Cardiovascular Exam: SHOW THAT YOU ARE LOOKING

WIPPPPE: Wash hands, Introduce, Permission, Patient Particulars, Pain, Position, Exposure 1. Knock Door 2. Say candidate number 3. INTRODUCE self: “Good morning/afternoon Sir/Mdm (? Shake hands to assess tone, coordination, power), my name is Sarah Tai, I’m a year 3 medical student. I’d like to examine your heart. Would that be okay? (PERMISSION) So in this exam, I’ll be looking at your hands, face, chest and listening to your heart. Is that okay?” “ thank you”. “May I confirm your name please?” “And your date of birth?”, “and how old does that make you?” (PARTICULARS) “Do you mind taking off your shirt and rolling up your pants for me please?” (MAKE SURE HAVE BLANKET!) you may use the blanket to cover yourself after you’ve undressed. (EXPOSURE) and please have your arms by your side and legs uncrossed. I’m going to wash my hands, please tell me when you’re ready.” (WASH HANDS) “Are you in any discomfort at all?”  If yes, note, CARE when examining area. Esp shoulder – collapsing pulse; chest (palpation), legs (pitting edema) “now I’m just going to POSITION the bed at a 45o angle” (POSITION BED) 1. GENERAL INSPECTION of SURROUNDINGS: “this might look a bit weird, but I’m just going to stand in front of the bed and look at you.” (remove blanket) - Medication: (pills (statins, antihypertensives antiarrhythmics, GTN), insulin, inhalers (salbutamol) GTN spray - Equipment (walking aids, wheelchair, sputum bowl, TEDS, spectacles, magnifying glass, hearing aids - Connected to patient (ECG, O2, iv cannula(see if connected to patient and what solution is it connected to), urine catheter (see if connected to patient and colour of urine), insulin pump, continuous glucose monitoring, dialysis, central line - Consumption: Cigarettes, alcohol, types of food (fatty, high carbo) and drinks (caffeine) - Signs: NBM, consultant name, scheduled for surgery

2. GENERAL INSPECTION of PATIENT: - Age: young/old - habitus: Obese/ Cachectic - Distress: pain/ distress? Breathing? (respiratory distress, strenuous effort in breathing, tachypnea, deep and labored, fast and shallow) Clutching chest pains?

osler’s nodes (pulps of fingers: raised.SCARS: midline sternotomy (CABG) if found.Clubbing: Shamroth’s window test: DEMONSTRATE at their eye level. should refill in < 2 sec (compare with other fingers) b. barrel chested (COPD).koilonychias (IDA): spoon nails .nicotine stains. facing them while standing on the RIGHT of their bed. capillary refill (hydration status): press for 5 sec. nails: .Bruises .Quincke's sign is pulsation of the capillary nail bed (with the very wide pulse pressure of aortic regurgitation). chest drains (2nd I. Fingers: . patient leaning forward and proppring themselves up and using accessory muscles to breathe) (THEN GO STAND AT PATIENT’S RIGHT) 3.Pallor (anemia)? Cyanosed? . midaxillary line) .peripheral anemia c.Leuconychia (Liver disease) . subacute bacterial endocarditis. . . can you stick out your index finger and put your fingernails facing each other like this for me please?” (cardiac causes of clubbing: atrial myxoma. congenital cyanotic disease) .s.Arachnodactyly aka achromachia: abnormally long.Pitting and ridging nails (Psoriasis) . HANDS . Pacemaker (under L clavicle). Check DORSUM and while looking test CAPILLARY REFILL: a.MALAR FLUSH (mitral stenosis. red: subacute bacterial endocarditis) . Thorocotomy (R side for mitral or aortic valve replacement).peripheral cyanosis. Colour: .Posture: Chest (pectus carinatum.c. pectus excavatum. . slender fingers (Marfan’s syndrome  Aortic dissection  radioradial delay) .“now can I see both your hands please?” 1. kyphosis scoliosis. while giving instructions: “Sir/Mdm.streak haemorrhages (for subacute bacterial endocarditis). d.Oriented? . SLE) .Fever: sweating? Shivering? .. painful. check legs for saphenous venous graft.

