Cardiovascular Examination

Position

Introduce, consent, wash hands, expose abdomen and chest, lying in bed at 45 degrees, stand at the right side of the pt.

General Inspection

1.  End of the bed: ill? Dyspnoeic/tachypnoeic/no distress? Cathetic? chest deformity,scar, IV lines, pacemaker Down Syndrome/Marfan? 2.  Marfan's syndrome? tall stature high arched palate thoracic escavatum pectus excavatum aortic regurgitation long arms and legs arachnodactyl (spider fingers)

The Hands

Clubbing	increase in the soft tissue of the distal part of the finger or toes.    Stage of clubbing: Fluctuation & softening of nail bed - loss of the nail-bed angle increase curvature of the nail drumstick appearance hypertrophic pulmonary osteoarthropathy   CVS Causes: Cyanotic congenital heart disease infective endocarditis Atrial myxoma -benign umor in the upper left or right side of the heart
Stigmata of infective endocarditis	Splinter Hemorrhage - linear haemorrhage lying parallel to the long axis of the nail. Other causes: trauma, vasculitis (rare) Osler's nodes - painful red, raised, tender nodules on the pulps of the fingers, thenar/hypothenar eminances. Seen in <;5% of pt. Janeway's lesion -painless, non-tender erythematous maculopapular lesions containing bacteria, which occur rarely on the palms. Roth's spots- erythematous lesions in the optic fundi.
Pallor of the palmar creases	Anaemia Usually normochromic, normocytic causes ; haemolytic anaemia (prosthetic valve), Infective endocarditis (chronic inflammation)
Tendon xanthomata	yellow deposits of lipid in the tendons that occurs in type II hyperlipidaemia
Tar staining	smoking

The Arterial Pulse

Radial pulse - just medial to the radius, check for Rate- normal 60-100 beats/min bradycardia (<60) atheletes, sleep, raised vagal tone, drugs (b-blocker, digoxin), hypothermia, hypothyroidism, raised ICP, MI Tachycardia (>100) exercise, fever, pregnancy, thyroitoxicosis, CHF, drugs (salbutamol, atropine), hypovolaemic shock Rhythm - regularly irregular (sinus arrhythmia) irregularly irregular (A. fib) radiofemoral delay  - coarctation of the aorta radial-radial delay - occlusion of atheroscleretic plaque/aneurysm, subclavian artery stenosis Character & volume- use carotid or brachial arteries

The Blood Pressure

1. Using sphygmomanometer. The cuff width must be >40% of the arm circumference. Wrap the cuff around upper arm with the bladder centred over the brachial artery (in the antecubital fossa) to estimate systolic BP, inflate the cuffwhile palpating the brachial artery, until the pulses dissapear Inflate the cuff until 30mmHg above estimated systolic BP. Place stethoscope over brachial artery. Deflate at 3mmHg/s. Systolic BP: a sound is first heard (Korotkoff I) Diastoic BP: sounds dissapear (Korotkoff V), or muffling sounds(KIV) in severe aortic regurge and pregnant women. if concern about an abnormal reading, repeat measurement 2. Findings BP in the legs 20mmHg higher. (require large cuff, stethoscope over the popliteal fossa) Pulsus paradoxus - normal BP reduction with inspiration is exaggerated, in cardiac temponade, pericarditis, severe asthma Kussmaul sign - a fall in BP and paradoxical rise in pulse rate. High BP (> 145/90) Postural hypotension - fall of >15mmHg in systolic BP or >10 in diastolic BP on standing. May cause dizziness. Causes: a-blocker, hypovolaemia, Addison's

The Face

Jaundice	in severe CHF and hepatic congestion
Xanthelasmata	intracutaneous yellow cholesterol deposits around the eyes. May indicate type II or III hyperlipidaemia
Arcus senilis/Corneal arcus	Cholesterol deposits in the corneal stroma result in a white/grey opaque ring surrounding the cornea. It is associated with hyperlipidaemia and with ageing
Mitral facies	rosy cheek with a bluish tinge caused by malar capillaries dilatation in severe mitral stenosis
High arched palate	Marfan's syndrome
Cyanosis	Peripheral cyanosis - lips, Central cyanosis - under tongue
Tooth decay	infective endocarditis

The Neck

Carotid arteries

medial to sternomastoid muscle, check for volume and character: Collapsing pulse- aortic regurgitation Pulsus alternans(altenating weak and strong pulse)-  LVF anacrotic, small volume - aortic stenosis jerky- hypertrophic cardiomyopathy

Jugular Venous Pressure (JVP)

