JamesWight

ExaminationoftheCardiovascularSystem
Washyourhands. Introduceyourselftothepatient,andaskpermissiontoexaminethem. Exposethepatient,andpositionthemat45.

Inspection
Lookaroundthebed Lookatthepatient GTNspray(IHD),oxygenmask/nasalprongs,drips(egIE),cigarettes Comfortableatrest,cyanosis,breathless,scars(egmidlinesternotomy forCABG,leftaxillaryscarformitralvalvereplacement),pacemaker boxes,syndromes(Marfans,Downs,Turners),cachexia Clubbing(congenitalcyanoticheartdisease,IE,atrialmyxoma),splinter haemorrhages(IE),Oslersnodes(IE),capillaryrefilltime,peripheral cyanosis,nicotinestaining,palepalmarcreases(anaemia),Janeway lesions(IE),tendonxanthomata(hypercholesterolaemia). Assessrate(over15s)andrhythm(sinus,regularlyirregularorirregularly irregular),assessforradioradialdelay(coarctationoftheaorta) FoundinAR Assesscharacter(slowrising,bounding,pulsusarterans,pulsus bisferiens)andaskforbloodpressure(widesplitting,narrowsplitting, pulsuspardoxus) Lookforsignsofpain(IHD),Cushings(possibleHT),malarflush(mitral stenosis). Xanthelasma,cornealarcus,anaemia,ophthalmoscopy(lookingforRoth spotsandhypertensiveretinopathy) Higharchpalate(Marfans),centralcyanosis,telangiectasia Assessthejugularvenouspressure,feelthecarotidpulse

Lookatthehands

Feeltheradialpulse Checkforcollapsingpulse Feelthebrachialpulse

Lookattheface Lookattheeyes Lookinthemouth Lookattheneck

Palpation
Feelfortheapexbeat Feelforthrillsandheaves Usuallyinthe5 intercostalspaceinthemidclavicularline.Theangleof nd Louismarksthe2 intercostalspace. UseaZshapedpatternforexamination
th

Percussion
UnnecessaryintheCVSexamination(exceptlungbases,seelater)

Auscultation
Simultaneouslylistenandpalpateapulse(preferablyacentralpulse)totimeanymurmurtothecardiac cycle. Listenovertheapexbeat(mitralarea)withthebell, andthendiaphragm th Listenattheleftsternaledgeinthe4 intercostal space(tricuspidarea) nd Listenattheleftsternaledgeinthe2 intercostal space(pulmonaryarea) nd Listenattherightsternaledgeinthe2 intercostal Listenforheartsounds1and2(and3and4), systolicanddiastolicmurmurs. Listenforheartsounds1and2,systolicanddiastolic murmurs. Listenforheartsounds1and2,systolicanddiastolic murmurs. Listenforheartsounds1and2,systolicanddiastolic

space(aorticarea) ListeninInspiration ListeninExpiration Listenovercarotids Askpatienttorollontotheirlefthandside,andlisten inthemitralareawiththebell Askpatienttositforwards,andlistenintheaortic area Percussandlistentothelungbases

murmurs. AccentuatesrIghtsidedmurmurs AccentuateslEftsidedmurmurs Foraorticstenosis Accentuatesmitralstenosis Accentuatesaorticregurgitation Foranysignsof pleuraleffusion(RVF)and pulmonaryoedema(LVF)

Finalmanoeuvres
Palpateforsacraloedema Palpatetheliver Palpatethespleen PalpateforAAA Palpateperipheralpulses Examineforankleoedema Thankthepatientandcoverthemup Rightheartfailure Pulsatileintricuspidregurgitation,hepatomegalyin rightheartfailure EnlargedinrightheartfailureandIE Femoral(incradiofemoraldelay),popliteal,posterior tibial,dorsalispedis. Rightheartfailure

Iwouldcompletemyexaminationby.
Iwouldliketotakeabloodpressure,lookattheobservationschart(temperature,sats),perform fundoscopyanddipsticktheurine. Glossary Oslersnodespainfulredbrownnodulesfoundonthefingerpulps,seeninIE Janewaylesionspainlesserythematousmaculesonthepalms,seeninIE Tendonxanthomatarubberyyellowdepositsonthetendons,seeninhypercholesterolaemia Pulsusarteransalternatestrongandweakbeats,seeninLVF Pulsusbisferiens adoublepeakpercardiaccycle,suggestiveofmixedaorticvalvedisease Pulsuspardoxusappallinglynamedsign,sinceitisneitherapulsenorparadoxical.Itisthe exaggerationofthenormaldecreaseinsystolicBPandpulsepressureoninspiration.Thisisseenis severeasthma,tamponadeandconstrictivepericarditis). Malarflushpurplecolouroverthenoseandcheeks,seeninmitralstenosis. Xanthelasmaperiorbitallipiddeposits,seeninhypercholesterolaemia. Cornealarcusagreyrimaroundtheiris,suggestiveofhypercholesterolaemia(butalsoanormalfinding intheelderly,whenitiscalledarcussenilis) Rothspotssmallredhaemorrhagesontheretina,suggestiveofIE. Jugularvenouspressure therearenovalvesbetweentheinternaljugularveinandtherightatrium,so pressurechangesintheinternaljugularveinreflectpressurechangesintherightatrium.Thedistancefrom themanubriosternalangletothetopofthecolumnofoscillatingbloodshouldbelessthan3cmwhenthe patientisat45. Thrillpalpablemurmur Heavepronouncedmovementoftheprecordium,suggestiveofheartfailure. Murmurturbulentflowthroughaheartvalveorseptaldefect rd 3 heartsoundKentucky,heardbestattheapex.Normalinchildren,alsofoundinheartfailure. th 4 heartsoundTennessee,heardbestattheapex.Signofstillventricularwalls,eginLVH,fibroticleft ventricle,hypertrophiccardiomyopathy.