Examination of the heart – PACES

1. Examination of the heart – PACES
   
   Position – approach from right/patient at 45’
2. 
   Ask permission/introduce self/adjust clothing
3. 
   Visual survey is patient/does patient have
   A. breathless?
   B. cyanosed?
   C. Pale?
   D. Malar flush? Mitral stenosis
   E. Franks sign (earlobe creases)?
   F. Forceful carotid pulsations (Corrigans sign in AI, forceful pulsation in coarctation of the aorta)
   G. Tall, sinuous venous pulsations (CCF, tricuspid incompetence, pulmonary HT, etc)
   H. Left thoracotomy scar (mitral stenosis) or midline sternal scar (valve replacement/CABG)
   I. Ankle oedema –
   J. Finger clubbing (cyanotic congenital heart disease, SBE)
   K. Splinter haemorrhages
   
   Pulse – rate & rhythm
   
4. Is pulse collapsing? Especially if large volume pulse – make sure you are seen to lift arm – ask if arm is sore before lifting
   
5. Radiofemoral delay (coarctation of the aorta)
   
6. other pulses – brachial & carotid looking for slow rising pulse – especially if low volume pulse
   
7. JVP – if interesting pulsations noted further examine. Corrigans sign (forceful rise and quick fall of pulsations) may be reinforced by collapsing pulse. Can time individual waves against opposite carotid. A large v wave which may oscillate the earlobe suggests tricuspid incompetence – should later demonstrate peripheral oedema and pulsatile liver using bimanual technique (place left palm posteriorly and right hand anteriorly over enlarged liver). If the venous wave comes before the carotid pulsation it is an a wave suggesting pulmonary hypertension (mitral valve disease, cor pulmonale) or pulmonary stenosis (rare)
   
8. Measure height of JVP in CM directly above the sternal angle
   
9. Localise apex beat with respect to mid-clavicular line and ribspaces, initially by visual inspection (ha ha) then by palpation. If apex beat is vigorous you should stand the index finger on it to localise point of maximum impulse (PMI) and assess the extent of its thrust. Impulse graded as just palpable, lifting (diastolic overload, i.e. mitral or aortic incompetence), thrusting (stronger than lifting) or heaving (outflow obstruction)
   
10. Palpation with hand placed from left lower sternal edge to apex will detect a tapping impulse (left atrial ‘knock’ in mitral stenosis) or thrills over the mitral area (mitral valve disease)
    
11. Feel for right ventricular lift (left parasternal heave). Place right palm parasternally over right ventricular area and apply sustained and gentle pressure. If RVH is present you will feel the heel of your hand lifted by the force (pulmonary hypertension)
    
12. Palpate the pulmonary area for palpable second sound (pulmonary hypertension) and aortic area for palpable thrill (aortic stenosis)
    
13. If you feel a strong RV heave recheck for giant a wave (pulmonary HT, pulmonary stenosis) or v wave (tricuspid incompetence, CCF). Palpable thrills over mitral (MS) or pulmonary (PHT) areas should make you think of and check for other complementary signs.
    
14. Auscultation – only leave heart if you have a strong expectation of being able to demonstrate interesting and relevant sign (e.g. pulsatile liver to strengthen diagnosis of tricuspid incompetence). Time the first sound with either the apex beat if palpable or by feeling the carotid pulse. Listen to expected murmurs in best positions. Mitral diastolic murmurs (MS) are best heard by turning the patient onto the left side. Diastolic murmur of atrial incompetence is best heard by asking patient to lean forward with breath held after expiration (with diaphragm of chest piece ready in position). For low pitched sounds (mid diastolic murmur of mitral stenosis, heart sounds) use the bell but do not press too hard! High pitched early diastolic murmur of aortic incompetence is easily missed so specifically listen for it.
    
15. Sacral oedema/ankle oedema
    
16. Listen to lung bases – routine although not often relevant in cardiovascular station. More relevant in breathless patient, aortic stenosis with displaced PMI, signs of left heart failure (orthopnoea, pulsus alternans, gallop rhythm)
    
17. Palpate liver – esp if large v wave and pansystolic murmur over tricuspid area. May demonstrate pulsatile liver by placing left hand posteriorly and right hand anteriorly over enlarged liver.
    
18. Offer to measure blood pressure - most relevant in aortic stenosis (narrow pulse pressure) and aortic incompetence (wide pulse pressure)
    

Examination of the pulse – PACES

1. Ask permission
2. Approach from right side
3. Face – malar flush (myxoedema, mitral stenosis), thyroid disease
4. Neck – Corrigan’s pulse(vigourous arterial pulses seen in neck), raised JVP, thyroidectomy scar, goitre
5. Chest – thoracotomy scar
6. General survey – ascities, clubbing, pretibial myxoedema, ankle oedema,etc
7. RADIAL pulse
8. rate – 15 seconds
9. Rhythmn – slow atrial fibrillation (concentrate on length of pauses) – pauses vary from beat to beat in slow AF
10. Character – assess at radial, brachial and carotid. Can be normal, collapsing, slow rising or jerky. Collapsing palpate radial and lift patients hand above head. Palpate brachial with other hand. If waterhammer pulse is present you feel a flick running along all four fingers while you may feel a flick at the brachial. Sensation of sharp knock – present in haemodynamically significant aortic incompetence and patent ductus arteriososis. Less pronounced collapsing pulse can be felt in moderate AI, PDA, thyrotoxicosis, fever, pregnancy, moderate severe mitral incompetence, anaemia, atherosclerosis. Slow-rising pulse – palpate brachial pulse with thumb. Bisferiens pulse – combination of plateau and collapsing effects.
11. Carotid –Confirmation of slow-rising and collapsing pulse
12. Radio-radial delay - ?fallots with blacklock shunt
13. Radiofemoral delay - coarctation of the aorta
14. all other peripheral pulses
15. additional diagnostic clues