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- Wash Your hands
- Introduce yourself by name and Role
- Check the patient’s identity – name and Date of Birth
- Explain the procedure – why you need to do it and what does it involve
- Ask for consent
- Expose the patient appropriately
- Check if the patient is currently in any pain
How to Introduce Yourself
“Good morning, my name is .. and I am a medical student. Can I just check your name and date of birth?
I have been asked to do a cardiovascular examination on you, which would involve me having a look at your hands, face and chest, and then having a feel and listen to your chest. Is that ok?
– For the purposes of this examination I’m just going to position the bed at 45 degrees.
– Would you mind removing your shirt for me please?
– And can I just check whether you are in any pain?”
- Observe the patient by standing at the end of the bed.
- Comment on whether the patient is ABC:
A – Alert B – (normal) Body habitus C – Comfortable at rest
- Observe the surroundings and comment of whether you can see any “paraphernalia of cardiovascular disease”:
This is a description of the objects or items around a patient’s bedside that will give you an idea into the condition that they might have. It is important to highlight this to the examiner as this can give you many clues about the patient’s underlying diagnosis. Things to look for include:
- Oxygen – is the patient currently on oxygen or room air, and what is the flow rate?
- Inhalers – does the patient have underlying respiratory disease?
- Medication – can you see any medication on the patient’s bedside e.g. beta-blockers?
- Test results – are there any investigation results like ECGs lying around the patient’s bedside.
- Fluid chart – this gives you an idea if they are fluid overloaded.
- Pillows – this is a useful marker of the level of heart failure as it shows that the patient might be suffering from orthopnea.
- Mobility aids – gives an idea about the functional status of the patient.
Ask the Patient to put the nails of their index fingers against each other. You will be looking to see if you can detect a small rhomboid shaped window (Schamroth’s window).
–> Finger clubbing: this is a term which describes swelling of the distal end of the fingers which leads to loss of the angle between the nail bed and the nail. It is associated with Congenital heart disease, Infective endocarditis, Atrial Myxoma, Eisenmenger syndrome.
Ask the Patient to put their hands outstretched. Using the back of your hands, feel down from their forearms to feel the temperature:
–> Cold peripheries: This is a sign of poor peripheral circulation. This is a common sign of shock and so may occur in hypovolaemia when the arterioles are vasoconstricted to reduce blood supply to the extremities.
Action: Look closely at the back of the patient’s hands.
–> Extensor Tendon Xanthomata: These are small non-tender lumps of cholesterol that can be found of the tendons of the extensor muscles of the wrist and palms. They are seen in hyperlipidaemia.
–> Peripheral Cyanosis: This is a blue discolouration of the nails and fingers which is indicative of peripheral ischaemia. It shows the patient is peripherally not perfusing well which can be seen in shock or hypothermia.
–> Tar staining: This is a black/brown staining of the nails and fingers which is seen in chronic smokers.
–> Koilonychia: These are spoon-shaped nails which are seen in iron-deficieny anaemia.
–> Splinter Haemorrhages: These are tiny brown spots that look like splinters under the nails, which occur due to damage of the underlying blood vessels. They are associated with infective endocarditis.
Action: Pinch the patient’s fingernail for 5 seconds and then release. Measure the capillary refill time.
–> Capillary refill time: This is the time taken for the capillaries to refill after a sustained period of pressure. Apply 5 seconds of pressure to the distal phalanx of the index finger and then release. Count how many seconds it taken to go red (re-vascularise). If >2 seconds, this shows poor peripheral circulation which could be a sign of shock.
Action: Ask the patient to turn their hands over and then look at the palmar surface of their hands:
–> Osler’s Nodes: These are purple lumps which are found on the fingers are toes, which occur due to immune complex deposition. Unlike Janeway lesions these are tender so ask the patient if they feel pain when you press on their finger-tips. They are associated with infective endocarditis.
–> Janeway lesions: These occur on palm and soles and are non-painful and are caused by septic emboli. They are also associated with infective endocarditis.
