Examination of the cardiovascular system

General points
Introduce yourself
Approach patient from right hand side
Adjust backrest so patient is at 45o to the mattress
Exposure - ask patient to remove shirt, etc.
While taking history look for any signs

1- Inspect from end of bed
Oxygen
Comfort
Inhalers

2 - Visual survey
Is patient
· Breathless
· Cyanosed
· Pale
· Xanthelasma
· Coronary arcus
· Malar flush (mitral stenosis)
· Examine earlobes for creases
Pulsation’s on neck -
· Forceful carotid pulsation’s (Corrigan’s sign in aortic incompetence, vigorous pulsation in coarctation of the aorta). Look for titubation
· Tall sinous venous pulsation’s - congestive cardiac failure, tricuspid incompetence, pulmonary hypertension
Inspect the chest
· Left thoracotomy scar (mitral stenosis) or midline sternal scar (valve replacement)
Look at feet
· Ankle oedema

3 - Inspect the hands
· Assess warmth, sweating & peripheral cyanosis
· Finger clubbing - cyanotic congenital heart disease, subacute bacterial endocarditis
· Splinter haemorrhages - infective endocarditis

4 - Pulses
· Radial - rate & rhythm
· Assess for collapsing pulse - visibly lift arm up. First ask patient if they have any shoulder pain
· Radio-radial delay
· Radio-femoral delay - coarctation of the aorta
· Brachial pulse - slow rising pulse
· Carotid pulse - slow rising pulse

5 - Neck
· Visual survey may already have found interesting points
· Corrigan’s sign - forceful rise & quick fall of carotid pulsation
· (Time individual waves of venous pulsation against opposite carotid. Don’t actually do this. MRCP stuff)
· JVP may move earlobe - tricuspid incompetence
· JVP - assess height of JVP above sternal edge in centimetres

6 - Apex beat
· Localise mid-clavicular line
· Inspect for pulsation
· Palpate
· Vigorous beat place index finger on it for point of maximum impulse (PMI)
· Impulse - palpable, lifting, thrusting or heaving

7 - Palpation of chest
1. Hand from lower left sternal edge to apex beat tapping impulse or thrills over mitral area if present
2. Press hand gently over left parasternal area sustained gentle pressure. If right ventricular hypertrophy is present you will feel the heel of your hand being lifted by the force
3. Palpate pulmonary area - palpable second sound (pulmonary hypertension)
4. Palpate aortic area palpable thrill (aortic stenosis)

8 - Auscultation
· Time first heart sound with either apex beat or carotid
· Position properly for different murmurs
· Mitral diastolic murmurs (mitral stenosis) turn patient onto left side. Use bell of stethoscope
· Early diastolic murmur of aortic incompetence ask patient to lean forward and hold breath in expiration
· ‘Lean forward for me please. Can you breathe out and hold your breath please.’
· Listen for aortic incompetence with bell.

10 Auscultate neck
· Listen for radiation of murmurs & carotid bruits

11 - Auscultate lung bases
· Looking for inspiratory crepitations. Essential part of routine cardiovascular examination. Not normally in exam but should do in breathless patient, aortic stenosis with displaced PMI or if there are signs of heart failure (orthopnoea, pulsus alternans, gallop rhythm)

12 - Check for peripheral oedema
· Sacral & ankle

13 - Palpate liver
· May be pulsatile in some cases

14 - Measure blood pressure
· Particularly important in patients with aortic stenosis (low systolic & narrow pulse pressure) and aortic incompetence (wide pulse pressure)

I would also like to…..
· Palpate abdomen for abdominal aorta
· Palpate peripheral pulses
· Fundoscopy diabetic or hypertensive retinopathy
· Palpate thyroid
· Dipstick urine for protein, glucose, blood, ketones