Cardiovascular Exam

Introduction

Wash hands Introduce yourself and your role to the patient Explain the purpose of the exam and what it entails to patient Obtain consent Adjust patient to 45 degrees

General Inspection

Pain Respiratory distress Discolouration: cyanosis and pallor Accessories: ECG leads, pacemaker, supplemental O2

Hands

Capillary refill < 2 seconds Apply pressure for 5 seconds to the distal phalanx of one of the patient's fingers then release Capillary refill time taken for colour to return to the nail.

Clubbing Clubbing is the loss of angle between nail and nail bed causing increased nail convexity Ask patient to hold distal phalanges back to back; a lack of space between the nail beds indicates clubbing

Peripheral cyanosis Blue discolouration extending medially from finger tips

Splinter hemorrhages Dark red or brown lines resembling splinters underneath the nail

Janeway Lesions and Osler's Nodes Janeway lesions: red flat painless lesions which tend to be on palms Osler's nodes: red raised tender lumps which tend to be on fingers

Tar staining Dark discolouration between fingers from holding cigarettes.

Xanthomas Visible skin lesions made from lipid deposits

Vitals

Face

(May need pen torch)

Xanthelasmas Yellow deposits of cholesterol surrounding eyelids

Pallor of conjunctiva Either pull patient's lower eyelid down or ask them to pull it down. Assess colouration of conjunctiva

High arched palate

Central cyanosis Ask the patient to move their tongue to the roof of their mouth. Assess colour below tongue

Dentition

Neck

Raised JVP Ask patient to rotate their head slightly to their left. The JVP has a double waveform, is poorly palpable and is found between the sternal and clavicular heads of the sternocleidomastoid. A raised JVP is when the JVP extends more than 3 cm above the sternal angle

Carotid pulse "Normal volume and character"

Auscultation Ask the patient to hold their breath and use the stethoscope bell to listen to the patient's carotid. A murmur is associated with aortic stenosis "No carotid bruits or murmurs"

Chest

Inspection

Chest wall deformities: pectus carinatum, pectus escavatum Visible palpitations Scars

Palpation

Apex Beat Feel for heartbeat at the apex of heart (5th intercostal space, mid axillary line) If it's not palpable, move hand horizontally to the axilla, ask patient to roll on to left side and reassess. Heartbeat at axilla indicates displaced apex beat.

Heaves and Thrills Place hand on apex and move hand in a "Z" pattern until it is over the aortic and pulmonary valves. Heaves are forceful heart contractions Thrills are palpable murmurs

Auscultation

(diaphragm of stethoscope)

Aortic Valve: right sternal edge, 2nd intercostal space

Pulmonary Valve: left sternal edge, 2nd intercostal space

Tricuspid Valve: left sternal edge, 4th intercostal space

Mitral Valve: left midclavicular line, 5th intercostal space

"Heart sounds were normal with no extra sounds or murmurs"

Dynamic Maneuvers

Mitral Stenosis: Hold bell of stethoscope over apex of heart (left midclavicular line, 5th intercostal space) and ask patient to roll onto their left side and breath out deeply.

Aortic Regurgitation (Erb's Point): Hold bell of stethoscope over left sternal edge, 3rd intercostal space and ask patient to roll onto their left side and breath out deeply.

Back

Palpation: sacral oedema Percussion: pulmonary oedema Auscultations: crepitations (pulmonary oedema and left sided heart failure)