Action: Feel for the Radial Pulse on one side and measure the radial pulse for 15 seconds
–> Rate (bpm), rhythm (regular, regularly irregular, irregularly irregular) and character (thready, bounding):
What the Radial Pulse Tells You
The radial pulse gives you a lot of information about the state of the cardiovascular system. There are 3 main variables to talk about when measuring the radial pulse:
– A rate of <60bpm is considered bradycardia
– A rate of >100bpm is considered tachycardia
2. Rhythm: There are 3 main rythms to talk about:
– Regular – this will most likely be due to sinus rhythm, however you can get this in ventricular tachycardia
– Regularly irregular – this will most likely be due to a form of heart block
– Irregularly irregular – this is one not to miss and is most likely due to atrial fibrillation.
3. Character – this is gives you an indication of the strength of the impulse. It can be:
– Thready – can be seen if the BP is low such as in shock if the patient is peripherally shutting down
– Bounding – seen in CO2 retention.
Action: Feel for both radial pulses at the same time and see if the pulse is synchronous on both sides.
–> Radio-radial delay: This is when the pulse is not synchronised between the arms. This may indicate a thoracic artery dissection or aneurysm
–> Also offer to test for radio-femoral delay.
Action: Feel for the brachial pulse in the antecubital fossa. This will give you a better indicator of the character of the pulse compared to the radial pulse.
Action: At this point, state that you would mention the blood pressure in both arms.
Action: Ask the patient whether they have any pain in their shoulder. Place one hand over the patient right forearm holding it lightly and your second hand on their shoulder.
– Explain that you will be raising their arm up quite briskly.
– Raise the arm up above the patient head and see whether you can feel a pulsing sensation in the patient’s forearm.
–> Collapsing pulse: This is also known as the water hammer pulse and is associated with aortic regurgitation. Lifting the patient’s arm up means that blood can backflow due to an incompetent valve, so you will feel the blood rushing backwards in the artery back to the heart. It is seen in moderate to severe disease.
Action: Ask the patient to pull their eyelid down with their finger and look up.
–> Conjunctival Pallor: This is a paleness of the conjunctiva which is a sign of anaemia
Action: Ask the patient to relax and look at their eyes.
–> Corneal Arcus: This is a deposit of cholesterol, phospholipids, and triglycerides in an “arc” on either the top or bottom side of the iris, which is a sign of hypercholesterolaemia. This is a risk factor for cardiovascular disease.
–> Xanthelasma: These are yellowish-white lumps of fatty material accumulated under the skin on the inner parts of your upper and lower eyelids, which are associated with hyperlipidaemia.
Action: Ask the patient to open their mouth and stick their tongue out.
–> High arched palate: This is associated with Marfan syndrome. You may also detect aortic regurgitation or mitral valve prolapse with this syndrome.
–> Poor dentition: This is a risk factor for infective endocarditis, especially due to streptococcus viridans.
–> Glossitis: This is a beefy atrophic tongue which is seen in iron deficiency anaemia
–> Angular stomatitis: This is a condition that causes red, swollen patches in the corners of your mouth where your lips meet which is associated with anaemia.
Action: Ask the patient to touch the tip of their tongue to the roof of their palate. Observe the area under the tongue for blue discolouration.
–> Central cyanosis: This is a blue tinge of the mucosa in the mouth. This is a sign of hypoxia and will indicate that your patient is very unwell and needs urgent management.
Action: Ask the patient to relax back on the couch at 45 degrees and turn their head so they are looking left.
–> JVP: A raised JVP is suggestive of right heart failure, cardiac tamponade, tricuscpid regurgitation
How to Measure the JVP and Hepatojugular reflux
The internal jugular vein is runs from the middle part of the clavicle to the ear lobe. Its height above the sternal angle is a good indicate of jugular venous pressure, which indirectly measures central venous pressure.