warm and cyanosed: sepsis) 2.track marks: iv drug users . Normal for palm creases to be darker in dark skinned people.RADIAL PULSE (peripheral pulse): medial to radial styloid.Palm creases: pallor (anemia). ONLY first!) . 1st degree AV block. near wrist): current/post –haemodialysis . dermatoses (e. over wrist.BLOOD PRESSURE: “I would now like to take the patient’s blood pressure” – say to examiner . With right hand over wrist and left hand feeling brachial pulse. R hand.palmar erythema:liver disease (portal hypertension.Radio-radial delay: now use BOTH hands (feel other hand first to find pulse. hyperthyroidism.tendon xanthoma(ta):wrist tendons and ELBOW (behind olecranon): hypercholesterolemia: pathognomic in young (familial hypercholesterolemia) but can be normal in old. Atrial flutter)/ irregularly irregular (Atrial fibrillation) . lateral to FCR tendon. but if bradycardia or irregular rhythm: take 1 whole min! (take on one hand. WRISTS .Cold/ warm hands (cold and cyanosed: congestive heart failure. prob not.Rate: report EXACT rate and then describe (normal/ tachycardia/ bradycardia): in bpm (WATCH! 15 sec x 4). psoriasis) . pregnant women.scratch marks: jaundice . 2nd degree AV block. non-raised (macular).  coarctation.e.Dupuytren’s contracture: alcoholism  liver disease (CARE! Diff from ulnar clawed hand where also ring and little finger most commonly affected!) Feels fibrosed . ecchymotic (bruise-like)  subacute bacterial endocarditis .AV fistula (lower arm. Arms: . palms: SHOW by really feeling palms rub fingers against patient’s palms! . eczema. . lift arm (water hammer pulse  aortic regurg.) 3.janeway lesions: painless.g. press against radial styloid: Test at heart lvl! (raise patient’s wrist to their heart level) .bruising: liver disease (decreased clotting factors) .Rhythm: regular (sinus)/ regularly irregular (e.Collapsing pulse: first ask patient “may I know if there is any PAIN in your shoulders at all? Wrap palm firmly but not hard enough to feel pulse. then press back for R hand to feel both together and compare): for radioradial delay. must have an OBVIOUS difference…if not sure. . hyperpigmented (addison’s)  compare with skin colour. of aorta.g. aortic dissection) – TAKE RESPIRATORY RATE AT SAME TIME .

BREATH IN: check breath!!! .at the same time check for MALAR FLUSH -EYES: . then around eyes for xanthelasma.marfan’s syndrome: high-arched palate (also have arachnodactyly (thumb and 2nd finger easily wrap around wrist).CHEEKS: . then inside eyes for jaundice and corneal arcus) and then conjunctiva pallor (“now can you look up again for me while I gently pull down your lower eyelids”).Exophthalmos:”: see upper sclera (normally not visible)  GRAVE’S disease (patient look like he’s staring at you)  do only if suspect hyperthyroidism .Lid-lag: “now I want you to follow my finger with your eyes while keeping your head straight facing me”: lid cannot close fast enough. dry mouth .xanthelasma (hypercholesterolemia) on skin around eyes .corneal arcus: around iris (blue): hypercholesterolemia . pectus excavatum. FACE – “now I’ll just have a closer look at your eyes) just look straight ahead for me please? (look over patient first for upper sclera. long arm span > height. and now use your tongue to touch the roof of your mouth) .EAR: earlobes normally smooth. tall) .angular stomatitis aka angular chelitis: at edges of mouth: IDA “and open your mouth for me please?” . radioradial delay if have aortic dissection. . But if CREASED = increased risk of coronary artery disease & MI (but not predictive in native American Indians and Asians) . pregnancy. SLE .Dentition (risk factor for bacterial endocarditis) -“stick out tongue” . see upper white sclera. And lastly: lid lag: ““now I want you to follow my finger with your eyes while keeping your head straight facing me” up and down.Conjunctiva pallor: “now can you look up again for me while I gently pull down your lower eyelids) .IDA: pale and smooth tongue .hyperthyroidism: (also AF? High output HF?) .General hydration: hairy tongue.Malar flush: mitral stenonis.MOUTH: “now can you open your mouth wide? (demonstrate) and stick out tongue.  Thyrotoxicosis (not just grave’s)  do only if suspect hyperthyroidism . thyrotoxicosis.4.Jaundice: yellow sclera (sclera icterus): RHF/ valve prosthesis… .

