Examination of the Cardiovascular System
| WIPE | Wash hands:
Introduce: + Explanation of procedure + Consent. Position: In bed at 45 degrees. Exposure: Chest Exposed. |
| Environment | Monitors? Oxygen? TED Stockings? Infusions? Insulin pen? Cigarettes? Etc… |
| Peripheral stigmata of disease: Look at the whole patient, hands, arms, face, eyes, mouth… | Impression: Sick or well? Sitting up, SOB, or comfortable? Thin and wasted? Obese (risk factor). Syndromic appearance.
Respiratory distress: Breathless, increased respiratory rate, cyanosis (peripheral and central). Anaemia: Pallor of hands, creases, under eyelids. Shock: Cold, clammy, pale, tachycardia, capillary refill > 2s. Smoker: Nicotine stains. Clubbing: Congenital cyanotic heart disease, infective endocarditis (IE). Infective endocarditis: Splinter haemorrhages; Osler nodes (tender subcutaneous papules); Janeway lesions (painless erythematous macules); poor dentition, needle marks (source of infection). Hyperlipidaemia: Xanthoma, xanthelasma (yellow plaques, eyelids), corneal arcus. Thyrotoxicosis: Hot, tremor. Malar flush: Mitral stenosis. |
| Pulse | Radial and carotid (auscultate for bruits).
Rate: Brady or tachycardia? (40-100). Rhythm: Is it regular? Irregularly irregular – atrial fibrillation. Volume: Thready – shock Character: Normal; slow rising – aortic stenosis; collapsing – aortic regurgitation. Radial-radial/femoral delay: Coarctation of the aorta. |
| Venous pulsation | JVP: Not usually palpable, obliterated by pressure, double pulsation, rises with pressure on abdomen. Measure height (not distance) from sternal notch.
Raised: Fluid overload / RVF. |
| Chest: Inspection | Scars: Median sternotomy (+ those of harvested vessels) – CABG, valve replacement. Pacemaker. |
| Chest: Palpation | Apex beat: Normally in the 5th intercostal space in the mid-clavicular line, with small impulse area. Laterally displaced, and diffuse impulse – LVF, dilated cardiomyopathy.
Parasternal heave: RV enlargement. Thrills: Transmitted murmurs, feel over the ausculattion areas. |
| Auscultation sites | Mitral – Apex; Tricuspid – 4th ICS Left; Aortic – 2nd ICS Right; Pulmonary – 2nd ICS Left;. |
| Heart Sounds | Listen in all four areas: Identify the 1st (synchronous with carotid pulsation) and 2nd heart sounds.
Added sounds: S3 (Ken-tucky); S4 (Tenne-ssee). Mechanical sounds of prosthetic heart valves. |
| Murmurs | Timing: Systole – Aortic stenosis, or mitral regurgitation.
Character: Ejection systolic – aortic stenosis; pansystolic – mitral regurgitation. Loudness: Grade out of 6; 1 – very soft, 2 – soft, 3 – clearly audibly, no thrill; 4 – palpable thrill; 5 – audible with stethoscope partially touching chest, 6 – can be heard without stethoscope. Area where loudest: E.g. Aortic stenosis is heard best in the right 2nd intercostal space. Radiation: Listen at the carotids (aortic stenosis), and in the axilla (mitral regurgitation). Accentuating manoeuvres: Lean forward – aortic stenosis; left lateral position – mitral regurgitation. Inspiration – right sided murmurs; expiration – left sided murmurs. |
| Lungs | Basal creps / stony dullness: Pulmonary oedema / effusion – LVF, CCF. |
| Oedema | Pitting oedema: Ankles, legs, sacrum (press down and note depression) – RVF, CCF. |
| Abdomen | Hepatomegaly and ascities: RHF, CCF |
| Finish up | BP, Pulse ox, dipstick, ECG, CXR. |