area):
- Apex: **Bell —> **Mitral stenosis —> compare with Carotid pulse as reference to time cardiac cycle
- Apex: **Diaphragm —> Mitral regurgitation
- Carotid: **Bell —> **Aortic stenosis / Carotid stenosis
- Left sternal border: **Bell —> S3, S4
- Left sternal border: **Diaphragm —> **Aortic regurgitation —> sit up, radiation to carotid + axilla
- Bi-basal crackles

Question 4

DDx of Irregularly irregular pulse

Answer 4

1. Atrial fibrillation
2. Atrial flutter with variable block
3. Atrial tachycardia with variable block
4. Multifocal atrial tachycardia

Question 5

Cyanotic heart disease vs Acyanotic heart disease

Answer 5

Cyanotic (R —> L shunt):

• Truncus arteriosus (1)
• Transposition of great vessels (2)
• Tricuspid atresia (3)
• Tetralogy of Fallot (4)
• Total anomalous pulmonary vascular return (5)

Acyanotic (L —> R shunt):

• Atrial septic defect (ASD)
• Ventricular septal defect (VSD)
• Patent ductus arteriosus (PDA)
• Coarctation of aorta