CARDIOVASCULAR SYSTEM
Examination of cardiovascular system is assessed in Station 3 A.
This station lasts for ten minutes – six minutes for physical examination and four minutes for discussion with the examiner. A waring bell is rung at the end of 5 minutes so as to be prepared for the presentation of the case.
Examples of possible cardiology case written instructions:
•“This patient complains of chest pain and episodes of lightheadedness. Please examine their cardiovascular system.”
•“This patient has palpitations. Examine their cardiovascular system.”
GENERAL SURVEY
1.Wash Your Hands
*Down syndrome (low-set ears, epicanthic folds, flat nasal bridge) : may be associated with VSD/ASD.
*Ankylosing spondylitis (question-mark posture, restricted neck
movements) : maybe associated with AR or AV blocks
*Turner syndrome (webbed neck, cubitus valgus, short stature,
infertility): may be associated with AS, Bicuspid aotic valve , AR and coarctation of aorta .
*Noonan’s syndrome (similar phenotype to Turner’s syndrome,
but may be present in men ) : associated with PS
* Williams syndrome (Elfin facies -prominent forehead,upturned nose,widely spaced eyes ,dental hypoplasia, underdeveloped mandible, patulous lips ) : Associated with AS
* Holt–Oram syndrome (triphalangeal thumb, radial hypoplasia) : maybe associated with ASD.
* Marfanoid features : Tall with long fingers ,Arm Span more than height by more than 1 cm could be associated with MVP , MR or AR.
* Malar flush : Mitral stenosis
* slate grey pigmentation in sunexposed areas in patients taking amiodarone
*Xanthelasma may indicate Atherosclerotic heart disease, sclerotic aortic valve
*Cyanosis : ask the patient to open his mouth ,look at the tip of the tongue ,undersurface of tongue and oral mucosa.
*Examine the uvula for pulsations which one might find in AR (Mullers sign ). Also examine the fingertips for cyanosis.
for example, ask the patient with marfanoid features to stand up and
demonstrate their arm span or ask the ankylosing spondylitis patient
to move their cervical spine thus revealing the restricted spinal
movements.
Tip: Do not spend more than 1 minute for general survey of the patient as more time is needed for detailed cardiac examination.
INSPECTION:
6.Examination of precordium : look tangentially from foot end
*Pericordial bulge ( Long standing Heart disease )
*Scars : CABG /sternotomy scars .In case the patient has sternotomy scar ,look at the legs for venous graft harvesting site or rarely from arms .
*Tunnelled lines over the chest These can be a source of endocarditis
(particularly of the tricuspid valve) but may also have been used to
administer long-term antibiotics giving a clue that the patient may have
suffered from endocarditis .
*Pace makers
*Cardiac apex
*Pedal oedema
7.Ask The Patient To Spread His Hand And Examine Dorsum For:
*Clubbing : Infective endocarditis ,congenital cyanotic heart disease, Eisenmengers . *Splinter Hemorrhage : thin reddish brown nails under fingernails or toenails .
*Long fingers Marfans syndrome
*Press on nail and observe for De Quinkes sign in Aortic regurgitation
8.Ask Him To Turn His Hand And Examine Palms :
* Janeway lesions -non tender ,popular lesions in infective endocarditis .
* Oslers nodes – purplish ,tender lesions on the pulp of fingers in infective endocarditis
9.Examine His Pulse carefully Carefully count the pulse for about 30 Sec and multiply by 2 .(carefully note the rhythm as atrial fibrillation is a common association ). Make a note of the following
*Rate
*Rhythm (Regular , Irregular , Irregular irregular)
*Volume (Small , normal , Large)
Low Volume in stenotic Lesions
Large volume in MR, VSD, AR
*Character
Collapsing in AR , PDA
Slow rising late peaking in aortic stenosis
Bisferiens pulse in AS with AR
*Condition of vessel wall
*Equality on both sides : With both arms straight and stretched out, feel both radial pulses at the same time. If there is a volume deficit between the 2 sides, consider
the presence of a Blalock–Taussig shunt and look for 2 additional scars:
a thoracotomy scar on the side of the shunt from the palliative Blalock
procedure and sternotomy scar from the subsequent total correction operation.
*Offer to check Radio-femoral delay (never check femoral pulse over the clothes of the patient ).
*Intact/impaired peripheral pulsations
10.Ask Him If He Has Any Pain In Shoulder And Examine For Water Hammer Pulse By: Suddenly elevating the arm feel with both hands .Feel for the collapsing pulse with the flat parts of your fingers around the distal interphalangeal joints, rather than the tips, which are too sensitive. Hold the patient’s wrist with your fingers over, not under, the wrist. This means that when you lift the wrist, you don’t end up twisting your own body and looking awkward. When you have lifted, it is often necessary to wait a few seconds before the tapping or ‘water-hammer’ character of the pulse is felt.
