Cardiovascular Examination

Dr Erika Keane Clinical Skills, School of Medicine

2015 - 16

WIPER

‒ Wash your hands

‒ Introduce yourself to the patient

‒ Permission / Consent (informed)

‒ Expose (appropriately)

‒ Reposition the patient

History

‒ Detailed clinical history can be more helpful than physical examination

‒ The history should suggest a differential diagnosis

‒ This should help to focus your physical examination

Symptoms

‒ Chest Pain

‒ Breathlessness

‒ Paroxysmal nocturnal dyspnoea

‒ Orthopnoea

‒ Palpitations

‒ Lightheaded, dizzy

‒ Fever

‒ Oedema

‒ Pink frothy sputum

‒ Wheeze

Risk Factors

For cardiovascular disease

History of :

‒ Smoking

‒ Obesity

‒ Diabetes mellitus

‒ Hypertension

‒ Hypercholesterolaemia

‒ Family history of heart diseas

Observations

The Setting

‒ IV Fluids

‒ Fasting

‒ Diabetic Diet

‒ Walking frame

‒ Oxygen / nasal prongs/ mask

‒ Catheter bag

‒ Inhaler

‒ Heart Monitor

‒ GTN Spray / Infusion pump

Video

General Inspection

‒ Look at the patient from the end of the bed

‒ Patient sitting at a 45 degree angle

‒ General appearance – distress, tachypnoea, cardiac cachexia

‒ Physical appearance

What conditions are associated with an increased risk of developing

cardiovascular disease?

Hands

‒ Tar / Nicotine staining

‒ Clubbing

‒ Pallor

‒ Marfan’s Arachnodactyly

‒ Down’s single crease

‒ Splinter Haemorrhages

‒ Janeway lesions ( non tender )

‒ Osler’s nodes ( tender )

‒ Xanthomata

‒ Peripheral Cyanosis

Clubbing Cardiovascular causes:

‒ Cyanotic Congenital Heart Disease

‒ Bacterial Endocaditis

‒ A bulbous swelling of terminal phalanges of fingers and toes

Grades 1 to 5

1 = increased fluctuation of nail on nail bed (springy)

2 = loss of angle between nail and nail bed

3 = increased longitudinal curvature of nail

4 = drumstick appearance

5 = HPOA (Hypertrophic Pulmonary Osteoarthropathy)

Infective Endocarditis

‒ Splinter haemorrhages – linear haemorrhages on nail bed

‒ Clubbing

‒ Osler Nodes – red, raised, tender nodules on fingers, thenar and hypothenar eminences

‒ Janeway Lesions – non-tender erythematous lesions on finger pulps

‒ Roth Spots (Fundoscopy)

‒ Mucosal Petechiae (mouth)

Xanthomata

‒ Yellow deposits of lipid

‒ Hyperlipidaemia

‒ Tendons ( Tuberous )

‒ Palms ( Palmar )

‒ Eyelids - Xanthelasmata

Arterial Pulses

‒ Rate ( beats per minute ) 60 to 100

( bradycardia less than 60, tachycardia more than 100 )

‒ Rhythm ( regular, irregular, irregularly irregular )

‒ Volume

‒ Character

‒ Delay ( radio-radial, radio-femoral )

‒ Condition of the vessel wall ( atherosclerosis )

‒ Peripheral pulses

Radial Pulse

Blood Pressure

Face

‒ General Appearance – jaundice, pallor

‒ Malar Flush – mitral stenosis

EYES

‒ Jaundice – CCF, congestion of liver

‒ Pallor – anaemia

‒ Xanthelasma – may indicate hyperlipidaemia

‒ Arcus Senilis

‒ Fundoscopy

Mouth

‒ Peripheral Cyanosis –lips

‒ Central cyanosis – under tongue

‒ High arched palate – Marfan’s

‒ Dentition – decay (IE)

‒ Mucosal Petechiae (IE)

Neck

Carotid pulse

‒ medial to sternomastoid muscles

JVP – Jugular venous Pressure

‒ Internal jugular vein – more reliable

‒ Patient at 45 degrees – turn their head to the left, measure the vertical distance between sternal angle and top of venous column

‒ ( normal less than 3 cm )

‒ Internal Jugular vein, medial and behind sternocleidomastoid muscle

Carotid Pulse Palpation

JVP

‒ Provides information about right atrial and right ventricular function

‒ Persistent elevation – sign of right ventricular failure

‒ Column of blood in Internal Jugular vein extends into the right atrium

‒ Multi-wave form, visible not palpable

‒ Can be occluded, fills from above

‒ Decreases with inspiration

Jugular Venous Pressure

JVP

Hepatojugular Reflux

‒ Apply firm pressure over upper abdomen, increases venous return and pressure

Kussmaul’s sign

‒ paradoxical rise of JVP during inspiration

‒ Cardiac tamponade, constrictive pericarditis

Elevated JVP

‒ RVF, Fluid overload, Tricuspid regurg/stenosis, pericardial effusion, constrictive pericarditis

