Cardiovascular exam

This is the general instructions on how to do a cardiovascular exam

Before you start you would like to:
Wash hands
Introduce yourself and gain consent
Position the patient at 45 degrees

General inspection

Look for paraphernalia
General state
Colour
Short of breath?
Any scars

Make a general statement such as 'Mr X looks alert, well perfused and comfortable at rest 

Hands

Tobacco staining
Peripheral cyanosis
Capillary refill time.
Nails - clubbing
Splinter haemorrhages (can be sign of IE)
Nailbed pulsation (a sign of aortic regurgitation (Quinke's sign))
Tendon xanthomata
Janeway lesions (painless) (PROXIMAL IS PAINLESS)
Osler nodes (painful) (both signs of IE)


Arm
Pulse
Radio-radial delay
Radiofemoral delay (can indicate coarctation of aorta or aortic arch aneurysm)
Collapsing pulse or waterhammer (check for pain in arm)(if positive, sign of aortic regurgitation)
Can check brachial pulse
Will give character
Blood pressure (wide pulse pressure indicates aortic regurg, narrow in aortic stenosis) (an easy way to remember this is stenosis means narrowing)

Neck
JVP
Carotid pulse
Examine character
Bounding pulse(CO2 retention)
Small volume (shock, pericardial effusion)
Anacrotic (Aortic stenosis)
Bisferiens pulse (Aortic stenosis & Regurg)
Pulsus alternans (suggets LVF, Cardiomyopathy or aortic stenosis)(alternating weak and strong beats)
Is it visible?
Corrigans sign of aortic regurgitation

Face
Colour - pale flushed central cyanosis
Eyes - Corneal arcus, xanthelasma
Conjunctivepallor
Malar flush (mitral stenosis)
Dentation (Bact endocardititis) check tongue as well.

Praecordium

Inspect chest:
Scars:
Midline sternotomy (can suggest CABG look for graft site at long saphenous)
Lateral thorocatomy (mitral stenosis valvotomy - pretty  rare in western world)

Palpate
Apex beat
Note position
Heaving in aortic stenosis or systemic hypertension.
Thrusting feeling in volume overload in eitheir mitral or aortic incompetence.
Tapping in mitral stenosis
Heaves
Thrusting feeling indicating ventriculomegaly (in RV)

Thrills
Palpable murmur

Auscultate
Apex (5th space MC)
Use bell and diaphragm
Can ask patient to roll over to left, breath out and hold to hear mitral stenosis ( mid diastolic murmur)
Mitral regurg is heard as a pansystolic murmur.

Lower left sternum (Tricuspid area)
Sit patient up and listen for early diastolic murmur - aortic regurg
2nd space on left (pulmonary area)
If suspected right sided murmur listen while patient is held in inspiration

2nd space on right (Aortic area)
Listen for aortic stenosis


To complete examination

Palpate sacral and ankle oedema
Auscultate the lung base (for inspiratory crackles)
Examine abdomen for aortic aneurysm and pulsatile liver - seen in tricuspid regurg
Spleen is enlarged with infective endocarditis.

Urine dipstick, Fundoscopy - look for roth spots, Sats, obs and peripheral pulses




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