11.Examine Axilla for: Skin wrinkling & plucked chicken appearance in Pseudoxanthoma elasticum : Associated with AR, MR
Look at skin for features of anticoagulation. ( echymotic patches or purpura if the patient is on warfarin after a prosthetic valve replacement surgery ).
* Pallor : look at the lower palpebral conjunctiva. (infective endocarditis ,prosthetic valve associated microangiopathic hemolytic anaemia ,atrial myxoma )
* polycythemia : ruddy conjunctiva in atrial myxoma /chronic hypoxic states.
*If the patient has Marfanoid habitus look for ectopia lentis , blue sclera and iridodonesis.
* Mouth for High arched palate ( Marfans syndrome )
*Cyanosis
15.Ask Him To Turn His Head And Examine JVP for elevation:
Venous pulsation are seen better than felt , obliterated by pressure on root of neck. If in doubt can confirm by first warning the patient and then gently pressing in the right upper quadrant( abdominojugular reflux )
PALPATION:
16-Feel The Carotid Artery For character of pulse . ( ask for neck pain before palpating ).
*Apex for: Site (normally in the 5 th ICS MCL) the outmost pulsation
Character Normal (doesn’t elevate your finger)
Heaving in aortic stenosis(elevates your finger & stays for a second before descent)
Hyperdynamic in MR , AR (elevate your finger & rapidly descends)
Tapping = MS (Tickling under your finger)
Tip: Check right side of chest too in case apex is not palpable as can occur in cases of dextrocardia
*Thrills
Diastolic = MS
Systolic =MR
*Left Parasternal Edge for Left parasternal heave in right ventricular hypertrophy
*Palpate pulmonary ,aortic, epigastric ,suprasternal areas for pulsations
AUSCULTATION:
Mitral area ,tricuspid area , pulmonary and aortic area.
Carefully note
* First and second heart sounds : intensity
*Murmur : systolic / diastolic
Describe the murmur : type , grade , area where its best heard,respiratory variation ,radiation or conduction, any change with manouvres like handgrip or Valsalva.
*Third or fourth heart sounds
*Any clicks or opening snaps.
Cardiology Case Presentation
This gentleman is lying comfortable in bed with average built , he doesn’t have pedal oedema, no cyanosis , his pulse is 80 beats per minute , regular normal volume and character, no radiofemoral delay and intact peripheral pulsations , the apex is in the 5 th intercostal space tapping in nature ,first heart sound is loud , second heart sound is normal. Theres a low pitched rough rumbling mid diastolic murmur best heard at the apex ,with the patient in the left lateral position and increases with expiration. I would like to complete my examination by doing a urine dipstick and checking temperature .With these findings I would like to think of a diagnosis of…
PATTERN OF DIAGNOSIS
*Valvular heart disease-congenital/acquired OR valve replacement (mitral or aortic or double ).
*possible etiology
*features of cardiac failure
* infective endocarditis
* sinus rhythm/atrial fibrillation
* pulmonary hypertension .
Cardiology Examination Common Pitfalls
1.Failure to ask or offer to check Blood pressure
2.Forgetting to examine the JVP
Top Tips for the Cardiovascular Examination Encounter
This gentleman is lying comfortable in bed with average built , he doesn’t have pedal oedema, no cyanosis , his pulse is 80 beats per minute , regular normal volume and character, no radiofemoral delay and intact peripheral pulsations , the apex is in the 5 th intercostal space tapping in nature ,first heart sound is loud , second heart sound is normal. Theres a low pitched rough rumbling mid diastolic murmur best heard at the apex ,with the patient in the left lateral position and increases with expiration. I would like to complete my examination by doing a urine dipstick and checking temperature .With these findings I would like to think of a diagnosis of…
*Valvular heart disease-congenital/acquired OR valve replacement (mitral or aortic or double ).
*possible etiology
*features of cardiac failure
* infective endocarditis
* sinus rhythm/atrial fibrillation
* pulmonary hypertension .
1.Failure to ask or offer to check Blood pressure
2.Forgetting to examine the JVP
3. Try to finish general survey and pulse within 2 minutes so that there is enough time for auscultation of heart in a meticulous manner.
Practice listening to murmurs of patients on the cardiology wards to familiarize yourself.
• It is good technique to time all murmurs against the carotid pulse. Do not time against the radial pulse as there may be a delay, especially with critical aortic stenosis.
• Don’t be so preoccupied with getting to the auscultation part of the exam that you fail to pick up important peripheral signs on inspection (e.g. clubbing, sternotomy scar).
• When feeling for a radial pulse, always take a mental note of rate, rhythm, character or absence.
• Finish your examination by mentioning to the examiners that you would like to perform other pertinent examinations or investigations e.g. examining the abdomen for hepatomegaly in right heart failure, ECG, BP etc.
