2. Brief anatomy and physiology
• The heart comprises two muscular pumps working in series, covered
in a serous sac (pericardium) that allows free movement with each
heart beat and respiration . The right heart (right atrium and
ventricle) pumps deoxygenated blood returning from the systemic
veins into the pulmonary circulation at relatively low pressures. The
left heart (left atrium and ventricle) receives blood from the lungs and
pumps it round the body to the tissues at higher pressures
Atrioventricular valves (tricuspid on the right side, mitral on the left)
separate the atria from theventricles.
3. • The pulmonary valve on the right side of the heart and the aortic
valve on the left separate the ventricles from the pulmonary and
systemic arterial systems, respectively. Cardiac contraction is
coordinated by specialised groups of cells. The cells in the sinoatrial
node normally act as the cardiac pacemaker. Subsequent spread of
impulses through the heart ensures that atrial contraction is complete
before ventricular contraction (systole) begins. At the end of systole
the ventricles relax and the atrioventricular valves open, allowing
them to refill with blood from the atria (diastole)
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5. General examination
• Look at the patient’s general appearance. Do they look unwell,
frightened or distressed? Are there any signs of breathlessness or
cyanosis? Is the patient overweight or cachectic? Are there any
features of conditions associated with cardiovascular disease such as
Marfan’s(p .6), Down’s (p. 7) or Turner’s syndrome (p. 8).
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9. Hands
• Feel the temperature of the hands and measure capillary refill time
• Examine the hands for tobacco staining , skin crease pallor or
peripheral cyanosis
• Look at the nails for finger clubbing , and for splinter haemorrhages:
linear, reddish-brown marks along the axis of the fingernails and
toenails
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11. Face
• Look in the mouth for central cyanosis: a purplish blue discoloration
of the lips and underside of the tongue
• Examine the eyelids for xanthelasmata: soft, yellowish plaques found
periorbitally and on the medial aspect of the eyelids
12. Atrial pulse
• The palpable pulse in an artery reflects the pressure wave generated
by the ejection of blood into the circulation from the left ventricle.
• Radial pulse Carotid pulse
• Brachial pulse
13. Ascultation
• Correct identification and characterisation of the heart sounds and of
any added sounds and/or murmurs require a careful, systematic
approach to auscultation.
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20. Murmer
• Heart murmurs are produced by turbulent flow across an abnormal
valve, septal defect or outflow obstruction. ‘Innocent’ murmurs are
caused by increased velocity of flow through a normal valve and
occur when stroke volume is increased, as in pregnant women,
athletes with resting bradycardia or patients with fever.