– Usually the IJV should not be seen as right atrial pressure should be low. However in conditions like heart failure, this raises the pressure in the venous system so the internal jugular vein may become visible.
– Measure the height of the JVP by measuring the veritcle distance between the angle of the sternum and the pulsation point of the jugular vein. It should be less than 3cm
– If >3cm, this indicates that the JVP is raised and is due to conditions which stress right side of the heart
The hepatojugular reflux test
This is a test that you can do to make the IJV more visible by applying pressure to the liver. Pressing on the liver increases venous return to the heart as it is a very vascular organ. As it can cause pain, your examiner might not want you to perform this test but you should mention it to them anyways. To perform the test:
– Warn the patient that you will press on their liver quite firmly
– Apply pressure to the RUQ over their liver and observe the IJV for a rise
– A positive result is if there is a sustained rise in jugular venous pressure for more than 3cm.
Action: Check the carotid pulse. First have a listen and then a feel to the carotid pulse side by side
–> Carotid bruits: These are sounds which indicate turbulent flow. They may indicate atherosclerosis to the carotids which demonstrate that the patient has established cardiovascular disease.
Action: Ask patient to put their hands on hips so that you can view their axilla. Have a good look all around for any potential scars or chest wall deformities.
–> Chest Wall Deformities:
- Pectus excavatum: This is a sunken appearance of the chest, which can be seen in Marfan’s syndrome
- Pectus carinatum: This is when the chest sternum bulges from the chest
- Lateral thoracotomy scar – may indicate previous mitral valvotomy
- Median sternotomy scar –indicates presence of previous coronary artery bypass or cardiac valve surgery
- Subclavian scar – site for pacemaker
Action: Find apex beat – 5th intercostal space in left mid-clavicular line
–> Apex beat displacement: If the apex beat is displaced, this can be a sign of cardiomegaly due to ventricular hypertrophy
Action: Place your hand on the patient’s chest parallel to the left sternal edge.
–> Heaves – This is a contraction impulse that can be felt by your hand and it is a sign of right sided hypertrophy. If heaves are present then you will be able to feel an upward force of your hand
Action: Place your fingers over the four heart valve auscultation points
–> Thrills: This is a vibration which is caused by the distrubance of normal laminar blood flow. It usually accompanies leaky or stenosed valves and will be felt if the valve disease is very severe.
Action: Using your stethoscope, have a listen to the 4 heart valves (15). Whilst you are auscultating, it is important to also feel the carotid pulse at same time. This will allow you to time the heart sounds according to systole and diastole to work out if the murmurs you hear are systolic or diastolic.
- Aortic Valve first – right 2nd intercostal space
- Pulmonary valve – Left 2nd + 3rd intercostal space
- Tricuspid valve – lower left sternal edge
- Mitral valve with bell first – 5th intercostal space in left-mid clavicular line
–> Murmurs: A murmur is a sign of turbulent flow, which is often associated with heart valve dysfunction. When listening you will want to try to characterise whether the murmur is systolic or diastolic and what are the main acoustic features of the murmurs. More information about specific murmurs and what condition they are associated with can be found in our medical notes here.
Action: Relisten to the heart sounds whilst performing murmur accentuating movements.
a) Ask the patient to roll over onto their left side. Then ask them to take a deep breath in. When the patient breathes out ask them to hold their breath. –> Used to assess for the mitral valve murmurs
b) Ask the patient to now roll back over. Then get them to lean up and forward. Then ask them to take a deep breath in and hold it there –> Relistn to the tricuspid and pulmonary murmur
c) Whilst learning forward ask the patient to BREATHE OUT → Listen to the Aortic murmur
Action: Ask the patient to lean forward and listen to lung bases on back
–> Bibasal Crackles: This may indicate a pleural effusion or pulmonary oedema. This is a sign of dysfunction fo the left heart and may indicate left sided heart failure.
Action: Whilst the patient is leaning forward, feel their sacrum
–> Sacral oedema: This is a sign of peripheral oedema which is associated with right-sided heart failure.