CARDIOVASCULAR SYSTEM
Examination of cardiovascular system is assessed in Station 3 A.
This station lasts for ten minutes – six minutes for physical examination and four minutes for discussion with the examiner. A waring bell is rung at the end of 5 minutes so as to be prepared for the presentation of the case.
Examples of possible cardiology case written instructions:
•“This patient complains of chest pain and episodes of lightheadedness. Please examine their cardiovascular system.”
•“This patient has palpitations. Examine their cardiovascular system.”
GENERAL SURVEY
1.Wash Your Hands
*Down syndrome (low-set ears, epicanthic folds, flat nasal bridge) : may be associated with VSD/ASD.
*Ankylosing spondylitis (question-mark posture, restricted neck
movements) : maybe associated with AR or AV blocks
*Turner syndrome (webbed neck, cubitus valgus, short stature,
infertility): may be associated with AS, Bicuspid aotic valve , AR and coarctation of aorta .
*Noonan’s syndrome (similar phenotype to Turner’s syndrome,
but may be present in men ) : associated with PS
* Williams syndrome (Elfin facies -prominent forehead,upturned nose,widely spaced eyes ,dental hypoplasia, underdeveloped mandible, patulous lips ) : Associated with AS
* Holt–Oram syndrome (triphalangeal thumb, radial hypoplasia) : maybe associated with ASD.
* Marfanoid features : Tall with long fingers ,Arm Span more than height by more than 1 cm could be associated with MVP , MR or AR.
* Malar flush : Mitral stenosis
* slate grey pigmentation in sunexposed areas in patients taking amiodarone
*Xanthelasma may indicate Atherosclerotic heart disease, sclerotic aortic valve
*Cyanosis : ask the patient to open his mouth ,look at the tip of the tongue ,undersurface of tongue and oral mucosa.
*Examine the uvula for pulsations which one might find in AR (Mullers sign ). Also examine the fingertips for cyanosis.
for example, ask the patient with marfanoid features to stand up and
demonstrate their arm span or ask the ankylosing spondylitis patient
to move their cervical spine thus revealing the restricted spinal
movements.
Tip: Do not spend more than 1 minute for general survey of the patient as more time is needed for detailed cardiac examination.
INSPECTION:
6.Examination of precordium : look tangentially from foot end
*Pericordial bulge ( Long standing Heart disease )
*Scars : CABG /sternotomy scars .In case the patient has sternotomy scar ,look at the legs for venous graft harvesting site or rarely from arms .
*Tunnelled lines over the chest These can be a source of endocarditis
(particularly of the tricuspid valve) but may also have been used to
administer long-term antibiotics giving a clue that the patient may have
suffered from endocarditis .
*Pace makers
*Cardiac apex
*Pedal oedema
7.Ask The Patient To Spread His Hand And Examine Dorsum For:
*Clubbing : Infective endocarditis ,congenital cyanotic heart disease, Eisenmengers . *Splinter Hemorrhage : thin reddish brown nails under fingernails or toenails .
*Long fingers Marfans syndrome
*Press on nail and observe for De Quinkes sign in Aortic regurgitation
8.Ask Him To Turn His Hand And Examine Palms :
* Janeway lesions -non tender ,popular lesions in infective endocarditis .
* Oslers nodes – purplish ,tender lesions on the pulp of fingers in infective endocarditis
9.Examine His Pulse carefully Carefully count the pulse for about 30 Sec and multiply by 2 .(carefully note the rhythm as atrial fibrillation is a common association ). Make a note of the following
*Rate
*Rhythm (Regular , Irregular , Irregular irregular)
*Volume (Small , normal , Large)
Low Volume in stenotic Lesions
Large volume in MR, VSD, AR
*Character
Collapsing in AR , PDA
Slow rising late peaking in aortic stenosis
Bisferiens pulse in AS with AR
*Condition of vessel wall
*Equality on both sides : With both arms straight and stretched out, feel both radial pulses at the same time. If there is a volume deficit between the 2 sides, consider
the presence of a Blalock–Taussig shunt and look for 2 additional scars:
a thoracotomy scar on the side of the shunt from the palliative Blalock
procedure and sternotomy scar from the subsequent total correction operation.
*Offer to check Radio-femoral delay (never check femoral pulse over the clothes of the patient ).
*Intact/impaired peripheral pulsations
10.Ask Him If He Has Any Pain In Shoulder And Examine For Water Hammer Pulse By: Suddenly elevating the arm feel with both hands .Feel for the collapsing pulse with the flat parts of your fingers around the distal interphalangeal joints, rather than the tips, which are too sensitive. Hold the patient’s wrist with your fingers over, not under, the wrist. This means that when you lift the wrist, you don’t end up twisting your own body and looking awkward. When you have lifted, it is often necessary to wait a few seconds before the tapping or ‘water-hammer’ character of the pulse is felt.
