Cardiovascular examination

Cardiovascular examination and questions for medical student exams, finals, OSCEs and MRCP PACES

Intro (WIIPPPPE)

• Wash your hands
• Introduce yourself
• Identity of patient – confirm
• Permission (consent and explain examination)
• Pain?
• Position at 45°
• Privacy
• Expose chest to waist

General Inspection

• Surroundings
  • Monitoring
    • pulse oximeter
    • ECG monitoring
    • Daily weights/ fluid restriction chart
  • Treatments
    • Oxygen therapy: type (e.g. venturi) and rate (e.g. 25% or 5L) of delivery
    • GTN spray
    • Warfarin INR card
    • Insulin pen
    • IV infusions
  • Paraphernalia
    • Wheelchair, walking aids
    • Cigarettes, nicotine patches, gum
• Patient
  • General
    • Well or unwell; short of breath; alert and orientated or drowsy and confused; comfortable at rest or in pain?
  • Syndromic features (e.g. Down’s or Marfanoid)
  • Colour
    •  Pale (anaemia); malar flush (mitral stenosis); cyanosis (low sats – consider lung disease and cor pulmonale)

Systemic examination

• Chest
  • Inspect
    • Scars
      • Lateral thoracotomy (mitral valve)
      • Midline sternotomy (CABG or valve)
      • Left subclavicular (pacemaker, AED)
      • Back (coarctation or ballic-torso shunt)
    • Deformity (e.g. pectus escavatum in Marfan’s syndrome)
    • Pacemaker or AED
  • Ticking of metallic heart valve? (stop to think about this or you may miss it)
• Face
  • Inspect
    • Malar flush (mitral stenosis)
    • Eyes:
      • Corneal arcus (elderly, hyperlipidaemia in young)
      • Conjunctival pallor (anaemia)
      • Petechial haemorrhages (endocarditis)
      • Xanthelasma (hyperlipidaemia)
    • Mouth
      • Hydration status
      • Dentition (risk of endocarditis)
      • Central cyanosis (under tongue)
      • High-arched palate (Marfan’s syndrome)
• Neck
  • Inspect and palpate
    • Carotid pulse (character and volume)
      • Collapsing: aortic regurgitation
      • Slow-rising: aortic stenosis
      • Thready: shock
      • Bounding: CO2 retention
    • JVP
      • JVP can be differentiated from carotid by:
        • Hepatojugular reflux; occludable; not pulsatile; double waveform
      • JVP is raised if vertical height is >3cm above sternal notch
    • See questions below for more information on the JVP
  • Auscultate
    • Carotid bruits
• Arms
  • Inspect
    • Scars from forearm vein harvesting
    • IV access
    • Track marks (IV drug use is an endocarditis risk factor)
    • Bruising
      • Anticoagulation therapy
  • Palpate
    • Offer to measure BP
      • Pulse pressure
        • Narrow (aortic stenosis)
        • Wide (aortic regurgitation)
      • Unequal arm BPs
        • Aortic dissection
        • Subclavian artery stenosis: BP reduced on side of stenosis
• Hands
  • Inspect
    • Temperature
    • Capillary refill (at level of heart)
    • Colour (peripheral cyanosis)
    • Clubbing – perform Shamroth’s window test and consider cardiac causes
      • Congenital cyanotic heart disease; endocarditis; atrial myxoma
    • Cigarette tar staining (not nicotine!)
    • Blood glucose testing on fingertips
    • Tendon xanthomata (hyperlipidaemia)
    • Janeway lesions (endocarditis)
    • Osler nodes (endocarditis)
    • Splinter haemorrhages
      • trauma, vasculitis, endocarditis
    • Pale palmar creases (anaemia)
    • Palmar erythema
      • Hyperthyroidism; pregnancy, polycythaemia
    • Arachnodactyly (Marfan’s syndrome)
    • Quincke’s sign (aortic regurgitation)
  • Palpate:
    • Radial pulse (rate, rhythm)
      • Weak left pulse post-Fontan procedure
    • Radio-radial delay
      • Aortic dissection
      • Aortic coarctation (delayed on left depending on level of coarctation)
      • Subclavian artery stenosis
    • Radio-femoral delay
      • Aortic coarctation
    • Collapsing pulse (aortic regurgitation)
      • Ask about pain in shoulder first
  • Palpate
    • Apex beat
      • Normal: 5^th intercostal space, mid-clavicular line
      • Forceful: LVH, aortic stenosis
      • Heaving/thrusting: aortic regurgitation, mitral regurgitation
      • Tapping: mitral stenosis
      • Double: HOCM
    • LV and RV heave (ventricular hypertrophy)
    • Thrills (palpable murmur)
  • Auscultate
    • Listen to heart sounds in four areas with diaphragm whilst feeling carotid pulse
    • If a systolic murmur is heard:
      • Listen in the axilla for radiation (mitral regurgitation)
      • Listen over the carotids for radiation (aortic stenosis)
    • Always perform the reinforcement manoeuvres to detect diastolic murmurs:
      • Bell on apex, roll on left side, hold breath in expiration (mitral stenosis)
      • Sit forwards, left lower sternal edge with diaphragm, hold breath in expiration (aortic regurgitation)
    • With patient sat forward, auscultate lung bases
      • Reduced air entry, bilateral crepitations (pulmonary oedema)
• Sacrum
  • Sacral oedema (heart failure, fluid overload)
• Legs
  • Check for pain in ankles first
  • If present find upper limit of peripheral oedema and feel for pulsatile liver (tricuspid regurgitation)
    • Scars (medial calf for saphenous vein harvesting)
    • Peripheral oedema (heart failure, fluid overload)

Closure

• Thank patient
• Patient comfortable?
• Help getting dressed?
• Wash hands
• Turn to examiner, hands behind back, holding stethoscope (try not to fidget!) before saying: “To complete my examination, I would like to…”
  • Further examinations:
    • Perform a peripheral arterial examination
    • Perform fundoscopy (hypertensive retinopathy, Roth spots in endocarditis)
  • Bedside investigations:
    • Obs: resp rate, pulse, BP, O2 sats, temperature
    • Measure lying and standing BP
    • 12-lead ECG
    • Urine dip
    • Blood glucose
  • Further investigations
    • Bloods: consider BNP (heart failure) and troponin (ischaemia or myocarditis)
    • Echo

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Common Cardiovascular examination exam questions for medical students, finals, OSCEs and MRCP PACES

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