JVP

Hepatojugular Reflex

Praecordium

Inspection

DEFORMITY

‒ Pectus Excavatum – Marfan’s

‒ Kyphoscoliosis may cause pulmonary hypertension

SCARS

‒ Sternotomy – midline – CABG, valve surgery

‒ Thoracotomy (lateral) – mitral valvotomy

PACEMAKER

Sites on Praecordium

Praecordium

Palpation

APEX BEAT

‒ Most lateral, inferior point of palpation

‒ Normal – 5th Intercostal space, mid-clavicular line

‒ Begin palpation in axilla and move medially

‒ Using the flat of the fingers and the palm

‒ To locate apex beat – count intercostal spaces from 2nd space

‒ Patient may need to be in left lateral position

Palpation of Apex with Patient in Left Lateral Position

Apex Beat

Displaced

‒ Left Ventricular dilatation

‒ Right ventricular dilatation

‒ Cardiomegaly

‒ Chest wall deformity

‒ Mediastinal mass

Impalpable

‒ Obesity

‒ Emphysema

‒ Shock

‒ Pericardial effusion

‒ Dextrocardia

Praecordium

Palpation

Parasternal Heave

‒ Heel of hand to left of sternum – right ventricular hypertrophy

Thrills

‒ Palpable murmurs, flat of the hand over the apex, left sternum, base of heart

‒ Percussion – not helpful in CVS Examination

Parasternal Palpation

Auscultation

Listen over all 4 areas with the bell and the diaphragm

‒ Begin in the mitral area (over apex beat)

‒ Then tricuspid area ( fifth left intercostal space)

‒ Listen in the pulmonary area (second left intercostal space)

‒ Listen in the aortic area (second right intercostal space)

‒ Bell – low pitched sounds (mitral stenosis)

‒ Diaphragm - high pitched sounds (mitral incompetence)

Sites for Auscultation

Auscultation

‒ Heart Sounds

‒ Additional sounds

‒ Murmurs

‒ Dynamic manoeuvres

Heart Sounds

S1 First Heart Sound

‒ Mitral and tricuspid valve closure

‒ Best heard at apex

S2 Second Heart Sound

‒ Aortic(A2) and pulmonary(P2) valve closure

‒ Best heard at left sternal edge 2nd/3rd space

‒ 2 components, may be split

‒ Palpate carotid pulse to time systole (S1)

Additional Sounds

S3 Third Heart Sound

‒ Heard at apex in children, young adults, during pregnancy

‒ Over 40 years – Left Ventricular Failure

S4 Fourth Heart Sound

‒ Heard at apex just before first heart sound

‒ LVH, hypertension

‒ Both S3 and S4 give “gallop” rhythm

Opening Snap mitral stenosis

Pericardial Friction Rub pericarditis

Murmurs ‒ Caused by turbulent flow across an abnormal valve

‒ Or increased flow through a normal valve

‒ “Innocent” murmurs may occur in a healthy heart

‒ Eg pregnancy, athlete, child with a fever

Timing

Grade

Area of maximum intensity

Character

Relationship to respiration

Effects of manoeuvres

Grade of Murmurs

‒ Graded according to loudness but this does not correspond with the severity of the valve lesion

‒ Grade 1/6 very soft, audible by expert

‒ Grade 2/6 soft

‒ Grade 3/6 moderate (no thrill)

‒ Grade 4/6 loud, palpable thrill

‒ Grade 5/6 very loud, thrill easily palpable

‒ Grade 6/6 audible without stethoscope

Timing of Murmur

Systolic

‒ Pansystolic – throughout, VSD, MR, TR

‒ Ejection – midsystolic, AS, PS

‒ Late – MVP

Diastolic

‒ Early – AR, PR

‒ Mid Diastolic – MS, TS

Continuous

‒ PDA, AV Fistula

Dynamic Manoeuvres

‒ Left Lateral position

‒ brings apex closer to chest wall (MR)

‒ Lean forward in full expiration

‒ Brings base of heart closer to chest wall (AR)

‒ RH murmurs – accentuated in inspiration

‒ LH murmurs – accentuated in expiration

Auscultation of Apex in left lateral position

Auscultation of base of heart with Patient leaning forward

Back

Inspection

‒ Scars Deformities

Palpation

‒ Sacral oedema (RVF)

Percussion

‒ Pleural effusion (LVF)

Auscultation

‒ Crackles at the bases (LVF)

Abdomen

Inspection

‒ Distension pulsatile mass

Palpation

‒ Hepatomegaly (RVF)

‒ Splenomegaly (IE)

‒ AAA

Percussion

‒ Ascites (RVF)

Auscultation

‒ Renal bruit ( renal artery stenosis )

Lower Limbs

Inspection

‒ cyanosis, PVD, loss of hair, ulceration, clubbing

Palpation

‒ Temperature, oedema, calf tenderness

‒ Pulses – femoral, popliteal, posterior tibial,

‒ dorsalis pedis

Auscultation

‒ Bruits at pulses sites

Dorsalis Pedis Pulse

Posterior Tibial Pulse

Popliteal Pulse

Summary

‒ Position of patient (45)

‒ General Inspection (from the end of the bed)

‒ Observations (of settings around the bed)

Hands

‒ Radial Pulse

‒ Blood Pressure

‒ Face

‒ Mouth

‒ Neck

(Carotid, JVP, Hepatojugular Reflex)

Praecordium

‒ Inspect

‒ Palpate

‒ Auscultate (Heart sounds, murmurs)

‒ Dynamic Manoeuvres

‒ Back

‒ Abdomen

‒ Lower Limbs

Thank You Department of Clinical Photography Trinity Centre, St James’s Hospital

Dr Brian Egan Dr Jimmy Woo

MaCleod Clinical Practice

Pectus Excavatum Post Surgical Correction