Cardiovascular System

The station is for a total of 10 minutes. 6 minutes for the candidate to do an uninterrupted
examination after which 1-2 minutes for presentation and the remaining time for discussion.

The appropriate sequence that has helped get a full mark is as below.

1. Approach from right side of the patient, adequately expose

2.Inspection is key- 10-15 sec from head to toe or toe to head raise hands on dorsal aspect, for
clubbing, cyanosis(peripheral), splinter hemorraghes, leukonychia or koilonychia, onycholysis,
nail pitting,nicotine staining, Then ask the patient to turn the hands over to examine the palmar
aspect for – radial artery scar ( fresh one or old one, ? recent radial artery angiogram, ?
prolonged ICU stay with an art line, Dupuytren’s contracture, Thenar & hypothenar wasting,
Oslers nodes, janeway lesions, palmar erythema, cutaneous calcinosis, diabetic finger pricks,
tar staining fingers( by separating the fingers). Moistness of palms( / hyperthyroid, Acromegaly
etc)Gently spread fingers over checking
3. Pulse
Feel for the both radials simultaneously , look for any r- r delay, then asses rate rhythm and
character (that can best felt in carotids). Then next proceed to feel brachial pulse . Check for
collapsing pulse asking the patient to raise his arm straightly up wards. next carotids are to be
looked for. Make sure that both carotids are not felt simultaneously. Look for character of pulse
and any thrills.
4.recline in 45°position on bed
5. EXAMINATION OF NECK: look for any goitre ,
Look for JVP: ask the patient to tilt his head slightly to opposite side that JVP visualised between
both heads of SCM, examiner should stand behind and look for JVP with light thrown obliquely .
6. Inspect mouth, high arched palate, cyanosis, AVMs, dental hygiene etc
7. Eye for icterus and anemia
 Cardiovascular System

PROPER CVS EXAMINATION:

8. INSPECTION: start inspecting the patient by standing from the foot end . Look for any
deformities of chest, precordial bulge, any obvious visible pulsations, scars on the chest
(midline sternotomy scar, left lateral thoracotomy scar)
9. PALPATION:
Palate from the left lower sternal edge to the apex till you feel the apex beat. If not able to feel
then ask the patient to turn left laterally and localize the apex beat. Count the position of apex
by taking sternal angle as a land mark that corresponds to 2nd ICS and proceed down wards till
apex.
Entire precordium should be palpated . Look for any thrills, also palpable hearts sounds like p2
in right 2 nd ICS and ejection clicks in aortic and pulmonic areas .
Look for left para sternal heave which is a indicative of right ventricular hypertrophy by placing
Palm on left parasternal area and apply sustainable gentle pressure. If RVH present u will
appreciate a lift of the hand.
10.AUSCULTATION:
Auscultate apex beat ( mitral area) , tricuspid, aortic , pulmonic areas. ( clockwise manner)
Time with carotids. Wit the diaphragm
11. DYNAMIC AUSCULTATION:
Left lateral position: auscultation of apex ( mitral area) with bell for diastolic sounds S3,S4,
MDM
Make the patient sit and ask him to lean forward , auscultate neoaortic area ( 3 left ICS ) for
early diastolic murmur with breath held in expiration. Later ask him to breath normally.
12. AUSCULTATE CAROTIDS: with bell r diaphragm for bruit.
Inch whenever a murmur heard, all systolic murmurs get patient to stand up and auscultate.
13. LUNG BASES are auscultated for inspiratory crypts.13. Look for SACRAL EDEMA14. Expose
the feet , look for anklEDEMA, 15. Palpate peripheral pulses , look for radio femoral delay . Tell
examiner that you would like to measure blood pressure.