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James Wight

Examination of the Cardiovascular System

Wash your hands. Introduce yourself to the patient, and ask permission to examine them. Expose the patient, and position them at 45.

Inspection

Look around the bed GTN spray (IHD), oxygen mask/nasal prongs, drips (eg IE), cigarettes

Look at the patient Comfortable at rest, cyanosis, breathless, scars (eg midline sternotomyfor CABG, left axillary scar for mitral valve replacement), pacemakerboxes, syndromes (Marfans, Downs, Turners), cachexia

Look at the hands Clubbing (congenital cyanotic heart disease, IE, atrial myxoma), splinterhaemorrhages (IE), Oslers nodes (IE), capillary refill time, peripheralcyanosis, nicotine staining, pale palmar creases (anaemia), Janewaylesions (IE), tendon xanthomata (hypercholesterolaemia).

Feel the radial pulse Assess rate (over 15s) and rhythm (sinus, regularly irregular or irregularlyirregular), assess for radioradial delay (coarctation of the aorta)

Check for collapsing pulse Found in ARFeel the brachial pulse Assess character (slow rising, bounding, pulsus arterans, pulsus

bisferiens) and ask for blood pressure (wide splitting, narrow splitting,pulsus pardoxus)

Look at the face Look for signs of pain (IHD), Cushings (possible HT), malar flush (mitralstenosis).

Look at the eyes Xanthelasma, corneal arcus, anaemia, ophthalmoscopy (looking for Rothspots and hypertensive retinopathy)

Look in the mouth High arch palate (Marfans), central cyanosis, telangiectasia

Look at the neck Assess the jugular venous pressure, feel the carotid pulse

Palpation

Feel for the apex beat Usually in the 5th

intercostal space in the midclavicular line. The angle ofLouis marks the 2

ndintercostal space.

Feel for thrills and heaves Use a Z-shaped pattern for examination

Percussion

Unnecessary in the CVS examination (except lung bases, see later)

Auscultation

Simultaneously listen and palpate a pulse (preferably a central pulse) to time any murmur to the cardiaccycle.

Listen over the apex beat (mitral area) with the bell,and then diaphragm

Listen for heart sounds 1 and 2 (and 3 and 4),systolic and diastolic murmurs.

Listen at the left sternal edge in the 4th

intercostalspace (tricuspid area)

Listen for heart sounds 1 and 2, systolic and diastolicmurmurs.

Listen at the left sternal edge in the 2nd

intercostalspace (pulmonary area)

Listen for heart sounds 1 and 2, systolic and diastolicmurmurs.

Listen at the right sternal edge in the 2nd

intercostal Listen for heart sounds 1 and 2, systolic and diastolic

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space (aortic area) murmurs.

Listen in Inspiration Accentuates rIght sided murmurs

Listen in Expiration Accentuates lEft sided murmurs

Listen over carotids For aortic stenosis

Ask patient to roll onto their left hand side, and listenin the mitral area with the bell

Accentuates mitral stenosis

Ask patient to sit f orwards, and listen in the aortic

area

Accentuates aortic regurgitation

Percuss and listen to the lung bases For any signs of pleural effusion (RVF) andpulmonary oedema (LVF)

Final manoeuvres

Palpate for sacral oedema Right heart failure

Palpate the liver Pulsatile in tricuspid regurgitation, hepatomegaly inright heart failure

Palpate the spleen Enlarged in right heart failure and IE

Palpate for AAA

Palpate peripheral pulses Femoral (inc radio-femoral delay), popliteal, posterior

tibial, dorsalis pedis.Examine for ankle oedema Right heart failure

Thank the patient and cover them up

I would complete my examination by.

I would like to take a blood pressure, look at the observations chart (temperature, sats), performfundoscopy and dipstick the urine.

Glossary

Oslers nodes painful red-brown nodules found on the finger pulps, seen in IEJaneway lesions painless erythematous macules on the palms, seen in IE Tendon xanthomata rubbery yellow deposits on the tendons, seen in hypercholesterolaemiaPulsus arterans alternate strong and weak beats, seen in LVFPulsus bisferiens a double peak per cardiac cycle, suggestive of mixed aortic valve diseasePulsus pardoxus appallingly named sign, since it is neither a pulse nor paradoxical. It is theexaggeration of the normal decrease in systolic BP and pulse pressure on inspiration. This is seen issevere asthma, tamponade and constrictive pericarditis).Malar flush purple colour over the nose and cheeks, seen in mitral stenosis.Xanthelasma periorbital lipid deposits, seen in hypercholesterolaemia.Corneal arcus a grey rim around the iris, suggestive of hypercholesterolaemia (but also a normal findingin the elderly, when it is called arcus senilis)Roth spots small red haemorrhages on the retina, suggestive of IE.

Jugular venous pressure there are no valves between the internal jugular vein and the right atrium, sopressure changes in the internal jugular vein reflect pressure changes in the right atrium. The distance fromthe manubriosternal angle to the top of the column of oscillating blood should be less than 3cm when thepatient is at 45.Thrill palpable murmurHeave pronounced movement of the precordium, suggestive of heart failure.Murmur turbulent flow through a heart valve or septal defect 3

rdheart sound Kentucky, heard best at the apex. Normal in children, also found in heart failure.

4th heart sound Tennessee, heard best at the apex. Sign of still ventricular walls, eg in LVH, fibrotic left

ventricle, hypertrophic cardiomyopathy.