Assessment Right internal jugular vein > accurate - extends directly into the atrium Left-sided veins < accurate because they cross from the left side of the chest before entering right atrium. Perpendicular height of pulsations from the sternal angle(angle of Louis) should be less than 3 cm. Sign of heart failure, fluid overload Character of jugular venous pulsations visible but not palpable complex wave form occludable Fills from above Decreases with inspiration Increases with hepatojugular reflux Causes of elevation renal failure- fluid overload RVF Tricuspid regurgitation  The abdominojugular reflux - pressure over the abdomen for 10 sec Normal : JVP rises transiently following manoeuvre RVF or LVF : JVP remain elevated (> 4cm) for the duration of compression

Pericordium

Inspection	Scar - median sternotomy (valve surgery), lateral thoracotomy (mitral stenosis) Pectus excavatum (funnel chest), kyphoscoliosis pacemaker, cardioverter-defribillator box (larger than pacemaker)
Palpation	apex beat - most lateral, inferior point at which your palpating finger are raised with each systole. 5th intercostal space (2nd one lies below sternal angle) midclavicular line Pressure loaded - aortic stenosis Volume loaded (thrusting)- mitral regurgitation double impulse-  HOCM impalpable - obesity, emphysema, pericardial effusion, shock, dextrocardia displaced- ventricular dilatation, cardiomegaly, thick chest wall, mediastinal mass parasternal impulse in right ventricular enlargement. The heel of hand is rested left of sternum Thrills/palpable murmur -palpate with the flat of the hand over the apex, left sternum, base of the heart. Apical thrills are best elicited with pt in the left lateral position.
Percussion	to define cardiac outline, little information
Auscultation	Apex beat with the diaphragm of stethoscope Valves : auscultate mitral, tricuspid, pulmonary, aortic with diaphragm first and then bell . Heart sound- auscultate while palpating the carotid pulse. S1 (first heart sound): mitral and tricuspid valves closure and S2 (second heart sound) :aortic and pulmonary valves closure, end of systole, lower pitch Auscultation of neck Carotid artery bruit -anterior part of sternomastoid above medial end of clavicle venous hum - disappears if pressure applied to the neck above stethoscope Dynamic manouvres: Lesions on the left side of the heart are best elicited on listening in full expiration. Lesions on the right side of the heart are best elicited on inspiration.

Cardiac Murmurs

Mitral regurgitation	pansystolic murmur maximal at the apex and radiating to the axilla, louder with isometric handgrib and left lateral position,
Aortic Stenosis	Ejection systolic murmur, radiates to carotid arteries, louder when pt squats rapidly from standing position
Aortic regurgitation	Early diastolic murmur, maximal at the left sternal border with diphargm and pt leans forward in full expiration Eponymous signs of aortic regurgitation - amusing but not often helpful Quinke's sign - capillary pulsation in the nail beds Corrigan's sign - prominent carotid pulsations De Musset's sign: head nodding with heart beat Hill's sign: increased BP (>;20mmHg) in the legs compared with arms Mueller's sign : pulsation of the uvula during systole Traube sign - Loud systolic sound over femoral arteries Duroziez sign - Systolic-diastolic murmur produced by compression of femoral artery with a stethoscope Gerhard's sign- pulsatile speen Austin Flint murmur - short rumbling diastolic mumur.
Mitral stenosis	mid-diastolic murmur over mitral area using bell, louder with isometric handgrib and left lateral position
Mitral valve prolapse	systolic click mumur
Tricuspid stenosis	mid-diastolic, murmur increases with inspiration
tricuspid regurgitation	pansystolic, murmur increases with inspiration
Pulmonary stenosis	Ejection systolic murmur
Hypertrophic Cardiomyopathy	ejection systolic murmur, louder with Valsalva strain
Patent ductus arteriosus	continuous murmur

Grade Murmurs 1-6

1/6: very soft 2/6: soft 3/6: moderate (no thrill) 4/6: loud, palpable thrill 5/6: very loud, thrill easily palpable 6/6: very, very loud (audible without stethoscope)

Extra Heart Sounds

S3	low pitch mid-diastolic sound, triple rhythm (Kentucky, with ky=S3). Causes: reduced ventricular compliance
S4	late diastolic sound pitched higher than S3, (Tennessee, Ten=S4). Causes: forceful atrial wave reflected back from a poorly compliant ventricle
Pericardial friction rib	caused by movement of inflamed pericardial surfaces. Pericarditis
Mediastinal crunch	or Hamman's sign - often after cardiac surgery, pneumothorax. Caused by air in the mediastinum

The back

1. Percussion and auscultation of the lung bases- late or pan-inspiratory crackles -signs of cardiac failure or pleural effusion 2. Sacral oedema

The Abdomen

RHF- enlarged tender liver, ascites, pitting oedema

The Legs

1. Pedal oedema - Palpate distal shaft of tibia. Compress the area for at least 15 seconds with the thumb. Area often tender, be gentle. 2. Pitting oedema - Skin is indented and only slowly refills. Note upper level of oedema, abdominal wall and scrotum may be involved.