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Approach to the cardiovascular examination

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Approach to the cardiovascular examination

  1. 1. Approach to the Cardiovascular Examination Carly Welch Final Year Medical Student University of Birmingham
  2. 2. Contents  Basic approach to the CVS patient  General observations  Hand signs  Pulse  Blood Pressure  Eyes & face  Neck & JVP  Legs  Examination of the praecordium  Observation  Palpation  Auscultation  Extra things to do  Case scenarios  Summary
  3. 3. Basic approach  WIPER  Wash hands, Introduce, ask about Pain, Exposure, Repositioning – 45o  CVS examination does not just mean auscultation!  Start with general observation and then examine systematically starting with the hands
  4. 4. General observation  Comfortable? Alert? Generally well or unwell?  Do they look breathless or cyanosed?  Can you see any obvious scars or pacemakers?  Any clues around the bed e.g. GTN sprays?
  5. 5. Hand signs Clubbing Koilonychia Palmar erythema Splinter haemorrhages Osler nodes Janeway lesions
  6. 6. Pulse  Rate (60-100)  Rhythm; regular or irregularly irregular (AF)  Volume  Character  Slow-rising or plateau = AS  Bounding (collapsing) = AR  Radial-radial delay (and radial-femoral delay)
  7. 7. The “Waterhammer” Pulse  AKA Collapsing pulse or Corrigan’s pulse  Does not necessarily mean AR  Many different techniques described  Basic principle is to elevate the arm above the level of the heart and to palpate the arm with the palm of the hand  Pulse feels forceful
  8. 8. Blood pressure  Very useful in the acute situation!  In stable patients:  Are they hypertensive?  Is there a wide or narrow pulse pressure?
  9. 9. Eyes & face Face Eyes Mouth General pallor Malar flush Corneal arcus Xanthelasma Conjunctival pallor Central cyanosis Poor dentition
  10. 10. Neck & JVP  Corrigan’s sign – visible carotid pulsations  de Musset’s sign – head nodding in time with carotid pulsation Jugular Venous Pressure  Various waveforms – forget!  Is it >4cm above sternal angle or <4cm?  Hepatojugular/ abdominojugular reflux – warn patient first!
  11. 11. Legs  Some prefer to leave this until the end  Check for peripheral oedema – pitting or non- pitting?  Check for vein harvesting scars
  12. 12. Observation of the praecordium  Any scars?  Central sternotomy or valve replacement  Any pacemakers?  Any obvious chest deformities?  Also take this time to listen carefully for the audible “click” of a mechanical valve that may be heard without a stethoscope
  13. 13. Palpation  Feel for any pacemakers or defibrillator devices  Feel for apex beat (don’t be disheartened if you find this tricky!)  Place flat of hand where you expect the apex to be (mid- clavicular line 5th intercostal space) and find point of maximum pulsation  Then count down from sternal angle to find the position of the apex beat  NB: remember dextracardia!  Determine the character of the apex  Tapping? Heaving? Thrusting? Jerky?  Then feel for any parasternal heaves using the flat of your hand  Finally feel for any thrills with ulnar border of your hand – these are palpable murmurs; feel in all areas where you will listen with your stethoscope (see next slide)
  14. 14. Auscultation  Four areas to listen:  Aortic = 2nd intercostal space right sternal edge  Pulmonary = 2nd intercostal space left sternal edge  Tricuspid = 4th intercostal space left sternal edge  Mitral = apex beat  Take your time and don’t panic!  Don’t move on to the next area until you are happy with what you have heard!  Feel carotid pulse simultaneously; systolic murmurs coincide with pulse  Listen with diaphragm in all areas and bell in mitral area  Listen at the carotids with the bell for a carotid bruit
  15. 15. System for heart sounds 1. Can I hear heart sounds? 2. Can I hear S1 and S2 equally? 3. Can I hear any other sounds?  E.g. gallop rhythm: S3 “tenessee” or S4 “kentucky” 4. Can I hear any murmurs?  Are they systolic or diastolic?  Are they continuous or can I clearly hear S1 and S2 separately?  If they are not continuous, are they early, middle or late in timing?  Where is the murmur loudest and can it be heard anywhere else?  Aortic murmurs radiate to the neck; mitral murmurs radiate to the axilla 5. Can I put this information together?
  16. 16. Manoeuvres to accentuate murmurs  Ask the patient to roll onto their left side  This will accentuate the murmur of MS so listen with the bell  Ask the patient to lean forward and listen at the lower left sternal edge  This will accentuate aortic murmurs  At the same time, take this opportunity to listen at the bases of the lungs for any basal crackles suggestive of heart failure or any sacral oedema  Asking the patient to hold their breath in expiration will accentuate aortic and mitral murmurs and in inspiration will accentuate pulmonary and tricuspid murmurs  This will be uncomfortable for the patient and make sure you tell them they can breathe normally afterwards!
  17. 17. Extra things to do  Take a full history!  Blood pressure  Even if you said it earlier as the examiner is likely to forget!  Feel for radial-femoral delay (if not done)  Examine the respiratory system  Measure oxygen sats  Perform a 12-lead ECG  Perform a chest X-ray
  18. 18. Case scenarios  Likely cases for OSCEs include:  Aortic stenosis/sclerosis  Mitral regurgitation (or PSM of other cause)  Aortic regurgitation (rarely!)  A patient who has had a previous Coronary Artery Bypass Graft (CABG)  A patient who has had a previous valve replacement
  19. 19. Aortic stenosis/sclerosis  Signs to look for on examination:  Slow-rising/ plateau pulse  Narrow pulse pressure  Ejection systolic murmur with radiation to the carotids  Differential diagnosis:  Aortic stenosis  Aortic sclerosis  (Pulmonary stenosis)  Some common questions:  How can you tell the difference between aortic stenosis and aortic sclerosis?  At what point might you consider valve replacement?
  20. 20. Pansystolic murmur  Signs to look for on examination:  Nature of apex beat  Pansystolic murmur – note where it is loudest and any radiation  Pulsatile liver edge – TR!  Differential diagnosis:  Mitral regurgitation  Tricuspid regurgitation  Ventricular septal defect  Some common questions:  What do you think might have caused this murmur?
  21. 21. Aortic regurgitation  Signs to look for on examination:  Lots of eponyms; here are 3:  Quincke’s sign = nail bed pulsations  de Musset’s sign = head nodding  Corrigan’s pulse = carotid pulsation  Also: collapsing/ waterhammer pulse  Wide pulse pressure  Early diastolic murmur  Differential diagnosis:  (Pulmonary regurgitation)  Some common questions:  What do you think might have caused this murmur?
  22. 22. Summary  The CVS examination demands a systematic approach  Many clues to clinical diagnosis can be picked up before auscultation  Try to stay calm and don’t rush  If you are unable to palpate the apex beat or hear heart sounds admit this and use it as a learning opportunity  Good luck and enjoy cardiology!!

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