Cardiovascular Examination
SESSION 2
Overview of Session
• An introduction to physical examinations
• Systematic run through of cardiovascular
examination
• Chance to practise in the sessions
Introduction to Physical
Examination
“Inspection, palpation,
percussion, auscultation”
“Looking, feeling, moving”
Introduction to Physical
Examination
• Tell/show the patient exactly what you
want them to do with clear instructions
• Cover the patient up when you’re not
examining them
• Always exam from the patients right
hand side
Beginning a Physical
Examination
• Introduce yourself: Full name, position and intent
•Explain what is going to happen and state that they
can ask you to stop at any time
• Gain the patients consent and ask if they have any
questions
• Confirm patient’s full name and DOB
• Position the patient appropriately
• 45 degrees for CV examination
WASH YOUR
HANDS
General Inspection
Looking
• Stand at the end of the bed and look
• Does this patient look unwell?
• Is there anything to indicate disease
around them?
• “The patient is in no obvious signs of
discomfort”
• “Nothing around the bed indicating
cardiac pathology”
Schedule for CVS
examination
• Hands
• Arms
• Neck
• Face
• Chest
• Back
• Legs/Feet
• Other Examinations
Hands
Examine the patients hands do not turn the
patient’s hands over, ask them to do it
themselves (ask if they have pain in hands or
wrists)
• Capillary refill – Gently press the nail/ back of
the hand for 5s: it should refill within 2s.
Any evidence of?
• Clubbing
• Janeway lesions (palmar), Osler’s nodes (on
finger pulps) and splinter haemorrhages (indicate
infective endocarditis)
• What's the appearance of the palmar creases?
Hands
http://vasculitis.med.jhu.edu/typesof/polyangiitis.html
http://emergencymedic.blogspot.com/2008/11
/peripheral-signs-of-infective.html - janeway
http://morningreporttwh.blogspot.com/2008/09/h
opingkong-isms-1.html - oslersnode
http://jama.amaassn.org/content/304/2/159/F1.expan
sion.html
Arms
• Radial Pulse – pads of digits 2,3 & 4 placed
lateral to the tendon of flexor carpi radialis
• Note the rate and rhythm – time for 15 seconds
• ‘Collapsing’ pulse – ask patient if they’ve had any
problems with their shoulder. If no, raise arm and
check for collapsing pulse
• Compare both sides for radial-radial delay
• Brachial Pulse – extend the arm at the elbow
and place thumb medial to the tendon of biceps
brachii
• Note the character and volume
• Take the patient’s BP (not in the OSCE)
Neck
• Jugular Venous Pressure (JVP)
• This is why your patient needs to be at 45 degrees
• Ask patient to turn their head to their left
• (Try not to say ‘look’; they will look…)
• Get eyes down below neck and look upwards
• The height of pulsation along the right internal jugular
vein is measured vertically in cm from the sternal
angle, then 5cm is added to this to give the JVP
• Normal JVP is 8cm of blood
• Carotid Pulse:
•Don’t palpate both at once…!
• Eyes
Face
•Pale conjunctiva – ask pt to look up. Gently pull lower
lids down – sign of anaemia
• Xanthelasma
• Corneal Arcus
• Mitral ‘facies’ – associated with mitral stenosis
• A facies is a distinctive facial appearance associated
with a condition
• Mouth
• Look for central cyanosis (below tongue) and
peripheral cyanosis (lips)
• Note dental hygiene
Face
http://www.stmellionclinic.com/index.php?page=xanthelasma
http://www.kardionet.com/Herzkrankh
eiten/Klappenfehler_Int.html
Chest – Inspection &
Palpation
• Expose the patient at this point
• Look closely for any abnormalities
• Scars/ deformities
•Ensure you also look at the lateral aspects of the thorax
• Apex beat:
• Place R. hand flat on chest, inferior to the R. nipple
• Practice!
• 5th ICS, L. MCL.
• Always find apex first, then check it’s position, not the other
way around
• Heaves and Thrills
• Thrill – due to a murmur
• Heave – Suggestive of hypertrophy of the heart
Counting Ribs
• Feel sternal angle and move
laterally – this is the 2nd rib
• Now move inferolaterally
and count down the ribs
• The ‘x’th intercostal space is
the space below the ‘x’th rib
http://parkin09.wikis.birmingham.k12.mi.us/Ecosystems+Glossary
Using Your Stethoscope
• Earpieces facing anteriorly in the ear
• ‘Diaphragm’ – Large face with membrane
• Tap it (gently) to check you’re listening through the right
part
• Most heart sounds
• ‘Bell’ – Looks like a bell…
• Twist the tubing 180° to change to the bell
• Deep sounds – Mitral stenosis
• Place it on the patients skin – no need to press.
• Find a way you’re comfortable with
Chest – Auscultation
• “All Prostitutes Take Money” – start at ‘A’
• Aortic – 2nd ICS, RSE
• Pulmonary – 2nd ICS, LSE
• Tricuspid – 4th ICS, LSE
• Mitral – 5th ICS, L. MCL
•You need to practise listening to these sounds
• ‘Lub’ HS 1 – Beginning of systole: inflow valves closing
• ‘Dup’ HS 2 – End of systole: outflow valves closing
• If you cannot tell which is which, palpate the carotid
pulse
• This HS 1
Valves
• Mitral
• Tricuspid
• Pulmonary
• Aortic
http://parkin09.wikis.birmingham.k12.mi.us/Ecosystems+Glossary
Chest – Auscultation
• Specific Tests:
• Mitral regurgitation – Auscultate in L. axilla.
•Mitral stenosis – Roll patient onto left hand side. Repalpate the apex beat. Listen over this place with the
bell.
•Aortic regurgitation – Sit patient forward. Listen over
the 4-5th ICS, LSE.
• Ask patient to take a deep breath in and hold
•Aortic stenosis – Ask patient to hold their breath and
auscultate over the R. common carotid artery use the
bell.
Chest Exam – Problems
Breasts
Back
•With the patient sitting forward auscultate the lungs
• Ask patient to take deep breaths in and out – then tell to
breathe normally
• Listen for ‘crackles’ over the lung bases on posterior
thoracic wall
• Due to pulmonary oedema: fluid within the
interstitium of the lungs – this closes the small airways
in expiration.
• Crackles are due to the airways ‘snapping’ back open
on inspiration ∴ this is heard on inspiration
• Press gently over sacrum (‘lower back’) to check for
pitting oedema
Legs
• Re-cover the patient
• Press over the tibia to check for pitting oedema
http://www.ptconsultan
ts.biz/photos.html
Other examinations
The conclusion
• Thank the patient
• WASH YOUR HANDS
• Conclude with stating what other investigations you
would do
• A full peripheral vascular examination
• Fundoscopy
• Temperature
• Urine Dipstick
• Abdominal examination for ascites and
hepatosplenomegaly
Schedule for CVS
examination
• Hands
• Arms
• Neck
• Face
• Chest
• Back
• Legs/Feet
• Other Examinations
The OSCE
• You will be performing a full CVS examination in the
OSCE
• You have to do the full examination in 5 minutes
• Practise Practise Practise
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