jugular vein fills up and flushes away when pressure is released (4) height decreases with inspiration. sepsis. hypovolemic . keep your tummy nice and soft. palpate: c4 lvl of laryngeal prominence of thyroid cartilage. in anterior triangle of neck. Distinguish from carotids: (1) seen. thyrotoxicosis.Inspect: JVP (patient 45o!). NECK “Sir/Mdm.hepatic fetor (sweet faecal smell): liver failure. Measure by the highest border vertical distance to sternal angle: normal = 3cm raised i..observe by BENDING DOWN and looking up along sternocleidomastoid! (JVP should be . can you please turn your head over to the LEFT and just relax your neck against the pillow” (GET A PILLOW to support head) . then release slight pressure to feel contours of pulse. but not palpable (2) double wave form (a &v) (3)if occlude at supraclavicular area. medial border of sternocleidomastoid. increases with expiration. LV outflow obstruction b) thready/ low volume: MI (cardiogenic).. . pregnancy. anemia. Just relax for me.Goitre: feel anterior part of neck (if suspect hyperthyroidism/ hypo): smooth/ nodular? Symmetrical enlargement? “I’m just going to feel your neck a bit from behind you…just relax your chin against my hands…Can you swallow for me please?” while touching enlargement : if move when swallow = thyroid gland. .” . exercise. anxiety.lymph nodes: not really in cardio . 3. CHARACTER: a) Slow-rising (anacrotic): aortic stenosis. fever. COPD .breath: .(usually fast pulse – tachycardia) c) collapsing/ water hammer: aortic regurgication (wide pulse pressure) d) hyperdynamic (and usually tachycardic) – cardiac output high and peripheral resistance is low: (in CO2 retention) : emotion. T1DM or severe stage T2DM): “pear drops” . look for JVP supraclavicular.e.central cyanosis (under tongue) – “lift up tongue” . or maybe higher if raised (sometimes at ear).ketones (DKA. Bruits…”now I’m just going to feel the side of your neck for your carotid pulse” 1. 8cm of blood.CAROTID PULSE (Central pulse): VOLUME and CHARACTER. heat. Press down slowly and deeply till feel pulse.HEPATOJUGULAR REFLEX: PERFORM IT if cannot find JVP! – “I’m just going to press down gently on your tummy while you are in this position.Vit B12 and folate deficiency: Beefy and red tongue .alcohol .

