Cardiovascular Examination

Cardiovascular Examination

1. Exposes from WAIST UP

   • Positions at 45 degrees

2. General Inspection around bed

   • Shortness of Breath
     • MI, congestive heart failure, anaemia, arrhythmia
   • GTN Spray near bed
     • pre-existing angina, ACS, possible MI
   • Scars
     • 1. Median sternotomy
       • Heart valve replacement
       • CABG
       • Heart transplant
     • 2. Pacemaker insertion
       • Pre-existing arrythmia
         • Bradycardia & heart block
           • May have suffered from MI in the past
           • Muscular dystrophy can cause bradycardia
         • Sick sinus syndrome
       • Heart failure
         • Cardiac resynchronization therapy (CRT)
         • Biventricular pacing
       • Hypertrophic cardiomyopathy
     • 3. Posterolateral thoracotomy
       • Pneumonectomy or lobectomy, chest wall resection, oesophageal surgery
     • 4. Anterolateral thoracotomy
       • Various pathology
     • 5. Axillary thoracotomy
       • Pneumonectomy & pneumothorax
   • Visible apex beat
     • lean patient or e.g. left ventricular aneurysm
   • Listen for metallic heart valve ticking
   • Oxygen

3. Examine Hands

   • Nails
     • Clubbing
       • ABC = Atrial myxoma, bacterial infective endocarditis, congenital cyanotic heart failure
     • Koilonichia (spoon shaped nails)
       • Iron deficiency anaemia
     • Splinter haemorrhage
       • Infective endocarditis
     • Quinke's Sign = Visible pulsation in nail beds
       • Aortic regurgitation
     • Xanthomata = Fatty deposits on tendons
       • Suggests hyperlipidaemia
     • Osler's nodes (tender) & Janeway lesions (haemorrhagic)
       • Infective endocarditis
   • Temperature changes
   • Capillary refil time
     • Poor perfusion of extremities may be caused by hypovolaemia, hypothermia, peripheral vascular disease or just cool peripheries (with associated vasoconstriction)
   • Cyanosis

4. Radial Pulse

   • Rate (>100bpm = Tachy, <60bpm = Brady)
   • Rhythm
     • Irregular
       • Regularly irregular = Ectopic beats
         • Variable heart block or premature ventricular excitation
       • Irregular irregular = Atrial fibrillation
     • Variation of rate with breathing
       • Accelerates on inspiration & slows on expiration
         • Sinus arrythmia
       • Slows on inspiration (pulsus paradoxus)
         • Pericardial effusion, constrictive pericarditis
         • Severe pneumothorax (esp. tension pneumothorax), severe asthma & COPD
         • NB: Here, systolic bp falls by >10mmHg on inspiration
           • Signifies severity of cardiac tamponade
   • Radio-femoral delay
     • Coarctation of aorta
       • More common in turner's syndrome
   • Radio-radial delay
     • Occlusion or stenosis on one side
     • Dissection of thoracic aorta
     • Aortic aneurysm
   • Radio-brachial delay
     • Aortic stenosis
   • Character
     • Bounding pulse
     • Waterhammer/Collapsing pulse
       • Aortic regurgitation
       • Hyperdynamic state e.g. pregnancy
     • Fast & weak pulse = Shock

5. Blood Pressure

   • Narrow Pulse pressure: Diastolic < 25% Systolic
     • Extremely low, i.e. 25 mmHg or less = Very low stroke volume, as in Congestive Heart Failure and/or cardiogenic shock
     • Aortic Stenosis
   • Wide pulse pressure (consistently greater than 100 mmHg)
     • Aortic regurgitation
     • Wide PP & bradycardia & increased ICP = Cushing's triad (Head trauma related to intracranial hemorrhage or oedema)

6. Face

   • Eyes
     • Jaundice
     • Pallor
       • Anaemia
     • Congunctival haemorrhage
       • Infective endocarditis
     • Xantholasma
       • Hyperlipidaema
   • Mouth
     • Central Cyanosis
       • Poor oxygenation due to MI, heart failure, valvular disease, congenital heart disease
     • Dental hygiene
       • Infective endocarditis
     • High arched palate
       • Marfan's = Increased risk of mitral valve prolapse & aortic aneurysm
   • Cheeks
     • Mitral facies
       • Severe mitral stenosis
       • Rosy cheeks, whilst rest of face has bluish tinge due to cyanosis

7. Neck

   • Carotid Pulse
     • Normal = Smooth, relatively rapid upstroke and a smooth, more gradual downstroke
     • Difference between the two = atherosclerosis
     • Hyperkinetic = Higher stroke volume
     • Hypokinetic = Low stroke volume
   • JVP
     • Indicates pressure in venous system awaiting entry to right atrium (SVC)
     • Measurement: Vertical distance (in cm) between horizontal lines drawn from upper level of venous pulsation & sternal angle
       • Normal = <4cm
         • JVP + 5cm = right heart filling pressure in cm of water
           • Total of 9cm = Raised

8. Chest

   • Scars (see above)
   • Visible pulsations
   • Obvious deformity

9. Palpation

   • Apex Beat
     • Normal site = 5th left intercostal space, 1cm medial to mid-clavicular line
   • Parasternal heave
     • Palm of hand to left of sternum with fingers lifted slightly off chest
     • Right ventricular enlargement
       • Right ventricular hypertrophy in chronic respiratory disease
   • Thrills
     • Aortic stenosis, pulmonary stenosis, mitral regurgitation

10. Auscultation

    • S3 = "Kentucky" Loud in young people or athletes, congestive heart failure = Passive LV filling
    • S4 = "Tennessee" Increase in stiffness of left ventricle due to scar tissue formation = Active LV filling
    • Aortic Stenosis = "Potato"
    • Mitral Regurgitation = Potaaaato
    • Mitral Valve Prolapse = "Oliver" with hiccup

11. Peripheral checks

    • Sacral oedema = Right sided heart failure
    • Pulmonary oedema = Left sided heart failure

12. "To complete"

    • Fundoscopy
    • Peripheral pulses
    • ECG, Echo etc.

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