CVS EXAMINATION

 Expose patient adequately from the chest to the lower abdomen and position patient propped up at
45̊
 General Examination
Pre-requisites- Stand at the foot end of the bed, look and see closely as possible
Comment on
 The general state of the patient whether, breathless, comfortable, able or unable to lie
flat
 The attitude of the limbs if needed, attachments,
 The chest for scars, surgical scars ( most COMMONLY coronary bypass, then mention
other possible scars like Valvular replacement). Do not mention valve replacement as
your first and only possible option even if you’re sure it is so. Keep your options open.
Inspect the lower limbs for a linear venous harvesting scar to futher enforce the fact
on the CABG scar.
 Look for any abnormal chest movements, asymmetry in expansion,
 Look for dilated neck veins, increased JVP, corrigans sign,
 Look for goitre, thyroid stare, lid retraction, parotid swellings, gynaecomastia(M) and
breast atrophy(F), caput medusa, ankle oedema(Must mention)
 Also look out for any Klinefelters, Turners, Cushings, Marfans Syndromic presentation.
 Once you’re approaching the patient also look for any facial palsy, ptosis.
 Hands- Pulse, Pallor, Clubbing
 Pulse – Rate
Rhythm- Regular, Irregular(RIR or IRIR)
Volume
Character- Collapsing pulse (Must mention), seen in hyperdynamic circulation.
 Mouth- Inspect mainly for any central cyanosis, high arched palate
 Neck veins- Check for increased in JVP, comment on the type of wave form
‘a’ wave- pulsation is before the carotid pulsation (seen in PS,TS and Pul HT)
‘v’ wave- pulsation after the carotid pulsation (seen in TR)
 Apex beat- Must be examined using the palms and not the finger tips. Its the lowest, and the
lateral most palpable beat at the chest region.
If the apex beat is….. forceful (hypertrophy), if displaced (Dilated).
 Thrills- Make sure you know if the thrills are of systolic or diastolic type of thrills. Be sure with
the carotid pulsation. Feel for the Left sternal border, pulmonary area (Palpable P2).
In a case of a diastolic thrill or a tapping apex beat, be sure not to mention it first, say it as a
part of your presentation after the examination. It may be a Mitral Stenosis but again be sure
before mentioning anything.
 Take note…… For a mitral stenosis to become symptomatic, it takes almost 20 years. Thus
patients with mitral stenosis will have sinus rhythm initially and not ATRIAL FIBRILLATION.
Patients become symptomatic when the valve is stenosed to area of 2.5cm² and become
severely sympatomatic when it is 1cm².
 Auscultation
 Listen for the first heart sound and followed by the second heart sound
 Then listen between the first and the second heart sounds as well as between the
second and the first heart sounds.
 Listen carefully for the intensity of the first heart sound at the mitral region
- Loud First heart sound indicates- mitral stenosis
- Soft first heart sound indicates- mitral regurgitation
 The second heart sound is better heard at the aortic region
 If you’ve heard an abnormal heart sound after the second heart sound, ask the
patient to cycle, and you will be able to hear better.
 Now listen if there is
 Opening snap- This occurs when the Intra atrial pressure is high, the mitral
valve opens earlier than normal. The snap is produced as a result of the wave
moving through the valves as they open faster and earlier.
 Mid diastolic murmur
 Pre-systolic accentuation
 When blood gushes through a narrower or tighter lumen, the presystolic
accentuation becomes closer to the S2, thus producing a longer murmur.
 Some murmurs may only present with presystolic accentuation.
 When in Atrial Fibrillation, there is no presystolic accentuation.