CV Exam

Cardiovascular Exam
Sources: Epstein, Study Guide Wk 3 Th4 Tute,
CV examination of the periphery
· General Appearance
o Dyspnoea, fatigue, cachexia.
· The Hands
o Temperature – extent of vasodilation in hands – guide to peripheral vasodilation. Pts with CHF have cold and sometimes sweaty hands from adrenaline secretion
o Clubbing – endocarditis or cyanotic congenital heart disease
o Splinter Haemorrhages (small bleeds under nail ) and osler’s nodes (painful raised red lesions on finger pulps) – subacute infective endocarditis
o Xanthomata
o Cyanosis
· The Arterial Pulses
o used to assess heart rate and rhythm and the carotid and femoral used to assess pulse character and cardiac performace due to proximity to heart.
o Sometimes good to feel the same pulse on both sides to assess proximal arterial pathology
o Sometimes good to feel femoral and radial simultaneously - a delayed femoral pulse is a feature of aortic coarctation (stenosis)
§ Radial
· located on the lateral of the wrist (radial artery). It can also be found in the anatomical snuff box.
§ Brachial
· Medial to biceps brachii tendon
§ Carotid
· Carotid artery can be felt against the precervical muscles lateral to larynx (a slow rising carotid pulse, often with a palpable shudder, indicates aortic stenosis.) Also listen for bruits while patient holds their breath with stethoscope.
§ Femoral
· Directly above the pubic ramus, midway between the ASIS and pubic tubercle.
§ Popliteal
· Popliteal fossa, felt against distal femur.
§ Dorsalis pedid + tibialis posterior
· Dorsum of foot lat. To ext. hal. Long. Tendon.
· Post to med. malleolus
· The Blood Pressure
o Covered in another topic

· The face
o Jaundice anaemia, xanthelasma, cyanosis
· The neck (JVP)
o Lie pt. on 45 degrees to view JVP without sternocleidomastoid muscle getting in the way (int. jugular collapsed on standing or sitting and completely filled when lying)
o If internal jugular pulsation is seen more than 4cm above manubriosternal angle, then JVP is raised.
o If raised DDx: CHF, tamponade, PE, Sup. VC obstruction
· The Lower limbs
o Oedema, Capillary Return, Pallor
CV examination of the precordium (external surface of the body overlying the heart)
Inspection

Pt lying supine 45 degrees.
Breathing rate and pattern.
Position of apex beat, defined as lowest and outermost point of cardiac pulsation, usually in 5th IC space, mid clavicular line. If you see other pulsations usually abnormal

Palpation

Locate apex beat (may have to lie pt on left side as this brings apex closer to chest wall.) – characteristics of this beat outlined in textbook to look for.
Presence of thrills (palpable vibration which sometimes accompanies a loud heart murmur)
Parasternal heave or impulse - A parasternal heave is detected by placing the heel of the hand over the left parasternal region. In the presence of a heave the heel of the hand is lifted off the chest wall with each systole.

Percussion

Not relevant in CV exams anymore.

Auscultation

Listening for heart sounds can be aided by, positioning pt differently, eg. Lying pt on their left to bring mitral valve closer to chest wall. Sitting pt forward to hear aortic and pulmonary valve better.
Getting patient to inspire and expire heavily, expiartion squeezes blood into left heart from pulmonary bed, aortic and pulmonary murmurs. Get pt to hold breath, lung thickness reduced, distance b/w heart and steth is decreased, easier to hear.

Heart Sound Areas:
1. Mitral : near apex of heart
2. Tricuspid: right sternal border, 5th IC
3. aortic: right of sternum, 2nd IC
4. pulmonary : left sternum 2nd IC

Sounds to listen for:

First and second heart sounds -
Third heart sound, can be normal in young fit people, pathological otherwise – impairment of LV fn
Fourth heart sound – coincides with atrial contraction – LA hypertrophy
Ejection click – high pitched ringing after S1 – aortic pulmonary valve stenosis
Opening snap – diastolic sound in mitral stenosis
Mid-systolic clicks – mitral valve prolapse – may be associated with late systolic murmur.
Sounds from artificial valves – have soft opening clicks and loud closing clicks
Murmurs (graded 1 – 5)