CARDIOVASCULAR PATIENT EXAMINATION

• Always Examine the patient in a sequential manner –

• At first start with the hand
• Look for peripheral stigmata of endocarditis – Osler node, Janeway lesion, splinter
hemorrhage, Clubbing
• Assess the pulse – rate, rhythm, volume and character
• Don’t go for checking BP. But at the end of the examination, tell the examiner that
you would like to do that
• Ascend above sequentially and look for JVP. If the JVP is raised, then don’t forget to assess
other features of pulmonary hypertension
• Parasternal heave, Palpable P2
• Loud 2nd heart sound
• Pan-systolic murmur of TR
• Pulmonary congestion/cardiac failure (bi-basal crepitation)
• Examine the face for anemia, malar rash, jaundice
• Now come to the chest (Chest examination) -
• Look for any scar mark, visible pulsation, Visible apex beat
• Feel for apex beat and assess two things particularly – whether it is displaced or not
and about its character (Thrusting, heaving)
• Examine the chest for Parasternal heave, thrill and palpable P2
• Go for the auscultation. Assess the -
• Heart sounds (Soft or loud, any splitting)
• Murmur –
• Type of murmur (Systolic/ Diastolic)
• Loudest in which area
• Relation with respiration
• Complete your examination by –
• Assessing for basal crepitation in lung
• Peripheral edema
After you are done with your examination, ask the doctor that you would like to do some
further examination like –
• Taking Detailed History
• Check the Observation chart and recent ECG
• Check the BP
• Do the Fundoscopy and Urine Analysis
APPROACH IN CVS
 Hi, I am dr. Talukder, a medical officer working in this clinic
 Am I talking with mr. X, 30 years of age?
 I have been asked to examine your chest. is that alright?)
 Can you please remove your tops/shirt/gown please)
 Do you have any pain or discomfort anywhere?
 If you get uncomfortable or feel any pain, just let me know. I will be more gentle

GENERAL INSPECTION (at 45)

At first, I am going to have a good look at you from the end of the bed
- Body built (malnourished, well nourished, obese)
 - Abnormal facies
- Breathlessness
Can you take a deep breath in and out for me please?
Give a cough for me please, Thank you
Do you have any pain in your legs? I'm going to press on those gently- Pedal edema

HAND
At first start with the hand
• Look for peripheral stigmata of endocarditis – Osler node, Janeway lesion, splinter
hemorrhage, Clubbing
• Assess the pulse – rate, rhythm, volume and character
• Don’t go for checking BP. But at the end of the examination, tell the examiner that
you would like to do that

Now I'm going to check your hands. Do you have any pain in your hands? Can you
please place your hands like this?
 Clubbing (congenital heart disease, infective endocarditis, atrial myxoma)
 Cyanosis (could be peripheral or central)
 Capillary pulsations (AR, PDA)
 Splinter haemorrhage, Osler’s nodes and Janeway lesions (IE]
 Palmer erythema (consider CO2 retention)
 Arachnodactyly, Xanthomas (dyslipidaemia)
Now turn your hand like this- palm upward (Palmar erythema)
Please, cock your wrist back- Flapping tremor
Now I am going to check for your pulse- Rate, rhythm, character, volume
 rate, rhythm, radio radial delay
 ask the examiner to see the radio femoral delay and BP
 Check for collapsing pulse

FACE EXAMINATION
Examine the face for anemia, malar rash, jaundice

 Now I'm going to check your eye, is that alright? Xanthelasma, corneal arcus
 Please look upward- Anaemia
 Please look downward- Jaundice
 MOUTH-
 Can you please open your mouth? - check with torch
 Can you stick out your tongue; now roll it over

NECK
 Now I'm going to check your neck, is that alright?
 Please turn your face to the left. Check for-
 Corrigan’s sign (visible carotid pulsation in AR)
 JVP (Check HJR)
 Do you have any pain in your tummy? I'm going to press it gently. If you feel any
pain/discomfort, please let me know- Press and hold gently but firmly for 10s

CHEST EXAMINATION
 Now come to the chest (Chest examination) -
• Look for any scar mark, visible pulsation, Visible apex beat
• Feel for apex beat and assess two things particularly – whether it is displaced or not
and about its character (Thrusting, heaving)
• Examine the chest for Parasternal heave, thrill and palpable P2
 Go for the auscultation. Assess the -
• Heart sounds (Soft or loud, any splitting)
• Murmur –
• Type of murmur (Systolic/ Diastolic)
• Loudest in which area
• Relation with respiration
 Complete your examination by –
• Assessing for basal crepitation in lung
• Peripheral edema

 Now I am going to examine your chest

 If the patient is female- (could you please lift up your breast with your hands):
To see the mitral valve repair scar
 Look for any scar mark, visible pulsation, visible apex beat
 Now I am going to feel for your apex beat
 If apex is unable to localize: Could you make a half turn to the left?
 Examine the chest for Parasternal heave, thrill and palpable P2
AUSCULTATION

 Now I’m going to listen your heart (Listen to all the heart areas for heart sound
and murmur)
 Ask the patient to sit up and lean forward: Breath held after expiration.
 Could you please sit for me and lean slightly forward?
 Please take a deep breath in, breath out and hold it for me.
 Now breath normally please.
 Listen over the lung bases (for basal crackles) - Now I am going to listen to your
back over lung bases

LEG (Edema)
Do you have any pain in your legs? I am going to press on them gently}

CLOSURE

I have completed my examination. Thank you very much for letting me examine
you. You can get dressed now. I would like to complete my examination by-
 check the observation chart
 bedside ECG & Echo
 BP measurement
 urine dip stick for hematuria & proteinuria

EXAPMPLE OF A CASE PRESENTATION (AORTIC STENOSIS)

I would like to complete my examination by:
• Taking Detailed History
• Check the Observation chart and recent ECG
• Do the Fundoscopy and Urine Analysis
I have examined this Gentleman/Lady, His/Her:
Pulse is:
• Between 70-80 / min
• Regular
• Low volume
• Slow rising
JVP is Not Raised
There is No Scar mark in the chest, no engorged vein and no visible apex beat
Apex beat is Un-displaced and normal in Character (Pressure Loaded)
On auscultation
1st Heart sound is normal and the 2nd heart sound is soft (May be Normal)
There is a Harsh Ejection Systolic murmur
• Best audible in the aortic area
• Becomes louder in expiration and radiates to the carotids.

However, there are -

• No peripheral stigmata of infective endocarditis
• Lungs are clear to auscultation
• No peripheral edema and
• Anemia
So, based on this, my most likely diagnosis is Aortic Stenosis and there are no signs of
pulmonary hypertension