S4 (Tennesse. MANUOVRE!: get patient to lie your body slightly on his left “Sir could you lie your body slightly on your left side please?” – and remain there for auscultation later! .might not be able to locate apical beat in pericardial effusion .Apex: use BELL. slightly medial to L mid-clavicular line. dub longer than lub. diaphragm for low frequency sounds . (PERCUSS)..scars (dun forget lateral sides!) . CHEST (MOST IMPT!): spend most time here! – INSPECT. EXTRA HEART SOUNDS: S3 (Kentucky. early diastolic.. PALPATE. “would you mind turning over to your left side please?” if the patient not already in that position * bell for higher frequency. listen for : and TIME WITH CAROTID PULSE! (systolic/ diastolic) and where is loudest! i) HEART SOUNDS (normal = lub-dub. (aortic valve stenosis: strongest murmur  usually can only feel this) c) AUSCULTATE “now I’m going to listen to your heart. prediastolic murmur. (just medial to nipple): (if cannot feel.  then localize with finger  then CHECK BACK…count ribs back (5-4-3-2-sternal angle).THRILLS (feel through BONES of chest wall): vibration buzzing feeling: use pulp of fingers: COUNT before putting fingers so know where to feel! 1) at pulmonary area: 2nd R ics. left heart failure). while feeling the side of your neck”.HEAVES: use heel of hand: will lift your heel up 1) at apex (LV hypertrophy) 2) at L Lower Parasternal edge (RV hypertrophy) .CHECK FOR ANY LATERAL AND INFERIOR DISPLACEMENT (LV hypertrophy): should be 5th ics. LV hypertrophy/ stiff) ii) MURMURS: 1) MITRAL area .at the same time.apex beat LOCATION: use palm of right hand to find it (PMI: point of maximal impulse).e) normal = dicrotic 4.REMEMBER where you palpate it for later! Auscultation . (pulmonary valve stenosis) 2) at aortic area: 2nd L ics. AUSCULTATE! a) INSPECT: really show that looking . PALPATE just below left clavicle and in left axilla for PACEMAKER b) PALPATE “I’m just going to feel for your heart beat” .

apex heave) and HEAD-NODDING with heart beat. “now can you take a deep breath in.patient REMAIN leaning forward (to differentiate b/w mitral and tricuspid: (only do when hear murmur) 1) Mitral louder on EXPIRATION. . (soft sound) opening snap in diastole (after S2). tricuspid louder on inspiration 2) Mitral louder in mitral area (apex). louder in pulmonic area .but louder on INSPIRATION. wide pulse pressure (BP measurement) – high SBP low DBP. Other sides of MS is MALAR FLUSH . and OUT all the way. tricuspid louder in tricuspid area (2nd to 5th left ics) 3) and tricuspid stenosis no presystolic accentuation (unlike mitral stenosis) 4) PULMONARY: (use diaphragm) auscultate at left 2nd Ics for PULMONARY STENOSIS (ejection systolic murmur): “ Dogbarking” …”now breath out all the way. and hold” – RMB intensity: 1) louder on inspiration or expiration? 2) louder where? to compare with tricuspid area later.less common than aortic stenosis (sounds the same) .Also hear AORTIC REGURGITATION (louder on expiration.or Mitral Regurgitation – PAN systolic murmur – “wind through trees”) – if cant hear. and hold” . and breathe IN all the way. presystolic accentuation. collapsing pulse and corrigan’s sign (bounding pulse at carotids – may be visible). 2) auscultate for radiation to LEFT AXILLA (mitral regurg) 3) “ Can you please sit forward now” while changing bell to DIAPHRAGM… ..TRICUSPID area: auscultate at Left 2nd-5th ics (COUNT!) “and breath out all the way and breath IN all the way and hold”: if murmur louder on expiration than inspiration. and louder than mitral area = tricuspid valve problem. leading back to loud S1) . loud S1.mitral stenosis – diastolic murmur. LV hypertrophy (Displaced apex beat. : . middiastolic mumur.