11.Examine Axilla for: Skin wrinkling & plucked chicken appearance in Pseudoxanthoma elasticum : Associated with AR, MR
Look at skin for features of anticoagulation. ( echymotic patches or purpura if the patient is on warfarin after a prosthetic valve replacement surgery ).
* Pallor : look at the lower palpebral conjunctiva. (infective endocarditis ,prosthetic valve associated microangiopathic hemolytic anaemia ,atrial myxoma )
* polycythemia : ruddy conjunctiva in atrial myxoma /chronic hypoxic states.
*If the patient has Marfanoid habitus look for ectopia lentis , blue sclera and iridodonesis.
* Mouth for High arched palate ( Marfans syndrome )
*Cyanosis
15.Ask Him To Turn His Head And Examine JVP for elevation:
Venous pulsation are seen better than felt , obliterated by pressure on root of neck. If in doubt can confirm by first warning the patient and then gently pressing in the right upper quadrant( abdominojugular reflux )
PALPATION:
16-Feel The Carotid Artery For character of pulse . ( ask for neck pain before palpating ).
*Apex for: Site (normally in the 5 th ICS MCL) the outmost pulsation
Character Normal (doesn’t elevate your finger)
Heaving in aortic stenosis(elevates your finger & stays for a second before descent)
Hyperdynamic in MR , AR (elevate your finger & rapidly descends)
Tapping = MS (Tickling under your finger)
Tip: Check right side of chest too in case apex is not palpable as can occur in cases of dextrocardia
*Thrills
Diastolic = MS
Systolic =MR
*Left Parasternal Edge for Left parasternal heave in right ventricular hypertrophy
*Palpate pulmonary ,aortic, epigastric ,suprasternal areas for pulsations
AUSCULTATION:
Mitral area ,tricuspid area , pulmonary and aortic area.
Carefully note
* First and second heart sounds : intensity
*Murmur : systolic / diastolic
Describe the murmur : type , grade , area where its best heard,respiratory variation ,radiation or conduction, any change with manouvres like handgrip or Valsalva.
*Third or fourth heart sounds
*Any clicks or opening snaps.
Cardiology Case Presentation
This gentleman is lying comfortable in bed with average built , he doesn’t have pedal oedema, no cyanosis , his pulse is 80 beats per minute , regular normal volume and character, no radiofemoral delay and intact peripheral pulsations , the apex is in the 5 th intercostal space tapping in nature ,first heart sound is loud , second heart sound is normal. Theres a low pitched rough rumbling mid diastolic murmur best heard at the apex ,with the patient in the left lateral position and increases with expiration. I would like to complete my examination by doing a urine dipstick and checking temperature .With these findings I would like to think of a diagnosis of…
PATTERN OF DIAGNOSIS
*Valvular heart disease-congenital/acquired OR valve replacement (mitral or aortic or double ).
*possible etiology
*features of cardiac failure
* infective endocarditis
* sinus rhythm/atrial fibrillation
* pulmonary hypertension .
Cardiology Examination Common Pitfalls
1.Failure to ask or offer to check Blood pressure
2.Forgetting to examine the JVP
Top Tips for the Cardiovascular Examination Encounter
This gentleman is lying comfortable in bed with average built , he doesn’t have pedal oedema, no cyanosis , his pulse is 80 beats per minute , regular normal volume and character, no radiofemoral delay and intact peripheral pulsations , the apex is in the 5 th intercostal space tapping in nature ,first heart sound is loud , second heart sound is normal. Theres a low pitched rough rumbling mid diastolic murmur best heard at the apex ,with the patient in the left lateral position and increases with expiration. I would like to complete my examination by doing a urine dipstick and checking temperature .With these findings I would like to think of a diagnosis of…
*Valvular heart disease-congenital/acquired OR valve replacement (mitral or aortic or double ).
*possible etiology
*features of cardiac failure
* infective endocarditis
* sinus rhythm/atrial fibrillation
* pulmonary hypertension .
1.Failure to ask or offer to check Blood pressure
2.Forgetting to examine the JVP
3. Try to finish general survey and pulse within 2 minutes so that there is enough time for auscultation of heart in a meticulous manner.
Practice listening to murmurs of patients on the cardiology wards to familiarize yourself.
• It is good technique to time all murmurs against the carotid pulse. Do not time against the radial pulse as there may be a delay, especially with critical aortic stenosis.
• Don’t be so preoccupied with getting to the auscultation part of the exam that you fail to pick up important peripheral signs on inspection (e.g. clubbing, sternotomy scar).
• When feeling for a radial pulse, always take a mental note of rate, rhythm, character or absence.
• Finish your examination by mentioning to the examiners that you would like to perform other pertinent examinations or investigations e.g. examining the abdomen for hepatomegaly in right heart failure, ECG, BP etc.
