Cardiovascular Examination Learning Materials

Cardiovascular Examination Component What to do/look for and rationale • Wash hands • Introduce self. • Briefly explain purpose and obtain consent. • Begin by getting the patient to be positioned at 45 degrees. • Ask about pain before you begin. • Ask if there is pain anywhere. • Ask for vitals and ECGs. General Inspection • Mobility aids. • Attachments such as ECG. • Looks for syndromes for example, Marfan’s syndrome. • Lines • Laboured breathing or use of accessory muscles. • Weight loss or muscle wasting -> cardiac cachexia. • Confusion. • Signs of anaemia. Hands • • • • • • • • Clubbing -> increase in soft tissues. - Due to platelets being trapped in the tips of the fingers and releasing a platelet growth factor. - Cyanotic CHF, infective endocarditis, COPD, lung abscess, cystic fibrosis, asbestosis, celiac disease, IBS, pregnancy etc. Pallor -> anaemia. Peripheral cyanosis. Xanthomata -> hyperlipidaemia/hypercholesterinaemia. Radial pulse -> note volume, rhythm and regularity, frequency etc. Bruises Tendon xanthomata -> lipid deposition. Splinter haemorrhages - Endocarditis (bacterial infection or other valvular infection) -> vasculitis. • Osler’s nodes - Rare manifestation of infective endocarditis. • • Nicotine stains. Pulse rate - 60 to 90 bpm. - If under -> bradycardia - If over -> tachycardia - Note regularity, character and volume. (see table below) Breathing rate - 12 to 16 breaths per minute Blood pressure Pallor. - Anaemia, CHF, pulmonary hypertension. Argyll-Robertson Pupils. Xanthelasma -> cholesterol plaques -> atherosclerosis. plum-red discolouration of the high cheeks -> could indicate SLE. • Eyes • • Malar flush • • • Mouth Neck Precordium • • • • central cyanosis -> CHF -> especially right heart failure. High arched palate. Dentition -> infective endocarditis. JVP -> if it is there should not be greater than 3cm. - Otherwise -> indicate right heart failure. • Carotid artery pulse. - If too high -> tachycardia. - If too low -> bradycardia. Scar and deformity inspection -> surgeries, indications of pacemakers etc. Look for visible palpitations. Feel for apex beat via firstly locating it. - Pressure loaded -> forceful apex beat -> aortic stenosis or hypertension. • • • - • • • Percussion • • • • • Posterior chest Lower limbs and others • • • • • • • Volume loaded -> diffuse, displaced or non-sustained impulse -> advanced mitral regurgitation or dilated cardiac myopathy. - Dyskinetic -> uncoordinated impulse -> usually left ventricular abnormality e.g., anterior MI. - Double impulse apex beat -> two distinct impulses felt with each systole -> hypertrophic cardiomyopathy. - Tapping apex beat -> felt when the first heart sound is palpable -> mitral stenosis or very rarely tricuspid stenosis. Heaves (parasternal) - Precordial impulse that can be palpated. - Place the heel of the hand parallel to the left sternal edges. - If present should feel hand lifted with each systole. - Indicates right ventricular hypertrophy. Thrills. - Palpable vibration caused by a turbulent blood flow through a heart valve -> palpable murmur. - Place hand horizontally across the chest wall with the flats of the fingers and palm over the valve to be assessed. Listen to heart sounds. - 1st heart sound: at apex for mitral valve and 4th intercoastal space for tricuspid. - 2nd heart sound left and right of sternum at second intercoastal spaces. - Note any abnormal heart sounds such as heart murmurs. - Look for indications of valvular diseases, murmurs (4th heart sound) and hypertrophies (3rd heart sound) Defines cardiac outline. Most accurately performed in the 5th intercoastal space and the mid axillary line towards the sternum. Patient should lay in supine position. Point at which the note becomes dull represents the left heart boarder. If the distance between the border of the heart and the middle of the sternum is more than 10.5 cm -> cardiomegaly. - Not useful in the presence of lung disease. Look for scars and deformities. Pleural effusions (listen at the base of the lungs) -> pulmonary diseases due to right heart failure. Breath sounds. Sacral edema. Edema -> right heart failure. Pulses in feet and medial malls and dorsal pulses. Liver, abdomen etc. for fluid back up due to right heart failure.