patient appears (well.is there any pain at all in your legs?”: start from ankles and move up if +ve sign. 6.. not in any distress). high pitched. surroundings? SCARS. and hold”… like pulmonary stenosis a pre-ejection systolic murmur.“ now I’m going to listen to your lungs.”now I’m just going to listen to it for a bit..5) AORTIC STENOSIS: (use diaphragm) ausculate at right 2nd ics. discontinuous or continuous sounds. furry tongue) peripheral stigmata of liver disease? MALAR FLUSH? Signs of hyperthyroidism/ graves? .INSPECT again for saphenous vein grafts and possible diabetic foot. pleuritis.can you take a deep breath in.  radiate to CAROTIDS (auscultated already while examining neck): listen for carotid bruits: . do you mind leaning a bit more forward for me please?” . a) carotid artery stenosis (turbulent blood flow) b) murmur radiating from aortic stenosis valve.listen to lung bases 1) decreased lung sounds: pleural effusion 2) crackles (more on inspiration): pulmonary edema (caused by LHF) 3) Wheeze (more on expiration): pulmonary edema: continuous. pacemaker? peripheral stigmata of subacute bacterial endocarditis? Peripheral or central cyanosis? Peripheral stigmata of anemia? Peripheral signs of hypercholesterolemia? Hydration status (capillary refill. both inspiratory and expiratory phases): pericarditis. and breathe OUT all the way. Assess the height of edema! . 7) SACRAL EDEMA (where the butt cracks start) “now I’m just going to check your lower back for edema” 8) LEGS “ and finally your legs for any pitting edema. (SHOW) To conclude: 1) Thank patient (“I have finished my examination. thank you very much” 2) “Do you need any help getting dressed?” 3) WASH HANDS 4) Present findings: “Present findings: . but i) more common than pulmonary stenosis ii) louder on EXPIRATION iii) louder in aortic area. pleural effusion.on INSPECTION. hissing sounds 4) Pleural rubs (creaking or brushing sounds produced when the pleural surfaces are inflammed or roughened and rub against each other. LUNGS . and HOLD” use BELL.. “ Dog-barking” …”now breath in all the way.

I would…? CXR. ankle) or signs of liver disease e. urine dipstick (proteinuria for kidney disease. glucosuria for DM. diabetic retinopathy and hypertensive retinopathy.any heaves/ thrills? .PULSE: Peripheral: HR (report absolute value and give description) and rhythm (regular/ regularly irregular/ irregularly irregular). ascites and loss of peripheral pulses if detect RV hypertrophy. MDM and PSA for mitral stenosis? Loudest where? Louder on inspiration or expiration? (RILE) Radiation to axilla (for mitral regug) or carotids (aortic stenosis) .APEX beat: displaced? . check for hepatomegaly. FBC (LFT. U&E for renal). ECG.. Other tests: .BLOOD PRESSURE: report and describe .on chest palpation: . ketonuria for T1DM.on Ausculation: .extra heart sounds? Or no heart sounds (pericardial effusion)…Beck’s triad for cardiac tamponade (hypotension. pan-systolic for MR. palmar erythema. raised JVP. loud S1.Central pulse: normal volume? Character normal/ slow-rising/ thready/ bounding/ hyperdynamic? . pulse oximetry (for O2 saturation). Regular? Shallow and fast?/ deep and labored? .g.g. mitral stenosis (malar flush).sacral edema? Ankle edema? Diabetic foot? 5) Assessment of patient: ? To further assessment.Lung bases (crackles/ decreased breathe sounds/ wheeze/ pleural rub) . dupuytren’s contracture. raised JVP and distant or muffled heart sounds) .JVP: how many cm rise  normal? Raised? .Roth’s spots with fundoscope (if ? subacute bacterial endocarditis) . collapsing pulse (aortic regurg). lying and standing BP (postural hypotension). jaundice. Collapsing pulse? Respiratory rate is : value. echocardiography (for valve disease). edema (pulmonary. extra heart sounds.carotid bruit (carotid artery stenosis) .echocardiography (for valve defects: audible/palpable murmurs. respiratory examination? Fundoscopy for roth’s spots (bacterial endocarditis). feel for peripheral pulses. RHF. leuconychia. coractation of aorta (associated with aortic stenosis)/ aortic dissection (marfan’s syndrome -arachnodactyly …(radioradial delay) . sacral.Murmur? (systolic/ diastolic? Or other special features e.

Notes: Jaundice (liver failure due to RHF/ hemolysis from valve replacements) .

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