Action: Ask the patient to keep their legs outstretched. Closely inspect their feet and legs for any signs of cardiovascular disease.
–> Scars: Look for vein harvesting scars for a CABG. The great saphenous vein is often used as the graft for a coronary bypass surgery, so this will indicate that the patient has ischaemic disease.
–> Varicose veins: These are dilated and tortuous veins secondary to chronic venous insufficiency
–> Calf Tenderness: A red swollen or tender calf unilaterally is a sign of a deep vein thrombosis. This needs urgent assessment with ultrasound as the patient is at high risk for a pulmonary embolus.
Action: Press on the medial malleolus of the patient ankles and assess if you can see/feel any sinking of the skin and whether it takes long to rise back up. If positive, see how far up the legs this oedema goes.
–> Pitting oedema: This is a sign that the patient is fluid overloaded. It is associated with right sided heart failure but can also be seen in conditions which reduce oncotic pressure e.g. hepatic failure.
Thank the patient and wash your hands to complete the examination!
You must remember that the physical examination is only one part of the overall assessment of your patient. Therefore, when completing your exam, state that you would do the following in order to complete your assessment of the patient. Much of this will depend on whether you have discovered any particular findings or have an idea about the overall diagnosis. However, some essential things to talk about are:
“To complete the examination, I would do a number of steps…”
- (History) Take a full history
- (Observations) Full Obs chart including blood pressure
- (Corresponding examination) Conduct a peripheral vascular examination/respiratory examination
- (Bedside tests) Take a urine dipstick (proteinuria + hematuria) and check for organomegaly + ECG
Bloods – Would take a full blood count + U&Es and cardiac markers
Imaging – Chest X-ray
Special tests – Echocardiogram
How to Present Your Findings
“I conducted a cardiovascular examination on … who seemed well and comfortable at rest.
- On inspection there were no peripheral signs of cardiovascular disease and no paraphernalia of cardiovascular disease.
- They had a pulse rate of … There was no radio-radial delay, and their pulse was regular and character normal
- The JVP was (3)cm so not raised. The carotid pulse was of fine character with no bruits on auscultation.
- Apex beat was non-displaced and no palpable heaves or thrills.
- Upon cardiac auscultation, heart sounds 1 and 2 were present with no added sounds, and lung bases clear bilaterally.
In summary, this is a normal examination.”
Finger Clubbing – Desherinka, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons
Tar Staining – James Heilman, MD, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons
Koilonychia – CHeitz, CC BY 2.0 <https://creativecommons.org/licenses/by/2.0>, via Wikimedia Commons
Splinter Haemorrhages – Splarka, Public domain, via Wikimedia Commons
Osler Nodes – Roberto J. Galindo, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons
Janeway Lesions – Warfieldian, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons
Conjunctival Pallor – Sheth TN, Detsky AS. The relation of conjunctival pallor to the presence of anemia. J Gen Intern Med. 1997;12(2):102-106.
Corneal Arcus – Loren A Zech Jr and Jeffery M Hoeg, CC BY 2.0 <https://creativecommons.org/licenses/by/2.0>, via Wikimedia Commons
Xanthelasma – Klaus D. Peter, Wiehl, Germany, CC BY 3.0 DE <https://creativecommons.org/licenses/by/3.0/de/deed.en>, via Wikimedia Commons
Glossitis – Martin Kronawitter, CC BY-SA 2.5 <https://creativecommons.org/licenses/by-sa/2.5>, via Wikimedia Commons
Angular Stomatitis – Matthew Ferguson 57, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons
Pectus Excavatum – From Wikimedia Commons, the free media repository
Pectus Carinatum – Jprealini, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons
Median Sternotomy – Stockholm, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons
Ausculation Points – OpenStax College, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons
Varicose Veins – self, Public domain, via Wikimedia Commons
Pitting oedema – James Heilman, MD, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons
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