Medically Fit For Exams
Medically Fit For Exams

Cardiovascular examination

Wash hands

 

Introduce yourself, check their details and gain consent

  • Tell the patient that this will involve them removing their top

 

General Inspection

  • Medications and oxygen
  • Comfort and ease of breathing
  • Cyanosis or pallor

 

Hands

  • Feel both for temperature
  • Capillary refill (press for 5 seconds, refill should be within 3 seconds)
  • Palmar creases for anaemia
  • Infective endocarditis:
    • Clubbing
    • Splinter haemorrhages (vertical reddish-brown lesions under the fingernails)
    • Osler’s nodes (small red nodules on finger (and toe) pulps)
    • Janeway lesions on the palms (visible red/pink/brown lesions on the palmar surface, including fingers)
  • Tar staining
  • Sweaty/clammy

 

Pulse and BP

  • Feel both radial pulses simultaneously – comment on their similarity, assess for radio-radio delay
  • Calculate pulse rate (only need to use one wrist), and comment on nature of the pulse (strength, regularity)
  • Feel for a collapsing pulse, ask the patient if they have shoulder pain first
  • Verbalise that you would take the blood pressure

 

Face

  • Assess eyes for:
    • Conjuctival pallor
    • Xanthelasma (fatty deposits under the skin – hypercholesterolaemia/hyperlipidaemia)
    • Corneal arcus (white/grey/blue ring around the corneal margin – hypercholesterolaemia)
  • Look under tongue for central cyanosis
  • Look for malar flush (plum red on the high cheeks – mitral stenosis)

 

Neck and JVP

  • Position the patient at 45 degrees, with their head facing away from you to locate the JVP, ask the patient to relax
    • Double waveform
    • Falls on inspiration
    • If you can’t locate it, can press on liver for hepatojugular reflux, ask about pain first
    • Measure the height of the JVP from the sternal angle, should be

 

Inspection of chest

  • Look for scars
    • Chest drain
    • Median sternotomy (vertical scar on front of chest)
    • Lateral thoracotomy
  • Pacemaker
  • Chest wall deformities
    • Scoliosis
    • Pectus excavatum
    • Pectus carniatum
  • Visible heaves/pulsations

 

Palpation

  • Palpate for the apex beat in the 5th intercostal space, mid-clavicular line
  • Move laterally if you cannot feel the beat, will be displaced in cardiac hypertrophy
  • If you cannot feel it, ask the patient to roll away from you, and attempt to palpate
  • If you still cannot palpate, verbalise that you cannot palpate it, and move on
  • Feel for parasternal heaves (hand vertically to the left of the sternum)
  • Feel for thrills (hand horizontally across the sternal angle)

 

Auscultation

Mitral regurgitation

Apex, radiates to axilla

Pan systolic murmur, possible 3rd HS

Aortic Stenosis

R. 2nd intercostal space, radiates to neck

Early systolic murmur, possible 4th HS

Mitral Stenosis

Apex, may have to roll to hear

Mid diastolic murmur, low pitch/rumbling

Aortic regurgitation

R. 2nd intercostal space, radiates to neck

Early diastolic murmur, collapsing pulse, wide PP

  • Feel for the pulse at the same time, to allow differentiation between systolic and diastolic added sounds/murmurs
  • Auscultate at the apex (mitral area) with diaphragm and bell, can ask to roll away from you to hear mitral stenosis (diastolic)
  • Auscultate at the tricuspid area (4th intercostal space by left sternal margin)
  • Auscultate the pulmonary area (2nd intercostal space by left sternal margin)
  • Auscultate the aortic area (2nd intercostal space by right sternal margin)
  • Auscultate for carotid bruits
  • Ask the patient to sit forward and auscultate the lung bases

 

Sacral and peripheral oedema

  • While the patient is sitting forward from lung auscultation, assess for sacral oedema
  • Look at ankles (remove socks and shoes, and roll up trousers) to assess for peripheral oedema

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